INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ’AAIDD

2014, Vol. 52, No. 1, 60–77 DOI: 10.1352/1934-9556-52.1.60

Perspectives
Lessons Learned From Our Elders: How to Study Polypharmacy
in Populations With Intellectual and Developmental Disabilities
Jessica N. Stortz, Johanna K. Lake, Virginie Cobigo, Hélène M. J. Ouellette-Kuntz, and Yona Lunsky

Abstract
Polypharmacy is the concurrent use of multiple medications, including both psychotropic and non-
psychotropic drugs. Although it may sometimes be clinically indicated, polypharmacy can have a
number of negative consequences, including medication nonadherence, adverse drug reactions, and
undesirable drug–drug interactions. The objective of this paper was to gain a better understanding of
how to study polypharmacy among people with intellectual and developmental disabilities (IDD).
To do this, we reviewed literature on polypharmacy among the elderly and people with IDD to
inform future research approaches and methods on polypharmacy in people with IDD. Results
identified significant variability in methods used to study polypharmacy, including definitions of
polypharmacy, samples studied, analytic strategies, and variables included in the analyses. Four
valuable methodological lessons to strengthen future polypharmacy research in individuals with
IDD emerged. These included the use of consistent definitions of polypharmacy, the
implementation of population-based sampling strategies, the development of clinical guidelines,
and the importance of studying associated variables.
Key Words: polypharmacy; intellectual and developmental disabilities; autism spectrum disorders,
medication

In its simplest form, polypharmacy is defined as the
concurrent use of multiple psychotropic and non-psycho-
tropic medications (Bjerrum, Rosholm, Hallas, &
Kragstrup, 1997; Chutka, Takahashi, & Hoel, 2004).
Polypharmacy often occurs in the context of chronic
medical conditions or psychiatric and medical comor-
bidities when the use of multiple medications may be
clinically indicated (Fulton & Riley Allen, 2005).
This paper emerges as part of ongoing health-
services research on the quality of health care
provided to adults with intellectual and develop-
mental disabilities (IDD) across a series of indicators
using population-based administrative health data.
In the context of this research program, we selected
indicators of the quality of health care based on
existing clinical guidelines for adults with IDD
(Sullivan et al., 2011). We identified polypharmacy
as a key indicator because the use of multiple
medications can be harmful and require clinical
attention (Sullivan et al., 2011). In an effort to inform
our study of polypharmacy at the population level,
including identification of important variables to
consider when studying and comparing polypharmacy
rates across different population groups, we examined
the literature on polypharmacy among people with
IDD. In conducting this literature review, we also
chose to examine literature on polypharmacy in the
elderly because (a) data on medications dispensed to
the elderly is available in many jurisdictions at the
population level, and (b) the aging population is
recognized as one at risk of polypharmacy (Chutka et
al., 2004).
Adults with IDD are often diagnosed with
comorbid conditions, including gastrointestinal
problems, sleep disorders, epilepsy, attention deficit
and hyperactivity disorder, schizophrenia, bipolar
disorder, anxiety, and depression (Bauman, 2010;
Levy, Mandell, & Schultz, 2009; Mahan et al.,
2010; Wood, Hall, Zhang, & Hou, 2006). In
addition, chronic diseases, such as diabetes, cere-
brovascular disease, and cardiovascular disease, are
becoming more prominent in individuals with IDD
as their life expectancy has increased in recent
years (Wood et al., 2006). Consequently, individ-
uals with IDD receive more prescriptions per year
and are at greater risk for polypharmacy than the

