Abstract

Objective:

To analyze polypharmacy prevalence and associated factors in older adults living in Rio Branco, Acre, Brazil, in 2014.

Methods:

This was a cross-sectional population-based study using complex sampling with older adults. Polypharmacy was defined as concomitant use of five or more medications.

Results:

Polypharmacy prevalence was 14.9% (95%CI 11.8;18.6), positively associated with females (OR=2.29 - 95%CI 1.41;3.74), white race/skin color (OR=1.61 - 95%CI 1.10;2.38), dependence (OR=1.65 - 95%CI 1.05;2.60), change in eating habits/dieting (OR=1.66 - 95%CI 1.16;2.36), hospitalization in the last 12 months (OR=1.61 - 95%CI 1.02;2.53) and presence of the following self-reported morbidities: systemic arterial hypertension (OR=2.40 - 95%CI 1.33;4.34), diabetes mellitus (OR=2.17 - 95%CI 1.23;3.84), osteoporosis (OR=2.92 - 95%CI 1.84;4.64) and heart problems (OR=2.94 - 95%CI 1.90;4.56).

Conclusion:

This study found that polypharmacy in the older adults was associated with demographic and health conditions.

Keywords:
Polypharmacy; Aged; Prevalence; Drug Utilization; Cross-sectional Studies.

Introduction

In Brazil in 2015 life expectancy at birth was 75.4 years and the proportion of people accounted for 14.3% of the population, whereas only 10 years earlier, in 2005, they accounted for 9.8% of the population. The proportion of Brazilians in 2039 is projected to be 24%.¹1. Instituto Brasileiro de Geografia e Estatística - IBGE. Sinopse do Censo Demográfico 2010 [Internet]. Rio de Janeiro: IBGE; 2011 [citado 2011 dez 12]. Disponível em: Disponível em: http://biblioteca.ibge.gov.br/visualizacao/livros/liv49230.pdf
http://biblioteca.ibge.gov.br/visualizac...

In general, people have a multiplicity of chronic morbidities, this being a fact which makes the treatment process complex due to bodily changes related to age, sex, reduction in cognitive and sensorial abilities, as well as greater difficulty in adhering to treatment.²2. Johansson T, Flamm M, Sönnichsen A, Schuler J. Interventions to reduce inappropriate polypharmacy: implications for research and practice. Maturitas [Internet]. 2017 Mar [cited 2021 Jan 6];97:66-8. Available from: Available from: https://doi.org/10.1016/j.maturitas.2016.12.007
https://doi.org/10.1016/j.maturitas.2016...

Polypharmacy can be associated with aging.³3. Sirois C, Tannenbaum C, Gagnon M, Milhomme D, Émond V. Monitoring polypharmacy at the population level entails complex decisions: results of a survey of experts in geriatrics and pharmacotherapy. Drugs Ther Perspect [Internet]. 2016 Apr [cited 2021 Jan 6];32:257-64. Available from: Available from: https://doi.org/10.1007/s40267-016-0299-0
https://doi.org/10.1007/s40267-016-0299-... Occurrence of polypharmacy, defined as concomitant use of five or more medications, is related to people needing more medication and its consequences include increased incidence of adverse reactions (to medication), such as urinary incontinence, drug interactions and hospitalizations, in addition to the cost of treatment and mortality.⁴4. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf [Internet]. 2014 Jan [cited 2021 Jan 6];13(1):57-65. Available from: Available from: https://dx.doi.org/10.1517%2F14740338.2013.827660
https://dx.doi.org/10.1517%2F14740338.20...

Polypharmacy prevalence in the rose from 13.0% to 40.0%, between 1988 and 2010, in the United States.⁵5. Charlesworth CJ, Smit E, Lee DS, Alramadhan F, Odden MC. Polypharmacy among adults aged 65 years and older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci [Internet]. 2015 Aug [cited 2021 Jan 6];70(8):989-95. Available from: Available from: https://doi.org/10.1093/gerona/glv013
https://doi.org/10.1093/gerona/glv013 ... In Brazil, between 2013 and 2014, polypharmacy prevalence was 18.0%, and was associated with demographic aspects and morbidities.⁶6. Ramos LR, Tavares NUL, Bertoldi AD, Farias MR, Oliveira MA, Luiza VL, et al. Polifarmácia e polimorbidade em idosos no Brasil: um desafio em saúde pública. Rev Saúde Pública [Internet]. 2016 [citado 2021 jan 6];50(Supl 2):9s. Disponível em: Disponível em: https://doi.org/10.1590/S1518-8787.2016050006145
https://doi.org/10.1590/S1518-8787.20160...

