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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790X

Rev. bras. epidemiol. vol.17 no.4 São Paulo Oct./Dec. 2014

http://dx.doi.org/10.1590/1809-4503201400040002 

Original Articles

Polypharmacy, chronic diseases and nutritional markers in community-dwelling older

Erika Aparecida Silveira I  

Luana Dalastra II  

Valéria Pagotto III  

ISchool of Medicine, Postgraduate Program in Health Sciences, Universidade Federal de Goiás - Goiânia (GO), Brazil

IISchool of Nutrition, Universidade Federal de Goiás - Goiânia (GO), Brazil

IIISchool of Nursing, Universidade Federal de Goiás - Goiânia (GO), Brazil

ABSTRACT

Polypharmacy is a common practice among the elderly, but few studies have evaluated its association with nutritional markers. The aim of this study was to estimate the prevalence of polypharmacy and its association with nutritional markers, chronic diseases, sociodemographic and health variables. This research is part of the Study Elderly/Goiânia, which evaluated 418 elderly community in a cross-sectional design. Polypharmacy was defined as the use of five or more concomitant medications. The following nutritional markers were investigated: BMI, waist circumference, percentage body fat, weight gain and loss, use of diet, daily consumption of fruits, vegetables, skimmed and whole milk. Multivariate analysis was performed using hierarchical Poisson regression, with significance level set at 5%. The prevalence of polypharmacy was 28% (95%CI 23.1 - 32.5), with a significant association with feminine gender, age range 75 - 79 years, eutrophic nutritional status and obesity, use of diet, poor self-rated health and presence of two, three or more chronic diseases. The high prevalence of polypharmacy and its association with nutritional markers and chronic diseases call the attention for the need of nutritional surveillance and monitoring in the elderly.

Key words: Aged; Polypharmacy; Nutritional Status; Diet; Chronic diseases; Self-assessment

INTRODUCTION

The demographic and epidemiological scenario in Brazil, characterized by a progressive increase in life expectancy1 and the high prevalence of Chronic Non-Communicable Diseases (NCDs)2, many of them concurrent3, entailed the use of various medications.

Polypharmacy (consumption of five or more concomitant medications) constitutes a common practice among the elderly, whose prevalence in Brazilian studies ranges from 5% to 27%6 - 13. Among the factors associated with this practice are: being female6 , 7 , 9 , 12 , 13, aged ≥ 80 years6 , 7 , 9 , 10, presenting a regular self-assessment of health14, chronic diseases6 , 7 , 9 , 11 and number of medical visits in the previous year7 , 8. The growth of the pharmaceutical industry and the marketing of medications can also contribute to increased prescription by health professionals, enabling the use of multiple medications by the elderly4 , 5.

Among these factors that contribute to polypharmacy, chronic diseases have greater relevance and association. Although pharmacological treatment is important for the control of chronic diseases, non-pharmacological treatment such as changes in lifestyle, especially diet therapy, it is essential for treating adults and older adults with such illnesses15 , 16. However, few studies have examined the relationship between polypharmacy and nutritional markers in the elderly, such as nutritional status, body fat, food intake and diet therapy17 , 18. The high prevalence of chronic diseases3 in the elderly may require nutritional treatment with the prescription of a diet and of some specific foods15 , 16, being relevant to study their association with polypharmacy. Therefore, the aim of this study was to investigate the association of nutritional markers, presence of chronic diseases, sociodemographic and health variables with polypharmacy in community-dwelling elderly, and to estimate their prevalence.

METHODOLOGY

This is a cross-sectional study, from a matrix project called The Seniors Project/Goiania, which evaluated health and nutrition in elderly users of the Unified Health System (SUS) in Goiânia (GO)3 , 19 , 20 , 21. This study was approved by the Research Ethics Committee of Universidade Federal de Goiás (CEP/UFG) and everyone who agreed to participate signed an informed consent form (ICF).

