Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

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Source: modified from Malyszko et al.<a class="elsevierStyleCrossRef" href="#bib0695">11</a>Abbreviations: Alpha-GST, alpha-glutathione S-transferase; IL-18, interleukin 18; KIM-1, kidney injury molecule type 1; L-FABP, Liver-type fatty-acid binding protein; NGAL, neutrophil gelatinase-associated lipocalin." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.I. Pérez Calvo, C. Josa Laorden, I. Giménez López" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J.I." "apellidos" => "Pérez Calvo" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Josa Laorden" ] 2 => array:2 [ "nombre" => "I." 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Polypathology" "titulo" => "Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "289" "paginaFinal" => "295" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Gómez Aguirre, A. Caudevilla Martínez, L. Bellostas Muñoz, M. Crespo Avellana, J. Velilla Marco, J. Díez-Manglano" "autores" => array:6 [ 0 => array:3 [ "nombre" => "N." "apellidos" => "Gómez Aguirre" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Caudevilla Martínez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Bellostas Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Crespo Avellana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Velilla Marco" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:4 [ "nombre" => "J." "apellidos" => "Díez-Manglano" "email" => array:1 [ 0 => "jdiez@aragon.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Ernest Lluch, Calatayud, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Investigación en Comorbilidad y Pluripatología de Aragón, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Medicina, Dermatología y Psiquiatría, Universidad de Zaragoza, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 698 "Ancho" => 1658 "Tamanyo" => 49235 ] ] "descripcion" => array:1 [ "en" => "Example of prescription cascade." ] ] ] "textoCompleto" => "Scientific/healthcare advances and the economic and social development of recent decades, along with the implementation of preventive measures, have led to better control and approach to chronic diseases and have increased life expectancy. In Spain, one of the countries with the longest life expectancy in the world, 18.5% of the population was older than 65 years in 2015,<a class="elsevierStyleCrossRef" href="#bib0290">1</a> and it is estimated that this age group could reach 36.5% by 2051, with 15.3% of octogenarians.<a class="elsevierStyleCrossRef" href="#bib0295">2</a> With this population shift, there is an exponential increase in patients with chronic diseases, who require a high number of drugs for their treatment, which represents a major impact on healthcare expenditures. In the National Survey of Chronically Ill Patients (Encuesta Nacional de Pacientes Crónicos) conducted in Spain in 2014, 71.8% of the individuals aged 65 years or older had some type of chronic disease, increasing in frequency with age.<a class="elsevierStyleCrossRef" href="#bib0300">3</a> Although chronic diseases are not exclusive to the elderly, the number and prevalence of these diseases increase with age, such that individuals older than 65 years account for the majority of pharmaceutical expenditures.Chronically ill patients entail greater complexity in their management. Therapies that are intensified as the disease progresses, along with therapies indicated for other comorbid conditions, inevitably require a progressive addition of drugs. Among chronically ill patients, polypathological patients constitute a special group, due not only to the number of chronic diseases but also to their progression and complexity, with greater morbidity and progressive functional impairment, which necessitates an increased consumption of healthcare resources.<a class="elsevierStyleCrossRef" href="#bib0305">4</a> It has been estimated that the prevalence of polypathology in the general population of Spain and, in particular, among those older than 65 years is 1.38% and 5%, respectively. In the departments of internal medicine and geriatric medicine, the rates are 31% and 44%, respectively.<a class="elsevierStyleCrossRefs" href="#bib0310">5,6</a>PolypharmacyApproximately 40% of adults older than 65 years take between 5 and 9 drugs daily, and 10% take more than 10, with a mean consumption of 4.2–8 drugs per individual.<a class="elsevierStyleCrossRef" href="#bib0320">7</a> If we follow the clinical practice guidelines, the treatment of a patient with multiple diseases involves numerous drugs and nondrug measures. Therefore, the profile of the polymedicated patient would be an elderly individual with multiple associated chronic diseases. Several studies have shown that polypathological patients consume a mean of 8 drugs and that polypharmacy is present in more than 85% of patients.<a class="elsevierStyleCrossRefs" href="#bib0325">8,9</a> In fact, complications resulting from polypharmacy in these patients are more frequent and severe. This situation is due to the physiological changes in pharmacokinetics that cause a reduced renal and hepatic clearance and an increased volume of distribution for liposoluble drugs, as well as a variation in the response of the target organs, which are more sensitive to various drug groups, such as cardiovascular drugs, anticoagulants and psychotropics.<a class="elsevierStyleCrossRef" href="#bib0335">10</a>Polypharmacy is defined as the use of multiple drugs by a patient, including over-the-counter drugs, supplements and vitamin complexes. The minimum number of drugs necessary to define this term is controversial in the literature, ranging from 3 to 6 drugs. The most widely accepted number is 5 drugs used long term.<a class="elsevierStyleCrossRef" href="#bib0340">11</a> The term has also been described as the use of more drugs than indicated, the indication of inappropriate drugs, the use of 2 or more drugs to treat the same disease and 2 or more drugs of the same therapeutic class.<a class="elsevierStyleCrossRef" href="#bib0335">10</a>The fragmentation of healthcare for polypathological patients by several specialties and different healthcare levels increases the risk of polypharmacy and the overlapping of drugs, with their potential associated complications. To ensure the quality of care for these patients, we need to ensure periodic reviews of the treatment, because there is often a high degree of discrepancy between the drug recorded in the consultation and that which the patient is actually taking.<a class="elsevierStyleCrossRefs" href="#bib0345">12,13</a> The therapeutic objectives are to reduce the number of drugs, develop regimens that ensure adherence and reduce the adverse effects.<a class="elsevierStyleCrossRefs" href="#bib0355">14,15</a>Although polypharmacy can be justified for polypathological patients by clinical reasons, polypharmacy is not associated with greater survival.<a class="elsevierStyleCrossRef" href="#bib0330">9</a> On the contrary, polypharmacy exposes patients to drug-related complications, increases the risk of drug interactions and has been associated with problems of adherence, inadequate prescription, functional impairment and hospitalization.