Polypharmacy: the cure becomes the disease

Drug utilization and health behaviours among indigent elderly patients in Crete, Greece

AIM

To examine pharmaceutical needs, prescribed drugs, knowledge about pharmacotherapy and health behaviours among Social Care indigent elderly patients.

PATIENTS

There were a total of 551 Social Care indigent patients registers in Chania, Crete, Greece at the time of the study (1995-97), of whom 89 (40 men and 49 women) were elderly patients (> or =65 years old). The control group comprised 171 (81 men and 90 women) Social Security insured elderly patients (> or =65 years old).

RESULTS

The socio-demographic profile of the indigent elderly patients reveals an unemployment rate of 99% (versus 5% in the control group, P<0.05) and an illiteracy rate of 38% (versus 5%, P<0.05). The most commonly prescribed defined daily doses (DDD) of medications were cardiovascular drugs (45.0% indigent versus 48.3%) and nervous system drugs (14.4% versus 8.8%). The most frequently prescribed drug, as a percentage of DDD, was nitroglycerin (14.5% versus 26.0%) and the most expensive drug, expressed as a percentage of the total cost of drugs, was omeprazole (6.5% versus 4.6%). The most common disease was hypertension (42.1% versus 23.2%, P<0.05). There were also significant differences between the two groups of patients (P<0.05) in the understanding of drug usage instructions (35.4% versus 68.6%), in asking the pharmacist for advice (44.6% versus 71.5%) and in understanding special diet instructions (18.7% versus 34.7%). Regarding the health behavior patterns, significant differences (P<0.05) were found in the consumption of sausages (38.6% versus 15.6%), salt (29.8% versus 12.0%), more than one glass per day of alcoholic drinks (13.8% versus 4.3%) and in daily smoking cigarettes (48.8% indigent versus 12.8% control).

CONCLUSION

The present study emphasizes the need for more information on drug use and the necessity for a continuing health educational intervention among Social Care indigent elderly patients.

The safety and efficacy of switching timolol maleate 0.5% solution to timolol hemihydrate 0.5% solution given twice daily

This study was undertaken to evaluate the safety and efficacy of switching patients treated with timolol maleate to timolol hemihydrate. In patients with ocular hypertension or chronic open-angle glaucoma treated with beta-blockers for at least three months, we prescribed timolol maleate solution 0.5% given twice daily for one month. We then switched each patient to timolol hemihydrate solution 0.5% (Betimol, Ciba Vision Ophthalmics) given twice daily for three months. This study found over the first three months in 30 completed subjects, using a worse eye analysis, that the intraocular pressure changed from 18.3+/-2.1 mm Hg on timolol maleate to 18.8+/-2.3 mm Hg on timolol hemihydrate (P=0.10) 12 hours after dosing. There was no difference in the overall incidence of unsolicited anterior segment side effects between timolol maleate (4 cases) versus timolol hemihydrate (3 cases) (P=0.69). One patient exited the study because of pain and burning in both eyes while on timolol maleate. No patient was discontinued due to loss of intraocular pressure control after switching to timolol hemihydrate. It was concluded that switching from timolol maleate to timolol hemihydrate is safe and effective in maintaining control of the intraocular pressure.

Decreasing polypharmacy in clients most at risk

Approximately one third of all drugs prescribed in the United States are considered unnecessary. Polypharmacy, the unnecessary, excessive use of prescription and over-the-counter medications, increases clients' risk for adverse drug reactions and drug-drug interactions. Reducing the incidence of polypharmacy is a health protection goal of Healthy People 2000. Older clients, particularly older women living independently in the community, are at highest risk for polypharmacy caused by age-related changes in pharmacokinetics and pharmacodynamics, the presence of comorbidities requiring pharmacologic management, and high rates of unintentional noncompliance with their therapeutic regimen. Health providers may contribute to polypharmacy directly by excessive or inappropriate prescribing practices or indirectly through their inability to resist client's demands for pharmacologic interventions. Strategies to prevent and detect polypharmacy are suggested to reduce its incidence and the severity of its consequences.

Oral antifungal drug interactions

The recent approval of itraconazole and terbafine for the treatment of onychomycosis has launched a new era in the therapeutic management of this previously resistant form of dermatomycoses. These agents represent safe and effective treatments. The clinician should, however, become knowledgeable with the potential drug interactions that are discussed in this article.

