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Original Articles • Rev. Saúde Pública 50 (suppl 2) • 12 Dec 2016 • https://doi.org/10.1590/S1518-8787.2016050006145 copy

Polypharmacy and Polymorbidity in Older Adults in Brazil: a public health challenge

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze variations in the prevalence of chronic use of medicines by older adults in Brazil according to its possible association with the most prevalent chronic diseases and demographic and health factors, and to identify risk factors for polypharmacy.

METHODS

A study based on data from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM), a cross-sectional, population-based survey with probability sampling in Brazilian urban areas. The independent variable was the number of chronic-use medicines taken by older adults, linked to eight chronic diseases investigated. The intervening variables were gender, age group, marital status, level of education, socioeconomic status, Brazilian region, body mass index, smoking, self-perceived health, hospitalization in the previous year and having health insurance, besides the investigated chronic diseases. A multivariable analysis identified risk factors for polypharmacy.

RESULTS

Prevalence of at least one chronic-use medicines among older adults was 93.0%. Of the total number of older adults, 18.0% used at least five medications (polypharmacy). Polypharmacy was higher among the oldest individuals (20.0%), in the South region (25.0%), in those with poor self-perceived health (35.0%), in obese individuals (26.0%), in those with reported health insurance (23.0%) or hospitalization in the previous year (31.0%), and among those who reported any of the investigated diseases, particularly diabetes (36.0%) and heart diseases (43.0%). The variables remaining in the final risk model for polypharmacy were age, region, perceived health, health insurance, hospitalization in the previous year and all investigated diseases except stroke.

CONCLUSIONS

Older adults with specific diseases have risk factors for polypharmacy modifiable by actions aimed at the rational use of medicines. With the current population aging and successful drug access policy, the trend is an increase in drug use by older adults, which should feature as a priority in the planning agenda of the Brazilian Unified Health System (SUS).