<a class="elsevierStyleCrossRefs" href="#bib0365">16,17</a> An increase has also been reported in the risk of fall-related hip fractures due to the consumption of drugs with central nervous system effects, such as benzodiazepines, phenothiazines and antidepressants.<a class="elsevierStyleCrossRefs" href="#bib0375">18,19</a>The adverse effects associated with polypharmacy, such as weight loss, falls and functional and cognitive impairment, affect 5–35% of the elderly who live in the community and 66% of hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0345">12</a> It is estimated the adverse effects are responsible for 10% of hospital admissions in these age groups and are associated with greater mortality.<a class="elsevierStyleCrossRefs" href="#bib0345">12,20</a> Occasionally, an adverse effect can be interpreted as a complication or a new medical process, resulting in the prescription of yet another drug, a situation known as “prescription cascade” (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0390">21</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Drug interactions explain up to 4.8% of hospitalizations in those older than 65 years and almost 5% of adverse effects recorded in primary care.<a class="elsevierStyleCrossRef" href="#bib0395">22</a> A Spanish study detected a drug interaction in up to 96.5% of polypathological patients, an interaction that was relevant in 45% of the cases.<a class="elsevierStyleCrossRef" href="#bib0400">23</a>Many patients with polypharmacy have poor treatment adherence and more errors when taking drugs, which contributes to poorer disease control, with an increased risk of morbidity and mortality and greater healthcare expenditures.<a class="elsevierStyleCrossRef" href="#bib0365">16</a> Adherence is usually optimal in short treatments and worsens the longer the treatment.<a class="elsevierStyleCrossRef" href="#bib0405">24</a> The risk of experiencing medication errors increases by 21% for each additional drug the patient takes. Thus, 1 of every 3 medication errors is due to omitting a dose or reducing the dose, sometimes due to forgetfulness or loss of interest. This situation often reflects a lack of information or a difficulty in interpretation by the patient.<a class="elsevierStyleCrossRef" href="#bib0360">15</a> In this respect, it is important to involve the patient more fully in the control of the drug, in terms of the dosage and indications, and to instruct them in detecting potential interactions and adverse effects.Therapeutic complexityThe complexity of a pharmacological regimen is typically assessed by quantifying the number of drugs taken by the patient. However, this approach is incomplete. The complexity of a drug regimen covers more aspects than the simple number of drug products consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions.Poorer adherence has been demonstrated in regimens of 2 or 3 doses per day than in those with a single daily dose, with the number of forgotten doses much higher in the first group.<a class="elsevierStyleCrossRef" href="#bib0410">25</a> Likewise, it has been observed that the rate of adherence is affected not only by the number of drugs and doses but also by the instructions and additional restrictions in the administration method and by the galenic form.<a class="elsevierStyleCrossRef" href="#bib0415">26</a>The Medication Regimen Complexity Index is an instrument developed to quantify the complexity of drug treatments.<a class="elsevierStyleCrossRef" href="#bib0420">27</a> The index is divided into 3 sections: section A, which covers the galenic form and assigns a score based on the difficulty of use or dosing, scoring once for each galenic form; section B refers to the posology, assigning a higher score the more often the drug has to be taken every day and a higher score the stricter the schedule; and section C, which references and scores the additional instructions associated with the taking of the drug. The sum of the 3 categories is the final score of the index and reports the complexity of a therapeutic regimen.The complexity of a drug regimen has been associated with age, comorbidity, pain, better cognitive state and functional impairment.<a class="elsevierStyleCrossRef" href="#bib0425">28</a> Greater mortality, more hospitalizations and more drug-related problems have been found with patients with more complicated treatments.<a class="elsevierStyleCrossRefs" href="#bib0430">29,30</a> In a study with polypathological patients, the therapeutic complexity measured with the Medication Regimen Complexity Index was very high and was directly associated with the female sex and the number of polypathology categories and was inversely associated with cognitive impairment.<a class="elsevierStyleCrossRef" href="#bib0440">31</a> However, greater complexity was not associated with increased survival.Appropriate use of drugsPolypharmacy is associated with inadequate prescription, increasing the risk of adverse effects and drug interactions.<a class="elsevierStyleCrossRef" href="#bib0370">17</a> The appropriate use of drugs consists of selecting those for which there is evidence for its use in the specific indication, which are appropriate for the patient's circumstances, are well tolerated and are cost-effective. In contrast, we talk of “inappropriate prescription” or of potentially inappropriate drugs when the risk of experiencing adverse effects is greater than the clinical benefit, especially if there are safer and more effective therapeutic alternatives. This concept includes the incorrect use of drugs (dosage, duration or duplication), the use of drugs with low therapeutic value, drug interactions and the non-use of clinically indicated beneficial drugs.<a class="elsevierStyleCrossRefs" href="#bib0445">32,33</a>The determinants for the prescription of potentially inappropriate drugs are numerous and highly diverse in character. There are patient-associated, disease-associated, practitioner-associated and healthcare-associated determinants.<a class="elsevierStyleCrossRef" href="#bib0455">34</a> Polypharmacy is the most common factor involved. There is a direct relationship between the number of drugs consumed, inappropriate prescription and the omission of prescribing indicated drugs.<a class="elsevierStyleCrossRefs" href="#bib0450">33–37</a> Other factors associated with the inappropriate use of drugs in our community are the presence of polypathology, institutionalization, severe dependence and depression.<a class="elsevierStyleCrossRefs" href="#bib0465">36,38,39</a>In our community, up to 70% of elderly polymedicated patients who are admitted to internal medicine departments are exposed to at least 1 potentially inappropriate drug. There is an association between drug-related problems and the onset of new comorbidities, geriatric syndromes and functional impairment, which entail a loss of quality of life and an increase in hospital admissions, institutionalization and, probably, mortality.