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1. 1
Polypharmacy Among Elderly Diabetic
Patients in Home Health Care
Eunjeong Kang, MPH
Ibrahim Awad Ibrahim, MD, PhD. Assistant Professor
Kathryn Dansky, PhD., Associate Professor
Department of Health Policy & Administration,
College of Health and Human Development
The Pennsylvania State University
116 Henderson Bldg., University Park, PA 16802
TEL (814)865-1472 FAX (814)863-0846
E- mail: iai2@psu.edu
FOR MORE INFO...
Contact Mrs. Eunjeong Kang e-mail: exk192@psu.edu

2. 2
Objectives
 To assess the possibility of occurrence of
polypharmacy in a home health diabetes
elderly population.
 To identify combinations of drugs that can
possibly result in serious health
consequences.
 To examine the correlates of
polypharmacy in this population.

3. 3
Introduction
 Polypharmacy has been defined as:
– Regimens with unnecessary drugs
– Use of 2 more drugs for >240 days
– Simultaneous use of 5 or more drugs
 Why is it important?
– Drug-drug Interaction (DDI)
– Drug Food Interaction (DFI)
– Adverse Drug Events (ADE)
 Who is at risk?
– Patients with multiple diseases, complicated
prolonged diseases, multiple providers

4. 4
Drug-Drug Interaction
 Possible mechanisms of action of
DDI:
– Synergy
– Antagonism
– Adverse effects

5. 5
Methodology
 Subjects
 Data
 Identification of possible interaction
 Inclusion criteria
 Statistical analysis

6. 6
Subjects
 Elderly diabetic patients who were
discharged from hospital to home
health care provided by a large Mid-
Atlantic home health agency.
 These patients received skilled
nursing visits at home through either
telehomecare or through traditional
home visits.

7. 7
Data
 Medication sheets for these patients
were examined for possible drug-
drug interaction
 We analyzed medication sheets for
139 patients
 There were another 37 patients for
whom medication sheets could not
be obtained.

8. 8
Data collection
 Data collection spanned 18 month
period from 3/1998 through 9/1999
J F M A M J J A S O N D J F M A M J J A S O N D
1998 1999

9. 9
Drugs considered
 Prescription systemic drugs for
diabetes and other conditions
– Different types of insulin were considered as
one drug and collapsed into one category.
 Drugs not considered
– Optic and topical drugs.
– Over-the-counter medications.

10. 10
Drug checker
 We used an automated
DrugChecker available through
Dr.Koop’s Website: www.drkoop.com
 This drug checker is designed and
compiled by Multum Information
Service, Inc.® who used medical
literature references to support the
results of possible DDI and enhance
their reliability.

11. 11
Statistical Analysis
 Descriptive statistics
 t-test comparison (comparing
participants and non-participants)
 Pearson correlation for correlates of
polypharmacy

12. 12
Results
 Sample demographic description
 Prevalence of comorbidities
 Polypharmacy rates
 Sample drug-drug interactions
 Correlates of drug-drug interactions

13. 13
Table 1. Comparisons between the study
sample and the non-participants
* p<.05 ** p<.01
Study Sample
(N=139)
Excluded Sample
(N=37)
Age** 73.6 (SD=9.50) 78.0 (SD=6.76)
Male
Female
39 (28.7%)
97 (71.3%)
9 (20.0%)
27 (80.0%)
Black/non-white
White, non-hispanic
90 (67.2%)
44 (32.8%)
24 (75.0%)
6 (25.0%)
Years of Education 10.5 SD=2.8) 10.9 (SD=3.4)
Number of Co-morbidities 3.0 3.1
Diabetes Severity* 2.4 2.0

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Table 2. Prevalence of diabetes-related
complications
Complication Frequency (%)
Ischemic heart disease 34 (25.8)
Cerebrovascular 25 (18.9)
Congestive heart failure 24 (18.2)
Infectious 21 (15.9)
Renal 11 (8.3)
Neurological 6 (4.5)
Peripheral vascular 5 (3.8)
Amputations 5 (3.8)
Retinal 1 (0.8)

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Prevalence of other comorbid
conditions
• The most common comorbid conditions were
hypertension, rheumatic arthritis, and neurological
disorders 40.5%, 9.2%, and 6.4%, respectively.
• Other conditions were urological conditions,
wounds, respiratory diseases, and gastrointestinal
conditions.

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Comorbid complications and
conditions
 137 patients (98.6%) had at least one diabetic
complication or other co-morbidities.
 The most common diabetes-related
complications were ischemic heart disease
(25.8%), cerebrovascular disease (18.9%), and
congestive heart failure (18.2%).
 hypertension was most prevalent comorbid
condition (40.5%) followed by rheumatoid
arthritis was (9.2%).

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Polypharmacy
 We found that 88% of the patients
reviewed were at risk for polypharmacy
(5+ drugs simultaneously)
 The average number of medications taken
by these diabetic patients was 8.9 (SD=3.4)
[range 2 – 19]
 Patients took 6.3 oral drugs per episode of
care (mean 48 days, SD 14 days).

18. 18
Possible Drug-Drug Interactions
 38.8% of patients at risk for least one severe DDI.
 92.8% of patients at risk for at least one moderate DDI
 70.5% of patients at risk for at least one mild DDI.
 Mild:clinically insignificant effects and neutral or even
favorable effects have been reported for these interactions.
 Moderate: serious, but non-lethal and non-life-threatening
injuries have been reported
 Severe: death and/or life-threatening injuries have been
reported.

19. 19
Table 4. Examples of Potential Severe Drug-Drug
Interactions and their Frequency in our study sample
Example Frequency (%)
Diuretic-NSAID furosemide-aspirin, 37 (39.4)
Diuretic-
Antihypertentive
Furosemide-digoxin, furosemide-
amiodarone, bumetanide-digoxin
18 (19.1)
Anticoagulant-
NSAID
Coumadin-aspirin 14 (14.9)
Cardiac agent-
Antihypertensive
Verapamil-digoxin, atenolol-verapamil 8 (8.5)
CNS agent-CNS
agent
Fluoxetine-imipramin, haloperidol-
sinemet, elavil-fluoxetine
3 (3.2)
CNS agent-Analgesic Carbamazepine-tramadol, norpramin-
tramadol
2 (2.1)
Other Captopril-allopurinol, vasotec-allopurinol,
coumadin-tamoxifen, coumadin-ampicillin,
coumadin-synthroid, coumadin-amiodarone,
coumadin-cyclosporin, cyclosporin-pravachol
12 (12.8)
Total 94 (100.0)

20. 20
Table 5. Pearson correlation coefficients
of factors associated with polypharmacy
Coefficients p-value
Age* -0.187 0.014
Gender (female)* 0.163 0.030
Race (white)* 0.173 0.022
Co-morbidity 0.007 0.936
Diabetes Co-morbidity -0.084 0.308
Diabetes Severity* 0.208 0.013
* p<0.05

21. 21
Service implications
 Need for
– Medication monitoring
– Prescription coordination
– Case management
• Community pharmacy
• Patients
• Home nurse

22. 22
Policy implications
 What can we do to prevent or reduce
the occurrence of polypharmacy and
its possible ill effects?

23. 23
Future research
 Did it really happen?
 To what extent?
 How can we prevent or reduce it?

24. 24
Thank you