60 Polypharmacy in Populations With IDD

INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
general population (Straetmans, van Schrojenstein
Lantman-de Valk, Schellevis, & Dinant, 2007). In
particular, the prescribing of psychotropic medica-
tion is common among individuals with IDD with
rates of psychotropic medication usage estimated
between 28% and 89% (Bisconer, Sine, & Zhang,
1996; Burd et al., 1997; Lott et al., 2004; Molyneux,
Emerson, & Caine, 1999; National Core Indicators,
2012; Spreat, Conroy, & Fullerton, 2004). Anti-
psychotic drugs are the most commonly prescribed
psychotropic medications among individuals with
IDD (Aman, Lam, & Collier-Crespin, 2003; Aman,
Lam, & Van Bourgondien, 2005; Esbensen, Green-
berg, Seltzer, & Aman, 2009; Hurley, Folstein, &
Lam, 2003; Marshall, 2004; Molyneux et al., 1999;
National Core Indicators, 2012; Robertson et al.,
2000; Spreat et al., 2004). In addition to high rates
of medication use, individuals with IDD often have
difficulty reporting and understanding side effects
(Aman, Benson, Campbell, & Haas, 1999; Bradley,
2002; Gardner Wilson, Lott, & Tsai, 1998; Lunsky
et al., 2008; Zametkin & Yamada, 1993), they are
at heightened risk of paradoxical side effects
(Gardner Wilson et al., 1998), and they may not
have the capacity to consent to medication use
(Aman et al., 1999; Lunsky et al., 2008).
Despite its clinical indication, polypharmacy is
concerning in individuals with IDD and the more
general population given its association with
medication nonadherence and the risk of adverse
drug reactions and drug–drug interactions (Ananth,
Parameswaran, & Gunatilake, 2004; Chutka et al.,
2004; Fulton & Riley Allen, 2005; Jyrkka, Enlund,
Korhonen, Sulkava, & Hartikainen, 2009a; Lunsky
& Elserafi, 2012; Straetmans et al., 2007). Poly-
pharmacy is also a risk factor for hospitalizations
(Flaherty, Perry, Lynchard, & Morley, 2000) and
falls (Ziere et al., 2005) and is associated with an
increased risk of mortality (Jyrkka, Enlund, Korho-
nen, Sulkava, & Hartikainen, 2009b).
Polypharmacy rates among individuals with
IDD range considerably with some studies reporting
rates as low as 11% and others as high as 60%,
depending on the study methods (Bisconer et al.,
1996; Burd et al., 1997; Lake, Balogh, & Lunsky,
2012; Lott et al., 2004; Lunsky & Elserafi, 2012;
Marshall, 2004; McGillivray & McCabe, 2006;
Stolker, Heerdink, Leufkens, Clerkx, & Nolen,
2001; Wood et al., 2006). Variability in polyphar-
macy rates highlights the need for careful consider-
ation of how rates are derived, particularly if they are
to be used as an indicator of quality of health care.
J. N. Stortz et al.
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
This article reviews and critically appraises
how polypharmacy (psychotropic and non-psycho-
tropic drugs) is studied in two highly medicated but
distinct populations: the elderly and individuals
with IDD. Results inform researchers on method-
ological considerations for future studies, including
activities aimed at monitoring the quality of health
care provided to people with IDD.
Methods
Comprehensive literature reviews of polypharmacy
in the elderly and individuals with IDD were
conducted using the following bibliographic data-
bases: Embase and Medline. Searches were limited
to English publications from January 1996 to
February 2011. The following terms were used to
capture medication use: polypharmacy, psychotro-
pic drug, neuroleptic drug, antipsychotic drug,
clinical indicators or health care quality. These
terms were combined with additional terms and
strategies aimed at identifying the populations of
interest (individuals with IDD and the elderly).
For the elderly, the term ‘‘elderly’’ was used in
combination with prespecified age categories: ‘‘all
aged (65 and over)’’ and ‘‘aged (80 and over).’’ For
individuals with IDD, the following terms were
used: developmental disability or intellectual dis-
ability or learning disability or autistic disorder or
Asperger syndrome or pervasive developmental
disorder–not otherwise specified. We also set age
limits such that studies were included only if they
focused on adults or adults as well as adolescents or
children. Titles and abstracts obtained from the
searches were scanned to exclude case series or
reports, sources that provided no information on
measurement or classification of polypharmacy or
inappropriate prescribing practices in the context of
multiple medications, or papers that did not
examine variables associated with polypharmacy.
Polypharmacy in individuals with learning disabil-
ities, a term synonymous with intellectual disability
in the British literature, were included only if it was
evident that the term referred to individuals with
IDD. Relevant references from papers obtained
from the literature search were also used. Addi-
tional papers were obtained directly from coauthors
of this review. Authors did not search for grey
literature and unpublished reports.
This review presents and discusses methods
used to study polypharmacy. In particular, defini-
tions of polypharmacy used, samples studied,
61
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
analytic strategies, and associated variables are
examined. To aid in the presentation of findings,
variables associated with polypharmacy were cate-
gorized based on a modified framework developed
by Bronskill and colleagues (2012) related to
categorizing and examining population-level med-
ication data in the elderly. Following the review,
variable categorization was informed by common
themes, which emerged from the literature searches
and were further adapted based on team discussions.
Variables associated with polypharmacy were
grouped into the following categories for the
current review: clinical, demographic, and organi-
zational variables. Demographic variables were
defined as the fixed characteristics of an individual
(e.g., gender, age), and variables describing clinical
characteristics were considered in a second category
(e.g., comorbidities, cognitive functioning). Orga-
nizational variables reflected the support or care
received by a specific population (e.g., residence,
primary and psychiatric care).
Results
Nine articles were obtained from the elderly
literature, and seven from the IDD literature. It
should be noted that some polypharmacy studies
examined the total number of medications, and
some either separated the type of medication or
only examined psychotropic medications. For
studies that focused on psychotropic polypharmacy
exclusively, this is indicated throughout the results.
Details of each study reviewed are included in
Tables 1 and 2.
Measurement and Definition
of Polypharmacy
Most of the studies reviewed employed different
definitions of polypharmacy. In both populations,
polypharmacy was most frequently defined on the
basis of a numerical cut-off value; however, this
number varied, depending on the population
examined. For individuals with IDD, polypharmacy
often constituted the combination of two or more
psychotropic drugs from the same or different
medication classes, also known as intraclass and
interclass polypharmacy, respectively. For the
elderly, polypharmacy typically constituted the
concurrent use of five or more, nine or more, or
10 or more medications (psychotropic and non-
psychotropic). Some studies of the elderly exam-
ined varying levels of polypharmacy based on the
62
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
number of medications prescribed, utilizing catego-
ries including polypharmacy versus excessive poly-
pharmacy or minor versus major polypharmacy. In
studies of individuals with IDD, all but one defined
polypharmacy using psychotropic medications only.
In contrast, all studies of polypharmacy in the
elderly included psychotropic and non-psychotro-
pic medications.
All studies of individuals with IDD based
definitions of polypharmacy on what was typically
reported in previous literature or commonly
observed medication combinations with no refer-
ence to the appropriateness of specific medication
combinations. Some studies in the elderly went
beyond this to examine polypharmacy in the
context of appropriateness of medication-prescrib-
ing practices. In two studies, inappropriate pre-
scribing practices, based on medication guidelines
(Medication Appropriateness Index and Beer’s
Criteria) were the major outcome of interest, but
both studies also examined polypharmacy (Carey
et al., 2008; Hajjar et al., 2005). Another study
examined medication combinations that were
known to be harmful in older adults (Raymond et
al., 2010).
As noted earlier, polypharmacy concerns the
concurrent use of medications. In the studies
reviewed for both populations, definitions of
‘‘concurrent’’ medication use were inconsistent.
The majority of studies counted all medications
dispensed on an arbitrary census date. No studies
included in this review allowed for a prescription-
overlap period, and any overlap in drug therapy was
considered concurrent use.
Samples Studied
Studies of polypharmacy among individuals with
IDD tended to employ clinic (Hurley et al., 2003;
Stolker et al., 2001) or convenience samples
(Esbensen et al., 2009; McGillivray & McCabe,
2006). As a result, samples of individuals with
IDD were relatively small with cohorts composed
of 109 (Stolker et al., 2001) to 2,052 (Stolker,
Koedoot, Heerdink, Leufkens, & Nolen, 2002)
individuals. In contrast, many studies of polyphar-
macy in the elderly included large, population-
based cohorts composed of more than 100,000
subjects (Bjerrum, Sogaard, Hallas, & Kragstrup,
1998; Carey et al., 2008; Haider, Johnell, Weitoft,
Thorslund, & Fastbom, 2009; Raymond et al.,
2010).
Polypharmacy in Populations With IDD
 Table 1
Studies Examining Variables Associated With Polypharmacy in Populations With IDD
Major statistical
analyses
Variables conducted

J. N. Stortz et al.
Sample
associated with to determine
2014, Vol. 52, No. 1, 60–77

Study Size and Polypharmacy polypharmacy association with

reference Location sampling strategy Age range Diagnoses definition (Y/N) polypharmacy
Burd et al., United n 51384 Mean age: All subjects had More than one Clinical: Bivariate
1997 States Survey of residents in 41 years intellectual psychotropic Psychiatric and analysis
every group home Age range: disability19% had medication prescribed medical
for people with 1–96 years psychiatric diagnosis at time of survey comorbidities (Y)
intellectual disability 23% had seizure
in North Dakota diagnosis
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Esbensen United n 5 286 Mean age: All subjects had a Examined drug class Demographic: Bivariate
et al., States Adolescents and adults 21.1 years previous diagnosis and the use of two Age (Y) analysis
2009 over a 4.5-year time (averaged on the autism and three or more
period recruited from across times) spectrum psychotropic medi-
service agencies, Age range: cations over time.
schools, diagnostic 10–48 years Non-psychotropic
clinics, and the media medications also
in Massachusetts and examined.
Wisconsin
Hurley United n 5 300 Mean age: Persons with and Total number of Clinical: Intellec- Bivariate
et al., States Medical chart review 37 years without intellectual psychotropic drug tual and adaptive analysis
2003 of patients at Age range: disability some with classes (prescribed functioning (N)
psychiatric clinic Unknown genetic and neuro- therapy by drug class)
in a hospital in (all adults) developmental prescribed at the end
Boston syndromes, autism of the psychiatric
spectrum disorders, evaluation
and physical
disabilities
’AAIDD
DOI: 10.1352/1934-9556-52.1.60

63
64
Table 1
Continued

Major statistical
analyses
2014, Vol. 52, No. 1, 60–77

Sample Variables conducted

associated with to determine
Study Size and Polypharmacy polypharmacy association with
reference Location sampling strategy Age range Diagnoses definition (Y/N) polypharmacy
McGillivray Australia n 5 873 Mean age: 38 All subjects had One or more anti- Demographic: Bivariate analysis
& Chemical restraint years intellectual psychotics; measured Age (Y)
McCabe, reports to Age range: disability number of prescriptions
2006 Intellectual 6.8–88 years for psychotropic drugs
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Disabilities and interclass and