In total, 418 seniors were included through a probabilistic sampling, which was proportional to the nine health districts in the city of Goiânia. This sample size was defined by the following parameters: 13% prevalence of diabetes mellitus (outcome of lower prevalence in the matrix study); power of 80%, confidence level of 95%; and ratio of exposed to unexposed 1:2; prevalence ratio of 2. As the prevalence of polypharmacy is superior to the outcome used in the calculation, the sample of The Senior Project/Goiânia is sufficient to ensure the validity of the study, in addition to providing greater statistical power.

Data collection was conducted in the homes of the elderly between November 2008 and March 2009. Sampling procedures in multiple stages, pilot study, staff training, data collection instruments, standardization of anthropometrists, anthropometric techniques22 and other methodological information are already described in other publications3 , 19 , 20.

At the end of data collection, the checking and coding of questionnaires was carried out, followed by a double entry for internal consistency analysis in the software Epi Data version 3.1.

The outcome variable in this study was polypharmacy, defined as the concomitant use of five or more drugs4 , 6 , 7. The variable was dichotomized as yes (use of 5 or more medications) and no (use of 0 - 4 medications). Medication use was assessed by the response of the elderly to the question: "What drugs do you usually take every day?" Furthermore, the elderly were asked to show the recipe and packaging of the drug used, and 100% of them presented both to the interviewer. In the questionnaire, the interviewer would take note of the active ingredient to further classify them according to the reference of the Anatomical-Therapeutic-Chemical Classification System (ATC), a method for classification of pharmaceutical substances (active ingredient) developed by the WHO Collaborating Centre for Drug Statistics Methodology23.

The following exposure variables were studied: sociodemographic variables (gender, age, skin color, living with a partner, years of education, and socioeconomic status), nutritional markers (nutritional status, waist circumference, body fat percentage, weight gain and loss, being on a diet, daily consumption of fruits, intake of vegetables, daily intake of skimmed and whole milk), chronic diseases and other health conditions (self-assessed health, hospitalization in the previous year).

The economy class variable was categorized as A/B, C, D/E, according to the Brazilian Association of Population Studies (ABEP)24, whose classification takes into consideration durable items of household and level of education of household head.

Nutritional status was defined by the Body Mass Index (BMI) from weight and height measured. The elderly were classified as underweight (BMI < 22.0 kg/m2) normal weight (BMI 22.0 to 27.0 kg/m2) and obese (BMI > 27.0 kg/m2)25 , 26. Waist circumference (WC) was classified according to the cutoff points proposed by the World Health Organization (WHO): increased WC (between 80 - 88 cm for women and 94 - 102 cm for men); greatly increased WC (> 102 cm for men and > 88 cm for women)27.

The percentage of body fat was assessed using the protocol of the sum of four skin folds. We used the equation of body density of Durnin and Womersley28 (1974): D (g/cm3) = 1.1339 - 0.0648 x log (å 4DC) and, for conversion of body density in body fat percentage, the Siri equation29 (1961) was applied: %G = (495/D) - 450. To sort the percentage of fat in excessive adiposity, the Gallagher proposition was used30, whose cutoff points for seniors are 42% for women and 30% for men.

For the classification of the daily consumption of fruits, vegetables, skim and whole milk, we analyzed the consumption once a day item from the Food Frequency Questionnaire (FFQ). These variables were classified as yes (consumption at least 1 time a day) and no (does not consume at least 1 time a day). Being on a diet was assessed through the question: "Do you follow a diet or any other food recommendation?"

Chronic diseases were identified through the responses to the question: "Which diseases the doctor has said that you have?" Later, they were classified as chronic or not and categorized numerically: 0 - 1; 2; > 3. Self-assessment of health was assessed by the question: "What do you think of your health in the past month", whose response options were: "very good", "good", "fair", "poor", "terrible"19.

Data were analyzed using STATA 8.0(r) software. A descriptive analysis of the types and classes of most commonly prescribed drugs was carried out. To evaluate the association between polypharmacy and the exposure variables, simple Poisson regression was performed with their respective confidence intervals (95%CI). The χ2 test for linear trend was also applied. Multivariate analysis was performed hierarchically in three levels: Level 1 - sociodemographic variables; Level 2 - nutritional markers; Level 3 - chronic diseases and other health variables. All variables that showed p-values lower than 0.20 in the bivariate analysis were included in the model.

