Polypharmacy in the Brazilian elderly population and associated chronic non-communicable diseases: a nationwide studyAbstract
Objective To analyze the prevalence of polypharmacy and the chronic non-communicable diseases (NCDs) associated with polypharmacy among Brazilian elderly based on data from the National Health Survey (PNS).
Method This was an observational, cross-sectional, quantitative, and exploratory study utilizing secondary data from public domain sources, derived from the most recent population-based survey, the PNS, conducted in 2019. The study population comprised older adults from across Brazil who were interviewed in the PNS. Polypharmacy was used as the dependent variable, while NCDs were considered as independent variables. The entirety of the information contained in the database (n=293,726) was considered. After applying exclusion criteria, the final sample comprised 31,633 individuals.
Results The sample predominantly consisted of males, with a mean age of 70.8 years, who were married, White, literate, had completed high school, and reported a mean monthly income of R$1,928.59. Among the older adults, the prevalence of polypharmacy was 23.8% (n=7,534). All evaluated NCDs were associated with polypharmacy (p<0.05), and individuals with at least one NCDs were more likely to use polypharmacy compared to those without NCDs (p<0.05).
Conclusion The prevalence of polypharmacy was high and demonstrated an association with NCDs among older adults across the five regions of Brazil, with a negative impact. This highlights the need for public policies aimed at reducing or preventing polypharmacy and its associated risks.
Keywords
Polypharmacy; Non-Communicable Chronic Diseases; Population; National Health Survey
Resumo
Objetivo Analisar a presença de polifarmácia e as doenças crônicas não transmissíveis (DCNT) associadas à polifarmácia na pessoa idosa brasileira com base na Pesquisa Nacional em Saúde (PNS).
Método Estudo observacional, transversal, quantitativo e exploratório, com fonte de dados secundários de domínio público, provenientes do último inquérito de base populacional, intitulado PNS, realizado em 2019. A população do estudo foi constituída por pessoas idosas, de todo território brasileiro, que foram entrevistados pela PNS. Foram usados como variável dependente a polifarmácia, e como independente DCNT. Foi considerado a totalidade de informações contida no banco (n=293.726), após aplicação dos critérios de exclusão, a amostra final resultou em 31.633.
Resultados A amostra foi composta em sua maioria pelo sexo masculino, com idade média de 70,8 anos, casados, brancos, alfabetizados, com ensino médio completo e renda mensal média de R$1.928,59. Das pessoas idosas, a prevalência da polifarmácia foi de 23,8% (n=7.534). Todas as DCNT avaliadas tiveram associação com a polifarmácia (p<0,05) e indivíduos que possuíam alguma DCNT, apresentaram maiores chances de fazer uso da polifarmácia, quando comparado aos indivíduos que não apresentaram DCNT (p<0,05).
Conclusão A prevalência da polifarmácia foi alta e apresentou relação com as DCNT de pessoas idosas nas cinco regiões do Brasil, com impacto negativo. Ressaltando a necessidade de políticas públicas, visando a redução ou a prevenção da polifarmácia, assim como seus riscos associados.
Palavras-Chave:
Polimedicação; Doenças Crônicas Não Transmissíveis; População; Inquérito Nacional de Saúde
INTRODUCTION
The natural aging process, when combined with an individual’s lifestyle and the social determinants of health they are exposed to throughout their life, leads to physiological changes that can increase medication consumption1,2.
The simultaneous use of five or more medications, with or without a prescription, is referred to as polypharmacy3. Both international and national studies have reported prevalence rates. For instance, a study conducted in Ireland among older adults aged over 65 years found that the prevalence of polypharmacy increased from 17.8% to 60.4% between 1997 and 20124. In a study carried out in Brazil involving 227 older adults, the prevalence of polypharmacy was 57.7%4. These rates of polypharmacy have a direct impact on quality of life and healthcare expenditures, as they increase the likelihood of adverse drug reactions (ADR) and drug interactions (DI)5.
The majority of medications used by older adults are prescribed for the treatment of NCDs (chronic non-communicable diseases), including cardiovascular, pulmonary, musculoskeletal, endocrine and metabolic diseases, neoplasms, diabetes, and dementias6,7.
Polypharmacy is a common condition among older adults and is associated with increased risks of falls, frailty, functional decline, greater dependency, hospitalization, and mortality. Additionally, it contributes to the rising costs of healthcare. One example is the reduction in the availability of free medications, resulting in a significant portion of the monthly income of individuals over 60 years old being allocated to medication expenses8,9.
Polypharmacy is one of the primary causes of health complications among older adults worldwide4. This underscores the importance of investigating polypharmacy and the chronic diseases that routinely affect older adults on a national scale, aiming to reduce its prevalence and consequently diminish the associated risk factors.