Review Panel intraclass polyphar-
macy also, but did not
look at variables
associated; counted
number of prescriptions
at time report was
completed
Robertson United n 5 500 Mean age: All subjects had Prescription for more Demographic: Bivariate analysis
et al., Kingdom Questionnaires and 40–48 years intellectual than one psychotropic Residence (Y)
2000 interviews with Age range: disability medication at time of
members of support Unknown questionnaires/
teams for individuals interviews; interested in
living in 18 residences specific psychotropic
across the United medication
Kingdom combinations only
’AAIDD

Polypharmacy in Populations With IDD

DOI: 10.1352/1934-9556-52.1.60
 Table 1
Continued

J. N. Stortz et al.
Major statistical
2014, Vol. 52, No. 1, 60–77

analyses
Sample Variables conducted
associated with to determine
Study Size and Polypharmacy polypharmacy association with
reference Location sampling strategy Age range Diagnoses definition (Y/N) polypharmacy
Stolker Netherlands n 5 105 Mean age: All subjects had Multiple psychotropic Demographic: Multivariate
et al., Medical records for 27 years borderline intel- drug use; defined Gender (N), analysis
2001 individuals admitted Age range: lectual functioning or specific medication age (N)
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

to a psychiatric 16–57 years an intellectual dis- combinations as Clinical: Psychiatric

hospital ward ability; some par- multiple drug use; and medical
ticipants had a counted all psycho- comorbidities
psychiatric diag- tropic drugs used during (Y), intellectual
nosis, some had a hospitalization, ex- and adaptive
behavioral diagnosis cluding medications functioning (N),
used only during hos- behavioral
pitalization, including problems (Y)
medications prescribed
Stolker Netherlands n 5 2052 Mean age: All subjects had More than one Clinical: Bivariate analysis
et al., Staff questionnaires 39–42 years intellectual dis- psychotropic Behavioral
2002 and medical records Age range: ability some had medication, counted problems (Y)
to obtain information 18+ years psychiatric/ at time of ques-
about residents from behavioral tionnaire; examined
573 group homes in symptoms total number of drugs
the Netherlands (ran- and number of drug
dom and nonrandom classes
selection of subjects)
’AAIDD
DOI: 10.1352/1934-9556-52.1.60

65
66
Table 2
Studies Examining Variables Associated With Polypharmacy in the Elderly
Major statistical
Sample Variables analysis method
2014, Vol. 52, No. 1, 60–77

associated with for determining

Study Size and polypharmacy associations with
reference Location sampling strategy Age range Polypharmacy definition (Y/N) polypharmacy
Bjerrum Denmark ntotal 5 466,567 Mean age: Concurrent use of more than one Demographic: Bivariate
et al., nelderly . 3,684 Unknown prescription medication on any day Gender (Y), age (Y) analysis
1998 Prescription records Age range: of the study period; two different
from 1993–1994 16+ years Elderly: definitions: two to four drugs (minor
of all individuals 65+ years polypharmacy) and five or more drugs
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

living in Funen, (major polypharmacy); prescription

Denmark medications only (psychotropic and
non-psychotropic); oral
contraceptives, sedatives, and
hypnotics were excluded from
medication count
Carey United n 5 218,567 Mean age: Main outcome of interest was Demographic: Age Multivariate
et al., Kingdom Records from 201 Unknown potentially inappropriate (N), socioeconomic analysis
2008 general physician Age range: prescriptions, but adjusted for status (Y), geographic
practices 65+ years number of medications; counted region (N)
‘‘repeat’’ prescriptions only if Organizational:
patient had received at least Residence (N)
three prescriptions for a particular
medication in a year, medication was
counted; prescription medications
only (psychotropic and non-
psychotropic)
’AAIDD

Polypharmacy in Populations With IDD

DOI: 10.1352/1934-9556-52.1.60
 Table 2
Continued
Major statistical
Sample Variables analysis method

J. N. Stortz et al.
associated with for determining
Study Size and polypharmacy associations with
2014, Vol. 52, No. 1, 60–77

reference Location sampling strategy Age range Polypharmacy definition (Y/N) polypharmacy
Haider Sweden n 5 626,258 Mean age: Two different definitions: Concurrent Demographic: Gender Multivariate
et al., General population Unknown use of five or more medications (Y), age (Y), analysis
2009 records from a Age range: 75– (polypharmacy), concurrent use of socioeconomic status
drug register 89 years nine or more medications (excessive (Y), geographic region
polypharmacy); counted number of (Y) Clinical:
prescriptions over a 3-month period; Psychiatric and medical
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

prescription medications only comorbidities (Y)

(psychotropic and non-psychotropic);
medications used in hospitals/nursing
homes were not captured in the
registry and excluded from
medication count
Hajjar United n 5 384 Mean age: Main outcome of interest was Clinical: Psychiatric Multivariate
et al., States Medical records Unknown unnecessary drug use, but adjusted and medical analysis
2005 of a random Age range: for number of medications; counted comorbidities (Y)
sample of patients 65+ years medications at hospital discharge; Organizational:
at hospital prescription medications only Primary and
discharge (psychotropic and non-psychotropic) psychiatric care (Y)
Jorgensen Sweden n 5 4642 Mean age: Prescription for five or more medica- Demographic: Multivariate
et al., Prescription records Unknown tions during 1 year; prescription Gender (N), age (Y) analysis
2001 from community Age range: medications only (psychotropic Clinical: Psychiatric
pharmacies in 65+ years and non-psychotropic) and medical
Tierp, Sweden comorbidities (Y)
Elderly living in long- Organizational: Primary
term care facilities and psychiatric
were not included care (Y)
’AAIDD
DOI: 10.1352/1934-9556-52.1.60

67
 Table 2

68
Continued
Major statistical
Sample Variables analysis method
associated with for determining
Study Size and polypharmacy associations with
reference Location sampling strategy Age range Polypharmacy definition (Y/N) polypharmacy
2014, Vol. 52, No. 1, 60–77

Jyrkka Finland n 5 523 Mean age: Two different definitions: Use of six Demographic: Gender Multivariate
et al., Interviews with Unknown to nine medications concomitantly, (Y), age (Y) analysis
2009a random sample Age range: and use of 10 or more drugs Clinical: Psychiatric and
of home-dwelling 75+ years concomitantly, counted at the time medical comorbidities
elderly individuals of interview; prescription and (Y), intellectual and
living in Kuopio, nonprescription medications adaptive functioning (N)
Finland (psychotropic and non-psychotropic) Organizational:
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

and vitamins included in medication Residence (N)

count; herbal products excluded
Jyrkka Finland n 5 601 Mean age: Two different definitions: Use of six Demographic: Bivariate
et al., Interviews with Unknown to nine drugs concomitantly, and Gender (Y), age (Y) analysis
2009b random sample Age range: use of 10 or more drugs concomi- Clinical: Psychiatric and
of home-dwelling 75+ years tantly, counted at the time medical comorbidities
and institution- of interview; prescription and (Y), intellectual and
alized elderly nonprescription medications adaptive functioning (N)
individuals living in (psychotropic and non-psychotropic) Organizational:
Kuopio, Finland and vitamins included in medication Residence (Y)
count; herbal products excluded
Linjakumpu Finland n 5 1197 Mean age: Use of more than five medications Demographic: Gender Bivariate
et al., 2002 Survey of all Unknown concomitantly in the 7 days (Y), age (Y), marital analysis
community- Age range: preceding the survey; prescription status (Y)
dwelling elderly 64+ years drugs only (psychotropic and Clinical: Psychiatric
individuals living non-psychotropic) and medical
in Lieto, Finland comorbidities (Y)
Organizational: Primary
and psychiatric care
(Y), residence (Y)
’AAIDD