<a class="elsevierStyleCrossRefs" href="#bib0365">16,36</a>In recent decades, various tools have been developed to assess the appropriate use of drugs and improve the quality of prescriptions for polymedicated elderly patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Although all patients who take drugs can benefit from some type of intervention, in practice those who can benefit the most are chronically ill polymedicated patients and individuals with short life expectancies or severe impairment, for whom the treatment objectives should be reassessed. When assessing the use of drugs, 2 different methods can be followed: the implicit, based on clinical judgment; and the explicit, based on objective criteria. Both methods can complement each other and are useful for improving the quality of the prescription.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The implicit methods are highly reliable and assess each drug by considering the patient's characteristics and the prescription's indication. The most widely used implicit method is the Medication Appropriateness Index,<a class="elsevierStyleCrossRef" href="#bib0485">40</a> developed in the US and validated in elderly polypathological and polymedicated patients at all healthcare levels. The index evaluates the appropriateness of each of the patient's drugs using several items on a 3-point scale and detects situations of unnecessary drugs and polypharmacy. The index's main disadvantages are that it is subjective, requiring specific training and time for its implementation (a mean of approximately 10min per drug), and does not record adverse effects, underutilization and therapeutic noncompliance.<a class="elsevierStyleCrossRef" href="#bib0455">34</a>The explicit methods are simpler, use consensus criteria from expert groups and are the most widely used. The Beers criteria, initially published in 1991 in the US, are sponsored by the American Geriatrics Society and, in its latest 2015 version, provide detailed lists of potentially inappropriate drugs in 3 categories: 1) drugs to always avoid in the elderly, 2) drugs to avoid in the elderly with certain diseases and 3) drugs that should be used with caution in the elderly.<a class="elsevierStyleCrossRefs" href="#bib0490">41,42</a> These criteria can be applied to patients older than 65 years, regardless of whether they are living in the community or are hospitalized or institutionalized. The criteria have been used for clinical, epidemiological and economical purposes but do not consider the potential drug interactions, duplications or undermedication.<a class="elsevierStyleCrossRef" href="#bib0465">36</a> The STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to the Right Treatment) criteria were developed in 2008 in Ireland and are grouped by organ systems.<a class="elsevierStyleCrossRef" href="#bib0500">43</a> The latest version in Spanish (October 2014) provides 81 STOPP criteria that include drug interactions and medication-clinical situations, therapeutic duplications and increased risk of cognitive impairment and falls in the elderly. Moreover, the 34 START criteria identify prescription omissions, such as vaccines, which could benefit (if administered to) elderly patients.<a class="elsevierStyleCrossRef" href="#bib0505">44</a> We have insufficient evidence that the routine application of the STOPP/START criteria improves patients’ quality of life or mortality. However, a reduction has been demonstrated in the rates of inappropriate prescription, falls, delirium, hospital stays, the rate of medical consultations, admissions to emergency departments and drug costs. These criteria are therefore being used as reference criteria in the European community.<a class="elsevierStyleCrossRef" href="#bib0510">45</a>Interventions and strategies for promoting the appropriate use of drugsThe optimization of drug prescriptions, especially for elderly polypathological and polymedicated patients, is a priority for the health systems of Western countries and is raising a growing interest among the involved health practitioners. These professionals can improve the appropriate use of drugs in clinical practice through various types of intervention: appropriate and “prudent” prescription, periodic drug review and deprescription. For appropriate and prudent prescription, prevention is always the best strategy and, therefore, the appropriate use of drugs should start at the time of the prescription, incorporating in this process other key factors such as the therapeutic objectives, the final goals, the patient's vital expectations and the estimated time to the onset of the clinical benefit.<a class="elsevierStyleCrossRefs" href="#bib0450">33,34</a> Based on studies that demonstrated new problems related to widely prescribed drugs, it has recently been suggested that the requirements be broadened to obtain a safer and more judicious prescription (“prudent prescription”), such as the following: reflecting on the actual need for the drug versus the potential nondrug alternatives, prescribing strategically, maintaining a high level of surveillance on its potential adverse effects, questioning the reliability of available information, assessing the implications of its compliance and considering its long-term effects.<a class="elsevierStyleCrossRef" href="#bib0515">46</a> Secondly, the periodic, systematic and structured review of drugs taken by patients helps improve the quality of the prescription and prevent drug-related problems. Therapeutic reconciliation is a specific drug review process that consists of obtaining a complete list of the drugs that the patient previously took, comparing them with those the patient is currently taking and analyzing and resolving the discrepancies. Reconciliation is indicated for implementation during the hospital admission, during the transfer between units, during the transfer between hospitals and during the hospital discharge; in other words, whenever there is a healthcare transition. This process helps detect medication errors, although there is still no definitive evidence that it decreases patient morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0520">47–49</a> Lastly, deprescription is the process of reducing the dosage, substituting or suppressing some of the drugs taken by the patient (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This action has scientific and ethical foundations and is especially indicated for population groups such as frail polymedicated elderly patients and terminal patients. Deprescription should be performed in a systematic and orderly fashion based on an individual analysis of each clinical situation, considering the life expectancy, pattern of comorbidity and healthcare objectives. Deprescription should always depend on the patient's (or their legal representative's) acceptance. It is also important to assess and follow the consequences resulting from the discontinuation.<a class="elsevierStyleCrossRefs" href="#bib0535">50–53</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The prescription of a drug depends on 3 elements: the patient, the prescriber and the environment. Populational strategies should address these elements if they are to help in the appropriate use of drugs. These actions can be grouped into 3 blocks: educational or training, computer systems for assisting the decision-making process and the collaborative intervention of clinical pharmacists.