Population-based studies aiming to assess the profile of medication use by the in Brazil are needed, principally in the Amazon region, due to peculiarities which include high levels of illiteracy and difficulties in accessing health services in the region.⁷7. Guibu IA, Moraes JC, Guerra Junior AA, Costa EA, Acurcio FA, Costa KS, et al. Características principais dos usuários dos serviços de atenção primária à saúde no Brasil. Rev Saúde Pública [Internet]. 2017 [citado 2021 jan 6];51(Suppl 2):17s. Disponível em: Disponível em: https://doi.org/10.11606/s1518-8787.2017051007070
https://doi.org/10.11606/s1518-8787.2017... High polypharmacy prevalence and scarcity of studies on its characteristics, as well as regional differences, motivated this study, the objective of which was to analyze polypharmacy prevalence and associated factors in older adults in Rio Branco, Acre, Brazil.

Methods

This study is comprised of a population-based survey conducted with people, i.e. over 60 years old, covering the urban and rural areas of the municipality of Rio Branco, capital of the state of Acre, between April and September 2014, focusing on estimated polypharmacy prevalence.

In 2010, the municipality of Rio Branco covered an area of 8,834.942km², with approximately 21,620 people, mostly living in its urban area (91.8%). In the same year, Rio Branco reached a human development index of 0.727,⁸8. Programa das Nações Unidas para o Desenvolvimento - PNUD. Atlas do Desenvolvimento Humano no Brasil 2013 [Internet]. [S.l.]: PNUD; 2013 [citado 2021 jan 6]. Disponível em: Disponível em: http://www.pnud.org.br/IDH/Atlas2013.aspx?indiceAccordion=1&li=li_Atlas2013
http://www.pnud.org.br/IDH/Atlas2013.asp... and what most contributed to this was the longevity of its citizens. The index for longevity was 0.798, followed by income (0.729) and education (0.661).

Eligible study participants comprised all over 60 years old, of both sexes, resident in Rio Branco. Those who had some form of cognitive impairment in relation to communicating and understanding the questions, as identified by the interviewer or as informed by family members, were excluded from the study.

Participants were selected by probabilistic sampling in two stages: census enumeration area (CEA) and household. In order to select the census enumeration area (CEA), we used probability proportional to the number of private households recorded by the 2010 Demographic Census, conducted and published by the Brazilian Institute of Geography and Statistics (IBGE). When selecting the households, we used systematic sampling which began randomly and had different intervals in each.

Probabilistic selection of the sample of elderly people followed cluster sampling procedures in two stages. Once the sample was defined, we selected 40 (out of a total of 338), as is usual in epidemiological studies using sampling based on. Selection of the sectors was done using probability proportional to size (PPS), to make allowance for size differences between clusters. As such, 73 households were selected independently with equal intervals in each by means of systematic sampling and all elderly residents were interviewed. Details of the sampling plan, sample size and sample weighting calibration have been published previously.⁹9. Amaral TLM, Amaral CAA, Portela MC, Monteiro GTR, Vasconcellos MTL. Estudo das doenças crônicas (Edoc): aspectos metodológicos. Rev Saúde Pública [Internet]. 2019 jan [citado 2021 jan 6];53:8. Disponível em: Disponível em: https://doi.org/10.11606/s1518-8787.2019053000847
https://doi.org/10.11606/s1518-8787.2019...

The interviews took place in each household and included administration of a questionnaire which was structured into thematic modules with the following variables:

The interviews enabled data collection. The interviewers were duly qualified and trained in a specific course and were either students of health-related courses or health professionals. A manual containing guidelines was prepared and provided to the interviewers with the aim of standardizing the interviews. Data collection was supervised by the study coordinator.

In order to investigate each person’s degree of independence, the Instrumental Activities of Daily Living (IADL) scale was used. The scale is comprised of eight activities: doing housework; doing laundry; cooking; shopping; using the phone and looking up numbers; driving or using public transportation; managing finances; and managing medications.¹⁰10. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist [Internet]. 1969 Autumn[cited 2021 Jan 6];9(3):179-86. Available from: Available from: https://doi.org/10.1093/geront/9.3_Part_1.179
https://doi.org/10.1093/geront/9.3_Part_... Based on this scale of activities and respective scores, elderly people who scored 27 points were classified as independent, while those who scored 26 points or less were classified as dependent.