However, national-level studies addressing polypharmacy and its relationship with NCDs remain scarce. This study sought to gather information on the prevalence of polypharmacy and its associated factors among Brazilian older adults, particularly the presence of NCDs, on a national level. A key distinction of this research lies in its use of data from the 2019 National Health Survey (PNS), which features a detailed methodology and provides the most recent consolidated data from a population-based national survey10,11. These findings have the potential to contribute to improving the care provided by health services, particularly for older adults.
This study aimed to analyze the presence of NCDs associated with polypharmacy among Brazilian older adults based on the 2019 PNS.
METHOD
This is an observational, cross-sectional, quantitative, and exploratory study utilizing secondary data from public domain sources, based on the most recent population-based survey, the PNS, conducted in 2019 across the entire Brazilian territory. The PNS was proposed by the Ministry of Health and coordinated by FIOCRUZ (Oswaldo Cruz Foundation) in partnership with and under the execution of the Brazilian Institute of Geography and Statistics (IBGE) 12. It stood out as the most comprehensive health survey in Brazil, addressing a wide range of topics and measured indicators12.
The 2019 PNS included a sample of 293,276 adults interviewed across 94,114 households. The survey consisted of three questionnaires: one on household characteristics, one concerning all household members, and an individual questionnaire completed by a randomly selected resident aged 18 years or older13. For this study, only data from the latter two questionnaires were considered. The study population consisted of information from individuals aged 60 years or older across Brazil who reported using continuous medications (n=31,633).
Data collection for this study was conducted between 2023 and 2024, utilizing data from the PNS, classified as primary data, which were extracted from its official website, provided by IBGE, through the latest available version. On the website, the data are made available in a compact format, within a zipped folder containing the following components: a database with raw data, dictionaries containing a key file that stores database codes serving as a legend, and input files for individuals, which are essential documents for decoding the database.
Prior to analysis, the raw data in TXT format were decoded into XLS format. A preliminary exploration of the PNS interview questionnaire was carried out, and the questions relevant to this study were selected. These secondary data were subsequently processed. In Excel, the data were cleaned, organized, and prepared for use in this research.
Regarding the selection of variables for this study, questions of interest from the PNS were chosen during the data collection process. Polypharmacy was used as the dependent variable. To characterize the sample, variables from thematic modules on general characteristics of the household members and education were considered. Chronic diseases were used as the independent variable.
The dependent variable ‘polypharmacy’ was derived from two questions: “Do you use any medication prescribed by a physician for regular or continuous use?” and “How many different medications prescribed by a physician have you used in the last two weeks?”, with responses for the first question being “yes” or “no”, and for the second question, the total number of medications used. However, the outcome variable ‘polypharmacy’ was categorized based on the number of continuous medications used by individuals, with the following options: Non-Polypharmacy – between one and four medications (not polypharmacy) and Polypharmacy – five or more medications (polypharmacy).
Sociodemographic characteristics: This category was composed of eight variables, including sex (female and male); age (60 to 69 years, 70 to 79 years, 80 to 89 years, and 90 years or older); skin color (white, black, yellow, mixed-race, or indigenous); marital status [married, separated/divorced, widowed, and single]; literacy (yes and no); education level (preschool, literacy, elementary school, elementary school equivalency program, high school, high school equivalency program, undergraduate or higher education, specialization, master's and doctorate); income up to 998.00 (one minimum wage), 999.00 to 1,995.00 (between one and two minimum wages), 1,996.00 to 2,993.00 (between two and three minimum wages), 2,994.00 or more (three minimum wages or more); and region of residence (North, Northeast, Central-West, Southeast, and South).
Chronic non-communicable diseases: Variables related to the presence of chronic diseases and their individual forms were analyzed, considering each disease listed in the instrument, including diabetes, hypertension, high cholesterol, heart disease, cerebrovascular accident, respiratory disease, chronic back pain, work-related musculoskeletal disorder, depression, arthritis or rheumatism, mental disorder, chronic obstructive pulmonary disease, cancer, and chronic kidney disease.
For the analysis, an initial descriptive analysis was conducted using absolute and relative frequencies, as well as prevalence ratios (PR). Subsequently, statistical analysis was performed using non-parametric association tests for nominal categorical variables. To measure the magnitude of the associations, binary logistic regression was conducted using Odds Ratios (OR), with a significance level of 95%.
The OR serves as an estimator that approximates the Relative Risk (RR). When the proportions of the two groups are equal, the OR result is one, indicating no association between the disease and the exposure to the supposed risk factor14.