An evaluation of community pharmacy records in the development of pharmaceutical care in The Netherlands

An electronic patient database linking prescribes with a Dutch community pharmacy consortium was evaluated in a subset of the population of Noordwijk (11,760 patients out of a total of 25,600). The pharmacy database (a file of 41 disease contra-indications representing a subset of the prescribers' medical diagnosis) was studied in order to assess its value for the accurate discrimination of target patient groups within the community and for support to the pharmaceutical care of individual patients. The aim was to examine the application of the pharmacy records to pharmaceutical care, tested by measuring the accuracy of the pharmacy database to predict the community public health profile; and, more specifically, the accuracy to identify three potential target groups for pharmaceutical care. The records of patients with angina, chronic respiratory disease and diabetes (n = 1116), representing 65% of the total pharmacy morbidity records, were studied in detail and verified by the files and texts of the prescriber's individual patient records. From samples of patients (n = 273) from the three patient groups, the extent and nature of co-morbidity, polypharmacy (drug entities prescribed annually) and drug therapy instability (prescription changes to dose or dose form annually) were characterised. Angina patients showed the most comorbidity, 46% having three or more additional diseases; chronic respiratory disease patients showed most drug therapy instability; and insulin-dependent diabetic patients received most polypharmacy per disease. The pharmacy database predicted the prevalence of 10 of 23 relevant disease categories (representing 51% of the total morbidity on the medical records). However, the prevalences of eight categories were underestimated and of five categories overestimated. Of the three patient groups, 73% of patients appeared on both the pharmacy and the medical database. Of the total co-morbidity recorded for these patients, 68% of records were common to both databases. The database discrepancies (32%) were due to morbidity omitted (12%) and morbidity unverified (10%) on the pharmacy database, together with morbidity omitted from the medical database (10%). The current pharmacy database provides a limited view of morbidity. A strategic approach to pharmaceutical care requires pharmacists and prescribers to verify and share patient information if patient groups and individuals within a group are to be usefully targeted.

Drug use by the elderly in Italy

OBJECTIVES

To evaluate drug consumption in the elderly aged 75 years or more living at home.

DESIGN

Cross-sectional study.

SETTING

Old-old (i.e., > or = 75 y) people living in central Turin, a city in northern Italy.

PARTICIPANTS

Thirty-four general practitioners (GPs), with 50 or more old-old people in their patient list, randomly chosen among the GPs working in the Unità Socio-Sanitaria Locale I (Local Health Unit I) of Turin; 261 old-old people (135 men and 126 women) randomly selected from the practice records.

METHODS

Data were collected by the GP through a structured questionnaire during an office visit and by a social worker in a home interview within 14 days of the GP visit. GPs were asked to record every diagnosis and drug currently taken by the patient; social workers were trained in the administration of a structured questionnaire exploring sociodemographic variables, drug use (following the medication inventory strategy), disability, cognitive functions, and depressive symptoms.

RESULTS

Nearly all subjects (95% of the women and 91% of the men) were taking at least 1 drug. The overall number of drugs recorded was 917 (47.1% for men and 52.9% for women), of which 172 (18.8%) were not reported by the GP but were recorded during the social worker's visit. The mean number of drugs was 3.2 for men and 3.8 for women, with a statistically significant difference (p = 0.02), while the mean number of diagnoses was 2.3 and 2.6, respectively. The study of correlates of drug consumption showed a strong association with number of diagnoses at univariate analysis (p < 0.0001, with a linear correlation coefficient of 0.64). No multivariate model showed a clear superiority over the simple one containing only the number of diagnoses in predicting the total number of drugs taken. Cardiovascular, nervous system, and alimentary tract drugs were the most frequently used. A total of 107 subjects (41%) were taking at least 1 unreported drug.

CONCLUSIONS

Our study shows high drug consumption among old-old people, with nearly 20% of drugs taken not reported by the GP. These results emphasize the need for an essential therapeutic approach in old-old people, prescribing only drugs of scientifically proven efficacy. Furthermore, the GP must make more effort when collecting a drug history from old-old patients.

Prescribed medication and nutrition of social care patients in Crete, Greece

OBJECTIVE

The aim of this study was to make a systematic registration of a group of 354 social care indigent patients in relation to: their pharmaceutical needs: the conditions for which it was prescribed, its cost, and details of prescriptions. In addition patients' eating patterns relating to and knowledge of how to use their medication was assessed. They were compared to a control group of 153 Social Security patients.

SUBJECTS

The Social Care indigent patients were of low income, consisting of groups as unmarried mothers with their children and Greeks emigrants coming back home from other countries (Albania, Russia, Georgia, Ukraine, Romania etc.). The socio-demographic profiles of this group reveal an unemployment rate of 74% and an illiteracy rate of 18%. As regards marital status, 20% are bachelors and 12% divorcees.

