Drug use by the elderly in Italy

Identification of the drug-use behaviors of the elderly living in nursing homes

Objective

As our society ages, the incidence of acute and chronic diseases increases, and so does chronic drug use and polypharmacy. This study was intended to examine the medication behaviors of the elderly who lived in the nursing homes in the Elazig and Malatya provinces, located in eastern Turkey, and in the Kayseri province located in Central Anatolia.

Materials and methods

The population of this cross-sectional study included people over the age of 60 years (n=310) who lived in the nursing homes in the Elazig, Malatya, and Kayseri provinces. The entire population was included in the research without sampling, of which 255 (82.2%) people participated. Data were collected using a survey form, and the survey was conducted through face-to-face interviews. The data were reported in numbers, percentages, and averages.

Results

Of the studied population, 87.8% were treated through polypharmacy, using various drugs. The most commonly used drugs were antihypertensives (52.2%). Females over 60 years used more polypharmacy than men (p<0.05). Of the elderly studied, 97.3% used drugs as recommended, 95.3% did not know about the side effects of the drugs they used, and 93.7% did not read the prospectuses of the drugs. Also, 82.7% stated that their drugs did not have any side effects and 70.2% said that the health care personnel did not educate them about their drugs. Of the elderly who were informed about their drugs, 55.3% obtained the information from the nurse and 44.7% from the physician. Of the elderly, 51.3% received education on the duration they would need to take the drug, 30.3% were educated on the intended use of the drugs, 7.9% received education on their drug dose, and 6.6% were educated on the side effects of the drugs.

Conclusion

The results of this study showed that the majority of the elderly studied used more than one drug (polypharmacy) and the most used drug group was antihypertensives.

Medication burden of Saudi Arabian women receiving antiresorptive therapy

Background and purpose

Osteoporosis is common in the Saudi Arabian population, and its successful treatment requires full compliance. Patients who require antiresorptive therapy, such as oral bisphosphonates, may suffer from other diseases requiring medications, which increases the medication burden and ends up in drug noncompliance on the part of patients, making them vulnerable to osteoporosis-related fractures. We decided to undertake this study to analyze the concomitant medications that osteoporotic patients are receiving at King Fahd Hospital of the University, Al Khobar.

Methods

Osteoporotic patients receiving antiresorptive therapy (ART) at King Fahd Hospital of the University, Al Khobar, were identified through the database of the QuadraMed Patient Care system and cross-checked with the radiology database of the dual-energy X-ray absorptiometry scan and pharmacy drug-dispensing system between January 2009 and December 2009. Concomitant medication is defined as the use of other drugs for ≥30 days with oral bisphosphonates, calcium, and vitamin D. Medication burdens are defined as mild (≤1 concomitant medication), moderate (≥2 and ≤4 medications), and severe (≥5 medications). The demographic data, such as age, sex, and diagnosis, were collected from the medical records. The data were analyzed using the Statistical Package for the Social Sciences (SPSS).

Results

During the study period, 516 patients were diagnosed with osteoporosis, and 473 were on ART while the rest were using anabolic Teriperatide. Sixty-eight (14.4%) of the patients, with an average age of 50.15 ± 2.4 years, were on one medication besides ART, vitamin D, and elemental calcium; 129 (27.3%) of the patients, with an average age of 51.6 ± 9.7 years, were taking 3.32 medications, and 276 (58.3%) of the patients, with a mean age of 62.1 ± 10.7 years, were on 8.02 concomitant medications. The most common concomitant medications in use were cardiac, endocrine, systemic nonsteroidal anti-inflammatory drugs, and analgesics, in that order. This study suggests that the majority of Saudi women who are osteoporotic and undergoing oral bisphosphonate therapy have a concomitant medication burden of ≥5 other medications. For full compliance with the therapy, the patients’ medication burden should be considered prior to selecting the treatment route.

Drug utilization and polypharmacy in an Italian elderly population: the EPIFARM-elderly project

OBJECTIVE

To investigate the prescribing patterns and the prevalence of polypharmacy in community-dwelling elderly people, and to analyze the association of chronic medications and number of drug prescriptions with age and sex.

