Late-life depression and the association with multimorbidity and polypharmacy: a cross-sectional study.

Background: Late-life depression often coincides with chronic somatic diseases and, consequently, with polypharmacy, which may complicate medical treatment. Objective: To determine the associations between patients diagnosed with late-life depression in primary care and multimorbidity and polypharmacy. Methods: This cross-sectional observational study was performed using 2012 primary care data. Depressed patients aged ≥60 years were compared to age and gender matched patients diagnosed with other psychological diagnoses and mentally healthy controls. Morbidity and prescription data were combined, and regression analyses were performed for the associations between depression and chronic disease and chronic drug use. Results: We included 4477 patients; 1512 had a record of depression, 1457 of other mental health or psychological diagnoses and 1508 were controls. Depressed patients had a 16% [Prevalence Ratio (PR) 1.16; 95% confidence interval (95% CI) 10%-24%] higher rate of chronic somatic disease and higher odds for multimorbidity (OR 1.55; 95% CI 1.33-1.81) compared with controls. No differences existed between depressed patients and patients with other psychological diagnoses. Compared with controls, depressed patients had a 46% (95% CI 39-53%) higher rate of chronic drug use and higher odds for polypharmacy (OR 2.89; 95% CI 2.41-3.47). Depressed patients also had higher rates of chronic drug use and higher odds for polypharmacy compared with patients with other psychological diagnoses (PR 1.26; OR 1.75; both P < 0.001). Conclusions: Late-life depression in primary care patients is associated with more chronic drug use, even beyond the increased rates of comorbid somatic diseases. General practitioners should consider medication reviews to prevent unnecessary drug-related problems in these patients.

Medication management strategy for older people with polypharmacy in general practice: a qualitative study on prescribing behaviour in primary care.

BACKGROUND: For older patients with polypharmacy, medication management is a process of careful deliberation that needs periodic adjustment based on treatment effects and changing conditions. Because of the heterogeneity of the patient group, and limited applicability of current guidelines, it is difficult for GPs to build up a routine. AIM: To gain insight into GPs' medication management strategies for patients with polypharmacy, and to explore the GPs' perspectives and needs on decision-making support to facilitate this medication management. DESIGN AND SETTING: Two focus group meetings with Dutch GPs, discussing four clinical vignettes of patients with multimorbidity and polypharmacy. METHOD: Questions about medication management of the vignettes were answered individually; the strategy chosen in each case was discussed in plenary. Analysis followed a Framework approach. RESULTS: In total, 12 GPs described a similar strategy regarding the patients' medication management: defining treatment goals; determining primary goals; and adjusting medications based on the treatment effect, GPs' and patients' preferences, and patient characteristics. There was variation in the execution of this strategy between the GPs. The GPs would like to discuss their choices with other professionals and they valued structured medication reviews with the patient, as well as quick and practical support tools that work on demand. CONCLUSION: To facilitate decision making, a more extensive and structured collaboration between healthcare professionals is desired, as well as support to execute structured medication reviews with eligible patients, and some on-demand tools for individual consultations.

Inter-practice variation in polypharmacy prevalence amongst older patients in primary care.

PURPOSE: Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics. METHODS: This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models. RESULTS: After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status. CONCLUSIONS: Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients. Copyright © 2016 John Wiley & Sons, Ltd.

Multimorbidity patterns in a primary care population aged 55 years and over.