<a class="elsevierStyleCrossRef" href="#bib0555">54</a>An example of institutional and societal involvement in our community is the Strategy for the Approach to Chronicity of the Spanish National Health System, which includes in its objectives the optimizing of drug therapies for patients with long-term treatments, with special attention to polymedicated patients.<a class="elsevierStyleCrossRef" href="#bib0560">55</a> Other examples include the Commitment to Quality of the Scientific Societies in Spain, sponsored by the Spanish Society of Internal Medicine and launched in 2013 by the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0565">56</a> which includes numerous recommendations for what not to do, based on scientific evidence. Many of these recommendations refer to potentially inappropriate drugs. Lastly, we have the blogs that are increasing drug-therapy awareness such as <a href="http://www.polimedicado.org/">http://www.polimedicado.org/</a> and <a href="http://polimedicados20.blogspot.com.es/">http://polimedicados20.blogspot.com.es/</a>.Actions for patients should be collectively directed to campaigns to raise the awareness of citizens and should be individually directed to facilitate correct information on all aspects of prescription, based on the best evidence, to enable patients’ active participation in the decision-making process, respecting their values and preferences.<a class="elsevierStyleCrossRef" href="#bib0570">57</a>The main strategies for improving prescription directed at practitioners are those that provide support resources, which include training aspects, the incorporation of specific recommendations in the clinical practice guidelines and, especially, the use of computer prescription help systems such as the shared electronic medical history, electronic prescription, personalized dispensing systems and specific alert systems in electronic prescription programs.<a class="elsevierStyleCrossRef" href="#bib0455">34</a> Moreover, it is important to encourage, the active participation in the various healthcare units of all practitioners, such as nurses, social workers and, particularly, pharmacists.Finally, we should note that our currently fragmented medication system (in which various practitioners from all healthcare settings and levels perform prescriptions for the same patient) needs a medical coordinator to ultimately decide on the prescription for the polypathological patient. In the hospital, this role should be assumed by the internist. In the community setting, the primary care physician should be ultimately responsible not only for the patient's continuity of care but also their prescription.FundingThe Aragon Research Group on Comorbidity and Polypathology receives funding from the European Regional Development Fund.Conflict of interestsThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres844947" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec839873" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres844946" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec839872" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Polypharmacy" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Therapeutic complexity" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Appropriate use of drugs" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Interventions and strategies for promoting the appropriate use of drugs" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-15" "fechaAceptado" => "2016-12-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec839873" "palabras" => array:4 [ 0 => "Polypathology" 1 => "Polypharmacy" 2 => "Therapeutic complexity" 3 => "Drug prescription" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec839872" "palabras" => array:4 [ 0 => "Pluripatología" 1 => "Polifarmacia" 2 => "Complejidad terapéutica" 3 => "Prescripción de medicamentos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalizations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los pacientes pluripatológicos suelen ser ancianos y consumen muchos fármacos. La polifarmacia afecta a un 85% de los mismos y no se asocia con mayor supervivencia. Al contrario, los expone a más efectos adversos, como pérdida de peso, caídas, deterioro funcional y cognitivo, y hospitalizaciones. La complejidad del régimen medicamentoso incluye más aspectos que el simple número de medicamentos consumidos. La forma galénica, la frecuencia de las dosis, o la forma de preparar la medicación pueden complicar la comprensión y el seguimiento de las prescripciones. Tanto la polifarmacia como la complejidad terapéutica se asocian con una peor adherencia de los pacientes. Para evitar la polifarmacia, la complejidad y mejorar la adherencia es necesario un uso adecuado de la medicación. Prescribir bien consiste en seleccionar aquellos medicamentos de los que hay claras evidencias para su empleo en la indicación, que son adecuados a las circunstancias del paciente, bien tolerados, coste-efectivos y en los que los beneficios de su uso superan a los riesgos. Para mejorar la prescripción de medicamentos es necesario llevar a cabo de forma periódica revisiones de la medicación, especialmente cuando el paciente cambia de médico y en las transiciones asistenciales. Los criterios de Beers y los STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) son herramientas eficaces para ello. La desprescripción en los pacientes pluripatológicos polimedicados atendiendo a sus circunstancias clínicas, pronóstico y preferencias puede contribuir a un uso más adecuado de la medicación." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez Aguirre N, Caudevilla Martínez A, Bellostas Muñoz L, Crespo Avellana M, Velilla Marco J, Díez-Manglano J. Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación. Rev Clin Esp. 2017;217:289–295." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 698 "Ancho" => 1658 "Tamanyo" => 49235 ] ] "descripcion" => array:1 [ "en" => "Example of prescription cascade." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 618 "Ancho" => 2312 "Tamanyo" => 61043 ] ] "descripcion" => array:1 [ "en" => "Example of a drug assessment for deprescription." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: START, Screening Tool to Alert doctors to Right Treatment; STOPP, Screening Tool of Older Person's Prescriptions." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Method \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Implicit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication Appropriateness Index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Each drug is evaluated individually by answering 10 questions with 3 potential answers, each of which receives a score Developed in the United States A Spanish version is available Takes a significant amount of time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Explicit</td><td class="td" title="table-entry " align="left" valign="top">Beers criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sets out criteria for the use of drugs in the elderly. The criteria include a list of drugs to always avoid, to avoid in certain circumstances and to use with caution. Developed in the United States A Spanish version is available Includes drugs that are not used in Europe \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STOPP–START criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Includes criteria for detecting potentially inappropriate drugs in the elderly and unprescribed drugs that are indicated and appropriate Developed in Ireland A Spanish version is available \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1427010.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Most widely used methods for assessing the appropriate use of drugs." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:57 [ 0 => array:3 [ "identificador" => "bib0290" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Instituto Nacional de Estadística Esperanza de vida. 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Symposium. Polypathology