METHODS

All prescriptions for people aged 65 years or older reimbursed by the Italian National Health Service (NHS) and dispensed by retail pharmacies of the 15 local health units (LHU) in the Lombardy Region during 2005 were analyzed. Logistic regression analysis was used to assess the association between drug prescription (overall, chronic drugs, and polypharmacy) and age, sex, and LHU of residence.

RESULTS

Eighty-eight percent of the 1 ,767 ,239 analyzed elderly received at least one drug prescription. The overall prescription rate was slightly higher for women than men (odds ratio [OR] 1.20; 95%CI 1.19-1.21). Seventy-six percent of the elderly received at least one chronic drug, 46% were exposed to polypharmacy, and 20% to chronic polypharmacy. At multivariate analysis, age and LHU residence of the elderly were the main determinants of drug exposure. A significant correlation was found between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy (r(s)  = 0.79, p < 0.0005 and r(s)  = 0.84, p < 0.0001, respectively).

CONCLUSIONS

Our findings indicate that age and LHU residence of the elderly are the main determinants of drug prescribing, and there is evidence of a significant correlation between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy.

Utilization and costs of antiepileptic drugs in the elderly: still an unsolved issue

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age- and aging-related clinical conditions. Management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance, the greater numbers of drugs required and drug interactions reported, and the increase in treatment-related costs. Epilepsy is a chronic clinical condition affecting both sexes and all ages with a worldwide distribution. The incidence of epilepsy, after childhood, increases with age and the cumulative risk of epilepsy by 80 years of age ranges from 1.3% to 4% in different study populations. Although the issues for people with epilepsy are similar for older and younger adults, the elderly may require more attention with regard to selection of antiepileptic drugs (AEDs) than younger patients. Elderly patients with newly diagnosed epilepsy are more likely to remain seizure-free on AED therapy than younger populations; however, the toxicity of AEDs in elderly patients is ill-defined because seizures may be difficult to recognize in this group and the symptoms and signs of toxicity can be attributed to other causes. Moreover, elderly people have chronic clinical conditions and are more likely to be taking medications that could possibly interfere with AEDs.Some older AEDs such as phenobarbital and phenytoin should not be used in the elderly because of their pharmacokinetic and pharmacodynamic profiles. There is no evidence that new AEDs, despite their better tolerability profiles, are advantageous in terms of attaining freedom from seizures compared with older agents.Older AEDs are much less expensive than the new compounds and, with some exceptions, appear to be more cost effective. New AEDs may be cost effective only in patients who are not able to tolerate or who are resistant to older compounds or when the use of an older drug is contraindicated. However, there are no cost-effectiveness studies in the elderly and further evidence is needed to confirm these assumptions.

The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people

OBJECTIVES

To investigate whether low educational attainment is associated with polypharmacy and potential inappropriate drug use (IDU) in older people.

DESIGN

Cross-sectional register-based study.

SETTING

Sweden.

PARTICIPANTS

Older people aged 75 to 89 who, filled at least one drug prescription between August and October 2005 and, consequently, were listed in the Swedish Prescribed Drug Register (SPDR) (N=626,258). Data were obtained from the SPDR, the inpatient register, and the education register.

MEASUREMENTS

The main outcome measures were polypharmacy (concurrent use of > or =5 drugs), excessive polypharmacy (concurrent use of > or =10 drugs), and potential IDU. Four quality indicators developed by the Swedish National Board of Health and Welfare were used for the assessment of potential IDU: concurrent use of three or more psychotropic drugs, prescription of long-acting benzodiazepines, prescription of anticholinergics, and at least one clinically relevant potential drug-drug interaction (DDI). Comorbidity was measured using the Charlson Comorbidity Index.