Polypharmacy in Populations With IDD

DOI: 10.1352/1934-9556-52.1.60
J. N. Stortz et al.
2014, Vol. 52, No. 1, 60–77

Table 2
Continued

Major statistical
Sample Variables analysis method
associated with for determining
Study Size and polypharmacy associations with
reference Location sampling strategy Age range Polypharmacy definition (Y/N) polypharmacy
Raymond et n 5 314,014 Mean age: Prescription for a combination of Demographic: Gender Multivariate
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

al., 2010 Community pharmacy Unknown second-generation antipsychotics (Y), age (Y), analysis
prescription Age range: with benzodiazepines or related socioeconomic status
records for .65 years medications, filled at least once in a (N), geographic region
community-dwelling particular quarter of a fiscal year; (Y)
and personal care examined prevalent and incident Organizational:
home-dwelling usage; prevalent defined as individuals Residence (Y)
individuals in who filled a prescription during the
Manitoba, Canada study period and did fill a prescription
for the same medication (or
combination of medications) in the
fiscal year prior to analysis; incident
defined as individuals who filled a
prescription during the study period and
did not fill a prescription for the same
medication (or combination of medi-
cations) in the fiscal year prior to analysis
’AAIDD
DOI: 10.1352/1934-9556-52.1.60

69
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
Analytic Strategies
Most studies conducted in individuals with IDD
employed bivariate analyses, comparing individual
variables (e.g., age, gender, marital status, residence,
intellectual and adaptive functioning, behavioral
problems, and psychiatric or medical comorbidities)
between groups prescribed multiple medications to
those not prescribed multiple medications. Multi-
variate analysis, which allows for examination of how
two or more variables are associated with polyphar-
macy, was used in only one study of individuals with
IDD (Stolker et al., 2001). Using multivariate
logistic regression, Stolker and colleagues examined
multiple patient parameters including age, gender,
comorbidities, intellectual functioning, and behav-
ioral problems with a small sample of 105 patients. In
contrast to research conducted in groups with IDD,
the majority of polypharmacy studies conducted in
the elderly assessed the impact of multiple variables
and, as described previously, utilized large popula-
tion-based cohorts.
Variables That May Explain Variations in
Rates of Polypharmacy
Clinical variables. The relationship between
psychiatric comorbidities and polypharmacy was
investigated in individuals with IDD. Individuals
with IDD who had an additional psychiatric or
seizure diagnosis (Burd et al., 1997) and those
specifically diagnosed with a psychotic disorder
(Stolker et al., 2001) were more likely to be
prescribed psychotropic polypharmacy compared to
individuals without these diagnoses (Burd et al.,
1997; Stolker et al., 2001). Similarly, individuals
prescribed psychotropic polypharmacy were signif-
icantly more likely to display bizarre and aggressive
behavior compared to individuals who were not
prescribed psychotropic polypharmacy (Stolker et
al., 2001). In another study, a group with problem
behaviors, defined by mental health issues includ-
ing psychosis, aggression, autism, paranoia, depres-
sion, and avoidant personality disorder, was pre-
scribed multiple psychotropic drugs more often
than a group with less severe behavioral problems
(Stolker et al., 2002). No studies in the IDD
literature examined the relationship between other
medical comorbidities and polypharmacy—likely
because the vast majority of studies defined
polypharmacy as the concurrent use of psychotropic
medications and did not consider non-psychotropic
medications.
70
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
Results from studies investigating polypharma-
cy and cognitive functioning in people with IDD
found no differences across individuals with mild,
moderate, or severe developmental disabilities
recruited from an outpatient clinic or psychiatric
hospital ward (Hurley et al., 2003; Stolker et al.,
2001). No studies examined the specific relation-
ship between adaptive functioning and polyphar-
macy; however, level of intellectual disability does
account for adaptive functioning in addition to
cognitive functioning.
In contrast to the literature on polypharmacy
among people with IDD, which focused almost
exclusively on psychiatric comorbidities, both
psychiatric and medical comorbidities were associ-
ated with polypharmacy in the elderly, and rates
increased with the number of comorbidities (Haider
et al., 2009; Hajjar et al., 2005; Jorgensen,
Johansson, Kennerfalk, Wallander, & Svardsudd,
2001; Jyrkka et al. 2009a, 2009b; Linjakumpu et al.,
2002). The association between polypharmacy and
cognitive and adaptive functioning is less well
understood in the elderly, with whom findings have
been inconsistent (Jykkra et al., 2009a, 2009b).
Further, it is unclear whether the relationship
between polypharmacy and cognitive functioning is
caused by or predicted by medication use.
Demographic variables. Only one study of
persons with IDD examined gender and polyphar-
macy, and no gender differences in rates of
psychotropic polypharmacy were observed (Stolker
et al., 2001). With respect to the age of the groups
studied, polypharmacy studies in individuals with
IDD varied. Some samples included only adoles-
cents and adults, and others included adults,
adolescents, and children. One study reported no
age differences among individuals prescribed psy-
chotropic polypharmacy (Stolker et al., 2001), and
another study reported that individuals between 30
and 55 years of age were significantly more likely to
be prescribed one or more antipsychotics compared
to older and younger age groups (McGillivray &
McCabe, 2006). No studies investigated the rela-
tionship between socioeconomic measures, marital
status, or geographic region and polypharmacy in
individuals with IDD.
In contrast, a number of demographic variables
beyond just age and gender have been studied in
the elderly. Gender (Bjerrum et al., 1998; Carey et
al., 2008; Haider et al., 2009; Jyrkka et al., 2009a,
2009b; Linjakumpu et al., 2002), age (Bjerrum et
al., 1998; Haider et al., 2009; Jorgensen et al., 2001;
Polypharmacy in Populations With IDD
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
Jyrkka et al., 2009a, 2009b; Linjakumpu et al.,
2002; Raymond et al., 2010), measures of socio-
economic status (Carey et al., 2008; Haider et al.,
2009), and geographic region (Haider et al., 2009)
have all been associated with polypharmacy.
Overall, findings from this research indicate that
females, older individuals, and those of lower
socioeconomic status were most likely to be
prescribed polypharmacy. Findings, however, were
not consistent across all polypharmacy research in
the elderly, as other studies reported no association
between polypharmacy and these variables (Carey
et al., 2008; Jorgensen et al., 2001; Raymond et al.,
2010).
Organizational variables. Few organizational
variables were studied among people with IDD. No
studies examining the association between access to
primary or psychiatric care, continuity of care, or
frequency of care and polypharmacy in people with
IDD were identified for inclusion in this review.
The only organizational variable examined in this
population was residential setting. Individuals with
IDD living in large residential facilities were more
likely to be prescribed multiple antipsychotics or a
combination of antipsychotics and antidepressants
compared to those in smaller residential settings
although demographic and clinical variables were