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación

N. Gómez Aguirrea,b, A. Caudevilla Martíneza,b, L. Bellostas Muñozc, M. Crespo Avellanad, J. Velilla Marcoc,d, J. Díez-Manglanob,c,d,

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jdiez@aragon.es

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a Servicio de Medicina Interna, Hospital Ernest Lluch, Calatayud, Spain

b Grupo de Investigación en Comorbilidad y Pluripatología de Aragón, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain

c Departamento de Medicina, Dermatología y Psiquiatría, Universidad de Zaragoza, Zaragoza, Spain

d Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, Spain

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due not only to the number of chronic diseases but also to their progression and complexity&#44; with greater morbidity and progressive functional impairment&#44; which necessitates an increased consumption of healthcare resources&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a> It has been estimated that the prevalence of polypathology in the general population of Spain and&#44; in particular&#44; among those older than 65 years is 1&#46;38&#37; and 5&#37;&#44; respectively&#46; In the departments of internal medicine and geriatric medicine&#44; the rates are 31&#37; and 44&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">5&#44;6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Polypharmacy</span><p id="par0015" class="elsevierStylePara elsevierViewall">Approximately 40&#37; of adults older than 65 years take between 5 and 9 drugs daily&#44; 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as well as a variation in the response of the target organs&#44; which are more sensitive to various drug groups&#44; such as cardiovascular drugs&#44; anticoagulants and psychotropics&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Polypharmacy is defined as the use of multiple drugs by a patient&#44; including over-the-counter drugs&#44; supplements and vitamin complexes&#46; The minimum number of drugs necessary to define this term is controversial in the literature&#44; ranging from 3 to 6 drugs&#46; The most widely accepted number is 5 drugs used long term&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">11</span></a> The term has also been described as the use of more drugs than indicated&#44; the indication of inappropriate drugs&#44; the use of 2 or more drugs to treat the same disease and 2 or more drugs of the same therapeutic class&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The fragmentation of healthcare for polypathological patients by several specialties and different healthcare levels increases the risk of polypharmacy and the overlapping of drugs&#44; with their potential associated complications&#46; To ensure the quality of care for these patients&#44; we need to ensure periodic reviews of the treatment&#44; because there is often a high degree of discrepancy between the drug recorded in the consultation and that which the patient is actually taking&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">12&#44;13</span></a> The therapeutic objectives are to reduce the number of drugs&#44; develop regimens that ensure adherence and reduce the adverse effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although polypharmacy can be justified for polypathological patients by clinical reasons&#44; polypharmacy is not associated with greater survival&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">9</span></a> On the contrary&#44; polypharmacy exposes patients to drug-related complications&#44; 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of hospital admissions in these age groups and are associated with greater mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">12&#44;20</span></a> Occasionally&#44; an adverse effect can be interpreted as a complication or a new medical process&#44; resulting in the prescription of yet another drug&#44; a situation known as &#8220;prescription cascade&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Drug interactions explain up to 4&#46;8&#37; of hospitalizations in those older than 65 years and almost 5&#37; of adverse effects recorded in primary care&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">22</span></a> A Spanish study detected a drug interaction in up to 96&#46;5&#37; of polypathological patients&#44; an interaction that was relevant in 45&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Many patients with polypharmacy have poor treatment adherence and more errors when taking drugs&#44; which contributes to poorer disease control&#44; with an increased risk of morbidity and mortality and greater healthcare expenditures&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">16</span></a> Adherence is usually optimal in short treatments and worsens the longer the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">24</span></a> The risk of experiencing medication errors increases by 21&#37; for each additional drug the patient takes&#46; Thus&#44; 1 of every 3 medication errors is due to omitting a dose or reducing the dose&#44; sometimes due to forgetfulness or loss of interest&#46; This situation often reflects a lack of information or a difficulty in interpretation by the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> In this respect&#44; it is important to involve the patient more fully in the control of the drug&#44; in terms of the dosage and indications&#44; and to instruct them in detecting potential interactions and adverse effects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Therapeutic complexity</span><p id="par0050" class="elsevierStylePara elsevierViewall">The complexity of a pharmacological regimen is typically assessed by quantifying the number of drugs taken by the patient&#46; However&#44; this approach is incomplete&#46; The complexity of a drug regimen covers more aspects than the simple number of drug products consumed&#46; The galenic form&#44; the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Poorer adherence has been demonstrated in regimens of 2 or 3 doses per day than in those with a single daily dose&#44; with the number of forgotten doses much higher in the