RESULTS

Subjects with low education had a higher probability of polypharmacy (odds ratio (OR)=1.11, 95% confidence interval (CI)=1.10-1.12), excessive polypharmacy (OR=1.15, 95% CI=1.13-1.17), and potential IDU (OR=1.09, 95% CI=1.07-1.17), after adjustment for age, sex, comorbidity, and type of residential area (urban or rural). Decreasing educational attainment was associated with a higher probability of using three or more psychotropic drugs and potential DDIs, whereas the opposite association was observed for anticholinergic drugs. Long-acting benzodiazepines showed no association. Elderly women with low education were slightly more likely to have polypharmacy, excessive polypharmacy, and potential IDU than men with low education. Overall, the ORs were modest and statistically significant because of the large sample size.

CONCLUSION

Low educational attainment was associated with a greater likelihood of poypharmacy, excessive polypharmacy, and potential IDU in elderly Swedish persons, even after controlling for age, sex, place of residence, and comorbidity. Women with low education had slightly higher likelihood of receiving polypharmacy and potential IDU than men with low education. The recently established SPDR may be useful for continuous monitoring and for designing interventions to improve drug quality in low-educated elderly people.

Polypharmacy in elderly hospitalised patients in Slovakia

OBJECTIVE

The aims of the present study were to: analyse the prevalence of polypharmacy in a group of older patients; evaluate the influence of hospital stay on the number of drugs taken; assess the most frequently prescribed pharmacological classes; identify risk factors that predisposed the patient to polypharmacy. Setting The study was carried out in the Department of Internal Medicine of a non-university general hospital.

METHOD

In the retrospective study, 600 patients aged 65 years or more were enrolled. They were hospitalised in the period from 1st December 2003 to 31st March 2005. Each person taking six or more medications per day was considered to be a patient with polypharmacy. Particular sociodemographic and clinical characteristics, as well as comorbid conditions, were evaluated as factors potentially influencing the prevalence of polypharmacy.

MAIN OUTCOME MEASURE

The number and type of medications taken at the time of hospital admission and discharge were recorded and compared for each patient.

RESULTS

Polypharmacy on admission and at discharge was observed in 362 (60.3%) and 374 (62.3%) patients, respectively. Hospitalisation led to a significant increase in the number of medications. The spectrum of medications used corresponded to the proportions of diagnoses in the evaluated group, in which cardiovascular diseases were most prevalent. According to the multivariate analysis using a logistic regression model, diabetes mellitus (odds ratio (OR) 2.40; 95% confidence interval (CI): 1.64-3.50), heart failure (OR 2.14; 95% CI: 1.46-3.14), dementia (OR 2.12; 95% CI: 1.26-3.57), living alone (OR 2.00; 95% CI: 1.28-3.10), arterial hypertension (OR 1.63; 95% CI: 1.08-2.44) and cerebrovascular disease (OR 1.58; 95% CI: 1.03-2.44) significantly increased the risk of the presence of polypharmacy.

CONCLUSION

Our study confirmed a relatively high prevalence of polypharmacy in Slovak elderly patients. Polypharmacy risk rose especially with the increased prevalence of diseases of advancing age (diabetes mellitus, heart failure, arterial hypertension, dementia and cerebrovascular diseases). The increasing numbers of medications in inpatients indicate the need for the careful re-evaluation of pharmacotherapy during the stay in hospital.

Changes in the use of cardiovascular medicines in the elderly aged 75 years or older - a population-based Kuopio 75+ study

OBJECTIVE

The aim of this population-based cohort study was to examine the changes in the regular use of cardiovascular medication among the elderly aged 75 years or more in Finland in 1998 and 2003.

METHODS

The study population (n = 700) was a random sample of all persons aged 75 years or more living in Kuopio, in eastern Finland. Of them, 601 persons participated in 1998. The surviving persons (n = 339) were re-examined in 2003. Of them 85% (n = 289) were home-dwelling and 15% (n = 50) lived in institutional care. Data on their use of medication and their physical and mental health was collected from interviews conducted by trained nurses.