Signs and symptoms of depression were investigated using the Geriatric Depression Scale.¹¹11. Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry [Internet]. 1999 Oct [cited 2021 Jan 6];14(10):858-65. Available from: Available from: https://doi.org/10.1002/(sici)1099-1166(199910)14:10%3C858::aid-gps35%3E3.0.co;2-8
https://doi.org/10.1002/(sici)1099-1166(... The scores of this scale range from 0 to 15, whereby scores of 6 or over are considered to be suggestive of depression. When analyzing body mass index (BMI), the cut-off points of the Nutrition Screening Initiative (NSI) for overweight people were considered: BMI >27kg/m².¹²12. Nutrition Screening Initiative. Nutrition interventions manual for professionals caring for older americans. Executive summary. Washington, DC: Nutrition Screening Initiative; 1992. This cut-off point takes into consideration body changes resulting from aging.¹²12. Nutrition Screening Initiative. Nutrition interventions manual for professionals caring for older americans. Executive summary. Washington, DC: Nutrition Screening Initiative; 1992. Physical assessment was performed in order to determine BMI, involving collecting anthropometric data on the participants: weight and height. Weight was measured using G-Tech® Bal Gl 200 digital weighing scales, with 50 gram resolution, placed on a stable and level surface. Height was measured using a portable Sanny® stadiometer, with resolution in millimeters, also placed on a stable and level surface.

Data on current medication use was obtained by asking the following questions:

Medication with prolonged use was identified by asking the question:

Medication use was verified as to active ingredient, dosage and frequency, by checking the prescription or packaging of all medication in use at the time participants were assessed. Medications were categorized using the Anatomical Therapeutic Chemical Code (ATC) adopted by the World Health Organization.¹³13. WHO Collaborating Centre for Drug Statistics Methodology. Guidelines for ATC classification and DDD assignment 2018 [Internet]. Oslo, Norway: WHO; 2017 [cited 2021 Jan 6]. Available from: Available from: https://www.drugsandalcohol.ie/29364/1/WHO%20Collaborating%20Centre%20for%20Drug%20Statistics%20Methodology.pdf
https://www.drugsandalcohol.ie/29364/1/W...

The dependent variable was polypharmacy, defined as ‘concomitant use of 5 or more medications’, dichotomized into ‘Yes’ (use of 5 or more medications) and ‘No’ (use of 0 to 4 medications). The variables analyzed were: sex; age; schooling; presence of self-reported morbidities; self-rated health; degree of independence; signs and symptoms suggestive of depression; obesity; and practicing physical activity.

A pilot study, in which 30 were interviewed and received physical assessment, was conducted for the purpose of controlling the quality of the information.¹⁴14. Stevens LA, Li S, Wang C, Huang C, Becker BN, Bomback AS, et al. Prevalence of CKD and comorbid illness in elderly patients in the United States: results from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis [Internet]. 2010 Mar [cited 2021 Jan 6];55(3 Suppl 2):S23-33. Available from: Available from: https://doi.org/10.1053/j.ajkd.2009.09.035
https://doi.org/10.1053/j.ajkd.2009.09.0...

The sample size was calculated based on prevalence of kidney function changes among elderly people - 40% - as indicated in international studies,¹⁴14. Stevens LA, Li S, Wang C, Huang C, Becker BN, Bomback AS, et al. Prevalence of CKD and comorbid illness in elderly patients in the United States: results from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis [Internet]. 2010 Mar [cited 2021 Jan 6];55(3 Suppl 2):S23-33. Available from: Available from: https://doi.org/10.1053/j.ajkd.2009.09.035
https://doi.org/10.1053/j.ajkd.2009.09.0... considering the population of 23,416 estimated to be resident in Rio Branco on July 1^st 2014, taking a 95% confidence interval and absolute error of 3 percentage points. As the sampling plan followed the procedures for complex sampling, a design effect of 1.95 was used, thus resulting in an estimate of 1,020 elderly people.

Descriptive analyses were made of the data, expressed in absolute and relative frequencies, in order to characterize the population studied. Analysis of the differences between proportions was based on Pearson’s chi-square test.

