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Original Investigation |

Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011

Dima M. Qato, PharmD, MPH, PhD1,2; Jocelyn Wilder, MPH1,2; L. Philip Schumm, MA3; Victoria Gillet, BS4; G. Caleb Alexander, MD, MS5,6
[+] Author Affiliations
1Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago
2Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health
3Department of Public Health Sciences, University of Chicago, Chicago, Illinois
4currently a medical student at the School of Medicine, University of Chicago, Chicago, Illinois
5Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
6Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2016;176(4):473-482. doi:10.1001/jamainternmed.2015.8581.
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Importance  Prescription and over-the-counter medicines and dietary supplements are commonly used, alone and together, among older adults. However, the effect of recent regulatory and market forces on these patterns is not known.

Objectives  To characterize changes in the prevalence of medication use, including concurrent use of prescription and over-the-counter medications and dietary supplements, and to quantify the frequency and types of potential major drug-drug interactions.

Design, Setting, and Participants  Descriptive analyses of a longitudinal, nationally representative sample of community-dwelling older adults 62 to 85 years old. In-home interviews with direct medication inspection were conducted in 2005-2006 and again in 2010-2011. The dates of the analysis were March to November 2015. We defined medication use as the use of at least 1 prescription or over-the-counter medication or dietary supplement at least daily or weekly and defined concurrent use as the regular use of at least 2 medications. We used Micromedex to identify potential major drug-drug interactions.

Main Outcomes and Measures  Population estimates of the prevalence of medication use (in aggregate and by therapeutic class), concurrent use, and major drug-drug interactions.

Results  The study cohort comprised 2351 participants in 2005-2006 and 2206 in 2010-2011. Their mean age was 70.9 years in 2005-2006 and 71.4 years in 2010-2011. Fifty-three percent of participants were female in 2005-2006, and 51.6% were female in 2010-2011. The use of at least 1 prescription medication slightly increased from 84.1% in 2005-2006 to 87.7% in 2010-2011 (P = .003). Concurrent use of at least 5 prescription medications increased from 30.6% to 35.8% (P = .02). While the use of over-the-counter medications declined from 44.4% to 37.9%, the use of dietary supplements increased from 51.8% to 63.7% (P < .001 for both). There were clinically significant increases in the use of statins (33.8% to 46.2%), antiplatelets (32.8% to 43.0%), and omega-3 fish oils (4.7% to 18.6%) (P < .05 for all). In 2010-2011, approximately 15.1% of older adults were at risk for a potential major drug-drug interaction compared with an estimated 8.4% in 2005-2006 (P < .001). Most of these interacting regimens involved medications and dietary supplements increasingly used in 2010-2011.

Conclusions and Relevance  In this study, the use of prescription medications and dietary supplements, and concurrent use of interacting medications, has increased since 2005, with 15% of older adults potentially at risk for a major drug-drug interaction. Improving safety with the use of multiple medications has the potential to reduce preventable adverse drug events associated with medications commonly used among older adults.

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Figure.
Weighted Prevalence Estimates of Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States

Error bars indicate 95% CIs. P values are based on a Wald test of the predictive margin calculated by averaging the age-specific differences in predicted prevalence (on the logit scale) between waves over the observed ages in the sample and by using a design-based estimate of variance.

aP < .05.

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Empower Pharmacists to Prevent Polypharmacy Harms
Posted on May 13, 2016
Lucas G. Hill, PharmD; Holli L. Temple, PharmD
The University of Texas at Austin College of Pharmacy
Conflict of Interest: None Declared
In the April 2016 issue of JAMA Internal Medicine, Qato et al presented striking data regarding the state of polypharmacy in older adults.1 From 2005 to 2011, the number of older adults taking at least five medications or supplements increased substantially and the proportion at risk for a major drug-drug interaction nearly doubled. In response, Steinman offered a thought-provoking commentary from the perspective of a seasoned geriatrician.2 While both articles recommended policy changes, the pivotal role of pharmacists was overlooked. As the most accessible healthcare professional, pharmacists have the unique skillset and perspective necessary to prevent polypharmacy harms.3

A 2011 report to the United States Surgeon General from the Office of the Chief Pharmacist advocated for enhanced utilization of pharmacists as advanced practice providers. This recommendation was supported by decades of experience with federal pharmacists providing clinical services. Policy, legislation, and compensation were noted as barriers to implementation in the private sector.3 In 2015, the Cardiovascular Team and Prevention Councils of the American College of Cardiology authored a similar call to action. They delineated the role of clinical pharmacists in providing team-based care for patients with cardiovascular disease but cited the same barriers to implementation as the 2011 report.4 Despite these public and private sector appeals, patient access to clinical services provided by pharmacists remains limited.

A 2010 meta-analysis of randomized controlled trials demonstrated the profound impact of engaging pharmacists as team members on therapeutic, humanistic, and safety outcomes. Pharmacist interventions ranged from patient education regarding drugs and diseases to comprehensive medication management with prescriptive authority. These services generally targeted chronic medical problems that lead to polypharmacy, including hypertension, diabetes, and lung disease. Significant improvements in hemoglobinA1c, low density lipoprotein, blood pressure, medication adherence, patient knowledge, and quality of life were associated with pharmacist intervention. Most impressive was the decreased risk for adverse drug events (OR = 0.53, 95% CI = 0.33-0.83, p=0.01).5

With polypharmacy and risk for drug interactions on the rise, pharmacists must become fully engaged members of healthcare teams. National pharmacy organizations are pushing for legislation to allow pharmacists to bill for clinical services under Medicare Part B in team-based models of care. Support from physician organizations will be key to the success of these efforts. Vocalizing your support will allow pharmacists’ unique skills to be better leveraged in the prevention of polypharmacy harms.

1. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-82.
2. Steinman MA. Polypharmacy–time to get beyond numbers. JAMA Intern Med. 2016;176(4):482-3.
3. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
4. Dunn SP, Birtcher KK, Beavers CJ, et al. The role of the clinical pharmacist in the care of patients with cardiovascular disease. J Am Coll Cardiol. 2015;66(19):2129-39.
5. Chisholm-Burns MA, Lee JK, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analysis. Med Care. 2010;48:923-33.
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