not controlled for in the analysis (Robertson et al.,
2000).
In contrast, organizational variables, such as
measures of health care receipt and residence, have
been more extensively studied in polypharmacy
literature among the elderly. After adjusting for
demographic and clinical variables, studies found
lower continuity of care (Hajjar et al., 2005) and
higher frequency of primary care visits (Jorgensen
et al., 2001) were associated with polypharmacy in
the elderly. In terms of residence, while controlling
for demographic and clinical variables, two studies
observed no significant difference in the likelihood
of being prescribed potentially inappropriate med-
ications or polypharmacy between elderly individ-
uals living in residential or nursing homes and in
the community (Carey et al., 2008; Jyrkka et al.,
2009b).
Discussion
This review provides a critical appraisal of research
methods used to study polypharmacy, including
measurement and definition of polypharmacy, study
samples, analytic strategies, and variables that may
J. N. Stortz et al.
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
explain variations in rates of polypharmacy. As
polypharmacy research methods varied greatly
between populations and even within the IDD
literature, it is difficult to determine exactly how to
use polypharmacy rates as an indicator of quality
health care among persons with IDD. The review
does, however, highlight a number of important
lessons to inform future research in the area of
polypharmacy and IDD.
Lesson 1: It is essential to be consistent in
how polypharmacy is defined. To use polypharma-
cy rates as an indication of quality of health care,
including comparisons of rates across health care
jurisdictions or time points, it is crucial that
standardized definitions of polypharmacy be em-
ployed for individuals with IDD. For example, one
definition of polypharmacy could include both
psychotropic and non-psychotropic medications, and
another definition could examine only psychotropic
polypharmacy. Consistent definitions are necessary
to better understand and draw conclusions about
polypharmacy in a given population. It is important
to consider the number of drugs prescribed, the type
of drugs prescribed, and when drugs are prescribed.
Across all populations reviewed, polypharmacy
was most commonly defined as the concurrent use
of multiple medications; however, the number of
concurrent medications used to define polyphar-
macy was inconsistent across studies, making
comparisons between studies of the same popula-
tion challenging. Studies of individuals with IDD
typically considered two or more psychotropic drugs
as polypharmacy, but other studies defined poly-
pharmacy as combinations of specific psychotropic
drug classes. In the elderly, polypharmacy defini-
tions ranged from two to 10 or more medications.
In studies of persons with IDD, polypharmacy
research was strictly focused on psychotropic
medications although studies of the elderly typical-
ly measured the total number of medications an
individual was prescribed. Given the medical
complexities experienced by people with IDD,
researchers must be cognizant of all medication
classes prescribed for concurrent use, particularly
when assessing the probability of potentially
harmful drug–drug interactions.
Most polypharmacy studies employed an arbi-
trary census date to count the number of medica-
tions and did not consider a medication-overlap
period. It is particularly important to consider a
medication-overlap period when studying psycho-
tropic medications because the dosage of some
71
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
psychotropic medications is slowly reduced as a new
treatment is simultaneously started (Morrato et al.,
2007). An acceptable period of overlap may also
address the issue of necessary short-term pharma-
cological therapies, such as the use of antibiotics.
The consensus guidelines for the primary health
care of adults with developmental disabilities
(Sullivan et al., 2011) recommend a medication
review every three months for individuals taking
multiple medications. They also suggest a ‘‘start low
and go slow’’ approach whereby medications should
be reviewed at both three months and six months
to account for medication additions or withdrawals.
In an unpublished report of medication prescrip-
tions in persons with IDD, an overlap period of
three months was employed to define polypharmacy
(Wood et al., 2006).
Lesson 2: Population-based studies must
be prioritized. Population-level research on poly-
pharmacy is important to ensure generalizability of
findings and to gain a greater understanding of
polypharmacy at the population level. Population-
based studies utilize a representative sample of a
population or a population in its entirety. The
majority of polypharmacy studies in the elderly
employed large, population-based samples, which
increased the generalizability of findings to other
elderly groups. Most studies of persons with IDD
consisted of small convenience or clinic-based
samples. Clinic or convenience samples do not
allow researchers to study individuals who are not
receiving services or who are unable or unwilling to
participate in research. It is possible that specific
groups of individuals with IDD, for example, those
with more severe disabilities who are unable to
consent to participate in research, may be excluded
using clinic or convenience-sampling strategies,
limiting generalizability of findings to the general
IDD population.
More recent studies and unpublished reports
suggest an emerging shift toward population-based
research of polypharmacy in persons with IDD
(Cobigo, Stortz, Lake, Ouellette-Kuntz, & Lunsky,
2012; National Core Indicators, 2012; Wood et al.,
2006). The use of administrative databases, which
included medication use in those with IDD, will aid
in obtaining large, population-based samples and
enhance the quality of polypharmacy research,
including the use of polypharmacy as an indicator
of quality of health care.
Lesson 3: The study of polypharmacy must be
linked to the development of specific clinical
72
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
guidelines. It is important to recognize that the
receipt of multiple medications may be clinically
indicated in certain individuals and therefore
appropriate. Examining inappropriate prescribing
practices, specifically unnecessary medications and
dangerous combinations, may provide researchers
with a more meaningful way to assess quality of care
with respect to medication receipt rather than
simply counting people prescribed multiple medi-
cations. Guidelines detailing potentially dangerous
or inappropriate medication combinations specific
to the elderly exist and have been applied to some
studies of polypharmacy in the elderly, including
Beer’s Criteria (Fick et al., 2003) and START/
STOPP Criteria (Gallagher, O’Conner, & O’Ma-
honey, 2011; O’Mahoney et al., 2010), but similar
lists of medication combinations have not been
developed specific to individuals with IDD. Exist-
ing medication guidelines for persons with IDD, for
example, the consensus guidelines for primary
health care of adults with developmental disabili-
ties (Sullivan et al., 2011), The International
Consensus Handbook: Psychotropic Medications and
Developmental Disabilities (Reiss & Aman, 1998),
the Frith Prescribing Guidelines in Adults with
Learning Disability (Bhaumik & Branford, 2005),
the Practice Parameters of the Assessment and
Treatment of Children, Adolescents and Adults
with Mental Retardation and Comorbid Mental
Disorders (Szymanski & King, 1999), and the
American Academy of Pediatrics Guidelines on
the Management of Autism Spectrum Disorders
(Myers & Plauche Johnson, 2007), all highlight the
risks of polypharmacy or warn against polypharma-