RESULTS

The final sample of The Senior Project/Goiânia consisted of 418 elderly, 66% females, 48.5% aged 60 - 69 years and 46.9% belonged to class C. The prevalence of polypharmacy was 28.0% (95%CI 23.1 - 32.5) and was significantly higher in eutrophic and obese females (32.7%), aged 75 - 79 years, in the presence of 2 chronic diseases and/or 3 chronic diseases and terrible self-assessed health (Figure 1). The average intake of medications was of 3.7 (± 2.4), with a maximum of 12 drugs per individual. Most used drug classes were: cardiovascular (49.2%), alimentary tract and metabolism (18.0%) and central nervous system (12.2%) (Figure 2).

Figure 1 Prevalence of polypharmacy in elderly users of Primary Care according to gender, nutritional status and number of chronic diseases, Goiânia, GO, 2009. 

Figure 2 Distribution of therapeutic categories in community-dwelling elderly, Goiânia, GO, 2009. 

The variables that were associated with polypharmacy in the bivariate analysis were: female gender (OR = 1.76; 95%CI 1.14 - 2.73) (Table 1), terrible self-assessed health (OR = 2.86; 95%CI 1.63 - 5.08), hospitalization in the previous year (OR = 1.57; 95%CI 1.07 - 2.31), presence of two chronic diseases (OR = 3.20; 95%CI 2.12 - 4.83) and three or more chronic diseases (OR = 3.85; 95%CI 2.29 - 6.48) (Table 2).

Table 1 Prevalence and association between polypharmacy and sociodemographic variables in community-dwelling elderly, Goiânia, GO, 2009 (n = 418). 

Variables n (%) Polypharmacy
Prevalence
n (%)
OR (95%CI) p-value
Gender 0,002
     Female 276 (66.0) 90 (32.8) 1.76 (1.14 – 2.73)
     Male 142 (34.0) 26 (18.6) 1.00
Age (years) 0.144
     60 – 64 86 (20.6) 19 (22.1) 1.15 (0.52 – 2.55)
     65 – 69 117 (28.0) 35 (30.4) 1.59 (0.76 – 3.31)
     70 – 74 101 (24.2) 28 (27.7) 1.45 (0.68 – 3.07)
     75 – 79 67 (16.0) 25 (37.8) 1.98 (0.92 – 4.24)
     ≥ 80 47 (11.2) 9 (19.1) 1.00
Skin color 0.068
     White 194 (46.4) 62 (32.2) 1.33 (0.92 – 1.92)
     Brown/Black 224 (53.6) 54 (24.2) 1.00
Living with partner 0.328
     Yes 229 (54.8) 59 (26.0) 1.00
     No 189 (45.2) 57 (30.3) 1.17 (0.81 – 1.68)
Years of education 0.132
     Did not study 112 (30.0) 27 (24.3) 1.04 (0.60 – 1.79)
     1 to 4 years 154 (41.2) 51 (33.3) 1.42 (0.88 – 2.30)
     5 years or more 108 (28.8) 25 (23.3) 1.00
Social class 0.406*
    A/B 63(15.1) 19 (30.6) 1.21 (0.70 – 2.09)
    C 196 (46.9) 57 (29.2) 1.15 (0.77 – 1.73)
    D/E 159 (38.0) 40 (25.3) 1.00

*Linear χ2.

Table 2 Prevalence and association between polypharmacy and nutritional markers, chronic diseases and others health variables in community-dwelling elderly, Goiânia, GO, 2009 (n = 418). 

