Drug prescribing for ambulatory patients 85 years of age and older

Patterns of Health and Social Services Utilization

Utilization of an array of health and social services from formal and informal sources is studied here 1) to identify profiles of services utilization and 2) to predict the location of elderly in these profiles by a set of independent variables such as the sociodemographic characteristics of the elderly, their physical and mental health status and the density of their social support network. Two samples of non-institutionalized elderly living in two middle-sized towns were drawn from the universal old-age Canadian pension scheme. Their utilization of hospital, medical and pharmaceutical services was assessed, and their use of services for help with adivities of daily living was measured by a set of six indicators. A cluster analysis was run to identify profites of services utilization, and a discriminant analysis used the profiles as the criterion to be predicted by a set of variables. Five profiles of utilization were obtained; four of them identified elderly with very few experiences of services utilization and a fifth, a low number of elderly with utilization of all of the services listed in this study. Most of the elderly were users of a small subset of medical and social services. The location of elderly in the profiles was predicted by physical health status, coresidence and income. These results show that health and social services from both formal and informal sources are utilized by elderly. It is suggested that new types of formal agencies which consider the simultaneous delivery of social and health services will succeed inasmuch as they have the ability to interact with a system of informal care.

Drug treatment in 70-82-year-old persons. A longitudinal study

The drug consumption has been studied in two 70-year-old cohorts within the frames of the longitudinal population study "70-year-old people in Göteborg, Sweden". The first cohort has been followed for 12 years and the second, which was born 5 years later, for 5 years. In the first cohort the proportion of men and women on drug treatment increased from 61 and 77% at age 70 to 90 and 97% at age 82. The average number of drugs among those on treatment increased from 3.1 (men) and 3.4 (women) to 3.9 and 5.4, respectively. The most common drugs at age 70 were anxiolytics (20 and 29%), diuretics (15 and 29%), analgesics (12 and 20%), and digitalis (13 and 14%) and at 82 years of age analgesics (39 and 56%), anxiolytics (27 and 49%), diuretics (26 and 42%), and laxatives (19 and 28%). The second examined cohort used more drugs mainly at age 75 than the first cohort. The longitudinal follow-up of the first cohort indicated an overmortality mainly among men on drug treatment at ages 70 and 75. The patients' knowledge of the indications for the treatment was often weak and at age 82, 25% of the patients were unaware of the indications for one or more of the drugs.

Drug utilization in the old old and how it relates to self-perceived health and all-cause mortality: results from the Bronx Aging Study

OBJECTIVE

To characterize medication use in a "well" very old population and relate the quantity and type of medication use to 10-year mortality.

DESIGN AND SUBJECTS

A longitudinal, 10-year, follow-up study involving 488 healthy, community-dwelling volunteers aged 75 to 85 years. The subjects underwent a detailed baseline evaluation and annual assessments that included comprehensive physical exams, laboratory and diagnostic tests, and related interviews. Prescription and nonprescription drug use was determined by self report, confirmation through hospital records, and reports by subjects and significant others.

RESULTS

At study baseline, the mean number of prescription and nonprescription medications used was 2.3 and 1.5, respectively. Female subjects (n = 315), those older than 80 years, or those who reported themselves to be in fair or poor health on initial health self-report were found to show significantly increased use of prescription medications. The most commonly used classes of medications were cardiovascular drugs and analgesics. Subjects who were consuming a greater number of prescription and nonprescription medications did not have higher mortality rates. After correcting for differences in cardiovascular health status between users and nonusers, only digoxin approached significance as an independent predictor of death (P < .08).

CONCLUSION

This study confirmed that medication use in an ambulatory, old old population is not excessive. The oldest subjects in the cohort consumed more medications than did the younger subjects. Women used more prescription drugs than men. Increased medication use was associated with worse ratings on health self report. Medication use alone, however, was not a predictor of 10-year mortality in this population. Questions are raised about the inappropriate prescription of digoxin in older subjects.

Prescribing patterns for older heavy drug users living in the community

We report an analysis of prescription drugs claimed under a government-sponsored, universal Pharmacare program for community-dwelling adults aged greater than or equal to 50 years in Manitoba during 1975, 1978, 1981, and 1984. We limited our analysis to claimants who reported over six drugs in a year in order to control for effects of inflation and a changing deductible. The median number of prescribed drugs and the percent of claimants over age 50 years receiving prescriptions from multiple physicians decreased during the course of our study. In this sample of heavy drug users, age and sex did not consistently correlate with overall drug use, although there was correlation for specific drug groups. The relative ranking of prescribed drugs changed over the years, although benzodiazepines, thiazide diuretics, topical steroids, and codeine-containing analgesics remained near the top. Barbiturates and topical antibiotics showed the greatest drop in prescription rates; acetaminophen and beta-blockers increased the most. Using these community data, we project the prevalence of drug-related adverse events to be highest with beta-blockers, nonsteroidal antiinflammatory drugs, thiazide diuretics, and benzodiazepines.