RESULTS

From 1998 to 2003 regular use of one or more cardiovascular medicine increased from 80% to 87% among all the survivors (n = 339, P < 0.001). The mean number of regularly used cardiovascular medicines increased from 2.1 (95% CI 1.9-2.3) to 2.7 (95% CI 2.5-2.9, P < 0.001) during the follow-up period. The most commonly used cardiovascular medicines were beta-blocking agents. The proportion of users of beta-blocking agents was in 1998 45% and in 2003 51%. The proportion of users of diuretics increased from 27% to 40% (P < 0.001), users of cardiac therapy from 35% to 43% (P < 0.001), users of ACE inhibitors and AT 1 receptor antagonists from 20% to 30% (P < 0.001) and users of lipid modifying agents from 7% to 12%.

CONCLUSIONS

The use of cardiovascular medicines was common among elderly persons. The proportion of users increased with age and over time. A large proportion of elderly persons would need medication monitoring focusing on cardiovascular medication.

Factors influencing the implementation of quality use of medicines in residential aged care

BACKGROUND

In response to concerns about, and issues pertaining to, medication use practices in residential aged-care facilities (RACFs), the Australian Pharmaceutical Advisory Council (APAC) established a working party on quality use of medicines (QUM) in nursing homes and hostels. The APAC is a representative ministerial advisory forum bringing together key stakeholders from the medical, nursing and pharmacy professions, as well as pharmaceutical industry, consumer and government sectors. The working party developed the integrated best practice model for medication management in RACFs.

OBJECTIVES

This study arose from concerns that, despite the availability of such guidelines to inform best practice in RACFs, there remain barriers to its implementation. Thus, the focus of this research was to explore factors influencing the implementation of best practice with respect to QUM in RACFs.

METHODS

This multimethod, multidisciplinary study was conducted in a representative sample of 12 RACFs in one Australian state - South Australia. The methods used were Critical Incident Technique (CIT) interviews, focus groups, nominal groups and Participatory Action Research.

RESULTS

In stage one of the research the CIT interviews identified four major issues/factors influencing the implementation of best practice: contextual/structural, boundaries, day-to-day practices and keeping up. These themes were developed in the focus and nominal group sessions and the project team prepared a discussion paper summarising stage one results. In stage two participants were asked to use the discussion paper to develop a way forward. Medication Advisory Committees (MACs) emerged as a key strategy. Each participating RACF was then supported to establish and maintain a MAC. A second workshop heard feedback from the facilities on factors supporting the MACs and barriers to their functioning. Eleven of the 12 RACFs had a functioning MAC at the end of the project. Key support factors included: an external facilitator to help organise MAC meetings, provision of resources, such as terms of reference, agendas, policy statements and the sharing of information between MACs. In stage three a set of agreed recommendations was prepared and submitted to the funding body. The recommendations reported here informed the development of the peak guidelines for medication management and administration in Australia.

CONCLUSION

This project has been groundbreaking in its impact on Australian aged-care practice. A major outcome has been significantly improved communication and collaboration between industry organisations, academic disciplines, professional bodies and educators involved in the RACFs.

Adverse drug reactions in elderly patients

Many studies from around the world show a correlation between increasing age and adverse drug reaction (ADR) rate, at least for some medical conditions. More than 80% of ADRs causing admission or occurring in hospital are type A (dose-related) in nature, and thus predictable from the known pharmacology of the drug and therefore potentially avoidable. Frail elderly patients appear to be particularly at risk of ADRs and this group is also likely to be receiving several medicines. The toxicity of some drug combinations may sometimes be synergistic and be greater than the sum of the risks of toxicity of either agent used alone. In order to recognize and to prevent ADRs (including drug interactions), good communication is crucial, and prescribers should develop an effective therapeutic partnership with the patient and with fellow health professionals. Undergraduate and postgraduate education in evidence-based therapeutics is also vitally important. The use of computer-based decision support systems (CDSS) and electronic prescribing should be encouraged, and when problems do occur, health professionals need to be aware of their professional responsibility to report suspected adverse drug events (ADEs) and ADRs. "Rational" or "obligatory" polypharmacy is becoming a legitimate practice as increasing numbers of individuals live longer and the range of available therapeutic options for many medical conditions increases. The clear risk of ADRs in this situation should be considered in the context that dose-related failure of existing therapy to manage the condition adequately may be one of the most important reasons for admission of the elderly to hospital. Thus, age itself should not be used as a reason for withholding adequate doses of effective therapies.