Association between use of medication and the independent variables was ascertained by crude and adjusted analysis, using logistic regression, to facilitate comparison with the results of other studies, using the hierarchical odds ratio (OR) model of measures of association. We used a process of modeling by blocks in which polypharmacy was initially adjusted by the ‘sex’ and ‘race/skin color’ distal variables. The ‘degree of independence’, ‘overweight’ and ‘change in eating habits/dieting’ variables were introduced in the intermediate block, while the variables relating to health conditions were incorporated into the proximal block, with the aim of controlling possible confounding factors. Adjustment was initially performed within each level of the model by including variables with p<0.10 in the bivariate analysis. Variables that reached p<0.05 were kept in the final model. A 5% significance level analyzed by the Wald test was adopted.

The SAS statistical package (version 9.4) was used. All the analyses took into account the sample design effect and the calibrated weights of the observations; the results obtained took the calibrated weights into consideration with the aim of their being extrapolated to the population by ‘estimation (n)’. To this end the maximum pseudolikelihood method was used, considering the sample weights and the structural information of the sample plan. The inferences were assessed using the Wald statistic, based on the sample plan, along with F distribution.

The study project was approved by the Federal University of Acre Human Research Ethics Committee: Opinion No. 518.531, issued on January 30^th 2014; Certificate of Submission for Ethical Appraisal No. 17543013.0.0000.5010. The study participants signed a Free and Informed Consent form and their right to refuse to take part and to have their data kept confidential was guaranteed.

Results

Out of the sample of 1,016 interviewees, there was a total of 59 losses and refusals, resulting in an expanded population of 23,416. Polypharmacy prevalence in that population was 14.9% (95%CI 11.8;18.6).

Polypharmacy was more frequent among women, individuals of white race/skin color, those who had no partner and older elderly people. Among sedentary individuals, there was 14.3% polypharmacy, while it was 21.9% among those who changed their eating habits/dieting (Table 1).

The proportion of those who had been hospitalized in the last 12 months was 16.6%. Among those with polypharmacy, this prevalence rate was 23.7% (Table 1). The main reasons for hospitalization were changes to arterial pressure (23.7%), followed by heart problems (17.9%), infections (14.1%), surgery (13.7%) and strokes (10.2%).

There was higher prevalence of polypharmacy among those who reported poor and very poor self-rated health, those with signs and symptoms of depression, those who were considered to be dependent according to IADL, those who were obese; and those who self-reported arterial hypertension, diabetes mellitus, insomnia, arthritis/arthrosis, osteoporosis, heart problems, dyslipidemia and depression (Table 1).

In the analysis adjusted by hierarchical level, the following variables kept their statistical significance on the intermediate level: female sex; white race/skin color; dependence according to IADL; and change in eating habits/dieting. The following variable remained in the third model (proximal level): white race/skin color; dependence according to IADL; hospitalized in the last 12 months; and self-reported morbidities - arterial hypertension, diabetes mellitus, osteoporosis and heart problems (Table 2).

Discussion

Polypharmacy prevalence was lower in Rio Branco, Acre, when compared to prevalence rates found by other studies.⁵5. Charlesworth CJ, Smit E, Lee DS, Alramadhan F, Odden MC. Polypharmacy among adults aged 65 years and older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci [Internet]. 2015 Aug [cited 2021 Jan 6];70(8):989-95. Available from: Available from: https://doi.org/10.1093/gerona/glv013
https://doi.org/10.1093/gerona/glv013 ... ^,66. Ramos LR, Tavares NUL, Bertoldi AD, Farias MR, Oliveira MA, Luiza VL, et al. Polifarmácia e polimorbidade em idosos no Brasil: um desafio em saúde pública. Rev Saúde Pública [Internet]. 2016 [citado 2021 jan 6];50(Supl 2):9s. Disponível em: Disponível em: https://doi.org/10.1590/S1518-8787.2016050006145
https://doi.org/10.1590/S1518-8787.20160... The associated factors on the distal level were female sex and being of white race/skin color; on the intermediate level, the associated factors were found to be dependence, according to the Instrumental Activities of Daily Living (IADL) assessment, and change in eating habits and/or dieting. On the proximal level, the following were found to be associated with polypharmacy: hospitalized in the last 12 months and presence of these self-reported morbidities: systemic arterial hypertension, diabetes mellitus, osteoporosis and heart problems.

