Prevalence and costs of hospitalizations for poisoning and accidental intoxication in Brazilian elderly

1Caruaruense Association of Higher Education, Caruaru, PE, Brazil, 2Hospital Pharmacy and Clinic, Restoration Hospital of Pernambuco, Recife, PE, Brazil, 3Faculty of Ipojuca Valley, Caruaru, PE, Brazil, 4Pernambuco University, School of Dentistry of Pernambuco, Caruaruense Association of Higher Education, Faculty of Ipojuca Valley, Caruaru, PE, Brazil, 5Faculty of Ipojuca Valley, Caruaru, PE, Brazil

A cross-sectional study of secondary data/information obtained from the Hospital Information System (HIS) spanning the years 2008 -2009 was performed.The distribution of the main hospital admissions by gender, age, color/race, region and federal unit of residence, average expenditure and average length of hospital stay, year of hospitalization and mortality rates (MR) were studied.The data collected were tabulated by TabNet and keyed into Microsoft Excel 2007.It was verified that elderly males (54.3%), from 60 to 69 years old (50.6%), nonwhites (36.3%) and residents of Southeast and North regions of the country had the highest rates of hospitalization.Seniors were hospitalized for an average of 4.8 days, and the major causes were exposure to alcohol (43.7%) and to drugs (33.9%).Expenses related to hospital admissions were, on average, R$ 529,817.70.The highest mortality rates were recorded among females (MR = 4.34), in elderly, 80 years or older (MR = 10.16) and Caucasians (MR = 3.95), where pharmacological substances with action on the Autonomic Nervous System were the leading cause of death.There are demographic differences in morbi-mortality of these elderly since, although men and younger elderly were the main victims, women and elderly of advanced age have greater mortality.The leading causes of hospitalization were alcohol and drugs.

INTRODUCTION
Alcohol, drugs and pesticide products are intensively used both worldwide and in Brazil, and the productive and marketing contexts in which they are present pose risks to health and the environment related to their use, including poisoning (Marinho, Mendonça, 2005).
Alcohol abuse is seldom recognized as a health problem, hampering the early diagnosis of alcoholism and its treatment.Studies performed in the United Kingdom have demonstrated the need for improved detection of alcohol abuse in patients treated in emergencies due to this morbidity, either directly (physiopathological, e.g.: hypertension, intoxication, cirrhosis, cancer) or indirectly (through social harm, e.g.: road accidents, drowning of children, abuse, murders, robberies, deaths by fire), a situation aggravated by the alcohol culture accepted by the Western world, by apathy or lack of skill on the part of physicians and denial by patients (Huntley, 2001).
Poisoning by biological substances is a pathological process caused by endogenous or exogenous chemical substances, characterized by a physiological imbalance as a result of biochemical changes in the body (Almeida et al., 2005).
In Brazil, akin to other countries, the large arsenal of new drugs and the role of the pharmaceutical industry in running advertisements for its products, has led to key shifts in the usage profile of these products, creating challenges to public health (Margonato et al., 2008).Since, according to the authors, drugs began to rank as the major cause of accidents resulting from exposure to toxic agents where, in 2002, drugs were responsible for 26.9% of the occurrences of poisonings recorded by the Brazilian national network of poison control centers.
According to estimates by the Community Health Service of Porto Alegre, Rio Grande do Sul, in 2001 and 2002, around 23% of the Brazilian population consumed approximately 60% of medicines produced nationally, with the biggest consumers being elderly over 60 years of age (Flores, Mengue, 2005).
It is essential to perform studies on the use of medications in the elderly to prevent overspending and unnecessary hospitalizations, since it is known that the elderly organism presents physiological modifications that lead to changes in pharmacokinetic and pharmacodynamics properties of the drugs.Hepatic metabolism, homeostatic mechanisms, as well as filtration ability and renal excretion can be compromised, hindering the elimination of metabolites, causing the accumulation of toxic substances in the body and ultimately producing adverse reactions (Hulse, 2002;Nobrega et al., 2005;Rocha et al., 2008;Medeiros et al., 2009).
In view of the above, and the need to ascertain the main causes of hospitalizations for poisoning or accidental intoxications by exposure to noxious substances, such as alcohol, drugs, pesticides and biological substances, the aim of this study was to describe these hospitalizations in elderly Brazilians, as well as to evaluate spending by the Brazilian National Health System (SUS) on these hospitalization for the years 2008 and 2009.