Variables n (%) Polypharmacy
Prevalence
(%)
OR (95%CI) p-value
Nutritional status                 0.003*
    Underweight 66 (15.8) 8 (12.3) 1.00
    Eutrophic 147 (35.2) 41 (28.1) 2.28 (1.07 – 4.86)
    Obesity 205 (49.0) 67 (32.8) 2.67 (1.28 – 5.55)
Waist circumference 0.000*
    Normal 99 (23.8) 15 (15.4) 1.00
    Increased 88 (21.1) 21 (23.9) 1.54 (0.79 – 2.99)
    Greatly increased 229 (55.1) 79 (34.6) 2.24 (1.29 – 3.89)
Body fat percentage 0.776
     Normal adiposity 206 (49.3) 56 (27.3) 1.00
     Excess adiposity 212 (50.7) 60 (28.5) 1.04 (0.73 – 1.50)
Is on a diet
     No 211(50.5) 37(17.6) 1.00 0.000
     Yes 207(49.5) 79(38.5) 2.19(1.48 – 3.23)
Daily consumption of fruits 0.311
     No 233 (56.0) 60 (26.1) 1.17 (0.81 – 1.69)
     Yes 183 (44.0) 56 (30.6) 1.00
Daily intake of vegetables 0.181
     No 216 (51.9) 54 (25.2) 1.00
     Yes 200 (48.1) 62 (31.2) 1.23 (0.86 – 1.78)
Daily consumption of whole milk 0.314
     No 215 (51.6) 64 (30.2) 1.17 (0.81 – 1.69)
     Yes 202 (41.4) 52 (25.7) 1.00
Daily intake of skimmed milk 0.004
     No 357 (85.6) 90 (25.4) 1.00
     Yes 60 (14.4) 26 (43.3) 1.70 (1.10 – 2.63)
Weight Gain 0.778
     No 319 (78.7) 87 (27.5) 1.00
     Yes 86 (21.3) 25 (29.1) 1.05 (0.68 – 1.65)
Weight loss 0.079
     No 264 (64.9) 66 (25.1) 1.00
     Yes 143 (35.1) 47 (33.3) 1.33 (0.91 – 1.93)
Self-assessment of health 0.000*
    Very good/Good 127 (30.9) 22 (17.4) 1.00
    Regular 173 (41.0) 48 (27.9) 1.60 (0.96 – 2.65)
    Poor 57 (13.8) 17 (29.8) 1.71 (0.91 – 3.22)
    Terrible 55 (13.3) 27 (50.0) 2.86 (1.63 – 5.08)
Hospitalization in the previous year 0.006
    No 316 (75.6) 77 (24.5) 1.00
    Yes 102 (24.4) 39 (38.6) 1.57 (1.07 – 2.31)
Number of chronic diseases 0.000*
     0 – 1 268 (64.3) 40 (15.0) 1.00
     2 111 (26.6) 53 (48.2) 3.20 (2.12 – 4.83)
     > 3 38 (9.1) 22 (57.9) 3.85 (2.29 – 6.48)

*Linear χ2.

Regarding nutritional markers, the bivariate analysis also showed an association between polypharmacy and nutritional status in the eutrophic (OR = 2.28; 95%CI 1.07 - 4.86) and obese (OR = 2.67; 95%CI 1.28 - 5.55) categories; greatly increased waist circumference (OR = 2.24; 95%CI 1.29 - 3.89); being on a diet (OR = 2.19; 95%CI 1.48 - 3.23); daily intake of skimmed milk (OR = 1.70; 95%CI 1.10 - 2.63) (Table 2).

After hierarchical multivariate analysis (Table 3), the following factors remained associated with polypharmacy: being female (OR = 1.76; 95%CI 1.21 - 2.65), aged 75 - 79 years (OR = 1.98; 95%CI 1.03 - 3.79), being eutrophic (OR = 2.17; 95%CI 1.11 - 4.27) and obese (OR = 2.41; 95%CI 1.24 - 4.70 ), being on a diet (OR = 2.09; 95%CI 1.49 - 2.92), terrible self-assessed health (OR = 1.96; 95%CI 1.25 - 3.09), presence of two chronic diseases (OR = 2.76; 95%CI 1.92 - 3.96) and three or more chronic diseases (OR = 2.73; 95%CI 1.77 - 4.20).

Table 3 Adjusted prevalence ratios for the association between polypharmacy and sociodemographic variables, nutritional markers and health conditions in community-dwelling elderly, Goiânia, GO, 2009. 