The prevalence rate found by this study is lower than that found in other developed countries, as can be seen in a study conducted in 2011 with a population of 12,301,537 Italians aged 65 or over, among whom polypharmacy prevalence was 49.0%;¹⁵15. Onder G, Bonassi S, Abbatecola AM, Folino-Gallo P, Lapi F, Marchionni N, et al. High prevalence of poor quality drug prescribing in older individuals: a nationwide report from the Italian Medicines Agency (AIFA). J Gerontol A Biol Sci Med Sci [Internet]. 2014 Apr [cited 2021 Jan 6];69(4):430-7. Available from: Available from: https://doi.org/10.1093/gerona/glt118
https://doi.org/10.1093/gerona/glt118... or the prevalence rate of 39.0% found in the United States, in a National Health and Nutrition Survey (1988-2010) with a sample of 13,869 people ≥65 years.⁵5. Charlesworth CJ, Smit E, Lee DS, Alramadhan F, Odden MC. Polypharmacy among adults aged 65 years and older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci [Internet]. 2015 Aug [cited 2021 Jan 6];70(8):989-95. Available from: Available from: https://doi.org/10.1093/gerona/glv013
https://doi.org/10.1093/gerona/glv013 ... On the other hand, the rate found by our study is higher than that found by a population-based study conducted in Cuiabá in 2012 (10.3%)¹⁶16. Almeida NA, Reiners AAO, Azevedo RCS, Silva AMC, Cardoso JDC, Souza LC. Prevalence of and factors associated with polypharmacy among elderly persons resident in the community. Rev Bras Geriatr Gerontol [Internet]. 2017 Jan-Feb [cited 2021 Jan 6];20(1):138-48. Available from: Available from: http://dx.doi.org/10.1590/1981-22562017020.160086
http://dx.doi.org/10.1590/1981-225620170... with 573; while it is similar to a study conducted in the Belo Horizonte metropolitan region (14.%)¹⁷17. Loyola Filho AL, Uchoa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública [Internet]. 2006 dez [citado 2021 jan 6];22(12):2657-67. Disponível em: Disponível em: http://dx.doi.org/10.1590/S0102-311X2006001200015
http://dx.doi.org/10.1590/S0102-311X2006... with 1,598 in 2003. However, the estimated prevalence found in our study with in Rio Branco was lower than that found by a study conducted in 2006 with individuals aged 65 and over living in São Paulo: 36.0%.¹⁸18. Carvalho MFC, Romano-Lieber NS, Bergsten-Mendes G, Secoli SR, Ribeiro E, Lebrão ML, et al. Polifarmácia entre idosos do Município de São Paulo - Estudo SABE. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2021 jan 6];15(4):817-27. Disponível em: Disponível em: http://dx.doi.org/10.1590/S1415-790X2012000400013
http://dx.doi.org/10.1590/S1415-790X2012... The above information indicates that polypharmacy prevalence in Brazil is heterogeneous and varies considerably according to geographic region. This heterogeneity may result from socioeconomic conditions and health care models adopted, as well as cultural, demographic and health status factors involved.¹⁷17. Loyola Filho AL, Uchoa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública [Internet]. 2006 dez [citado 2021 jan 6];22(12):2657-67. Disponível em: Disponível em: http://dx.doi.org/10.1590/S0102-311X2006001200015
http://dx.doi.org/10.1590/S0102-311X2006...

Being of the female sex kept association with polypharmacy in Rio Branco, as was also found by a study conducted in São Paulo city with 1,115 participant aged 65 and over.¹⁸18. Carvalho MFC, Romano-Lieber NS, Bergsten-Mendes G, Secoli SR, Ribeiro E, Lebrão ML, et al. Polifarmácia entre idosos do Município de São Paulo - Estudo SABE. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2021 jan 6];15(4):817-27. Disponível em: Disponível em: http://dx.doi.org/10.1590/S1415-790X2012000400013
http://dx.doi.org/10.1590/S1415-790X2012... This fact may be related to the higher number of chronic morbidities and, consequently, women seeking health care more. Here it is appropriate to remember what has already been recognized: women are more concerned about their health condition and live longer than men.¹⁷17. Loyola Filho AL, Uchoa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública [Internet]. 2006 dez [citado 2021 jan 6];22(12):2657-67. Disponível em: Disponível em: http://dx.doi.org/10.1590/S0102-311X2006001200015
http://dx.doi.org/10.1590/S0102-311X2006...

