Potentially inappropriate medications among older adults in Pelotas, Southern Brazil

Lutz, Bárbara Heather; Miranda, Vanessa Irribarem Avena; Bertoldi, Andréa Dâmaso

doi:10.1590/S1518-8787.2017051006556

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Original Articles • Rev. Saúde Pública 51 • 2017 • https://doi.org/10.1590/S1518-8787.2017051006556 copy

Potentially inappropriate medications among older adults in Pelotas, Southern Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To assess the use of potentially inappropriate medications among older adults.

METHODS

This is a population-based cross-sectional study with 1,451 older individuals aged 60 years or more in the city of Pelotas, State of Rio Grande do Sul, Brazil, in 2014. We have investigated the use of medications in the last 15 days. Using the Beers criteria (2012), we have verified the use of potentially inappropriate medications and their relationship with socioeconomic and demographic variables, polypharmacy, self-medication, and burden of disease.

RESULTS

Among the 5,700 medications used, 5,651 could be assessed as to being inappropriate. Of these, 937 were potentially inappropriate for the older adults according to the 2012 Beers criteria (16.6%). Approximately 42.4% of the older adults studied used at least one medication considered as potentially inappropriate. The group of medications for the nervous system accounted for 48.9% of the total of the potentially inappropriate medications. In the adjusted analysis, the variables female, advanced age, white race, low educational level, polypharmacy, self-medication, and burden of disease were associated with the use of potentially inappropriate medications.

CONCLUSIONS

It is important to known the possible consequences of the use of medication among older adults. Special attention should be given to the older adults who use polypharmacy. Specific lists should be created with more appropriate medications for the older population in the National Essential Medicine List.

Aged; Self Medication; Drug Therapy, Combination; Drug Utilization; Socioeconomic Factors; Pharmacoepidemiology

Levels 1 and 2 of the ATC classification	Potentially inappropriate medications

	n	%
N – Nervous system (n = 897)	458^b	48.9^b
Psycholeptics	217	23.2
Antiepileptics	113	12.1
Psychoanaleptics	105	11.2
Other	23	2.4
M – Musculoskeletal system (n = 316)	169^b	18.0^b
Anti-inflammatories and antirheumatics	107	11.4
Muscle relaxants	62	6.6
C – Cardiovascular system (n = 2,481)	144^b	15.4^b
Antihypertensives	47	5.0
Cardiac therapy	47	5.0
Calcium channel blockers	34	3.6
Other	16	1.8
A – Alimentary tract and metabolism (n = 1,070)	117^b	12.5^b
Medications used in diabetes	96	10.3
Other	21	2,2
Other ATC1 groups (n = 875)	49^b	5.2^b

Total	937^c	100

Levels 2 and 5 of the ATC classification	Potentially inappropriate medications, regardless of dose or diagnosis

	n	%
N05 – Psycholeptics (n = 231)	209^b	28.6^b
Diazepam	48	6.6
Alprazolam	44	6.0
Bromazepam	38	5.2
Other	79	10.8
M01 – Anti-inflammatories and antirheumatics (n = 179)	107^b	14.7^b
Diclofenac sodium and potassium	37	5.1
Ibuprofen	13	2.1
Nimesulide	12	1.6
Other	45	5.9
N03 – Antiepileptics (n = 143)	90^b	12.3^b
Clonazepam	78	10.7
Other	12	1.6
A10 – Medications used in diabetes (n = 409)	89^b	12.2^b
Glibenclamide	88	12.1
Other	1	0.1
M03 – Muscle relaxants (n = 65)	62^b	8.5^b
Caffeine + paracetamol + diclofenac sodium + carisoprodol	40	5.5
Orphenadrine citrate + metamizole sodium + caffeine	18	2.5
Other	4	0.5
C02 – Antihypertensives (n = 53)	47^b	6.4^b
Doxazosin mesylate	39	5.3
Other	8	1.1
N06 – Psychoanaleptics (n = 329)	38^b	5.2^b
Amitriptyline hydrochloride	27	3.7
Other	11	1.5
C01 – Cardiac therapy (n = 172)	26^b	3.6^b
Amiodarone hydrochloride	24	3.3
Other	2	0.3
Other pharmacological groups (n = 4,049)	62^b	8.5^b

Total	730^c	100

Active ingredient	N used	Inappropriate

		n	%
Acetylsalicylic acid and associations	212	6	3.1
Digoxin	42	21	55.3
Spironolactone and associations	38	13	39.4
Insulin	35	7	21.9
Estrogens	7	5	83.3
Doxepin	0	-
Reserpine	0	-