The PNS survey approved by the National Research Ethics Committee for Human Beings, of the Ministry of Health, with CAAE 11713319.7.0000.0008, under Opinion number 3.529.376. The data are publicly accessible and available on the IBGE and PNS websites.
RESULTS
The sample was predominantly composed of males, with a mean age of 70.8 years, married, white, literate, with completed high school, and a mean income of R$1,928.59 (Table 1).
Sociodemographic characteristics of the sample of older adults using continuous-use medications, PNS-2019 (n=31,633). Ponta Grossa, PR, 2023.
Regarding the presence of NCDs in older adults, all are associated with polypharmacy (p<0.05) (Table 2).
Presence of NCDs in Brazilian older adults by polypharmacy use, PNS - 2019 (n=13,932). Ponta Grossa, PR, 2023.
The results from the logistic regression analysis revealed that individuals with any NCDs had higher odds of using polypharmacy compared to those without NCDs (p<0.05) (Table 3).
Explanatory models of polypharmacy associated with the presence of NCDs in older adults from the Brazilian community, PNS-2019 (n=13,932). Ponta Grossa, PR, 2023.
DISCUSSION
The results indicated a high prevalence of polypharmacy. However, when compared to developed countries, this prevalence was lower. For instance, a study conducted in Italy in 2011 involving 12,301,537 individuals aged 65 and older reported a polypharmacy prevalence of 49%15. In Spain, a study with 2,919 participants aged over 65 revealed a mean consumption of 8 medications per older adult and a polypharmacy prevalence close to 50%4.
National studies show heterogeneous prevalence rates of polypharmacy, which can vary by geographic region, potentially due to socioeconomic conditions and the healthcare models adopted in specific areas15. For instance, a study conducted with 23,416 older adults in Acre reported a polypharmacy prevalence of 14.6%15.
Another study involving 537 older adults in Minas Gerais found a polypharmacy prevalence of 36.9%16. An investigation conducted with 189 older adults in a community in Paraná reported a 38% prevalence of polypharmacy17. However, in a study in Minas Gerais involving 686 older adults in the community, the polypharmacy prevalence was 23.5%18, the same prevalence as in the present research. When comparing national studies, we can observe a closer approximation in polypharmacy prevalence, which may be attributed to the geographic region in question.
Polypharmacy is not limited to prescribed pharmacotherapy but also includes self-medication and sporadic use of drugs3. However, in the present study (using secondary data), only prescribed medications were considered due to the PNS survey (primary data), which only assessed medications used with a medical prescription. Therefore, the prevalence of polypharmacy could have been different if non-prescribed medications had also been evaluated.
Thus, polypharmacy in older adults occurs due to various factors, as previously mentioned, one of which is the high prevalence of chronic non-communicable diseases (NCDs), where medications are used as the primary form of treatment19. Additionally, the presence of NCDs requires appropriate therapeutic management, such as polypharmacy, which predisposes older adults to interactions and adverse drug reactions (DI and ADR), making them more vulnerable20.
In the present study, individuals with NCDs had higher chances of using polypharmacy compared to those without NCDs. All NCDs were associated with polypharmacy, including heart disease, cerebrovascular accident, diabetes, depression, chronic renal insufficiency, chronic lung disease, cancer, arthritis or rheumatism, other mental disorders, hypertension, respiratory disease, high cholesterol, and chronic back pain.
In studies conducted in Brazil, a relationship between NCDs and polypharmacy was also identified. For instance, in the Health, Well-Being, and Aging Study (SABE), the prevalence of polypharmacy was observed among older adults with diabetes, heart diseases, rheumatism, and arterial hypertension21. Similarly, in the National Survey on Access, Use, and Promotion of Rational Use of Medicines (PNAUM), which focused on older adults, the prevalence of polypharmacy was associated with hypertension, diabetes, heart disease, respiratory disease, high cholesterol, rheumatism, and depression21.
Both of the previously cited studies support the findings of this study, indicating that individuals with NCDs are more likely to develop polypharmacy. This can be attributed to the continuous and inappropriate use of medications, typically involving pharmacological treatment that could be complemented by non-pharmacological approaches for better disease management.
Among the NCDs, heart diseases, such as myocardial infarction, angina, heart failure, arrhythmia, and other conditions, were the most impactful in terms of polypharmacy. In the study conducted in Rio Branco, hypertension and heart diseases, including arrhythmias and heart failure, were the most prevalent and were also associated with polypharmacy15.