NSAID and aspirin use by the elderly in general practice: effect on gastrointestinal symptoms and therapies

BACKGROUND

The relationship between NSAID use and gastrointestinal (GI) symptoms and their treatment in elderly patients is not well defined.

OBJECTIVES

To identify the prevalence of specific drug use in elderly outpatients and to identify the relationship between NSAID use and GI disturbances and treatments in elderly subjects treated by their general practitioner (GP).

SETTING AND PARTICIPANTS

The study was carried out by 63 GPs in north-eastern Italy; 3154 elderly subjects were included in the study over a 2-week period.

DESIGN

By using a structured interview, subjects' medical histories and current medication were identified. In particular, the presence and use pattern (i.e. occasional, 'acute' or 'chronic') of NSAIDs and/or aspirin (acetylsalicylic acid) were recorded. In all subjects, the presence of upper GI symptoms, i.e. abdominal pain, reflux symptoms and indigestion syndrome, were noted.

RESULTS

The prevalence of drug use was 96.4% (males 96%, females 96.7%). The most prescribed drugs were ACE inhibitors (38%), diuretics (26.7%), NSAIDs and regular-dose aspirin (24.7%), GI drugs (20.6%), and anxiolytics/hypnotics (20.3%). Of 779 subjects who had taken NSAIDs or regular-dose aspirin, 32.9% were 'chronic' users, 24.9% were 'acute' users and 42.1% occasional users. A significantly higher prevalence of upper GI symptoms was observed in elderly NSAID and low-dose aspirin users compared with non-users (24.9% vs 28% vs 16.6% respectively, p < 0.0001). GI symptoms were reported by 27.6% of 'chronic' NSAID users, 22.9% of 'acute' users and 24.7% of occasional users. A significantly higher prescription rate for any GI drug was found in NSAID users than in low-dose aspirin users and non-users (24.0% vs 19.6% vs 19.4% respectively, p = 0.007). This difference was mainly because of a higher number of upper GI drugs taken by NSAID users than by low-dose aspirin users and non-users (18.1% vs 16% vs 13.7% respectively, p = 0.004). Multivariate analysis demonstrated that female gender (odds ratio [OR] = 1.32, 95% CI = 1.16-1.44), low-dose aspirin (OR = 1.88, 95% CI = 1.33-2.65), NSAIDs and/or regular-dose aspirin (OR = 1.48, 95% CI = 1.19-1.83) and multiple therapies, i.e. taking more than four drugs per day (OR = 1.42, 95% CI = 1.14-1.77) were risk factors for GI symptoms in elderly outpatients.

CONCLUSION

NSAIDs and/or aspirin use was very high in this elderly outpatient population. The use of these drugs was significantly associated with a greater number of upper GI symptoms and prescriptions for GI drugs. Educational and clinical strategies need to be implemented in order to reduce the GI impact of NSAID and aspirin use in elderly people.

Changes in drug treatment in the elderly between 1971 and 2000

OBJECTIVE

To investigate changes in drug treatment among elderly men and women over a 29-year period between 1971 and 2000.

METHODS

Drug consumption was investigated in five representative population samples of 70-year-olds born in 1901-1902 (n=973), 1906-1907 (n=1036), 1911-1912 (n=619), 1922 (n=449) and 1930 (n=506) and in three representative samples of 79- to 80-year-olds born in 1901-1902 (n=537), 1906-1907 (n=538) and 1915 (n=212).

