The delicate choice of optimal basic therapy for multimorbid older adults: A cross-sectional survey

Res Social Adm Pharm. 2019 Jun;15(6):761-766. doi: 10.1016/j.sapharm.2018.09.008. Epub 2018 Sep 19.


Background: Clinical practice guidelines are useful to suggest pharmacological therapies for the treatment of single chronic diseases. However, there is little guidance for multimorbidity, and specific quality measures for people with multimorbidity that can be used at a population level are lacking.

Objective: To describe what pharmacists and geriatricians consider to be an optimal basic pharmacological therapy for an older individual with type 2 diabetes (DM), chronic obstructive pulmonary disease (COPD) and heart failure (HF).

Methods: An online cross-sectional survey among 162 pharmacists and geriatricians, in Quebec, Canada, was performed. Participants were invited to choose, from a list of 32 medications or classes, the optimal basic therapy for an individual aged 65-75 years with the 3 chronic diseases. Descriptive statistics were used to calculate the median number of medications chosen and the proportions of participants who chose each medication, according to the participant's specialty. A Kruskall-Wallis test was performed to detect whether there were differences in the median number of medications recommended according to speciality.

Results: There was little consensus on the optimal basic pharmacological therapy for this hypothetical multimorbid individual, with 157 different combinations provided by the 162 participants. Nevertheless, 5 classes were chosen by at least 75% of the participants: metformin, long-acting anticholinergic agents, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta-blockers, and short-acting beta-agonists. The median number of recommended medications was 10 (interquartile range [IQR]: 6-13). There was a statistically significant difference between specialties (p = 0.0396). Geriatricians recommended the lower median number of medications, 7 (IQR: 5-10).

Conclusions: At least half of the participants considered polypharmacy (≥10 medications) inevitable for an optimal basic treatment of DM, COPD and HF. The heterogeneity of responses raises issues when considering quality indicators in population-based studies.

Keywords: Chronic obstructive pulmonary disease; Diabetes; Heart failure; Multimorbidity; Polypharmacy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adrenergic beta-Agonists / therapeutic use
  • Adrenergic beta-Antagonists / therapeutic use
  • Aged
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Cholinergic Antagonists / therapeutic use
  • Diabetes Mellitus, Type 2 / drug therapy*
  • Diabetes Mellitus, Type 2 / epidemiology
  • Geriatricians*
  • Heart Failure / drug therapy*
  • Heart Failure / epidemiology
  • Humans
  • Metformin / therapeutic use
  • Multimorbidity
  • Pharmacists*
  • Polypharmacy
  • Practice Patterns, Physicians'
  • Pulmonary Disease, Chronic Obstructive / drug therapy*
  • Pulmonary Disease, Chronic Obstructive / epidemiology
  • Quebec


  • Adrenergic beta-Agonists
  • Adrenergic beta-Antagonists
  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Cholinergic Antagonists
  • Metformin