Aged; Comorbidity; Polypharmacy; Aging; Chronic Disease; Population Surveys

Variable	Age group (years)			Total	p

	60–69	70–79	≥ 80

	% (95%CI)	% (95%CI)	% (95%CI)
Gender					0.094
Male	43.7 (41.8–45.6)	40.6 (38.4–42.9)	40.6 (36.5–44.9)	42.2 (40.7–43.8)
Female	56.3 (54.4–58.2)	59.4 (57.1–61.6)	59.4 (55.1–63.5)	57.8 (56.2–59.3)
Marital status					< 0.001
Partner	64.0 (61.8–66.1)	52.6 (49.8–55.4)	34.8 (30.4–39.5)	55.8 (53.9–57.7)
No partner	36.0 (33.9–38.2)	47.4 (44.6–50.2)	65.2 (60.5–69.6)	44.2 (42.3–46.1)
ABEP^b					0.005
A/B	23.1 (20.7–25.7)	19.3 (16.7–22.2)	21.7 (17.9–26.1)	21.7 (18.5–24.0)
C	55.2 (52.9–57.5)	55.4 (52.2–58.5)	51.3 (47.1–55.5)	54.7 (52.7–56.6)
D/E	21.7 (19.8–23.7)	25.3 (22.5–28.4)	27.0 (23.4–30.8)	23.7 (21.8–25.7)
Level of educations (in years)					0.003
0	13.9 (12.4–15.6)	15.2 (13.2–17.4)	20.8 (17.5–24.5)	15.4 (13.9–16.9)
1-8	44.7 (42.3–47.1)	42.9 (40.3–45.5)	41.6 (36.6–46.7)	43.6 (41.8–45.5)
≥ 8	41.4 (38.9–44.0)	42.0 (39.2–44.8)	37.7 (33.4–42.1)	41.0 (39.2–42.9)
Brazilian region					0.034
North	5.2 (4.1–6.6)	4.6 (3.5–6.0)	4.1 (3.1–5.5)	4.8 (3.8–6.1)
Northeast	20.6 (16.7–25.1)	21.6 (17.3–26.6)	22.7 (17.9–28.4)	21.2 (17.2–25.8)
Southeast	51.4 (45.4–57.4)	53.1 (46.7–59.5)	54.9 (47.7–61.9)	52.5 (46.5–58.4)
South	15.5 (12.5–19.1)	14.3 (11.2–18.0)	12.7 (9.6–16.6)	14.7 (11.8–18.1)
Midwest	7.3 (5.8–9.3)	6.4 (5.0–8.3)	5.6 (4.2–7.5)	6.8 (5.4–8.5)
BMI					0.247
Low	19.9 (18.3–21.5)	22.4 (20.3–24.7)	29.6 (26.5–33.0)	22.4 (21.1–23.6)
Normal	53.4 (51.2–55.6)	54.0 (51.5–56.4)	49.2 (44.7–53.8)	52.9 (51.4–54.4)
Overweight	10.6 (9.5–11.9)	10.3 (8.8–11.9)	10.3 (6.9–15.0)	10.5 (9.5–11.5)
Obese	16.1 (14.5–17.7)	13.3 (11.5–15.3)	10.9 (8.5–13.8)	14.3 (13.1–15.5)
Current smoker					< 0.001
Yes	12.4 (11.1–13.9)	9.4 (8.0–11.1)	5.7 (4.1–7.8)	10.6 (9.6–11.6)
No	87.6 (86.1–88.9)	90.6 (88.9–92.0)	94.3 (92.2–95.9)	89.4 (88.4–90.4)
Self-perceived health					< 0.001
Very good or good	60.3 (57.9–62.7)	55.2 (52.6–57.7)	49.0 (45.3–52.7)	56.9 (55.0–58.8)
Average	33.7 (31.5–35.9)	37.6 (35.1–40.1)	40.4 (37.2–43.7)	36.0 (34.4–37.6)
Poor or very poor	6.0 (5.1–7.1)	7.3 (5.9–8.9)	10.6 (8.6–13.0)	7.1 (6.4–7.9)
Health insurance					< 0.002
Yes	24.8 (22.0–27.9)	29.0 (25.7–32.5)	30.6 (26.3–35.4)	27.0 (24.3–29.9)
No	75.2 (72.1–78.0)	71.0 (67.5–74.3)	69.4 (64.6–73.7)	73.0 (70.1–75.7)
Hospitalization in previous 12 months					< 0.001
Yes	8.5 (7.4–9.7)	10.3 (8.7–12.2)	14.6 (12.1–17.6)	10.0 (9.1–11.0)
No	91.5 (90.3–92.6)	89.7 (87.8–91.3)	85.4 (82.4–87.9)	90.0 (89.0–90.9)
High blood pressure					< 0.001
Yes	47.2 (45.2–49.3)	34.6 (32.1–37.0)	33.6 (30.0–37.3)	41.0 (39.5–42.6)
No	52.8 (50.7–54.8)	65.4 (63.0–67.9)	66.4 (62.7–70.0)	59.0 (57.4–60.5)
Diabetes mellitus					0.018
Yes	81.8 (80.1–83.1)	78.5 (76.5–80.5)	82.1 (79.0–84.8)	80.8 (79.6–82.0)
No	18.2 (16.8–19.6)	21.5 (19.5–23.5)	17.9 (15.2–21.0)	19.2 (18.0–20.4)
Heart disease					< 0.001
Yes	88.8 (87.6–89.9)	82.2 (79.7–84.3)	78.3 (74.9–81.3)	85.0 (84.0–86.1)
No	11.2 (10.1–12.4)	17.8 (15.7–20.3)	21.7 (18.7–25.1)	15.0 (13.9–16.0)
High blood cholesterol					0.129
Yes	77.7 (75.9–79.3)	75.2 (72.5–77.8)	78.6 (75.1–81.7)	77.0 (75.4–78.5)
No	22.3 (20.7–24.1)	24.8 (22.2–27.5)	21.4 (18.3–24.9)	23.0 (21.5–24.6)
Stroke					< 0.001
Yes	95.5 (94.6–96.2)	94.9 (93.7–95.9)	90.0 (87.9–91.8)	94.5 (93.9–95.0)
No	4.5 (3.8–5.4)	5.1 (4.1–6.3)	10.0 (8.2–12.1)	5.5 (5.0–6.1)
Lung disease					0.071
Yes	96.0 (95.2–96.7)	94.6 (93.3–95.6)	94.3 (91.7–96.1)	95.3 (94.6–95.9)
No	4.0 (3.3–4.8)	5.4 (4.4–6.7)	5.7 (3.9–8.3)	4.7 (4.1–5.4)
Rheumatism					< 0.001
Yes	85.5 (83.7–87.2)	80.4 (78.1–82.6)	82.8 (79.7–85.5)	83.5 (82.0–84.8)
No	14.5 (12.8–16.3)	19.6 (17.4–21.9)	17.2 (14.5–20.3)	16.5 (15.2–18.0)
Depression					0.676
Yes	90.6 (89.3–91.8)	89.9 (88.0–91.6)	91.1 (88.5–93.1)	90.5 (89.4–91.4)
No	9.4 (8.2–10.7)	10.1 (8.4–12.0)	8.9 (6.9–11.5)	9.5 (8.6–10.6)