Variables Adjusted OR (95%CI) p-value*
1st Level
Gender
Female 1.76 (1.21 – 2.65) 0.004
Male 1.00
Age group
60 – 64 1.15 (0.57 – 2.31) 0.693
65 – 69 1.60 (0.85 – 3.00) 0.144
70 – 74 1.50 (0.79 – 2.85) 0.219
75 – 79 1.98 (1.03 – 3.79) 0.040
≥ 80 1.00
2nd Level
Nutritional status
Underweight 1.00
Eutrophic 2.17 (1.11 – 4.27) 0.024
Obesity 2.41 (1.24 – 4.70) 0.010
Is on a diet
No 1.00
Yes 2.09 (1.49 – 2.92) 0.000
3rd Level
Self-assessment of health
Very Good/Good 1.00
Regular 1.45 (0.95 – 2.23) 0.085
Poor 1.37 (0.79 – 2.37) 0.255
Terrible 1.96 (1.25 – 3.09) 0.003
Chronic diseases
0 – 1 1.00
2 2.76 (1.92 – 3.96) 0.000
> 3 2.73(1.77 – 4.20) 0.000

*Wald test.

DISCUSSION

The use of medicine is a common practice among the elderly, given that, in this study, 72% used one or more drugs and the prevalence of polypharmacy was 28%. These findings are superior to studies already developed in Brazil6 , 10, but similar to the results of Bambuí Project9 and Porto Alegre7. Some factors may contribute to the high consumption of drugs, such as low frequency of use of non-pharmacological treatments for chronic diseases and/or other health problems, as well as easy access to medications7. In addition to these factors, in some cases, in an attempt to alleviate symptoms or have faster response compared to non-pharmacological therapies, practitioners prescribe drugs in a distorted or impulsive manner, which can contribute to the unnecessary use of drugs and increase the number of drugs consumed by the elderly5. One of the consequences of the use of multiple drugs is the increased risk of Adverse Drug Reactions (ADR), which in turn, increases the morbidity and mortality among the elderly4.

The most frequently used medications were the ones that act on the cardiovascular system, followed by those that act on the digestive system, metabolism and central nervous system, which is consistent with findings of previous studies6 - 11 , 19. These findings are consistent with the epidemiological profile of Chronic Noncommunicable Diseases (NCDs) in Brazil2 and the high prevalence of cardiovascular risk factors among the elderly in this study, as discussed above3. Older people commonly complain of insomnia, anxiety and confusional states, contributing to high rates of prescription drugs acting on the central nervous system6. The consumption of drugs that act on the digestive tract observed in this and other studies7 , 8 may be related to the need to alleviate symptoms in the gastric mucosa caused by excessive use of drugs as a result of polypharmacy itself. It is noteworthy that some drugs can cause gastric symptoms, such as anti-inflammatory drugs, which cause irritation and gastric ulcer, and anticholinergics, which reduce the motility of the gastrointestinal tract4. In this study, the profile of chronic disease and the predominant drug classes demonstrate that polypharmacy in the elderly may be related to long-term treatments, suggesting a continuity of practice in later years, which requires attention and continuous monitoring by health professionals.

Women had 1.76 times higher prevalence of polypharmacy than men, corroborating results from other studies6 , 7 , 9 , 12. Considering the current demographic and epidemiological scenario, women have a high prevalence of diseases, longer life expectancy than men1 and a different attitude towards the disease, as they report signals and symptoms with higher frequency and use more health services, being, therefore, more subject to medicalization7 , 9 .

This study also supports the majority of epidemiological studies that demonstrate significant increase in the use of drugs with advancing age6 , 7 , 9 , 10, with a higher prevalence of polypharmacy in the 75 - 79 years age group. However, a low prevalence of polypharmacy was observed in the 80 years or older age group. With increasing life expectancy, the 80 years or more age group, has been considered a distinct age group. It is suggested that future research investigate the medicinal practices in this age group.