cy. However, only one guideline advises against
specific medication combinations, and none pro-
vide information on dosing or consideration of
medication appropriateness for individuals with
specific medical or psychiatric comorbidities. Fur-
ther, when guidelines do discuss polypharmacy,
they focus only on psychotropic medications and
not specific risks associated with combinations of
psychotropic and non-psychotropic medications.
Medication guidelines specific to the elderly
discourage the prescription of certain psychotropic
medications, including long-term use of antipsy-
chotics and the prescription of antidepressants for
persons with cognitive impairment (O’Mahoney et
al., 2010). Antipsychotic and antidepressant med-
ications are among the most frequently prescribed
psychotropic medication classes in populations with
IDD (Aman et al., 2003; Burd et al., 1997;
Polypharmacy in Populations With IDD
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
Esbensen et al., 2009; Hurley et al., 2003; Lake et
al., 2012; Lott et al., 2004; Lunsky & Elserafi, 2012;
Martin, Scahill, Klin, & Volkmar, 1999; Marshall,
2004; Molyneux et al., 1999; Robertson et al., 2000;
Spreat et al., 2004), yet guidelines specific to the
care of these individuals do not advise beyond
general psychotropic medication considerations. It
is clear that population-specific, explicit guidelines
for prescribing medications are necessary to aid in
assessing and improving the quality of care received
by this population. These guidelines could also
guide future research examining medication pre-
scribing in persons with IDD by allowing research-
ers to monitor adherence to guidelines and
appropriateness of medications prescribed, and to
use this criteria as an indication of the quality of
care with respect to medication received by those
with IDD.
Lesson 4: It is important to study the
association between polypharmacy and clinical,
demographic, and organizational variables. It is not
enough to simply describe polypharmacy rates; we
need to also examine what variables are associated
with polypharmacy to understand why polyphar-
macy rates differ within populations. In addition to
clinical variables directly related to medication
needs, there is evidence to suggest that other
parameters may influence prescribing practices and
the likelihood of an individual being dispensed
polypharmacy. It is important to examine multiple
clinical, demographic, and organizational variables
in order to understand why individuals are pre-
scribed polypharmacy in a particular population.
Some studies of the elderly investigated
demographic, clinical, and organizational variables
and utilized multivariate analyses, which allowed
researchers to control for potential confounding
variables and more clearly assess the relationships
between polypharmacy and variables of interest. In
all but one study of people with IDD, researchers
failed to employ this type of analysis, making it
harder to draw definite conclusions from the results
presented. In the only published IDD paper in our
review that employed multivariate analysis, over 10
variables were tested in the regression model with a
sample of only 105 individuals. A general rule of
thumb when conducting regression analyses is that
a minimum of 10 to 20 outcome events are required
per predictor (Nunnally, 1978); thus, results from
the previous analysis may not be valid. In addition,
because the sample was obtained from a psychiatric
hospital ward, the generalizability of these findings
J. N. Stortz et al.
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
to the greater IDD population is questionable. No
studies of individuals with IDD examined clinical,
demographic, and organizational variables, and
therefore, they were not able to control for clinical
variables, which may have confounded relation-
ships between polypharmacy and demographics or
organizational variables. As a result, it is unclear
whether differences in rates of polypharmacy are
attributable to the medication needs of specific
populations or to external factors, such as prescrib-
ing physician or residence. Without this informa-
tion, it is difficult to assess the extent to which
nonclinical variables may influence prescribing
practices.
Additionally, other variables, including psy-
chotherapeutic and psychosocial therapies have not
been investigated and may influence the likelihood
of receiving polypharmacy in individuals with IDD.
In terms of organizational variables, it may also be
important to consider whether specific medications
are paid out of pocket or funded by government
and/or insurance programs. Consideration of clin-
ical, demographic, and organizational variables in
the study of polypharmacy will aid researchers in
understanding external factors that drive prescrib-
ing practices for populations with IDD and provide
additional information that will assist in interpre-
tation of polypharmacy rates as they relate to
quality of care.
Conclusions and Future Directions
Research on polypharmacy among individuals
with IDD is still in its infancy. We know that
polypharmacy occurs at high rates in this popula-
tion, but the long-term consequences and why it
occurs remain unclear. We also know that some
clinical, demographic, and organizational variables
appear to be associated with polypharmacy, but it
continues to be challenging to synthesize findings
given the methodological limitations of many
studies. To begin to address these research gaps
and to use polypharmacy as an indicator of quality
of care received by individuals with IDD, we must
heed the four lessons identified through this review.
Consistency in the number of medications
studied is necessary across polypharmacy studies. In
the absence of detailed guidelines related to
medication appropriateness for people with IDD,
categorization of polypharmacy should, at mini-
mum, examine the use of two or more medications.
It may also be informative to further categorize
73
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
those prescribed multiple medications, similar to
research conducted in the elderly, which has
considered varying levels of polypharmacy (Bjerrum
et al., 1998; Haider et al., 2009; Jyrkka et al. 2009a,
2009b). Veehof, Steward, Meyboom-de Jong, and
Haaijer-Ruskamp (1999) utilized the following
medication categories to define minor, moderate,
and major polypharmacy in the elderly: 2–3, 4–5,
and .5. A similar categorization scheme may be
useful in the study of polypharmacy in individuals
with IDD. When feasible, we must also consider all
medication types and build in an acceptable
medication-overlap period or, if not possible,
interpret polypharmacy rates with caution. Based
on recommendations for monitoring prescription
medications in the consensus guidelines for the
primary health care of adults with developmental
disabilities (Sullivan et al., 2011), medications
should be examined at three months and six
months of concurrent use.
Conducting population-level, prospective co-
hort studies in individuals with IDD represent an
ideal starting point for this research; however, issues
of feasibility may make this work challenging to
carry out. Large administrative databases contain-
ing medication information are an ideal data source
for polypharmacy studies; however, identifying
groups with IDD within these databases can be
difficult (Cobigo et al., 2012). It is evident from the
polypharmacy literature that population-based re-
search in persons with IDD is imperative to increase
generalizability and to gain a greater understanding
of polypharmacy in this population. For some
individuals, polypharmacy is warranted, and the
number of medications in itself is not an indication
of inappropriate care. In order to assess the