BACKGROUND: To support the management of multimorbid patients in primary care, evidence is needed on prevalent multimorbidity patterns. OBJECTIVE: To identify the common and distinctive multimorbidity patterns. METHODS: Clinical data of 120480 patients (≥55 years) were extracted from 158 general practices in 2002-11. Prevalence rates of multimorbidity were analyzed (overall, and for 24 chronic diseases), adjusted for practice, number of diseases and patients' registration period; differentiated between patients 55-69 and ≥70 years. To investigate multimorbidity patterns, prevalence ratios (prevalence rate index-disease group divided by that in the non-index-disease group) were calculated for patients with heart failure, diabetes mellitus, migraine or dementia. RESULTS: Multiple membership multilevel models showed that the overall adjusted multimorbidity rate was 86% in patients with ≥1 chronic condition, varying from 70% (migraine) to 98% (heart failure), 38% had ≥4 chronic diseases. In patients 55-69 years, 83% had multimorbidity. Numerous significant prevalence ratios were found for disease patterns in heart failure patients, ranging from 1.2 to 7.7, highest ratio for chronic obstructive pulmonary disease-cardiac dysrhythmia. For diabetes mellitus, dementia or migraine patients highest ratios were for heart failure-visual disorder (2.1), heart failure-depression (3.9) and depression-back/neck disorder (2.1), respectively (all P-values<0.001). CONCLUSIONS: Multimorbidity management in general practice can be reinforced by knowledge on the clinical implications of the presence of the comprehensive disease patterns among the elderly patients, and those between 55 and 69 years. Guideline developers should be aware of the complexity of multimorbidity. As a consequence of this complexity, it is even more important to focus on what matters to a patient with multimorbidity in general practice.

The prevalence of disease clusters in older adults with multiple chronic diseases--a systematic literature review.

BACKGROUND: Since most clinical guidelines address single diseases, treatment of patients with multimorbidity, the co-occurrence of multiple (chronic) diseases within one person, can become complicated. Information on highly prevalent combinations of diseases can set the agenda for guideline development on multimorbidity. With this systematic review we aim to describe the prevalence of disease combinations (i.e. disease clusters) in older patients with multimorbidity, as assessed in available studies. In addition, we intend to acquire information that can be supportive in the process of multimorbidity guideline development. METHODS: We searched MEDLINE, Embase and the Cochrane Library for all types of studies published between January 2000 and September 2012. We included empirical studies focused on multimorbidity or comorbidity that reported prevalence rates of combinations of two or more diseases. RESULTS: Our search yielded 3070 potentially eligible articles, of which 19 articles, representing 23 observational studies, turned out to meet all our quality and inclusion criteria after full text review. These studies provided prevalence rates of 165 combinations of two diseases (i.e. disease pairs). Twenty disease pairs, concerning 12 different diseases, were described in at least 3 studies. Depression was found to be the disease that was most commonly clustered, and was paired with 8 different diseases, in the available studies. Hypertension and diabetes mellitus were found to be the second most clustered diseases, both with 6 different diseases. Prevalence rates for each disease combination varied considerably per study, but were highest for the pairs that included hypertension, coronary artery disease, and diabetes mellitus. CONCLUSIONS: Twenty disease pairs were assessed most frequently in patients with multimorbidity. These disease combinations could serve as a first priority setting towards the development of multimorbidity guidelines, starting with the diseases with the highest observed prevalence rates and those with potential interacting treatment plans.

Implementation intentions for buying, carrying, discussing and using condoms: the role of the quality of plans.

Forming implementation intentions (i.e. action plans that specify when, where and how a person will act) could be effective in promoting condom use on a large scale. However, the technique implies that people are able to form high quality implementation plans that are likely to induce behaviour change. Young single females, aged 16-30 years old, were asked to form either an implementation intention for the target behaviour using condoms (n = 159) or preparatory implementation intentions for buying, carrying, discussing and using condoms (n = 146). Condom preparations were assessed at follow-up 2 months later. The implementation intentions that participants formed were rated on quality. In general, it appeared hard for young women to form high quality general implementation intentions for the target behaviour condom use. Implementation intentions for the preparatory behaviours were of better quality than general implementation intentions. Females who formed strong implementation intentions in the preparatory behaviours condition were more committed to these plans and perceived them as more useful. Plan commitment and perceived usefulness predicted condom preparations at follow-up. We conclude that it is important to ask individuals to form implementation intentions for the preparatory behaviours rather than for the target behaviour alone.