Drug-prescribing patterns in old age. A study of the impact of hospitalization on drug prescriptions and follow-up survey in patients 75 years and older

A prospective drug surveillance study was undertaken in 300 elderly patients admitted to a geriatric clinic. Prescribing patterns were determined on admission, at discharge and 3.6 and 18 months after discharge. Patients referred from long-term care institutions were on significantly more drugs than non-institutionalized subjects. A 34% reduction in the number of medicines prescribed at discharge was accompanied by a significant decrease in the mean number of prescriptions per patient, from 4.3 to 2.8, irrespective of whether the patient was institutionalized. Polypharmacy, defined by 5 or more concomitant drugs, declined from 43 to 17%. Dosage schedules were simplified in the majority of patients, as expressed by a significant decrease in the mean number of daily doses to be taken from 6.7 on admission to 4.4 at discharge. Cardiovascular drugs, diuretics and psychotropic drugs accounted for 64% of all drug prescriptions. At discharge, prescription frequencies were reduced for most medication categories, except diuretics and gastrointestinal drugs, which were being taken more often. The prescribing frequency of cardiac glycosides, the single most frequently prescribed drug class, decreased from 60 to 33% of the patients. Three months after discharge, prescribing patterns and frequencies were found to be very similar to the pre-admission situation. Eighteen months after discharge, overall drug use had increased by 15% compared to admission, and polypharmacy was recorded in 54% of patients. It is concluded that a substantial reduction in drug prescriptions was possible in the majority of elderly patients, particularly if they are institutionalized, on admission to a geriatric clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

Reducing polypharmacy in the elderly. A controlled trial of physician feedback

A prospective, controlled trial to reduce polypharmacy in patients 65 years or older was carried out in the residents' clinic of a teaching hospital. Of 272 elderly patients surveyed, 89 (33%) were taking five or more prescription drugs. Recommendations to discontinue medications or to simplify regimens were formulated for 79 polypharmacy patients. Compared to 41 controls, the 38 patients whose physicians were informed of the recommended changes demonstrated a small but significant reduction in the mean number of drugs, the complexity, and the cost of their regimens. Physicians complied with eight (100%) of eight recommendations to simplify a dosage schedule, eight (62%) of 13 recommendations to substitute a new drug for the old one, and only eight (40%) of 20 recommendations to stop a medication (P = .04). Noncompliance usually resulted from patient refusal or from medications being prescribed by another provider. Whereas feedback to the primary physician is beneficial, more substantial reductions in outpatient polypharmacy may require overcoming patient barriers and limiting the number of prescribing physicians.

Clinicians, the Elderly and Drugs

The increase of the elderly within our population makes for increased chronic disease and, hence, greater use of sophisticated medications now available. This paper reviews current knowledge of the pharmacodynamics and pharmacokinetics among elderly users of drugs and estimates the prevalence of use of prescribed drugs. Less is known of specifics of prescribing patterns, but evidence clearly suggests the strong influence of patient/doctor communication in compliance and control of side effects. There is little hard evidence on the populations considered at high risk for inappropriate prescribing and use and for side effects. The influence of race, socioeconomic class and age are all suggested Since drugs and their uses increase daily, it is important to investigate the area of high-risk populations in order to accumulate evidence which can lead to appropriate interventions.

Medication and the elderly. Issues of prescription and use

Use of medication has become an increasingly important issue in the health and health care of older populations. The demographic changes resulting in greater numbers of individuals 65 and over, accompanied by a higher prevalence of chronic disease, focus attention on prescription and over-the-counter drugs, the major strategy in treatment regimens for these conditions. In addition, the numbers of new and powerful drugs being developed increase daily. This article reviews and evaluates existing information on the prevalence of medication use and adverse drug reactions. It examines the role of physicians and patients in occurrence and management of side effects of drugs and in patterns of prescription and use. Following this, it identifies areas of research necessary to address the gaps in the current state of knowledge in these areas and discusses the need for strong and substantial information about this essential therapeutic strategy in health care for older people.

Reliability of drug histories in a specialized geriatric outpatient clinic

To examine the reliability of drug histories of elderly outpatients, records of 122 frail elderly patients in a geriatric outpatient evaluation clinic were reviewed. Drug histories were taken by an internist during an initial clinical evaluation and by a nurse practitioner during a home visit. Home and office drug lists disagreed in 39 cases (32%). Roughly equal numbers of "extra" drugs were listed in the two settings. Number of medications (especially two or more), number of active medical problems (especially four or more), and depression were significant, independent predictors of an unreliable drug history. Neither dementia nor living situation was a significant predictor of an unreliable drug history. The only drugs associated with an unreliable history were megavitamins, beta-blockers, and centrally-acting antihypertensive agents. Using the home list as the reference, there were equal numbers of omission errors and commission errors in the office drug histories. Strategies to optimize the reliability of office drug histories need further investigation.

Medication use characteristics in the elderly: the Iowa 65+ Rural Health Study

Medication use was studied in a rural, elderly population. Household interviews were conducted of 3,467 individuals aged 65 years or older. A total of 9,955 prescription or nonprescription drugs were reported by the respondents. The overall mean number of drugs per respondent was 2.87, while 12% of all respondents were not taking any drugs. Mean prescription and overall drug use increased significantly with increasing age (P less than .001), while mean nonprescription drug use was relatively constant across age groups. Significantly more women were prescription and nonprescription drug users. Directions for scheduled daily dosing accounted for 75% of all directions. The majority of prescription and nonprescription drugs had been taken on the previous day. General practitioners accounted for more prescription drugs (39.7%) than any other medical specialty. The most frequently stated purpose was cardiovascular for prescription drugs and musculoskeletal for nonprescription drugs. The three most frequent prescription drug therapeutic categories were cardiovascular (54.7%), central nervous system (CNS) agents (11.4%), and analgesics (9.4%). For nonprescription drugs, the three most frequent therapeutic categories were analgesics (39.6%), vitamins and minerals (32.9%), and laxatives (14.1%). Implications of these findings are discussed.