RESULTS

The proportion of 70-year-olds who used drugs increased from 60% to 79% in men and from 76% to 88% in women from 1972 to 2000. Among 80-year-olds, 21% of the men and 11% of the women were without drug treatment in 1980, compared with 7% in 1995. The average number of drugs among 70-year-olds on treatment increased during the observation period from 2.8 to 3.5 in men and from 2.8 to 4.0 in women. At age 79-80 years, the mean number of drugs was 3.3 in men and 4.0 in women in 1980 and 4.0 in men and 4.7 in women in 1995. The most common drugs were cardiovascular drugs, analgesics and drugs for diseases in the central nervous system. The most pronounced changes in the consumption of specific drugs were found for anti-ulcerative drugs (increased), digitalis (decreased), diuretics (decreased in women), anti-thrombotic drugs (increased), calcium/vitamin D (increased), insulin (increased in men aged 70 years), analgesics (increased), levaxin (increased in women), anti-depressants (increased in women aged 70 years) and oestrogen in women (increased). The treatment patterns for cardiovascular diseases changed during the observation period and the use of calcium antagonists, angiotensin converting enzyme inhibitors, beta-blockers and lipid-lowering drugs increased.

CONCLUSION

The proportion of the population with drug treatment at ages 70 years and 79-80 years increased as did the average number of drugs among treated subjects between 1971 and 2000. Important differences in the treatment patterns for different diseases were observed.

Concomitant coumarin-NSAID therapy and risk for bleeding

OBJECTIVE

To investigate the risk of bleeding complications during the combined use of coumarin derivatives and nonsteroidal antiinflammatory drugs (NSAIDs) compared with the use of coumarin derivatives alone.

SUBJECTS AND METHODS

In this 1-year observational study, the local outpatient anticoagulation office detected all coumarin users with bleeding complications. These patients were sent questionnaires regarding the type and consequences of the bleeding as well as previous NSAID use. The local pharmacists detected patients with concomitant coumarin and NSAID prescriptions (but no bleeding). The relative risk for bleeding due to concomitant coumarin and NSAID use was estimated.

RESULTS

During 1 year, 738 hemorrhages were identified in 681 coumarin users. In 12.2% of these cases, an NSAID was involved. In contrast, in the whole population of coumarin users, 2.5% were prescribed an NSAID. Therefore, the relative risk of NSAID use with regard to bleeding complications was 5.8 (95% CI 2.3 to 13.6).

CONCLUSIONS

NSAID use during coumarin therapy considerably increases the bleeding risk compared with coumarin therapy alone. Although in daily practice these medications are frequently prescribed concomitantly, our results underscore the contraindication of concomitant use of NSAIDs and coumarin derivatives.

Knowledge of prescription medications among elderly emergency department patients

STUDY OBJECTIVE

We determine how knowledgeable elderly (>65 years old) patients seen in the emergency department are of their prescription medications.

METHODS

Patients older than 65 years who presented to the ED of an urban teaching hospital were interviewed concerning their prescription medications and the indications for their use. Medications and dosages were verified through the patients' pharmacies. Medication indications were assessed for accuracy by referencing the Physicians' Desk Reference.

RESULTS

Data on 88 patients were collected over a period of 2 months. Eleven patients were excluded from the study because of logistics (9) and rescinding of consent (2). Patients averaged 5.9 prescription medications on presentation to the ED. Patients correctly identified 78.4% (359/458) of these medications. Thirty-three (42.8%) patients were able to correctly identify all of their prescription medications. Furthermore, patients correctly identified 65.5% (236/359) of dosages (25 [32.5%] patients named all dosages correctly), 91.4% (328/359) of dosing intervals (44 [57.1%] patients named all intervals correctly), and 83.3% (299/359) of indications (49 [63.3%] patients named all indications correctly).

CONCLUSION

Elderly patients presenting to the ED have only a fair knowledge of their prescription medications.

Geriatric drug therapy and healthcare utilization in the United kingdom

OBJECTIVE

To describe the use of prescription drug therapy, especially polypharmacy, in an elderly general population; to relate that use to age, gender, and different types of healthcare utilization; and to investigate the influence of selection of different time windows on the result of the quantity as well as the categories of drugs used.

