[State of practice: overview of polypharmacy and use of potentially inappropriate medications among people aged 65 and over in Quebec]

Bressan C, Caron M, Jantzen R, Rousseau MP
Record ID 32018012114
Original Title: Portrait de la polypharmacie et de l’usage de médicaments potentiellement inappropriés chez les personnes âgées au Québec
Authors' objectives: Polypharmacy, defined in this work as the use of 10 or more prescription medications, is a frequent phenomenon, particularly in older populations or those with comorbidities. This use increases the risk of adverse events, notably an increased risk of hospitalization or falls, as well as the risk of drug interactions. Polypharmacy also increases the risk of using one or more potentially inappropriate medications (PIMs). PIMs can be defined as drugs whose use should be avoided in most circumstances, or in specific situations, particularly in people aged 65 and over. Regular medication assessment by a healthcare professional, with the aim of adjusting or discontinuing medications that are no longer required, is an important aspect of healthcare provision for the older adults. The aim of this work is to provide a provincial overview of prescription drug use by the community-dwelling population aged 65 and over in Quebec3, as well as the use of targeted PIMs - sulfonylureas, antipsychotics, benzodiazepines, and proton pump inhibitors. Healthcare system use indicators by people aged 65 and over with polypharmacy are also presented. Finally, where possible, Quebec data have been compared with data from similar countries or provinces.
Authors' results and conclusions: RESULTS (#1 THE PROPORTION OF PEOPLE AGED 65 AND OVER WITH POLYPHARMACY AND THE PROPORTION OF OLDER ADULTS NOT CLAIMING DRUGS FROM THE RPAM HAVE REMAINED RELATIVELY STABLE OVER TIME): The population aged 65 and over insured with RPAM increased by 41% between 2012 and 2022. The proportion of people reimbursed for 0, 1 to 4, 5 to 9, and 10 or more drugs has remained relatively stable over time, with the exception of the pandemic period. Thus, in 2022, around 34% of these people (approximately 519,000 people) claimed for at least 10 separate drugs during the year. This is the highest proportion of all Canadian provinces. (#2 THE PROPORTION OF QUEBEC’S OLDER ADULTS WHO CONSULTED THEIR FAMILY DOCTOR IN THE LAST SIX MONTHS HAS DECLINED OVER THE PAST TEN YEARS, AS THEY HAVE DIVERSIFIED THEIR CONSULTATIONS WITH OTHER HEALTHCARE PROFESSIONALS): The proportion of people aged 65 and over who consulted their family doctor in the last 6 months of the year fell by 14% between 2012 and 2022, reaching 63% in 2022. At the same time, the average number of prescribers per patient and claims for drugs not prescribed by a family doctor have increased. These figures can be explained by the possibility of renewing prescriptions with a specialist physician, a community pharmacist, or a specialized nurse practitioner. (#3 MORE THAN HALF OF QUEBEC’S OLDER ADULTS ARE TAKING ONE OF THE FOUR TARGETED POTENTIALLY INAPPROPRIATE MEDICATIONS): People aged 65 and over are 51% taking at least one of the four targeted PIMs. For each individual PIM, this proportion is 39% for proton pump inhibitors (PPIs), 16% for benzodiazepines, 6.8% for antipsychotics, and 6.3% for sulfonylureas. The use of benzodiazepines fell by 41% between 2012 and 2022, while that of antipsychotics rose by 19%. A similar decline in the proportion of people with benzodiazepine claims is also seen in the US, but in that country, unlike Quebec, antipsychotic claims have also fallen slightly. The use of PPIs and sulfonylureas has remained stable over time. (#4 WOMEN, PEOPLE AGED 85 AND OVER, PEOPLE LIVING IN MORE DISADVANTAGED AREAS, AND THOSE CLAIMING 10 OR MORE DRUGS ARE GENERALLY MORE LIKELY TO HAVE REIMBURSEMENT FOR ONE OF THE FOUR TARGETED PIMS): These sub-groups are traditionally associated with polypharmacy and PIM use, and the Quebec data are no exception. Around 54% of women, 63% of people aged 85 and over, and 54% of people living in more disadvantaged areas claimed at least one of the targeted PIMs. Up to 83% of people taking 10 or more medications claimed at least one PIM; this proportion was 68% for PPIs and 29% for benzodiazepines. However, sulfonylureas have a different reimbursement profile, with the highest proportion of reimbursed drugs observed among men and people aged 75 to 84. (#5 IN QUEBEC, THE PROPORTION OF PEOPLE AGED 65 AND OVER WITH POLYPHARMACY AND THOSE CLAIMING AT LEAST ONE OF THE TARGETED PIMS ARE AMONG THE HIGHEST IN CANADA AND AMONG COMPARABLE COUNTRIES): Across Canada, Quebec has the highest proportion of people aged 65 and overwho have had reimbursements for 10 or more drugs. It is also one of the provinces with the highest proportions of people claiming PPIs and benzodiazepines. No comparable data were found for antipsychotics or sulfonylureas. Internationally, Quebec is also among the jurisdictions with the highest proportion of older adults who have had reimbursements for 10 or more drugs and for benzodiazepines, antipsychotics, and PPIs. No comparable data were found for sulfonylureas. CONCLUSION: The proportions of people with polypharmacy or using one of the four targeted PIMs remained relatively stable between 2012 and 2022. Despite this, the aging population means that the total number of people in this situation is increasing. It is therefore more important than ever to regularly monitor the medication taken by people aged 65 and over, evaluate its appropriateness, and encourage deprescribing where necessary. There are many tools available to support clinicians and facilitate shared decision-making, many of which stem from Canadian and Quebec initiatives. Various organizational projects are underway in the healthcare network to increase the proportion of the population cared for by a healthcare professional in FMGs. At the same time, in recent years, the number of prescribers per patient has increased, and family doctor visits have become less regular. This could lead to difficulties in coordinating efforts to assess the drugs taken by an individual, and act as a brake on deprescribing. It should be remembered that the results of indicators associated with older adults’ medication can be provided to FMGs wishing to specifically characterize their clientele, as part of continuous quality improvement projects such as CoMPAS+ and Repères GMF.
Authors' methods: This summary is based on three information sources: 1) Analysis of clinical-administrative data associated with drug consumption. The indicators presented come from a pan-Canadian research project on deprescribing, which led to workshops offered in family medicine groups (FMGs) by the research team4. INESSS participated in this project, producing the indicators with data from the FMGs involved in the process. This work describes the results of these province-wide indicators for the 2012-2022 period. 2) Literature review. The literature search allowed for the identification of the results of similar indicators from other countries or provinces, and to compare them with the results obtained for Quebec. 3) Advisory Committee perspective. This committee was made up of pharmacists, a family physician, an internist, and a geriatric internist, a nurse practitioner specialized in primary care, and patient partners, whose mandate was to contextualize and support the interpretation of the results.
Project Status: Completed
Year Published: 2024
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
MeSH Terms
  • Polypharmacy
  • Medication Review
  • Aged
  • Aged, 80 and over
  • Prescription Drug Overuse
  • Inappropriate Prescribing
  • Deprescriptions
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)
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