first group&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">25</span></a> Likewise&#44; it has been observed that the rate of adherence is affected not only by the number of drugs and doses but also by the instructions and additional restrictions in the administration method and by the galenic form&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">26</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The Medication Regimen Complexity Index is an instrument developed to quantify the complexity of drug treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">27</span></a> The index is divided into 3 sections&#58; section A&#44; which covers the galenic form and assigns a score based on the difficulty of use or dosing&#44; scoring once for each galenic form&#59; section B refers to the posology&#44; assigning a higher score the more often the drug has to be taken every day and a higher score the stricter the schedule&#59; and section C&#44; which references and scores the additional instructions associated with the taking of the drug&#46; The sum of the 3 categories is the final score of the index and reports the complexity of a therapeutic regimen&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The complexity of a drug regimen has been associated with age&#44; comorbidity&#44; pain&#44; better cognitive state and functional impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">28</span></a> Greater mortality&#44; more hospitalizations and more drug-related problems have been found with patients with more complicated treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">29&#44;30</span></a> In a study with polypathological patients&#44; the therapeutic complexity measured with the Medication Regimen Complexity Index was very high and was directly associated with the female sex and the number of polypathology categories and was inversely associated with cognitive impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">31</span></a> However&#44; greater complexity was not associated with increased survival&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Appropriate use of drugs</span><p id="par0070" class="elsevierStylePara elsevierViewall">Polypharmacy is associated with inadequate prescription&#44; increasing the risk of adverse effects and drug interactions&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> The appropriate use of drugs consists of selecting those for which there is evidence for its use in the specific indication&#44; which are appropriate for the patient&#39;s circumstances&#44; are well tolerated and are cost-effective&#46; In contrast&#44; we talk of &#8220;inappropriate prescription&#8221; or of potentially inappropriate drugs when the risk of experiencing adverse effects is greater than the clinical benefit&#44; especially if there are safer and more effective therapeutic alternatives&#46; This concept includes the incorrect use of drugs &#40;dosage&#44; duration or duplication&#41;&#44; the use of drugs with low therapeutic value&#44; drug interactions and the non-use of clinically indicated beneficial drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">32&#44;33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The determinants for the prescription of potentially inappropriate drugs are numerous and highly diverse in character&#46; There are patient-associated&#44; disease-associated&#44; practitioner-associated and healthcare-associated determinants&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">34</span></a> Polypharmacy is the most common factor involved&#46; There is a direct relationship between the number of drugs consumed&#44; inappropriate prescription and the omission of prescribing indicated drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">33&#8211;37</span></a> Other factors associated with the inappropriate use of drugs in our community are the presence of polypathology&#44; institutionalization&#44; severe dependence and depression&#46;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">36&#44;38&#44;39</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In our community&#44; up to 70&#37; of elderly polymedicated patients who are admitted to internal medicine departments are exposed to at least 1 potentially inappropriate drug&#46; There is an association between drug-related problems and the onset of new comorbidities&#44; geriatric syndromes and functional impairment&#44; which entail a loss of quality of life and an increase in hospital admissions&#44; institutionalization and&#44; probably&#44; mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">16&#44;36</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In recent decades&#44; various tools have been developed to assess the appropriate use of drugs and improve the quality of prescriptions for polymedicated elderly patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Although all patients who take drugs can benefit from some type of intervention&#44; in practice those who can benefit the most are chronically ill polymedicated patients and individuals with short life expectancies or severe impairment&#44; for whom the treatment objectives should be reassessed&#46; When assessing the use of drugs&#44; 2 different methods can be followed&#58; the implicit&#44; based on clinical judgment&#59; and the explicit&#44; based on objective criteria&#46; Both methods can complement each other and are useful for improving the quality of the prescription&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The implicit methods are highly reliable and assess each drug by considering the patient&#39;s characteristics and the prescription&#39;s indication&#46; The most widely used implicit method is the Medication Appropriateness Index&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a> developed in the US and validated in elderly polypathological and polymedicated patients at all healthcare levels&#46; The index evaluates the appropriateness of each of the patient&#39;s drugs using several items on a 3-point scale and detects situations of unnecessary drugs and polypharmacy&#46; The index&#39;s main disadvantages are that it is subjective&#44; requiring specific training and time for its implementation &#40;a mean of approximately 10<span class="elsevierStyleHsp" style=""></span>min per drug&#41;&#44; and does not record adverse effects&#44; underutilization and therapeutic noncompliance&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">34</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The explicit methods are simpler&#44; use consensus criteria from expert groups and are the most widely used&#46; The Beers criteria&#44; initially published in 1991 in the US&#44; are sponsored by the American Geriatrics Society and&#44; in its latest 2015 version&#44; provide detailed lists of potentially inappropriate drugs in 3 categories&#58; 1&#41; drugs to always avoid in the elderly&#44; 2&#41; drugs to avoid in the elderly with certain diseases and 3&#41; drugs that should be used with caution in the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">41&#44;42</span></a> These criteria can be applied to patients older than 65 