People considered to be dependent reported higher polypharmacy prevalence than people who were more independent, given that a larger number of morbidities is found in dependent people, thus increasing their demand for medications.¹⁹19. Lima ALB, Espelt A, Lima KC, Bosque-Prous M. Activity limitation in elderly people in the European context of gender inequality: a multilevel approach. Ciênc Saúde Coletiva [Internet]. 2018 Sep [cited 2021 Jan 6];23(9):2991-3000. Available from: Available from: http://dx.doi.org/10.1590/1413-81232018239.20662016
http://dx.doi.org/10.1590/1413-812320182... A study conducted in Ireland between 2009 and 2011 with 3,499 people aged 65 and over, concluded that simultaneous use of five or more medications resulted in association with instrumental activities of daily living (OR=1.68 - 95%CI 1.04;2.70). That study also noted the importance of preventive actions for changeable factors associated with functional limitations.²⁰20. Connolly D, Garvey J, McKee G. Factors associated with ADL/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA). Disabil Rehabil [Internet]. 2017 Apr [cited 2021 Jan 6];39(8):809-16. Available from: Available from: https://doi.org/10.3109/09638288.2016.1161848 21 .
https://doi.org/10.3109/09638288.2016.11... It should be emphasized that for the most part medication use is appropriate. However, its improper use is a dangerous reality, especially for the functional health of the.

Greater polypharmacy prevalence was also found among individuals who had changed their eating habits or who dieted regularly. This information may be explained, albeit partially, by receipt of guidance on changing eating habits or prescription of a specific diet, as a response to prior diagnosis of diseases related to obesity. Weight loss results in improved arterial pressure and blood glucose levels²¹21 Zhao Y, Zhang M, Luo X, Wang C, Li L, Zhang L, et al. Association of 6-year waist circumference gain and incident hypertension. Heart [Internet]. 2017 Sep [cited 2021 Jan 6];103(17):1347-52. Available from: Available from: https://doi.org/10.1136/heartjnl-2016-310760
https://doi.org/10.1136/heartjnl-2016-31... and thus favors disease control and the result expected from treatment with medication. In our study, given its temporality limitation, it was not possible to identify the effect of this change on diet.

Prevalence of hospitalization increases with age, due to degenerating health status, thus generating more demand for treatment with medication. Having been hospitalized in the last twelve months showed positive association with polypharmacy, as also reported by another study.¹⁸18. Carvalho MFC, Romano-Lieber NS, Bergsten-Mendes G, Secoli SR, Ribeiro E, Lebrão ML, et al. Polifarmácia entre idosos do Município de São Paulo - Estudo SABE. Rev Bras Epidemiol [Internet]. 2012 dez [citado 2021 jan 6];15(4):817-27. Disponível em: Disponível em: http://dx.doi.org/10.1590/S1415-790X2012000400013
http://dx.doi.org/10.1590/S1415-790X2012... Cardiovascular complications are among the leading causes of hospitalization, in this study, and are related to aging, which favors arteriosclerosis, reduction in aortic distensibility and that of the great arteries, impairment of cardiac conduction and reduction in the baroreceptor function.²²22. Zaslavsky C, Gus I. Idoso: doença cardíaca e comorbidades. Arq Bras Cardiol [Internet]. 2002 [citado 2021 jan 6];79(6):635-9. Disponível em: Disponível em: http://publicacoes.cardiol.br/abc/2002/7906/79060011.pdf
http://publicacoes.cardiol.br/abc/2002/7...

In Rio Branco, arterial hypertension and heart problems (fibrillation, arrhythmias and heart failure) were most prevalent among the self-reported morbidities. The effects of age on the circulatory system, already observed elsewhere, as well as diabetes mellitus and osteoporosis were also found. These morbidities are highly prevalent in Brazil and, in most cases, require continuous use of medication.²³23. Tavares NUL, Costa KS, Mengue SS, Vieira MLFP, Malta DC, Silva Júnior JB. Uso de medicamentos para tratamento de doenças crônicas não transmissíveis no Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saúde [Internet]. 2015 abr-jun [citado 2021 jan 6];24(2):315-23. Disponível em: Disponível em: http://dx.doi.org/10.5123/S1679-49742015000200014
http://dx.doi.org/10.5123/S1679-49742015...