The prevalence of heart diseases increases progressively with age20. Heart diseases are complex and can progress rapidly, posing a significant public health issue as they affect over 37.7 million individuals worldwide. In Brazil, they account for 2.25% of all hospitalizations, with 73% of these cases involving individuals over 60 years of age20. A study involving 120 older adults highlighted the presence of multiple comorbidities, with heart diseases being prominent (54%), showing a strong association with polypharmacy20.
Thus, the main reasons for heart diseases presenting higher chances of polypharmacy include physical inactivity and smoking, which are risk factors for increased pharmacological treatment; hospitalizations due to the severity of the condition, which may lead to higher medication use; potentially inappropriate medications (PIM) for the elderly; self-medication; physiological changes related to aging, such as cardiac function; and changes in health profiles, including the presence of the condition itself or other associated NCDs like hypertension and diabetes22,23. These factors help explain why, in this study, heart diseases had the most significant impact on polypharmacy.
Similar to heart diseases, cerebrovascular accidents (CVA) also showed high chances of polypharmacy use. The prevalence of CVA increases with age and is considered a leading cause of death that can lead to disabling sequelae worldwide24. A study conducted in the United Kingdom with patients diagnosed with CVA found that approximately 56% of individuals were using polypharmacy21.
In a study conducted in seven Brazilian municipalities with 2,217 individuals over the age of 65, about 30% had heart disease, diabetes, and CVA, with higher rates of polypharmacy21. These findings reinforce the results of the present study, which shows that CVA is associated with high chances of polypharmacy use.
The prevalence of polypharmacy in patients who suffered a CVA can be explained by several modifiable factors, such as physical inactivity, inappropriate or incomplete treatments, presence of other associated NCDs (like hypertension, diabetes, high cholesterol), obesity, smoking, and alcohol consumption, which can negate the effects of medication25. These factors help explain why CVA was the second NCDs with the most significant impact on polypharmacy in this study.
Individuals over the age of 60 are the group most likely to use medications, making them more susceptible to adverse drug reactions26. Diabetes, along with hypertension, is considered one of the main diseases associated with increased polypharmacy and its associated risks. An example of this is the use of antihypertensive drugs, the most commonly used class of medication among the elderly26.
In a study conducted in Brazil with 40 older adults, 75% of diabetic patients reported taking 5 to 8 medications daily, and the remainder of the sample used 8 or more medications per day26. In a study involving 189 older adults in a Brazilian community, although most were using antihypertensives, 38% were using polypharmacy17. These findings support the results of the present study, which found higher chances of polypharmacy use in patients diagnosed with diabetes and hypertension compared to those without these diagnoses.
In relation to the general health of older adults with hypertension and diabetes, there is an increase in other NCDs, such as high cholesterol17. A study conducted in Japan identified that polypharmacy was more common in the treatment of certain NCDs, including hypertension, high cholesterol, and diabetes27. This finding supports the data in the present study, which highlighted the relationship between polypharmacy and these NCDs. As mentioned earlier, high cholesterol is associated with an increased likelihood of polypharmacy use, which can be explained by factors such as physical inactivity, obesity, comorbidities, and inadequate diets27.
In relation to depression and mental disorders, an increase in cases among the elderly is observed, attributed to the aging process itself. A study conducted in Brasília with 226 older adults reported that 18.71% of those diagnosed with depression were using polypharmacy28. Another study in Brazil involving 496 individuals over the age of 60 found that 22% of patients using polypharmacy had a diagnosis of depression28. This demonstrates an association between the likelihood of polypharmacy use in individuals diagnosed with depression, aligning with the findings of the present study.
Older adults are predominantly affected by chronic kidney disease (CKD), particularly those with multiple comorbidities who are exposed to polypharmacy29. Renal patients typically take a mean of six medications per day, increasing the likelihood of polypharmacy related to the condition29. While the complications of polypharmacy are well-known, it is necessary to delay the progression of kidney disease; however, it is found in 66.5% of renal patients29, similar to the occurrence of polypharmacy in individuals with renal insufficiency in the present study.
Among the main factors contributing to the presence of polypharmacy in patients with chronic kidney disease are the presence of other associated NCDs, such as hypertension and diabetes, which lead to increased medication consumption, as evidenced in the research in question; older adults, who are affected by aging and pharmacodynamics, when there is an association of medications and kidney failure, which results in the excretion of drugs, thereby increasing the use of medications for therapeutic purposes29.
Regarding cancer, older adults are considered more susceptible due to exposure to carcinogenic agents or the presence of associated comorbidities30. Cancer treatment often involves the use of antineoplastic drugs, which have toxicities requiring additional medications for management, contributing to increased polypharmacy30. A study conducted with 20 elderly cancer patients in an outpatient clinic in Maranhão showed a mean of 6.7 medications per patient per day30. Comparing this with our study, we can see that NCDs increase the likelihood of polypharmacy, affirming the findings of the present work.