years&#44; regardless of whether they are living in the community or are hospitalized or institutionalized&#46; The criteria have been used for clinical&#44; epidemiological and economical purposes but do not consider the potential drug interactions&#44; duplications or undermedication&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">36</span></a> The STOPP &#40;Screening Tool of Older Person&#39;s potentially inappropriate Prescriptions&#41; and START &#40;Screening Tool to Alert Doctors to the Right Treatment&#41; criteria were developed in 2008 in Ireland and are grouped by organ systems&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">43</span></a> The latest version in Spanish &#40;October 2014&#41; provides 81 STOPP criteria that include drug interactions and medication-clinical situations&#44; therapeutic duplications and increased risk of cognitive impairment and falls in the elderly&#46; Moreover&#44; the 34 START criteria identify prescription omissions&#44; such as vaccines&#44; which could benefit &#40;if administered to&#41; elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">44</span></a> We have insufficient evidence that the routine application of the STOPP&#47;START criteria improves patients&#8217; quality of life or mortality&#46; However&#44; a reduction has been demonstrated in the rates of inappropriate prescription&#44; falls&#44; delirium&#44; hospital stays&#44; the rate of medical consultations&#44; admissions to emergency departments and drug costs&#46; These criteria are therefore being used as reference criteria in the European community&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Interventions and strategies for promoting the appropriate use of drugs</span><p id="par0100" class="elsevierStylePara elsevierViewall">The optimization of drug prescriptions&#44; especially for elderly polypathological and polymedicated patients&#44; is a priority for the health systems of Western countries and is raising a growing interest among the involved health practitioners&#46; These professionals can improve the appropriate use of drugs in clinical practice through various types of intervention&#58; appropriate and &#8220;prudent&#8221; prescription&#44; periodic drug review and deprescription&#46; For appropriate and prudent prescription&#44; prevention is always the best strategy and&#44; therefore&#44; the appropriate use of drugs should start at the time of the prescription&#44; incorporating in this process other key factors such as the therapeutic objectives&#44; the final goals&#44; the patient&#39;s vital expectations and the estimated time to the onset of the clinical benefit&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">33&#44;34</span></a> Based on studies that demonstrated new problems related to widely prescribed drugs&#44; it has recently been suggested that the requirements be broadened to obtain a safer and more judicious prescription &#40;&#8220;prudent prescription&#8221;&#41;&#44; such as the following&#58; reflecting on the actual need for the drug versus the potential nondrug alternatives&#44; prescribing strategically&#44; maintaining a high level of surveillance on its potential adverse effects&#44; questioning the reliability of available information&#44; assessing the implications of its compliance and considering its long-term effects&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">46</span></a> Secondly&#44; the periodic&#44; systematic and structured review of drugs taken by patients helps improve the quality of the prescription and prevent drug-related problems&#46; Therapeutic reconciliation is a specific drug review process that consists of obtaining a complete list of the drugs that the patient previously took&#44; comparing them with those the patient is currently taking and analyzing and resolving the discrepancies&#46; Reconciliation is indicated for implementation during the hospital admission&#44; during the transfer between units&#44; during the transfer between hospitals and during the hospital discharge&#59; in other words&#44; whenever there is a healthcare transition&#46; This process helps detect medication errors&#44; although there is still no definitive evidence that it decreases patient morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">47&#8211;49</span></a> Lastly&#44; deprescription is the process of reducing the dosage&#44; substituting or suppressing some of the drugs taken by the patient &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; This action has scientific and ethical foundations and is especially indicated for population groups such as frail polymedicated elderly patients and terminal patients&#46; Deprescription should be performed in a systematic and orderly fashion based on an individual analysis of each clinical situation&#44; considering the life expectancy&#44; pattern of comorbidity and healthcare objectives&#46; Deprescription should always depend on the patient&#39;s &#40;or their legal representative&#39;s&#41; acceptance&#46; It is also important to assess and follow the consequences resulting from the discontinuation&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">50&#8211;53</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The prescription of a drug depends on 3 elements&#58; the patient&#44; the prescriber and the environment&#46; Populational strategies should address these elements if they are to help in the appropriate use of drugs&#46; These actions can be grouped into 3 blocks&#58; educational or training&#44; computer systems for assisting the decision-making process and the collaborative intervention of clinical pharmacists&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">54</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">An example of institutional and societal involvement in our community is the <span class="elsevierStyleItalic">Strategy for the Approach to Chronicity of the Spanish National Health System</span>&#44; which includes in its objectives the optimizing of drug therapies for patients with long-term treatments&#44; with special attention to polymedicated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">55</span></a> Other examples include the <span class="elsevierStyleItalic">Commitment to Quality of the Scientific Societies in Spain</span>&#44; sponsored by the Spanish Society of Internal Medicine and launched in 2013 by the Ministry of Health&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">56</span></a> which includes numerous recommendations for what not to do&#44; based on scientific evidence&#46; Many of these recommendations refer to potentially inappropriate drugs&#46; Lastly&#44; we have the blogs that are increasing drug-therapy awareness such as <a href="http://www.polimedicado.org/">http&#58;&#47;&#47;www&#46;polimedicado&#46;org&#47;</a> and <a href="http://polimedicados20.blogspot.com.es/">http&#58;&#47;&#47;polimedicados20&#46;blogspot&#46;com&#46;es&#47;</a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Actions for patients should be collectively directed to campaigns to raise the awareness of citizens and should be individually directed to facilitate correct information on all