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Multiple Comorbidities and Multiple Medications: The Challenges Facing Older Adults with Heart Failure

Kwak MJ, Cheng M, Goyal P, et al. Medication Complexity Among Older Adults with HF: How Can We Assess Better?. Drugs Aging. 2022;39(11):851-861. doi:10.1007/s40266-022-00979-2

Heart failure affects 6 million Americans today, over half of whom are 75 and older. Older adults with heart failure face complex medication regimens that are further complicated by the cognitive, physical, and social challenges of aging. Older adults taking multiple medications are at greater risk of adverse drug events, medication errors, drug-drug or drug-disease interactions, and nonadherence. Few studies, however, have assessed the complexity of medications or clinical outcomes among older adults with heart failure. USDeN Pilot Awardee Dr. Min Ji Kwak led a review of heart failure medication management, covering medication regimen complexity assessment, outcome assessment, and the representation of older adults in the literature. Nine research articles on medication complexity among heart failure patients were included in the literature view.

Assessment of Medication Regimen Complexity:

The most commonly used assessment tools were the Medication Complexity Index (MCI) and the Medication Regimen Complexity Index (MRCI). The MCI accounts for the number and frequency of medications and additional medication directions. The MRCI also includes the number of units per dose and dosage forms, and is a well-validated measure.

Outcome Assessment:

The most commonly assessed clinical outcome was rehospitalization. Other recurring outcomes were medication adherence, quality of life, healthcare costs and utilization, and side effects. Despite similarities across clinical outcomes, reported associations between complexity and outcomes were inconsistent.

Representation of Older Adults:

Only three of the nine studies focused on older adults, and only one of the three included very old adults and those with cognitive impairment. Excluding groups who struggle most with medication management, such as those with cognitive impairment, affects the reliability of study results.

The authors conclude that additional studies are needed to effectively and consistently assess medication regimen complexity. These studies must include older adults with heart failure to contribute to our understanding of medication management. Primary author Dr. Kwak weighs in on the importance of this topic:

“The current medication complexity measurement tools mainly focus on the number of medications, frequencies, or special instructions, but do not incorporate older adults’ unique characteristics that can significantly affect the clinical outcomes of various pharmacotherapy. For example, older adults’ frailty can alter the pharmacokinetics of the medication causing more side effects, cognitive impairment may cause nonadherence or medication errors resulting in more adverse drug events, or multimorbidity can put the older adults in a situation of therapeutic competition. Therefore, when assessing medication complexity for older adults, a more comprehensive approach is needed to account for such geriatric syndromes, not merely counting the number of medications or frequencies.”

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