appropriateness of specific medications and medi-
cation combinations, medication guidelines that
address these issues for persons with IDD must be
developed. Current guidelines address the use of
two antipsychotic medications concurrently (Reiss
& Aman, 1998; Taylor, Paton, & Kapur, 2012), but
more detailed guidelines addressing appropriateness
of other medications and combinations for individ-
uals with IDD are required. Collaboration among
scientists, policymakers, pharmacists, and medica-
tion prescribers is needed to help facilitate the
further development of medication guidelines for
people with IDD. Collaborating with experts across
these different fields will inform the types of
questions we ask, and will help determine how best
to translate findings into meaningful change for the
74
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
care of individuals with IDD. These collaborations
also play a key role in the development of research
to enhance our knowledge and understanding of
polypharmacy in this population. Finally, to use
rates of polypharmacy as an indicator of quality of
health care over time or across systems may require
adjusting for covariates. Going forward, research on
polypharmacy in persons with IDD should involve
multivariate analyses to better understand what
factors impact the likelihood of receiving polyphar-
macy.
References
Aman, M. G., Benson, B. A., Campbell, K. M., &
Haas, B. A. (1999). Patients’ rights and
responsibilities. Columbus, OH: The Ohio
State University Nisonger Center.
Aman, M. G., Lam, K. S. L., & Collier-Crespin, A.
(2003). Prevalence and patterns of use of
psychoactive medicines among individuals
with autism in the autism society of Ohio.
Journal of Autism and Developmental Disorders,
33, 527–534.
Aman, M. G., Lam, K. S. L., & Van Bourgondien,
M. E. (2005). Medication patterns in patients
with autism: Temporal, regional, and demo-
graphic influences. Journal of Child and Adoles-
cent Psychopharmacology, 15, 116–126.
Ananth, J., Parameswaran, S., & Gunatilake, S.
(2004). Antipsychotic polypharmacy. Current
Pharmaceutical Design, 10(18), 2231–2238.
Bauman, M. L. (2010). Medical comorbidities in
autism: Challenges to diagnosis and treatment.
Neurotherapeutics, 7, 320–327.
Bhaumik, S., & Branford, D. (Ed.). (2005). Frith
prescribing guidelines in adults with learning
disability (1st ed.). Oxfordshire, United King-
dom: Taylor Francis Ltd.
Bisconer, S. W., Sine, L. F., & Zhang, X. (1996).
Prevalence and patterns of psychotropic med-
ication use by adults with mental retardation
living in community settings. Journal of Devel-
opmental and Physical Disabilities, 8(4), 291–
311.
Bjerrum, L., Rosholm, J. U., Hallas, J., & Kragstrup,
J. (1997). Methods for estimating the occur-
rence of polypharmacy by means of a prescrip-
tion database. European Journal of Clinical
Pharmacology, 53(1), 7–11.
Polypharmacy in Populations With IDD
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
Bjerrum, L., Sogaard, J., Hallas, J., & Kragstrup, J.
(1998). Polypharmacy: Correlations with sex,
age and drug regimen. A prescription database
study. European Journal of Clinical Pharmacolo-
gy, 54, 197–202.
Bradley, E. (2002). Guidelines for managing the client
with intellectual disability in the emergency room.
Toronto, ON: Centre for Addiction and
Mental Health.
Bronskill, S. E., Gill, S. S., Paterson, J. M., Bell,
C. M., Anderson, G. M., & Rochon, P. A.
(2012). Exploring variation in rates of poly-
pharmacy across long-term care homes. Journal
of the American Medical Directors Association,
13(3), 309.e15–309.e21.
Burd, L., Williams, M., Klug, M. G., Fjelstad, K.,
Schimke, A., & Kerbeshian, J. (1997). Preva-
lence of psychotropic and anticonvulsant drug
use among North Dakota group home resi-
dents. Journal of Intellectual Disability Research,
41(6), 488–494.
Carey, I. M., De Wilde, S., Harris, T., Victor, C.,
Richards, N., Hilton, S. R., & Cook, D. G.
(2008). What factors predict potentially inap-
propriate primary care prescribing in older
people? Analysis of UK primary care patient
record database. Drugs & Aging, 25(8), 693–
706.
Chutka, D. S., Takahashi, P. Y., & Hoel, R. W.
(2004). Inappropriate medications for elderly
patients. Mayo Clinic Proceedings, 79, 122–139.
Cobigo, V., Stortz, J., Lake, J. K., Ouellette-Kuntz,
H., & Lunsky, Y. (2012). Defining & measur-
ing multiple, concurrent, excessive prescrip-
tions. Plenary presentations. Journal of Intellec-
tual Disability Research, 56, 655–657. doi:10.
1111/j.1365-2788.2012.01583.x
Esbensen, A. J., Greenberg, J. S., Seltzer, M. M., &
Aman, M. G. (2009). A longitudinal investi-
gation of psychotropic and non-psychotropic
medication use among adolescents and adults
with autism spectrum disorders. Journal of
Autism and Developmental Disorders, 39, 1339–
1349.
Fick, D. M., Cooper, J. W., Wade, W. E., Waller,
J. L., Maclean, R., & Beers, M. H. (2003).
Updating the Beer’s Criteria for potentially
inappropriate medication use in older adults:
Results of a US consensus panel of experts.
Archives of Internal Medicine, 163(22), 2716–
2724.
J. N. Stortz et al.
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
Flaherty, J. H., Perry, H. M., Lynchard, G. S., &
Morley, J. E. (2000). Polypharmacy and
hospitalization among older home care pa-
tients. Journal of Gerontology, 55A(10), M554–
M559.
Fulton, M., & Riley Allen, E. (2005). Polypharma-
cy in the elderly: A literature review. Journal of
the American Academy of Nurse Practitioners,
17(4), 123–132.
Gallagher, P., O’Conner, M. N., & O’Mahoney, D.
(2011). Prevention of potentially inappropriate
prescribing for elderly patients: A randomized
controlled trial using STOPP/START criteria.
Clinical Pharmacology & Therapeutics, 89(6),
845–854.
Gardner Wilson, J., Lott, R. S., & Tsai, L. (1998).
Side effects: Recognition and management. In
S. Reiss and M. G. Aman (Eds.), Psychotropic
medications and developmental disabilities: The
international consensus handbook (pp. 95–114).
Columbus, OH: The Ohio State University
Nisonger Center.
Haider, S. I., Johnell, K., Weitoft, G. R., Thor-
slund, M., & Fastbom, J. (2009). The influence
of educational level on polypharmacy and
inappropriate drug use: A register-based study
of more than 600,000 older people. Journal of
the American Geriatrics Society, 57(1), 62–69.
Hajjar, E. R., Hanlon, J. T., Sloane, R. J., Lindblad,
C. I., Pieper, C. F., Ruby, C. M., … Schmader,
K. E. (2005). Unnecessary drug use in frail
older people at hospital discharge. Journal of the
American Geriatrics Society, 53, 1518–1523.
Hurley, A. D., Folstein, M., & Lam, N. (2003).
Patients with and without intellectual disabil-
ity seeking outpatient psychiatric services:
Diagnoses and prescribing pattern. Journal of
Intellectual Disability Research, 47(1), 39–50.
Jorgensen, T., Johansson, S., Kennerfalk, A.,
Wallander, M. A., & Svardsudd, K. (2001).
Prescription drug use, diagnoses, and health-
care utilization among the elderly. The Annals
of Pharmacotherapy, 35, 1004–1009.
Jyrkka, J., Enlund, H., Korhonen, M. J., Sulkava, R.,
& Hartikainen, S. (2009a). Patterns of drug use
and factors associated with polypharmacy and
excessive polypharmacy in elderly persons:
Results of the Kuopio 75+ study: A cross-
sectional analysis. Drugs & Aging, 26(6), 493–
503.
Jyrkka, J., Enlund, H., Korhonen, M. J., Sulkava, R.,
& Hartikainen, S. (2009b). Polypharmacy
75
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
status as an indicator of mortality in an elderly
population. Drugs & Aging, 26(12), 1039–
1048.
Lake, J. K., Balogh, R., & Lunsky, Y. (2012).
Polypharmacy profiles and predictors among
adults with autism spectrum disorders. Research
in Autism Spectrum Disorders, 6, 1142–1149.
Levy, S. E., Mandell, D. S., & Schultz, R. T.