METHODS
A cross-sectional study of secondary data on hospitalization recorded in Brazilian hospitals participating or linked to the Brazilian National Health System (SUS) was performed.Elderly victims of poisoning and accidental intoxication by exposure to harmful substances, whose authorization for Hospital Admittance (AIH) was registered on the Hospital Information System (HIS) during the period spanning from January 1 st , 2008 to December 31 st , 2009, were the research subjects.It is noteworthy that in 2009, the elderly population estimated by the Brazilian Institute of Geography and Statistics (IBGE) was 19,428.086,representing 10.15% of the Brazilian population.
The poisoning and accidental intoxication records were obtained through a data tabulator prepared by the Ministry of Health -HS (TabNet) to provide data online at Datasus (www.datasus.gov.br).These poisonings are classified under the Chapter XX code (External causes of morbidity and mortality) of the International Classification of Diseases, Tenth Revision (ICD-10), in the Large Groups of Causes of Death (W00 -X59 -Other external causes of accidental injury) according to the coding of Categories of Causes (X40 -X49 -poisoning by accidental intoxication and exposure to noxious substances) (WHO, 2008).It is noteworthy that the cause of hospitalization is reported as the principal diagnosis, defined as the underlying reason for admission.
Thus, these are listed under X40 (Accidental poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics), X41 (Accidental poisoning by and exposure to antiepileptic, sedativehypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified -NEC), X42 (Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified -NEC), X43 (Accidental poisoning by and exposure to other drugs acting on the Autonomic Nervous System), X44 (Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances), X45 (Accidental poisoning by and exposure to alcohol), X46 (Accidental poisoning by and exposure to organic solvents and halogenated hydrocarbons and their vapours), X47 (Accidental poisoning by and exposure to other gases and vapours), X48 (Accidental poisoning by and exposure to pesticides), X49 (Accidental poisoning by and exposure to other and unspecified chemicals and noxious substances).
The evolution of hospitalizations for these causes in the period studied, and their distribution according to the variables, were analyzed: gender (male and female); age group (60 to 69 years, 70 to 79 years and 80 years of age or older); color/race (white or nonwhite); region and federative unit of residence; the average expenditure per admission (in R$); average length of hospital stay (in days); year of hospitalization and hospital deaths (number of deaths and mortality rate).
The average length of hospital stay regarding paid AIH, as well as mortality rates for these poisonings and intoxications (ratio between the number of deaths and the number of paid AIH computed as hospital admissions in the period multiplied by 100), were obtained from the database.The data collected were tabulated by Tabnet and keyed into the Microsoft ® Excel program, 2007, in which the categorical variables were presented as absolute frequencies and/or percentages in tables.
Therefore, since this was a study involving humans, the study protocol (Cover Page for Research, version October/99 -Resolution 196/96 of the National Health Council), was submitted to and approved by the Ethics and Research Committee of the Caruaruense Association of Higher Education, under CAAE 0023.0.217.000-10.