Independent variable	Number of chronic–use medicines

	zero	1	2	3 a 4	≥ 5

	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Gender
Male	9.0 (7.2–11.3)	25.0 (22.8–27.3)	25.8 (23.5–28.3)	24.6 (22.4–27.0)	15.6 (13.8–17.5)
Female	5.2 (4.3–6.3)	21.6 (19.5–23.8)	21.6 (19.8–23.5)	31.5 (29.3–33.8)	20.1 (18.4–21.9)
Age (years)
60-69	8.0 (6.7–9.5)	25.0 (22.7–27.4)	24.1 (22.0–26.5)	27.1 (25.2–29.1)	15.8 (14.0–17.7)
70-79	5.3 (3.8–7.3)	20.9 (18.8–23.1)	21.9 (19.6–24.4)	30.4 (27.7–33.2)	21.5 (19.2–24.0)
≥ 80	5.7 (3.5–9.2)	20.9 (18.0–24.1)	23.0 (19.7–26.7)	30.9 (27.0–35.2)	19.5 (16.3–23.1)
Marital status
Partner	7.1 (5.9–8.6)	23.6 (21.9–25.5)	24.1 (22.2–26.0)	27.5 (25.6–29.4)	17.7 (16.0–19.5)
No partner	6.2 (4.9–7.7)	22.0 (19.9–24.2)	22.1 (19.9–24.4)	30.6 (28.1–33.3)	19.2 (17.3–21.3)
ABEP^b
A/B	6.3 (4.6–8.6)	23.9 (21.0–27.1)	20.7 (18.2–23.4)	28.7 (25.5–32.3)	20.4 (17.5–23.6)
C	6.4 (5.3–7.7)	22.5 (20.5–24.5)	23.3 (21.3–25.4)	29.3 (27.0–31.7)	18.5 (16.8–20.3)
D/E	7.7 (5.5–10.7)	23.2 (20.5–26.0)	25.3 (22.3–28.5)	27.7 (24.9–30.7)	16.2 (13.7–19.0)
Level of educations (in years)
0	8.1 (6.1–10.9)	22.1 (18.9–25.7)	23.0 (20.1–26.3)	28.8 (25.2–32.7)	18.0 (14.6–21.9)
1-8	6.6 (5.3–8.1)	23.8 (21.7–26.1)	23.9 (21.5–26.4)	28.0 (25.6–30.5)	17.7 (15.7–19.9)
≥ 8	6.2 (4.9–7.8)	22.4 (20.1–24.9)	22.5 (20.5–24.7)	29.7 (27.2–32.3)	19.2 (17.2–21.3)
Brazilian region
North	10.3 (8.2–12.9)	46.2 (41.7–50.8)	22.6 (20.2–25.3)	17.6 (15.1–20.5)	3.2 (2.3–4.5)
Northeast	10.2 (8.5–12.3)	24.2 (22.2–26.4)	25.7 (23.4–28.2)	24.9 (22.2–27.7)	14.9 (12.8–17.3)
Southeast	5.7 (4.2–7.6)	21.2 (18.7–23.9)	23.0 (20.5–25.8)	31.1 (28.3–34.0)	19.0 (17.0–21.3)
South	4.4 (3.2–6.1)	20.4 (17.7–23.3)	20.8 (18.4–23.4)	29.4 (26.7–32.2)	25.1 (21.8–28.7)
Midwest	6.3 (4.8–8.3)	23.0 (20.3–26.0)	22.2 (19.3–25.5)	29.7 (26.8–32.8)	18.7 (15.8–22.0)
BMI
Low	7.5 (5.3–10.4)	27.5 (24.5–30.7)	22.3 (19.5–25.4)	28.3 (25.2–31.6)	14.5 (11.9–17.6)
Normal	7.2 (5.7–9.1)	22.5 (20.6–24.6)	24.3 (22.3–26.5)	28.1 (26.1–30.2)	17.8 (16.1–19.8)
Overweight	4.9 (3.3–7.4)	23.1 (18.5–28.6)	23.8 (20.0–28.0)	29.5 (25.2–34.3)	18.7 (14.9–23.1)
Obese	3.5 (2.2–5.5)	16.1 (13.1–19.6)	22.4 (19.2–26.1)	32.5 (28.4–36.9)	25.4 (21.9–29.3)
Current smoker
Yes	9.5 (6.9–12.9)	27.4 (23.0–32.3)	21.2 (17.4–25.7)	29.2 (24.4–34.6)	12.7 (9.5–16.7)
