الفهرس 
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Abstract
Ageing is associated, at a biological level, with the gradual accumulation of a wide variety of molecular and cellular damage. Over time, this damage leads to a gradual decrease in physiological reserves, an increased risk of many diseases, and a general decline in the capacity of the individual.
The exact mechanisms involved remain largely unknown and several changes that occur on the cellular level are thought to be responsible, including damage to mitochondrial and nuclear DNA due to oxidative stress, increased lipid peroxidation, altered gene expression and upregulation of cell apoptosis.
Population ageing is the outcome of demographic transition. Reductions in infant, child and maternal mortality and decreases in fertility rates during the post-half of the last century have resulted in numerical growth of older populations around the world.
Polypharmacy is defined simply as the use of multiple medications by a patient (concurrent use of many drugs). The WHO defines polypharmacy as “the administration of many drugs at the same time or the administration of an excessive number of drugs”.
The issue of polypharmacy is of particular concern in older adults as individuals are living longer and suffering from multiple chronic illnesses, many are taking numerous medications.
The prevalence of polypharmacy is multifactorial with risk factors spanning from the patient level; (increasing longevity, coexistence of chronic medical conditions, availability of over‐the‐ counter drugs, use of more than one pharmacy) to the physician level (medical guidelines, prescribing practices) to systems‐level issues (multiple prescribing providers, electronic medical records, transitions of care). Medical practitioners adherence to clinical guidelines for multiple concomitant chronic conditions may inadvertently lead to adverse outcomes for patients due to complications from multiple medications for multiple medical conditions as the treatment beneficial for one disease may be harmful for another .The benefit of a medication could be more difficult to achieve in the presence of one or more comorbidities due to changes in pharmacokinetics drug interactions, the patients’ function (e.g., difficulty with adherence due to dementia), or life expectancy (e.g., end-stage heart disease or malignancy).
Presence of comorbidities in elderly people require use of multiple medications which increase the irrational prescription and use of inappropriate medications which causes large economic burden. The WHO estimated that mismanaged polypharmacy contributed to 4% of the world’s total avoidable costs due to suboptimal medicine use. A total of 18 billion dollars, 0.3% of the global total health expenditure could be avoided by appropriate polypharmacy management.
This study was designed to Implement tools for assessment of inappropriate medication use and polypharmacy, assess the effect of polypharmacy and potentially inappropriate medications on the comprehensive geriatric assessment and to evaluate the economic reflections of rational medication changes.
This study included 274 patients attending University Hospital Geriatrics Clinic, Alexandria, Egypt. Full history was obtained with emphasis on drugs used and history of chronic diseases. comorbidity status of the patients had been evaluated using the charlson Comorbidity Index (CCI).
Full physical examination was done followed by comprehensive geriatric assessment including The Mini-Mental State Examination (MMSE), The Montreal Cognitive Assessment (MoCA), Yesavage Geriatric Depression Scale (YGDS), Barthel Index for Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale, Up & Go scale, Tinetti Performance Oriented Mobility Assessment (POMA) for balance (POMA-B) and gait (POMA-G) and the Mini-Nutritional Assessment (MNA) tool.
Laboratory tests were performed to all the subjects including: complete blood count (CBC), urea, creatinine, SGOT, SGPT, total cholesterol level, thyroid stimulating hormone (TSH), HbA1c, vitamin B12, folic acid, 25 OH vitamin D.
The drugs, drug groups, and number of drugs that the patients use had been recorded. Using five or more drugs is considered polypharmacy and using ten or more drugs is considered hyperpolypharmacy. patients were divided into 3 groups: group I: Non-polypharmacy group, group II: Polypharmacy group, group III: Hyperpolypharmacy group.
Implementation of strategies to reduce polypharmacy and inappropriate drug use in polypharmacy and hyperpolypharmacy groups was identified by: Medication Appropriateness Index (MAI), Beers criteria and STOPP/START criteria.
Based on these criteria, PIMs had been discontinued and PPOs had been determined thus, treatments of the patients had been rearranged. All the studied subjects were followed and reassessed after six months. CGA and the laboratory investigations performed at the beginning of the study were repeated and cost analysis was done to estimate the cost reduction.
The results showed that at the beginning of the study the mean age was higher in hyperpolypharmacy group compared to the other two groups and there was statistically significant positive correlation between age and number of drugs used while there was no relation between polypharmacy and sex or educational level.
The mean hemoglobin level and platelet number were lower in polypharmacy and hyperpolypharmacy groups compared to non polypharmacy group and there was statistically significant negative correlation of both parameters with number of drugs used while there was no relation between polypharmacy and WBCs count.
The mean urea, creatinine, SGOT, SGPT and HbA1c levels were significantly higher in polypharmacy and hyperpolypharmacy groups compared to non polypharmacy group and there was statistically significant positive correlation of all these parameters with the number of drugs used.
The mean level of total cholesterol, TSH and VITD didn’t show any significant difference between the studied groups and none of them had a significant correlation with polypharmacy.
The mean VITB 12 and folic acid were higher in hyperpolypharmacy group compared to non polypharmacy group but there was no statistically significant correlation between them and the number of drugs used.
The mean CCI and UP & Go scores were significantly higher in polypharmacy and hyperpolypharmacy groups compared to non polypharmacy group and there was statistically significant positive correlation of both of them with the number of drugs used.
The mean MNA and total POMA scores were significantly lower in polypharmacy and hyperpolypharmacy groups compared to non polypharmacy group and there was statistically significant negative correlation of both of them with the number of drugs used.
The mean MMSE, MoCA and Barthel Index for ADL scores were significantly lower in hyperpolypharmacy groups compared to non polypharmacy group and there was statistically significant negative correlation of both of them with the number of drugs used.
The mean scores of YGDS and IADL didn’t show any significant difference between the studied groups and none of them had a significant correlation with polypharmacy.
Reassessment after six months of implementation of strategies of reduce polypharmacy in both polypharmacy and hyperpolypharmacy groups showed that there was significant improvement in multiple parameters including hemoglobin, platelets, urea, creatinine, SGOT, SGPT, HbA1c and total cholesterol levels. Also, there was significant improvement in mean CCI, MMSE, MoCA, YGDS, Barthel Index for ADL, Lawton-Brody IADL Scale, Up & Go scale, POMA and MNA scores. Moreover there was a considerable cost reduction in both polypharmacy and hyperpolypharmacy groups which was significantly higher in hyperpolypharmacy group.