Diabetes mellitus is a serious chronic morbidity, can lead to complications and requires continuous medication to control it.²⁴24. Sociedade Brasileira de Diabetes -SBD. Diretrizes Sociedade Brasileira de Diabetes 2019-2020 [Internet]. São Paulo: Editora Clannad; 2019 [citado 2021 jan 6]. Disponível em: Disponível em: https://www.diabetes.org.br/profissionais/images/DIRETRIZES-COMPLETA-2019-2020.pdf
https://www.diabetes.org.br/profissionai... Among the adequate self-control of blood glucose is infrequent, thus increasing the risk of hypoglycemia or hyperglycemia and, as a consequence, microvascluar and macrovascular complications which result in polypharmacy. Targets for improving quality of life and increasing life expectancy should be the health focus for elderly diabetic patients. They are possible to achieve, by continually controlling blood glucose levels, which in turn requires a joint effort on the part of health workers, family members, carers and patients themselves.²⁵25. Atif M, Saleem Q, Babar ZU, Scahill S. Association between the vicious cycle of diabetes-associated complications and glycemic control among the elderly: a systematic review. Medicina (Kaunas) [Internet]. 2018 Oct [cited 2021 Jan 6];54(5):73. Available from: Available from: https://doi.org/10.3390/medicina54050073
https://doi.org/10.3390/medicina54050073...

As age advances, manifestation of osteomuscular problems is recurrent and they can result in disabilities and morbidity and mortality. Another study found association between osteoporosis and greater intake of medication among people, as well as abusive medication intake being associated with the appearance of osteoporosis.²⁶26. O'Connell MB, Borgelt LM, Bowles SK, Vondracek SF. Drug-induced osteoporosis in the older adult. Aging Health [Internet]. 2010 Aug [cited 2021 Jan 6];6(4):501-18. Available from: Available from: https://doi.org/10.2217/ahe.10.42
https://doi.org/10.2217/ahe.10.42...

Regardless of which morbidity, the choice of medications for treating and controlling diseases in the should be based on joint decision making, taking into consideration presence of comorbidities, polypharmacy, physical frailty and potential adverse effects. In this way, patients are guaranteed awareness not only of the benefits but also possible complications resulting from using the medications indicated. Use of electronic medical records helps health professionals involved in prescribing medication to identify risk of adverse health events and complications, and in this sense it is important to implement medication safety management programs²⁷27. Mair A, Fernandez-Llimos F, Alonso A, Harrison C, Hurding S, Kempen T, et al. Polypharmacy management by 2030: a patient safety challenge [Internet]. 2nd ed. Coimbra: SIMPATHY Consortium; 2017[cited 2021 Jan 6]. Available from: Available from: https://rgu-repository.worktribe.com/output/246840/polypharmacy-management-by-2030-a-patient-safety-challenge
https://rgu-repository.worktribe.com/out... aimed at the safe, efficacious and adequate use.

It is essential to eliminate any uncertainties about treatment regimens that the their carers and family members may have and this requires providing precise information. In addition, health professionals must assess both the need to treat symptoms or adverse events, and also the need to prescribe more than five medications for a patient; and always ask about and check what medication they are using, before prescribing new medication.²⁸28. Alsuwaidan A, Almedlej N, Alsabti S, Daftardar O, Al Deaji F, Al Amri A, et al. A comprehensive overview of polypharmacy in elderly patients in Saudi Arabia. Geriatrics[Internet]. 2019 Jun [cited 2021 Jan 6];4(2):36. Available from: Available from: https://dx.doi.org/10.3390%2Fgeriatrics4020036
https://dx.doi.org/10.3390%2Fgeriatrics4...

This cross-sectional population-based study with a sample of non-institutionalized older adults living in Rio Branco, Acre, revealed polypharmacy prevalence in this population and associated factors. Given this study design, it is appropriate to recognize limitations inherent to it. Firstly, causality between the variables studied cannot be confirmed. Moreover, the data on morbidities were self-reported, so that lack of information about the amount of time that has passed since diagnosis may be a confounding factor for polypharmacy; however, the need for self-reporting, with the aim of obtaining more reliable information, led to the researchers opting for this exclusion criterion. Finally, excluding individuals with cognitive and communication impairment may have underestimated the prevalence rate found.

Polypharmacy prevalence was lower than that found for Brazil as a whole, and was more frequent among women, people who self-reported their race/skin color as being white, those who were dependent, those who had changed their eating/dieting habits, those who were hospitalized in the last 12 months and those with systemic arterial hypertension, diabetes mellitus, osteoporosis and heart problems. These social segments, identified as groups more vulnerable to polypharmacy, require drug safety actions capable of avoiding unwanted effects of medication on their health.

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