No	6.5 (5.5–7.7)	22.7 (21.0–24.5)	23.6 (21.9–25.4)	28.7 (26.8–30.6)	18.5 (17.1–20.1)
Self-perceived health
Very good or good	8.2 (6.6–10.1)	28.5 (26.5–30.6)	25.4 (23.3–27.6)	26.3 (24.2–28.6)	11.6 (10.1–13.3)
Average	5.2 (4.2–6.4)	18.9 (16.6–21.4)	22.0 (20.0–24.1)	31.6 (29.2–34.0)	22.4 (20.3–24.7)
Poor or very poor	5.2 (3.6–7.5)	11.2 (8.4–14.7)	16.6 (13.4–20.4)	30.2 (25.7–35.0)	36.8 (31.5–42.5)
Health insurance
Yes	5.1 (3.6–7.4)	21.3 (18.9–23.8)	21.4 (18.7–24.4)	30.0 (26.8–33.4)	22.2 (22.0–25.1)
No	7.3 (6.2–8.6)	23.6 (21.8–25.4)	23.9 (22.2–25.7)	28.4 (26.6–30.3)	16.8 (15.3–18.4)
Hospitalization
Yes	4.0 (2.7–5.8)	13.5 (10.6–17.1)	20.0 (16.5–24.0)	30.2 (26.1–34.7)	32.3 (27.7–37.3)
No	7.1 (6.0–8.3)	24.2 (22.5–26.0)	23.6 (22.0–25.3)	28.8 (27.1–30.6)	16.3 (15.0–17.8)
High blood pressure
Yes	21.1 (17.6–25.0)	29.2 (26.1–32.5)	22.2 (19.2–25.6)	19.0 (16.1–22.3)	8.5 (6.7–10.9)
No	2.9 (2.4–3.6)	21.3 (19.7–22.9)	23.4 (21.7–25.2)	31.4 (29.6–33.4)	20.9 (19.3–22.6)
Diabetes mellitus
Yes	7.8 (6.6–9.0)	28.0 (26.2–29.9)	25.0 (23.3–26.9)	26.8 (24.9–28.9)	12.4 (11.1–13.7)
No	3.5 (2.4–5.2)	8.2 (6.7–10.0)	17.8 (15.3–20.7)	34.8 (31.8–38.0)	35.6 (32.7–38.6)
Heart disease
Yes	7.5 (6.4–8.7)	26.7 (24.9–28.6)	25.4 (23.6–27.3)	28.1 (26.2–30.0)	12.3 (11.0–13.7)
No	3.4 (2.1–5.4)	7.8 (6.0–9.9)	14.2 (11.9–16.9)	32.1 (29.0–35.5)	42.4 (38.6–46.3)
High blood cholesterol
Yes	7.3 (6.2–8.7)	28.3 (26.6–30.2)	26.4 (24.5–28.4)	25.5 (23.7–27.4)	12.4 (11.1–13.8)
No	5.2 (3.9–6.9)	10.8 (9.0–12.9)	16.0 (13.7–18.6)	36.3 (33.5–39.3)	31.7 (28.8–34.7)
Stroke
Yes	6.7 (5.7–7.9)	23.9 (22.3–25.5)	23.8 (22.2–25.4)	28.5 (26.7–30.3)	17.2 (15.9–18.6)
No	6.0 (4.0–8.9)	10.7 (7.6–14.8)	16.0 (12.4–20.4)	33.7 (28.4–39.5)	33.6 (27.9–39.9)
Lung disease
Yes	6.5 (5.6–7.7)	23.6 (22.0–25.3)	23.6 (22.1–25.3)	28.9 (27.1–30.6)	17.4 (16.0–18.8)
No	8.4 (3.8–17.6)	12.4 (8.9–17.0)	16.4 (12.4–21.3)	29.4 (23.7–35.9)	33.4 (26.6–41.0)
Rheumatism
Yes	6.3 (5.2–7.6)	25.9 (24.0–27.8)	25.1 (23.3–27.0)	27.8 (26.0–29.7)	14.9 (13.6–16.4)
No	8.0 (6.3–10.0)	12.5 (10.3–15.3)	16.5 (14.2–19.0)	32.7 (29.8–35.7)	30.4 (27.2–33.7)
Depression
Yes	7.1 (6.1–8.3)	24.9 (23.1–26.7)	24.4 (22.8–26.0)	27.9 (26.1–29.7)	15.8 (14.4–17.3)
No	3.5 (2.0–6.2)	9.5 (7.3–12.4)	15.1 (11.8–19.1)	35.9 (31.6–40.4)	36.0 (31.0–41.2)