(2009). Autism. Lancet, 374, 1627–1638.
Linjakumpu, T., Hartikainen, S., Klaukka, T.,
Veijola, J., Kivela, S. L., & Isoaho, R. (2002).
Use of medications and polypharmacy are
increasing among the elderly. Journal of Clinical
Epidemiology, 55, 809–817.
Lott, I. T., McGregor, M., Engelman, L., Touch-
ette, P., Tournay, A., Sandman, C., … Walsh,
D. (2004). Longitudinal prescribing patterns
for psychoactive medications in community-
based individuals with developmental disabil-
ities: Utilization of pharmacy records. Journal of
Intellectual Disability Research, 48(6), 563–571.
Lunsky, Y., & Elserafi, J. (2012). Antipsychotic
medication prescription patterns in adults with
developmental disabilities who have experi-
enced a psychiatric crisis. Research in Develop-
mental Disabilities, 33, 32–38.
Lunsky, Y., Fedoroff, P., Klassen, K., Gracey, C.,
Havercamp, S., Fedoroff, B., & Lennox. N.
(2008). Medical rights for people with intel-
lectual disabilities. In F. Owen and D. Griffiths
(Eds.), Challenges to the human rights of people
with intellectual disabilities (pp. 155–183). Phil-
adelphia, PA: Jessica Kingsley Publishers.
Mahan, S., Holloway, J., Bamburg, J. W., Hess,
J. A., Fodstad, J. C., & Matson, J. L. (2010).
An examination of psychotropic medication
side effects: Does taking a greater number of
psychotropic medications from different classes
affect presentation of side effects in adults with
ID? Research in Developmental Disabilities, 31(6),
1561–1569.
Martin, A., Scahill, L., Klin, A., & Volkmar, F. R.
(1999). Higher functioning pervasive develop-
mental disorders: Rates and patterns of psy-
chotropic drug use. Journal of the American
Academy of Child and Adolescent Psychiatry, 38,
923–931.
Marshall, T. (2004). Audit of the use of psycho-
tropic medication for challenging behaviour in
a community learning disability service. Psy-
chiatric Bulletin, 28(12), 447–450.
76
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
McGillivray, J. A., & McCabe, M. P. (2006).
Emerging trends in the use of drugs to manage
the challenging behaviour of people with
intellectual disability. Journal of Applied Re-
search in Intellectual Disabilities, 19(2), 163–
172.
Molyneux, P., Emerson, E., & Caine, A. (1999).
Prescription of psychotropic medication to
people with intellectual disabilities in primary
health-care settings. Journal of Applied Research
in Intellectual Disabilities, 12(1), 46–57.
Morrato, E. H., Dodd, S., Oderda, G., Haxby,
D. G., Allen, R., & Valuck, R. J. (2007).
Prevalence, utilization patterns, and predictors
of antipsychotic polypharmacy: Experience in a
multistate Medicaid population, 1998–2003.
Clinical Therapeutics, 29(1), 183–195.
Myers, S. M., & Plauche Johnson, C. (2007).
Management of children with autism spectrum
disorders. Pediatrics, 120, 1162–1182.
National Core Indicators. (2012). What does NCI
tell us about adults with intellectual and
developmental disabilities who are taking
prescribed medications for anxiety, behaviour
challenges, mood disorders or psychotic disor-
ders? NCI Data Brief, 6, 1–9.
Nunnally, J. C. (1978). Psychometric theory (2nd
ed.). New York, NY: McGraw Hill.
O’Mahoney, D., Gallagher, P., Ryan, C., Byrne, S.,
Hamilton, H., Barry, P., … Kennedy, J. (2010).
STOPP & START criteria: A new approach to
detecting potentially inappropriate prescribing
in old age. European Geriatric Medicine, 1, 45–
51.
Raymond, C., Metge, C., Alessi-Severini, S., Dahl,
M., Schultz, J., & Guenette, W. (2010).
Pharmaceutical use in Manitoba: Opportunities
to optimize use. Manitoba, Canada: Manitoba
Centre for Health Policy.
Reiss, S., & Aman, M. G. (Eds.). (1998). The
international consensus handbook: Psychotropic
medication and developmental disabilities. Colum-
bus, OH: The Ohio State University Nisonger
Center.
Robertson, J., Emerson, E., Gregory, N., Hatton, C.,
Kessissoglou, S., & Hallam, A. (2000). Receipt
of psychotropic medication by people with
intellectual disability in residential settings.
Journal of Intellectual Disability Research, 44,
666–676.
Spreat, S., Conroy, J. W., & Fullerton, A. (2004).
Statewide longitudinal survey of psychotropic
Polypharmacy in Populations With IDD
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2014, Vol. 52, No. 1, 60–77
medication use for persons with mental retar-
dation: 1994 to 2000. American Journal on
Mental Retardation, 109, 322–331.
Stolker, J. J., Heerdink, E. R., Leufkens, H. G. M.,
Clerkx, M. G. M., & Nolen, W. A. (2001).
Determinants of multiple psychotropic drug use
in patients with mild intellectual disabilities or
borderline intellectual functioning and psychi-
atric or behavioral disorders. General Hospital
Psychiatry, 23(6), 345–349.
Stolker, J. J., Koedoot, P. J., Heerdink, E. R.,
Leufkens, H. G. M., & Nolen, W. A. (2002).
Psychotropic drug use in intellectually disabled
group-home residents with behavioural prob-
lems. Pharmacopsychiatry, 35, 19–23.
Straetmans, J. M., van Schrojenstein Lantman-de
Valk, H. M., Schellevis, F. G., & Dinant, G. J.
(2007). Health problems of people with
intellectual disabilities: The impact for general
practice. The British Journal of General Practice,
57, 64–66.
Sullivan, W. F., Berg, J. M., Bradley, E., Cheetham,
T., Denton, R., Heng, J., … McMillan, S.
(2011). Primary care of adults with develop-
mental disabilities: Canadian consensus guide-
lines. Canadian Family Physician, 57, 541–553.
Szymanski, L., & King, B. H. (1999). Practice
parameters for the assessment and treatment of
children, adolescents, and adults with autism
and other pervasive developmental disorders.
American Academy of Child and Adolescent
Psychology, 38, 5S–31S.
Taylor, D., Paton, C., & Kapur, S. (Eds.) (2012).
The Maudsley prescribing guidelines in psychiatry
(11th ed.). West Sussex, UK: Wiley-Blackwell.
Veehof, L. J. G., Steward, R. E., Meyboom-de Jong,
B., & Haaijer-Ruskamp, F. M. (1999). Adverse
drug reactions and polypharmacy in the elderly
in general practice. European Journal of Clinical
Pharmacology, 55, 533–536.
Wood, D., Hall, A. G., Zhang, J., & Hou, T.
(2006). Predictors of psychoactive medication
J. N. Stortz et al.
’AAIDD
DOI: 10.1352/1934-9556-52.1.60
use by persons on the MR/DD home and
community based waiver. Report to the
Agency for Health Care Administration,
December 2006. Florida Center for Medicaid
& the Uninsured, College of Public Health and
Health Profession, and University of Florida.
Zametkin, A. J., & Yamada, E. M. (1993).
Monitoring and measuring drug effects. In J.
S. Werry & M. G. Aman (eds.), Practitioner’s
guide to psychoactive drugs for children and
adolescents (pp. 86–91). New York, NY:
Plenum Press.
Ziere, G., Dieleman, J. P., Hofman, A., Pols, H. A.
P., van der Cammen, T. J. M., & Stricker, B.
H. C. H. (2005). Polypharmacy and falls in the
middle age and elderly population. British
Journal of Clinical Pharmacology, 61(2), 218–
223.
Submitted 7/22/2013, accepted 11/4/2013.
The authors would like to acknowledge Felicia Leung
for her contribution to the polypharmacy literature
review.
Authors:
Jessica N. Stortz (e-mail: jess.stortz@gmail.com),
Queen’s University, Department of Public Health
Sciences Kingston, Ontario Ontario, Canada;
Johanna K. Lake, Centre for Addiction and
Mental Health, Dual Diagnosis Service, Toronto,
Ontario, Canada; Virginie Cobigo, University of
Ottawa, School of Psychology, Ottawa, Ontario,
Canada; University of East Anglia; Hélène M. J.
Ouellette-Kuntz, Queen’s University, Department
of Public Health Sciences Kingston, Ontario,
Canada; Yona Lunsky, Centre for Addiction and
Mental Health, Dual Diagnosis Service, Toronto,
Ontario, Canada.
77
Copyright of Intellectual & Developmental Disabilities is the property of American
Association on Intellectual & Developmental Disabilities and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.