Regarding pulmonary disease, a study conducted in Minas Gerais with 197 individuals aged over 60 diagnosed with chronic obstructive pulmonary disease (COPD) reported polypharmacy in 26.8% of respondents31, which confirms the present study's findings that COPD is associated with an increased chance of polypharmacy. The risk of polypharmacy in COPD can be explained by factors such as the treatment of the condition with certain medication classes, including analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying drugs, and biologics; hospitalization; advanced age; smoking; and other associated NCDs31,32.
Regarding rheumatoid arthritis, a study conducted in a rheumatology outpatient clinic with 190 patients diagnosed with this condition showed that it increased the likelihood of polypharmacy32, which supports the present study. Thus, polypharmacy in rheumatology is associated with diseases with higher inflammatory activity, requiring greater care, better adherence to treatment, and, consequently, improvement of the condition through the continuous use of multiple medications32.
Chronic back pain, on the other hand, was the NCD that showed the lowest chance of polypharmacy use when compared to the other NCDs analyzed. In a study conducted with 271 older adults in the Federal District, it was found that the prevalence of polypharmacy was 69.7%, and chronic back pain was identified in 63.3% of the participants33. This indicates that chronic back pain presents a chance of polypharmacy use, as observed in our study.
According to the studies analyzed in this research, NCDs can indeed lead to polypharmacy, as they can be a cause of it. Most medications used by individuals over 60 are intended for the treatment of chronic diseases6,17, indicating that the higher number of medications in use is directly related to the treatment of a greater number of diseases17. Similarly, NCDs can also be a consequence of polypharmacy, which can pose several risks to patients, such as DI, ADR, iatrogenesis, and low treatment adherence, including administration errors that can harm the patient’s health, leading to hospitalizations and other health issues, such as the emergence of new NCDs8.
The strengths of this study include its approach to the association between NCDs and polypharmacy, utilizing comprehensive and relevant national data, such as the PNS.
The study's limitations include, in relation to primary data from the PNS, the inclusion of only prescribed medications, which may have altered the prevalence of polypharmacy in this study. Another limitation of the PNS is the lack of data on the classes of medications used, such as vitamins or minerals, which could have impacted the prevalence of polypharmacy, potentially making it higher or lower. Lastly, as a cross-sectional study, it was not possible to establish a cause-and-effect relationship, although an important association between polypharmacy and NCDs in older adults was demonstrated.
CONCLUSION
The study highlighted that the prevalence of polypharmacy, as revealed by the data, showed that the use of five or more medications was a reality among older adults nationwide, as assessed through the PNS. An association between all NCDs and polypharmacy was observed. Individuals with any NCDs had a higher likelihood of using polypharmacy.
The findings discussed in this study will support the work of healthcare teams, from professionals to managers, in the prevention and management of polypharmacy in older adults. This includes promoting physical exercise, appropriate prescribing, balanced diets, health events, and the development of public policies aimed at non-pharmacological interventions, as well as encouraging further research on polypharmacy and enhancing the PNS survey for future data collection, such as medication classes and prescriptions.
Therefore, it is crucial for the multidisciplinary team to monitor this population, regularly assessing medication reconciliation to prevent potential drug interactions, adverse drug reactions, and the use of potentially inappropriate medications for older adults, which could worsen their health status and increase the risk of developing new chronic diseases.
ACKNOWLEDGEMENTS
We would like to thank the National Health Survey (PNS) for contributing its data to the completion of this research.
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No funding was received for the execution of this study.
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All the data supporting the results of this study are available and freely accessible on the IBGE and PNS websites: https://www.pns.icict.fiocruz.br.
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» https://doi.org/10.11606/S1518-8787.2017051007136 - 32 Zmijevski AF, Makiyama JS, Laurani LA, Skare TL. A polifarmácia e sua influência na adesão ao tratamento da artrite reumatóide. Rev. méd. Paraná. [Internet] 2020 [acesso em: 16 mai 2024]; 78(2):60-64. Disponível em: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1222695
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33 Reis KMC, Jesus CAC. Relação da polifarmácia e polipatologia com a queda de idosos institucionalizados. Texto & Contexto-Enfermagem. [Internet] 2017 [acesso em: 16 mai 2024]; 26(2):1-9. Disponível em: https://doi.org/10.1590/0104-07072017003040015
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Edited by
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Editor by: Cristian Arnecke Schröder
All the data supporting the results of this study are available and freely accessible on the IBGE and PNS websites: https://www.pns.icict.fiocruz.br.