METHODS

Data on a sample of 5000 patients aged 65-90 years in 1996 were derived from the General Practice Research Database (GPRD). The population covered by GPRD is broadly representative of the UK population treated in general practice. Drug use was assessed using 2 time windows - current use of individual drugs on a random day (index date) and 1 month following the index date. Healthcare utilization was analyzed by use of information on visits to general practitioners (GPs), hospitalizations, and referrals to specialists.

RESULTS

Women used more drugs than men; however, the prevalence of polypharmacy, defined as concomitant use of > or =5 drugs, was similar in both genders. The most frequently used therapeutic groups were cardiovascular, central nervous, and gastrointestinal system drugs. Almost 80% of both women and men visited a GP at least once a year. Overall, women used more ambulatory care services and men were hospitalized more often. Use of random date compared with 1-month period resulted in a significant underestimation of the amount of drugs used for acute conditions and, consequently, the risk of polypharmacy.

CONCLUSIONS

The overall results confirm the findings in earlier studies suggesting that the GPRD might be a useful tool in further studies on prescription drug use among elderly persons. More information on the appropriateness of drug use is needed to prevent overuse as well as underuse of medications among the elderly.

Is it possible to reduce polypharmacy in the elderly? A randomised, controlled trial

OBJECTIVE

The present trial was originally designed to investigate the effectiveness of comprehensive day hospital care in chronically ill elderly patients. Another aim, reported here, was to investigate to what extent it is possible to reduce polypharmacy and simplify drug regimens during the short term tight control conditions of day hospital care.

PATIENTS

All home care patients (n = 174, mean age 77 years) in a rural area, Kirkkonummi-Siuntio, in Finland.

DESIGN AND SETTING

Patients were randomised into 2 groups, one of which was offered a 2-month period of day hospital care. Patients assumed to be noncompliant (because they did not want day hospital care) were also included in order to see the effect of intervention in 'real-life'. The medications of all participants were reviewed and counted during an in-home assessment by a home nurse. In the intervention group, necessary revisions (dose reduction, discontinuation, possible additions) were performed through the tight monitoring of day hospital care and in co-operation with the patient. The patients were followed up for 10 months after completion of the intervention programme.

OUTCOME MEASURES

Number of prescribed medications, number of over-the-counter (OTC) drugs, number of doses taken daily by the patients. Assessments were performed at baseline, and after 2, 5 and 12 months.

RESULTS

There were no significant changes in the number of prescribed medications. In patients in day hospital care, the number of doses was reduced significantly (p = 0.02) during the 2-month day hospital period compared with the control group. However, the patients compensated for the reductions by increasing the use of OTC drugs during the day hospital period (p = 0.05). In addition, only 3 months after the trial, the number of drugs had already returned to the baseline level.

CONCLUSIONS

In real life it seems to be difficult to reduce polypharmacy in the elderly. Some drug reductions may be achieved with tight control under trial conditions, but when the intervention ceases the number of drugs used soon returns to its earlier level.

Prescription drug use, diagnoses, and healthcare utilization among the elderly

BACKGROUND

More elderly patients affected by severe and chronic diseases are treated in primary care. Reports on the use of prescription drugs by the general elderly population are scarce, and more investigations are needed to optimize pharmaceutical care for these patients.

OBJECTIVE

To analyze prescription drug use, diagnoses, and healthcare utilization among noninstitutionalized elderly patients.

DESIGN

Retrospective cohort study.

SETTING AND PATIENTS

All people > or =65 years old (n = 4642) living in the community of Tierp, Sweden, in 1994 were included. Prescription drug use and healthcare utilization have been registered for all inhabitants of the community since 1972. Information about filled prescriptions and diagnoses were obtained from a computerized research register.

RESULTS

Prescription drug use was high among the elderly (78%); the most used pharmacologic groups were cardiovascular, nervous system, and gastrointestinal medications. Women used more prescription drugs than men (average 4.8 vs. 3.8) and had more nonfatal diagnoses. Use of five or more different prescription drugs during 1994 was common (39.0%), and multivariate analysis showed that the greatest number of primary care visits occurred with multiple drug use (> or =5 drugs over 1 y).