RESULTS
Analysis of the 1058 hospital admissions recorded in Brazil during the period studied, yielded the following data.
Regarding the demographic profile of patients (Table I), it was observed that majority of older adults were males (54.3%), between 60 and 69 years old (50.6%) and nonwhites (36.3%), whereas the data on color/race was not given in 32.7% of cases.Residents in the Southeast and North of the country had the highest percentage of hospitalizations (35.1% and 30.2%, respectively), however, some Federative Units (UF) in the Northern Region (Amapá, Amazonas and Roraima) recorded no hospitalizations due to this cause, and likewise in the state of Sergipe (Northeast Region).
The distribution of poisoning by harmful substances for the elderly age group is shown in Table II.It is evident that the largest percentage of hospital admissions were due to exposure to alcohol (43.7%) and medicines [categories X40 to X44 (33.9%)].In this study, the exposure to alcohol was 8.5 times higher among the elderly aged 60 to 69 years compared to analgesics, antipyretics and antirheumatics, reducing to 5.0-fold greater in elderly aged 70 to 79 years, and 1.9 times in those aged 80 years or older.
The average hospital stay in elderly patients was 4.8 days, ranging from 2.5 (category X45 ) to 5.9 days (category X46), as shown in Table III .It is noteworthy that cases of exposure to alcohol (X45) in the elderly aged 60 to 69 years and 80 or older required a longer hospital stay (average of 5.6 and 5.7 days, respectively), and likewise for accidental exposure to other gases and vapors (X47) and other pharmacological substances that act on the Autonomic Nervous System (X43) in elderly aged 70 to 79 years (9.7 and 6.7 days, respectively).
Table IV shows that, from the years 2008 to 2009, the Single Health System spent R$ 529,817.70 on hospitalization for accidental poisoning, of which R$ 256,214.40 was spent due to exposure to alcohol and R$ 127,713.75 to medicines.
Regarding the demographic profile of hospitalized patients who evolved to death (Table V), it is evident that the highest mortality rates were recorded in women  (MR = 4.34), in elderly aged 80 or over (MR = 10.16) and in Caucasians (MR = 3.95).It is noteworthy that the deaths among the elderly aged 80 or over were five times higher than in those aged 60 to 69 years.There was no percentage difference between whites and nonwhites.However, this information was not given in 35.0% of cases.
Among the categories of intoxication, the type that most led to death in the elderly was accidental poisoning by and exposure to other drugs acting on the Autonomic Nervous System (MR=21.43) which was 7.6 times higher than the rate for exposure to alcohol (MR=2.81).

DISCUSSION
T h e v e r i f i c a t i o n t h a t t h e o c c u r r e n c e o f hospitalizations for poisoning was higher in males, corroborates the results of studies in Brazil (Bortoletto,   , 1999;Marinho, Mendonça, 2005;Moreira et al., 2010) and other countries (Pérez-Barquero et al., 2001;Wu-Chien et al., 2011).Arozullah et al. (2006), emphasized that males, elderly and those without the social support of medical care are 4-5 times more likely to be rehospitalized.of chronic disease, and therefore, a great consumption of medication (Karbakhsh, Zandi, 2008).In addition, this study showed that older people die more due to the use of alcohol where, according to data from the World Health Organization (2002), alcohol consumption is responsible for about 3% of all deaths globally, including clinical causes such as poisoning.Moreover, chronic alcoholics have a significantly worse survival with advancing age (Pérez-Barquero et al., 2001).

Bochner
Possible limitations of this study should be highlighted, for example, the fact that it was conducted using secondary data, which does not allow the researcher to control for possible errors due to typing and recording, in addition to possible sub-registries on hospitalizations for acute poisoning, since (Flanagan, Rooney, 2002;Landigran, Garg, 2002) mention that not all cases of suspected poisoning are referenced and not all intoxicated patients are included in these statistics.Also, it is known that attendances at health centers do not generate Authorizations for Hospital Admittance (AHA) and therefore are not computed by the SIH/SUS, leading to an underestimation of the true magnitude of morbidity arising from these causes.
Finally, it is noteworthy that poisoning from alcohol abuse are not registered in the National Poisoning Information System (SINITOX) and, according to (Bortoletto, Bochner, 1999), its statistics do not include all of the poisoning cases recorded in Brazil, owing to the fact that centers do not cover the whole of the national territory.Despite some limitations of this study, it is believed that since it drew on official national data the results led to the achievement of the study objectives.

CONCLUSION
There were demographic differences in the morbimortality of these elderly since, although men and younger elderly were the main victims, women and elderly of more advanced age had a greater mortality in the Brazilian hospitals participating or linked to the national health system (SUS).In elderly nonwhites and due to alcohol there are differences between the distribution of the main causes of hospitalization for poisoning and ages of the elderly.Alcohol and drugs incurred greater spending for the SUS and were associated with a longer average hospital stay.
Based on these results, it is reasonable to conclude that public health policies targeting the elderly should be implemented, with a focus on alcohol consumption and on the use of therapeutic drugs, since these are the leading causes of hospitalization among older adults.

TABLE I -
Demographic

TABLE III -
Average hospital stay (in days) for accidental poisoning by age group.Brazil, 2008Brazil,  -2009

TABLE IV -
Expenditure on hospitalizations for accidental poisoning in the elderly.Brazil, 2008Brazil,  -2009

TABLE V -
Demographic and epidemiological characteristics of elderly inpatients by number of deaths and mortality rates.Deaths recorded only in nonwhite elderly/ Source: Raw data from Datasus /HS.SIH -SUS.