Total	6.7 (5.7–7.8)	22.9 (21.4–24.5)	23.2 (21.6–24.8)	28.9 (27.2–30.6)	18.4 (17.0–19.8)

Variable	Category	PR	95%CI	p
Age	60-69	1.00		0.033
	70-79	1.20	1.04–1.38
	≥ 80	1.08	0.90–1.30
Region	North	1.00		< 0.001
	Northeast	3.61	2.56–5.09
	Southeast	4.22	3.02–5.89
	South	5.03	3.58–7.07
	Midwest	3.89	2.74–5.51
Perception	Very good or good	1.00		< 0.001
	Average	1.40	1.21–1.61
	Poor or very poor	1.65	1.37–2.00
Health Insurance	Yes	1.11	0.99–1.26	0.083
Health Insurance	No			0.083
Hospitalization	Yes	1.28	1.10–1.49	0.001
Hospitalization	No			0.001
High blood pressure	Yes	2.08	1.66–2.61	< 0.001
Diabetes mellitus	Yes	2.30	2.02–2.62	< 0.001
Heart disease	Yes	2.26	1.97–2.60	< 0.001
High blood cholesterol	Yes	1.76	1.55–2.01	< 0.001
Lung disease	Yes	1.29	1.03–1.61	0.024
Rheumatism	Yes	1.53	1.32–1.76	< 0.001
Depression	Yes	1.78	1.53–2.07	< 0.001

Medicines	% of reports
Hydrochlorothiazide	8.3
Losartan	7.6
Simvastatin	6.7
Metformin	5.5
Enalapril	4.7
Captopril	4.5
Atenolol	3.7
Amlodipine	2.9
Acetylsalicylic acid	2.9
Glibenclamide	2.4

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