RESULTS

The results of the study indicated no significant difference between the two groups in the mean cost of prescription (40 ECU for Social Care patients vs 32 ECU for Social Security patients), in the mean number of medication per prescription (2.6 vs 2.6 respectively), in the percentages of the Daily Defined Doses and the cost of the various categories of drugs. For both groups, the most common drugs were those of the Cardiovascular system (30% vs 26%), Gastrointestinal system (17% vs 27%) and Nervous system (16% vs 18%). The most common diagnosis was Hypertension (10% vs 8%) and the most common drugs were Ranitidine (3% vs 2%), Diclofenac (3% vs 3%), Salbutamol (3% vs 3%) and Paracetamol (2% vs 2%). Significant differences between Social Care patients to Social Security patients respectively were found regarding: knowing how to take their medication correctly (47% vs 77%), knowing for how long treatment needed to be taken (21% vs 43%), requesting information from the pharmacist (39% vs 68%) knowledge of dietary instructions regarding medication (17% vs 41%) and in smoking more than 20 cigarettes per day (15% vs 3%).

CONCLUSIONS

The results indicated that the Social Care patients, in comparison with the patients of the Social Security, need more education and more help in the area of the proper use of drugs and in the personal contact that this procedure involves.

Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure

PURPOSE

The objectives of this investigation were to prospectively assess medication compliance rates in elderly patients with congestive heart failure, to identify factors associated with reduced compliance, and to evaluate the effect of a multidisciplinary treatment approach on medication adherence.

PATIENTS AND METHODS

A total of 156 patients > or = 70 years of age (mean, 79.4 +/- 6.0; 67% female, 65% nonwhite) hospitalized with congestive heart failure were evaluated prospectively. Prior to discharge, patients were randomized to the study intervention (n = 80) or conventional care (n = 76). The intervention consisted of comprehensive patient education, dietary and social service consultations, medication review, and intensive postdischarge follow-up. Detailed data were collected on all prescribed medications at the time of discharge, and compliance was assessed by pill counts 30 +/- 2 days later.

RESULTS

The overall compliance rate during the first 30 days after discharge was 84.6 +/- 15.1% (range, 23.1-100%). Compliance was 87.9 +/- 12.0% in patients randomized to the study intervention, compared with 81.1 +/- 17.2% in the control group (P = 0.003). A compliance rate of > or = 80% was achieved by 85.0% of the treatment group versus 69.7% of the control group (P = 0.036). By multivariate analysis, assignment to the treatment group was the strongest independent predictor of compliance (P = 0.008). Other variables included in the model were Caucasian race (P = 0.044) and not living alone (P = 0.09).

CONCLUSIONS

A multidisciplinary treatment strategy is associated with improved medication compliance during the first 30 days following hospital discharge in elderly patients with congestive heart failure. Improved compliance may contribute to improved outcomes in these patients.

Pharmacotherapy problems in the elderly

As the elderly population increases, pharmacists will routinely confront aging-related problems in drug therapy. Drug therapy plans must take into account that diseases will present and progress differently in the elderly. Individual variations characterize the aging process, and it is physiologic-versus chronologic-aging that underlies age-related differences in pharmacokinetics and pharmacodynamics. More than one in six elderly Americans are taking prescription drugs whose adverse effects can have serious consequences in this age group.

Drug-nutrient interactions in three long-term-care facilities

OBJECTIVE

To assess the risk of drug-nutrient interactions (DNIs) in three long-term-care facilities.

DESIGN

Retrospective audit of charts.

SETTING

Three long-term-care facilities in central New York State.

SUBJECTS

Fifty-three patients selected randomly from each facility.

MEASUREMENT

Data were collected from the medical record of each patient for a period of 6 months. A computerized algorithm was used to assess the risk for DNIs. Mean drug use, most frequently consumed drugs, incidence of potential DNIs, and the most commonly observed potential DNIs are reported.

RESULTS

In facilities A, B, and C, respectively, patients consumed a mean of 4.86, 4.04, and 5.27 drugs per patient per month and were at risk for a mean of 1.43, 2.69, and 1.43 potential DNIs per patient per month. The most commonly observed potential DNIs were gastrointestinal interactions affecting drug bioavailability and interactions affecting electrolyte status.

CONCLUSIONS

Patients in long-term-care facilities, who are primarily elderly and chronically ill and who consume multiple medications, are at notable risk for certain DNIs. Efforts need to be made to ensure appropriate pharmacologic and nutrition therapies as well as adequate and timely monitoring of patients in these facilities. Dietitians can play an important role in training other health professionals and in designing policies to prevent DNIs.

Cognitive impairment and medication adherence

1. The findings of this study are congruent with previous work that found that subjects' knowledge about medication is not necessarily correlated with adherence to medication regimens. 2. The nature and experience of forgetting medications merits further investigation. Asking patients about forgetting medication is easy to do, and many methods of compensating for forgetfulness are available. 3. Cognitive impairment was not associated with medication adherence. Cognitively impaired elders were likely to have caregivers assisting in the administration of their medication in the period immediately after discharge from acute care facilities.