Among the variables related to health status, a terrible health self-assessment and the presence of two or more chronic diseases had statistically significant associations with polypharmacy, as described in previous studies6 , 7 , 9 , 11 , 14 , 19. This is an expected result, given that the elderly who have multiple illnesses can use multiple drugs and consequently self-assess their health as poor/terrible. Self-assessment of health expresses the perception of the subject based on interpretations of physical, cognitive and emotional health, as well as their expectations and their references for comparison19. Thus, the routine use of medications, including timetables, route of administration, drug and correct dose and the amount of medications consumed can contribute to a feeling of lack of health and consequent poor/terrible health self-assessment. The presence of multiple diseases, potential drug interactions or adverse effects may enhance the self-reported poor/terrible health. These findings reaffirm the need for health professionals to use non-pharmacological treatments and in health education activities, which, in turn, may contribute to the reduction of polypharmacy and to a better health perception.

As for nutritional markers, it was observed that, with increasing BMI, the prevalence of polypharmacy also increases. A review study18 demonstrated the existence of association between polypharmacy and nutritional status, but with controversy, because, in some studies, polypharmacy was associated with weight loss and, in others, with obesity. However, studies18 show greater consistency in the association between polypharmacy and obesity, corroborating the findings of this research. The hypothesis for this association is based on the knowledge that obesity is a risk factor for the occurrence of comorbidities such as diabetes and hypertension, as well as hampering the control of blood glucose and blood pressure levels3, and therefore, the use of medications is necessary15 , 16.

The reduction in BMI, regardless of the use of drugs, leads to the lowering of blood pressure and blood glucose. Thus, the non-pharmacological treatment including diet therapy (or nutritional treatment) is an important therapeutic approach to control these chronic diseases15 , 16 . In this research, there was an association between diet and use of polypharmacy, which may indicate that the elderly received dietotherapeutic prescription due to the presence of chronic diseases, that is, received pharmacological and non-pharmacological treatment. It is noteworthy that the elderly were not asked about the dietotherapeutic prescription, therefore, this was a self-reported information. It is noteworthy that the elderly who participated in this research are the users of the Unified Health System (SUS), and the primary health care network in the municipality is composed of a multidisciplinary team, including nutritionists, who perform individual consultations and health and nutrition education groups. This may have facilitated the access of seniors to information about the importance of using diet to treat diseases.

The dietary intake variables did not remain significantly associated with polypharmacy after adjustments in the final multivariate regression. It is, however, relevant information that this research presents, because other data that evaluated the association between dietary intake and polypharmacy were not located.

Due to the cross-sectional design, this study is not adequate to test relationships between causes and effects, since they presuppose guarantee that selected variables precede the outcome in time. However, it can be observed that there is an association between polypharmacy and the variables described above, which in itself reflects important links between the patient characteristics and use of medications. On the other hand, some measures were taken to ensure the quality of information: training and standardization of evaluators, pilot study and calibration of equipment. Data on medications were also carefully collected to ensure the accuracy and validity of results.

CONCLUSION

This study showed an association between polypharmacy and eutrophic and obese females in the 75 - 79 years age range, who were on a diet, had a poor health self-assessment, and presented two, three or more chronic diseases.

Studies like this are important because they signal reflections on the need for reorientation of pharmaceutical care and the adoption of non-pharmacological treatments among the elderly population. In addition, they guide the actions of all health professionals to make drug therapy more efficient in internal and external contexts of SUS. Nutritional guidelines aimed at improving eating habits for the control of diseases, education for the family, carers and the elderly themselves about the effects of polypharmacy and the qualification of the professionals as to prescription are possibilities of prevention of polypharmacy and hence of possible drug interactions.

It is recommended that further studies on polypharmacy are developed with an emphasis on nutritional aspects, mainly cohort, to advance and enhance non-pharmacological strategies that are effective and accessible to the elderly.

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Financial support: National Counsel of Technological and Scientific Development (CNPq), Universal Public Notice 014/2008.

Received: February 18, 2013; Revised: February 04, 2014; Accepted: April 28, 2014

Corresponding author: Valéria Pagotto. Universidade Federal de Goiás. Faculdade de Enfermagem. Rua 227, Qd.68 s/n, Setor Leste Universitário. CEP: 74605-080, Goiânia, GO, Brasil. E-mail: valeriapagotto@gmail.com

Conflict of interests: nothing to declare

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