CONCLUSIONS

This study shows an extensive multiple drug use among elderly people living at home. Whether this multiple drug use per se is harmful to the patients or not could not be evaluated in this study. Further focused investigations are needed to assess the effect of multiple drug use in an elderly population.

Impact of the earthquake of September 26, 1997 in Umbria, Italy on the socioenvironmental and psychophysical conditions of an elderly population

The consequences of natural disasters on the social and health status of older people have not been deeply considered. The aim of this study was to evaluate the socioenvironmental and psychophysical conditions of an elderly population after a devastating earthquake. A randomly selected group of 332 older people (> or =64 years) was selected among 1548 eligible subjects living in the city of Nocera Umbra four months after an earthquake of 5.6 magnitude on the Richter scale. Three geriatricians evaluated the study subjects by means of a structured interview, and standardized scales, which considered physical and mental status, mood and anxiety, and self-perception of well-being, as well as the characteristics of family composition and social interactions. Of the study subjects, 11.1% lived alone, and 33.4% with the spouse only. Most were self-sufficient in the basic activities of daily life. Musculoskeletal diseases and hypertension were the most frequently observed pathologies in this geriatric population. In addition, 47.9% of the subjects lived in temporary houses; this group more frequently suffered from hypertension, and had a higher score of comorbidity as measured by Cumulative Illness Rating Scale (CIRS) compared to people who remained at home. People living in the pre-fabricated huts also showed a higher score on the Geriatric Depression Scale and the Hamilton scale for anxiety, and complained more often of their health status, evaluated as self-perception of well-being, when compared to the home dwellers. Although all the studied subjects suffered from the discomforts caused by the earthquake, the precariousness of living in temporary houses, whose structural characteristics do not take the needs of elderly subjects into account, could justify the higher distress experienced by persons housed in the huts. These observations suggest that, after natural disasters, emergency programs should be more adapted to elderly people, whose needs and expectations are often different from those of young adults.

Predictors of medication use, compliance and symptoms of hypotension in a community-based sample of elderly men and women

OBJECTIVE

To investigate use of prescription and non-prescription drugs, predictors of drug use and symptoms of postprandial and postural hypotension were examined in 765 men and 846 women.

METHOD

A questionnaire mailed to 6324 subjects randomly chosen from the electoral roll.

RESULTS

Drug use, both prescription and non-prescription, was greater (P < 0.0001) in women (mean 4.1 total drugs, CI 3.9, 4.3) than in men (3.5 drugs, CI 3.3, 3.7); 41% of women and 36% of men used at least four drugs. Total drugs used were significantly greater in women (standardized regression coefficient (b) = 0.101, P < 0.0001), and increased with the number of diagnoses (b = 0.461, P < 0.0001) and taking antidepressants (b = 0.160, P < 0.0001). Use of non-prescription drugs was also greater in women (b = 0.094, P < 0.0001) and in association with arthritis (b = 0.053, P = 0.036) but decreased with age (b = -0.013, P < 0.0001). Potentially important drug interactions occurred in 10% of subjects and included hypoglycaemic agents with b-blockers and asthma with b-blockers. Symptoms of postprandial hypotension, reported in 2.6% of subjects, increased with the number of drugs used (OR 1.17, CI 1.05, 1.31) and with diabetes (OR 2.27, CI 1.05, 4.89). Symptomatic postural hypotension, recorded by 13% of subjects, related significantly to age (OR 1.04, CI 1.02, 1.06), tranquillisers (OR 1.98, CI 1.11, 3.54), antidepressants (OR 2.23, CI 1.30, 3.84) and ACE inhibitors (OR 2.14, CI 1.42, 3.22).

CONCLUSION

Reduction in the number and frequency of drug doses and better knowledge about drugs may improve compliance. Observed associations with polypharmacy or hypotension suggest possible approaches to decreasing drug-related illness and limiting the adverse effects of hypotension in the elderly.