aspects of prescription&#44; based on the best evidence&#44; to enable patients&#8217; active participation in the decision-making process&#44; respecting their values and preferences&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">57</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The main strategies for improving prescription directed at practitioners are those that provide support resources&#44; which include training aspects&#44; the incorporation of specific recommendations in the clinical practice guidelines and&#44; especially&#44; the use of computer prescription help systems such as the shared electronic medical history&#44; electronic prescription&#44; personalized dispensing systems and specific alert systems in electronic prescription programs&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">34</span></a> Moreover&#44; it is important to encourage&#44; the active participation in the various healthcare units of all practitioners&#44; such as nurses&#44; social workers and&#44; particularly&#44; pharmacists&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Finally&#44; we should note that our currently fragmented medication system &#40;in which various practitioners from all healthcare settings and levels perform prescriptions for the same patient&#41; needs a medical coordinator to ultimately decide on the prescription for the polypathological patient&#46; In the hospital&#44; this role should be assumed by the internist&#46; In the community setting&#44; the primary care physician should be ultimately responsible not only for the patient&#39;s continuity of care but also their prescription&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">The Aragon Research Group on Comorbidity and Polypathology receives funding from the European Regional Development Fund&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polypathological patients are usually elderly and take numerous drugs&#46; Polypharmacy affects 85&#37; of these individuals and is not associated with greater survival&#46; On the contrary&#44; polypharmacy exposes these individuals to more adverse effects&#44; such as weight loss&#44; falls&#44; functional and cognitive impairment and hospitalizations&#46; The complexity of a drug regimen covers more aspects than the simple number of drugs consumed&#46; The galenic form&#44; the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions&#46; Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients&#46; To prevent polypharmacy&#44; reduce complexity and improve adherence&#44; the appropriate use of drugs is needed&#46; Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication&#44; which are appropriate for the patient&#39;s circumstances&#44; are well tolerated and cost-effective and whose benefits outweigh the risks&#46; To improve the drug prescription&#44; periodic reviews of the drugs need to be conducted&#44; especially when the patient changes doctor and during healthcare transitions&#46; The Beers and STOPP&#47;START &#40;Screening Tool of Older Person&#39;s potentially inappropriate Prescriptions&#47;Screening Tool to Alert doctors to the Right Treatment&#41; criteria are effective tools for this improvement&#46; Deprescription for polymedicated polypathological patients that considers their clinical circumstances&#44; prognosis and preferences can contribute to a more appropriate use of drugs&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los pacientes pluripatol&#243;gicos suelen ser ancianos y consumen muchos f&#225;rmacos&#46; La polifarmacia afecta a un 85&#37; de los mismos y no se asocia con mayor supervivencia&#46; Al contrario&#44; los expone a m&#225;s efectos adversos&#44; como p&#233;rdida de peso&#44; ca&#237;das&#44; deterioro funcional y cognitivo&#44; y hospitalizaciones&#46; La complejidad del r&#233;gimen medicamentoso incluye m&#225;s aspectos que el simple n&#250;mero de medicamentos consumidos&#46; La forma gal&#233;nica&#44; la frecuencia de las dosis&#44; o la forma de preparar la medicaci&#243;n pueden complicar la comprensi&#243;n y el seguimiento de las prescripciones&#46; Tanto la polifarmacia como la complejidad terap&#233;utica se asocian con una peor adherencia de los pacientes&#46; Para evitar la polifarmacia&#44; la complejidad y mejorar la adherencia es necesario un uso adecuado de la medicaci&#243;n&#46; Prescribir bien consiste en seleccionar aquellos medicamentos de los que hay claras evidencias para su empleo en la indicaci&#243;n&#44; que son adecuados a las circunstancias del paciente&#44; bien tolerados&#44; coste-efectivos y en los que los beneficios de su uso superan a los riesgos&#46; Para mejorar la prescripci&#243;n de medicamentos es necesario llevar a cabo de forma peri&#243;dica revisiones de la medicaci&#243;n&#44; especialmente cuando el paciente cambia de m&#233;dico y en las transiciones asistenciales&#46; Los criterios de Beers y los STOPP&#47;START &#40;<span class="elsevierStyleItalic">Screening Tool of Older Person&#39;s potentially inappropriate Prescriptions&#47;Screening Tool to Alert doctors to the Right Treatment</span>&#41; son herramientas eficaces para ello&#46; La desprescripci&#243;n en los pacientes pluripatol&#243;gicos polimedicados atendiendo a sus circunstancias cl&#237;nicas&#44; pron&#243;stico y preferencias puede contribuir a un uso m&#225;s adecuado de la medicaci&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Aguirre N&#44; Caudevilla Mart&#237;nez A&#44; Bellostas Mu&#241;oz L&#44; Crespo Avellana M&#44; Velilla Marco J&#44; D&#237;ez-Manglano J&#46; Pluripatolog&#237;a&#44; polifarmacia&#44; complejidad terap&#233;utica y uso adecuado de la medicaci&#243;n&#46; Rev Clin Esp&#46; 2017&#59;217&#58;289&#8211;295&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Implicit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Medication Appropriateness Index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Each drug is evaluated individually by answering 10 questions with 3 potential answers&#44; each of which receives a score<br>Developed in the United States<br>A Spanish version is available<br>Takes a significant amount of time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Explicit</td><td class="td" title="table-entry  " align="left" valign="top">Beers criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sets out criteria for the use of drugs in the elderly&#46; The criteria include a list of drugs to always avoid&#44; to avoid in certain circumstances and to use with caution&#46;<br>Developed in the United States<br>A Spanish version is available<br>Includes drugs that are not used in Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STOPP&#8211;START criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Includes criteria for detecting potentially inappropriate drugs in the elderly and unprescribed drugs that are indicated and appropriate<br>Developed in Ireland<br>A Spanish version is available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Most widely used methods for assessing the appropriate use of drugs&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2016.12.008

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