Total	334	52	17.0

Medication*	N used	Inappropriate n	%	Diagnoses involved
Fluoxetine hydrochloride	49	17	34.7	History of falls or fractures
Diltiazem hydrochloride	41	25	61.0	Heart failure; Chronic constipation
Citalopram hydrobromide	40	14	35.0	History of falls or fractures
Cilostazol	39	8	20.5	Heart failure
Sertraline hydrochloride	39	16	41.0	History of falls or fractures
Phenytoin	27	15	55.6	History of falls or fractures
Paroxetine hydrochloride	22	13	59.1	History of falls or fractures
Escitalopram oxalate	18	7	38.9	History of falls or fractures
Verapamil hydrochloride	10	5	50.0	Heart failure; Chronic constipation
Sulpiride	9	8	88.9	Dementia/cognitive loss; History of falls or fractures; Parkinson’s disease; Lower urinary tract symptoms; Benign prostatic hyperplasia; Chronic constipation
Gabapentin	8	2	25.0	History of falls or fractures
Ipratropium bromide	7	2	28.6	Lower urinary tract symptoms; Benign prostatic hyperplasia
Carbamazepine	6	2	33.3	History of falls or fractures
Tramadol hydrochloride	6	1	16.7	Epilepsy
Ranitidine hydrochloride	5	4	80.0	Dementia and cognitive loss
Loratadine	5	4	80.0	Dementia and cognitive loss; Lower urinary tract symptoms; Benign prostatic hyperplasia; Chronic constipation
Oxybutynin hydrochloride	4	2	50.0	Chronic constipation
Isometheptene + dipyrone + caffeine	4	1	25.0	Insomnia
Topiramate	4	1	25.0	History of falls or fractures
Oxcarbazepine	3	1	33.3	History of falls or fractures
Pregabalin	3	1	33.3	History of falls or fractures
Meclizine hydrochloride	2	2	100	Dementia and cognitive loss; Lower urinary tract symptoms; Benign prostatic hyperplasia; Chronic constipation
Desloratadine	2	1	50.0	Dementia and cognitive loss; Lower urinary tract symptoms; Benign prostatic hyperplasia; Chronic constipation
Tiotropium bromide	1	1	100	Lower urinary tract symptoms; Benign prostatic hyperplasia
Cimetidine	1	1	100	Dementia and cognitive loss
Solifenacin succinate	1	1	100	Dementia and cognitive loss; Lower urinary tract symptoms; Benign prostatic hyperplasia; Chronic constipation
Sodium valproate	1	1	100	History of falls or fractures

Total	357	156	43.7

Variable^a	n	Inappropriate (%)	Crude PR	95%CI	p	Adjusted PR	95%CI	p
	Level 1

Gender					0.001^b			< 0.001^b
Male	537	36.7	1			1
Female	914	45.7	1.25	1.10–1.42		1.26	1.11–1.44
Age (years)					0.001^c			0.016^c
60 to 69	756	39	1			1
70 to 79	460	45.2	1.16	1.02–1.32		1.11	0.97–1.27
80 or more	230	48.7	1.25	1.07–1.45		1.18	1.01–1.38
Race					0.028^b			0.004^b
White	1,211	43.7	1			1
Non-White	236	36.4	0.83	0.71–0.98		0.79	0.68–0.93
Education (years of study)					0.001^c			0.001^c
11 or more	316	36.1	1			1
8 to 10	143	37.1	1.03	0.81–1.31		1.04	0.82–1.32
4 to 7	445	41.6	1.15	0.95–1.40		1.17	0.97–1.41
0 to 3	533	48.2	1.34	1.12–1.60		1.35	1.12–1.62
Economy level (ABEP)					0.043^c			0.979^c
A/B	483	38.5	1			1
C	720	43.1	1.12	0.97–1.28		1	0.85–1.18
D/E	169	45.6	1.18	0.98–1.42		0.99	0.80–1.23

	Level 2

Polypharmacy					< 0.001^b			< 0.001^b
No	746	23.1	1			1
Yes	705	62.8	2.73	2.36–3.14		2.29	1.93–2.70
Self-medication					< 0.001^b			< 0.001^b
No	1,369	41.1	1			1
Yes	82	64.6	1.57	1.33–1.87		1.41	1.19–1.67
Burden of disease					< 0.001^c			< 0.001^c
No chronic diseases	109	19.3	1			1
1	200	22.5	1.17	0.73–1.88		1.04	0.64–1.68
2	269	33.5	1.74	1.15–2.62		1.34	0.88–2.04
3	282	42.9	2.23	1.46–3.39		1.44	0.93–2.23
4 diseases or more	570	57.4	2.98	1.37–3.06		1.64	1.09–2.45

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

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[1] Correspondence: Bárbara Heather Lutz. Departamento de Medicina Social – UFPel. Av. Duque de Caxias, 250 3º piso. 96030-001 Pelotas, RS, Brasil. E-mail: barbaralutz@msn.com