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Polypharmacy cut-points in older people with cancer: how many medications are too many?

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Abstract

Purpose

Polypharmacy is often defined as use of ‘five-or-more-medications’. However, the optimal polypharmacy cut-point for predicting clinically important adverse events in older people with cancer is unclear. The aim was to determine the sensitivities and specificities of a range of polypharmacy cut-points in relation to a variety of adverse events in older people with cancer.

Methods

Data on medication use, falls and frailty criteria were collected from 385 patients aged ≥70 years presenting to a medical oncology outpatient clinic. Receiver operating characteristic (ROC) curves were produced to examine sensitivities and specificities for varying definitions of polypharmacy in relation to exhaustion, falls, physical function, Karnofsky Performance Scale (KPS) and frailty. Sub-analyses were performed when stratifying by age, sex, comorbidity status and analgesic use.

Results

Patients had a mean age of 76.7 years. Using Youden’s index, the optimal polypharmacy cut-point was 6.5 medications for predicting frailty (specificity 67.0 %, sensitivity 70.0 %), physical function (80.2 %, 49.3 %) and KPS (69.8 %, 52.1 %), 5.5 for falls (59.2 %, 73.0 %) and 3.5 for exhaustion (43.4 %, 74.5 %). For polypharmacy defined as five-or-more-medications, the specificities and sensitivities were frailty (44.9 %, 77.5 %), physical function (58.0 %, 69.7 %), KPS (47.7 %, 69.4 %), falls (44.5 %, 75.7 %) and exhaustion (52.6 %, 64.1 %). The optimal polypharmacy cut-points were similar when the sample was stratified by age, sex, comorbidity status and analgesic use.

Conclusions

Our results suggest that no single polypharmacy cut-point is optimal for predicting multiple adverse events in older people with cancer. In this population, the common definition of five-or-more-medications is reasonable for identifying ‘at-risk’ patients for medication review.

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Acknowledgments

The authors would like to thank the staff of the medical oncology outpatient clinic and the geriatric oncology multidisciplinary team at the Royal Adelaide Hospital for their enthusiastic support, participation and dedication to data collection.

Preliminary results of this study were presented in poster form at the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists Annual Scientific Meeting, Melbourne, December 2014.

Contributions of authors

JT, KJ and SB contributed to the conception and design of the study.

NS and RP contributed to the acquisition of the data.

JT, KJ, SS and SB contributed to the analysis and interpretation of the data.

JT drafted the manuscript.

All authors critically revised the manuscript for important intellectual content.

All authors gave final approval for the manuscript to be published.

All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Authors and Affiliations

  1. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, 3052, Melbourne, VIC, Australia

    Justin P. Turner, Kris M. Jamsen & J. Simon Bell

  2. School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia

    Justin P. Turner & J. Simon Bell

  3. Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia

    Justin P. Turner & Sepehr Shakib

  4. NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, University of Sydney, Sydney, NSW, Australia

    Kris M. Jamsen & J. Simon Bell

  5. Department of Medical Oncology, Royal Adelaide Hospital, Adelaide, SA, Australia

    Nimit Singhal

  6. School of Medicine, Adelaide University, Adelaide, SA, Australia

    Nimit Singhal

  7. Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia

    Robert Prowse

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  1. Justin P. Turner
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Correspondence to Justin P. Turner.

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Funding

Justin Turner was funded through an Australian Postgraduate Award at the University of South Australia and Faculty Scholarship from the Centre for Medicine Use and Safety at the Faculty of Pharmacy and Pharmaceutical Sciences, Monash University.

Conflict of interest

The authors have declared no conflicts of interest.

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Turner, J.P., Jamsen, K.M., Shakib, S. et al. Polypharmacy cut-points in older people with cancer: how many medications are too many?. Support Care Cancer 24, 1831–1840 (2016). https://doi.org/10.1007/s00520-015-2970-8

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  • DOI: https://doi.org/10.1007/s00520-015-2970-8

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