Multiple pathology, a common phenomenon among the elderly, fosters the practice of multiple drug therapy which in turn is particularly hazardous for this age grouping. The total drug exposure of two typical elderly persons, one institutionalized and one living at home, were analyzed. Potentially harmful drug interactions were discerned in both cases. The findings suggest that health professionals, policy makers, and others who work with the elderly should take into account their total drug exposure (prescription, over-the-counter, social — alcohol, nicotine and caffeine) with special reference to iatrogenic and self-medicated hazards.
Hazards of Drug Use Among the Elderly1 Lawrence R. Krupka, PhD,2 and Arthur M. Vener, PhD3
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dase inhibitors and sedatives. Of 185 doctors The elderly (65 and older) comprising 10% surveyed only 17% had accurate knowledge of of the population consume 22 to 25% of all these drug interactions (Petrie et al., 1975). prescription drugs in the U.S. (Butler, 1975; The problem of multiple drug use among the Rabin, 1972). In the United Kingdom, the elderly elderly has serious implications because of representing 12% of the population, consume as pharmacokinetic (differences in absorption, dismuch as 30% of the National Health Service tribution, metabolism and excretion) and funding for drugs (Carlson, 1975). pharmacodynamic (alterations of action at Multiple pathology, a common phenomenon receptor sites) considerations (James, 1976b). among the elderly, fosters the practice of poly- Attention has been directed to the iatrogenic pharmacy in attempts to treat several disorders hazards of drugs to geriatric patients (D'Arcy, simultaneously (James, 1976a). The number of 1976). Such potentially harmful, commonly drugs prescribed for hospitalized individuals prescribed medicines include antidepressants, rises with the age of the patient (Hurwitz, 1969). antirheumatics, cardiac glycosides, diuretics, Adverse drug reactions accelerate with in- barbiturates and tranquilizers. Geriatric patients creased drug exposure. When six to ten drugs often have decreased renal and liver function are taken, typically, 7.4% of the recipients have resulting in a narrowing of the safety margin adverse drug reactions (Martin, 1971). Hospital between the therapeutic and toxic doses. For patients who were given one to five drugs had an example, although phenobarbital is frequently adverse drug reaction incidence of 18.8%, prescribed as a sedative for young people it whereas patients ingesting six or more pre- may be especially hazardous for the older pascribed drugs, had an incidence of 81.4% tient. Large doses of the drug can result in stupor Games, 1976a). A reduction in the number of and coma. The failure of the liver to metabolize drugs prescribed for older individuals has been the drug adequately and/or the inability of the recommended to lessen the number of drug kidney to excrete the drug into the urine eninteractions (Caird, 1977). hances potential drug toxicity. Furthermore, In a study of 138 patients living in an extended brain impairment (stroke) in a geriatric patient care facility, 30 patients had prescriptions for 38 may result in increased susceptibility to the "non-recommended" drugs (Ingman et al., effects of phenobarbital, wherein a decreased 1975). Furthermore, a study of physicians in dosage would have the same impact as a larger Scotland showed that they were generally un- dose (Felstein, 1969). aware of the potential interactions involving five In the U.S., only 4 to 5% of the elderly live in groups of drugs — adrenefgic neurone blockers, institutionalized settings (i.e., nursing facilities). warfarin, antidiabetic agents, monamine oxi- Thus, the overwhelming majority of older people have minimal supervision with respect to their overall exposure to drugs. Several investigators 'This research was supported by the NIH Biomedical Research Support Grant, have argued that three drugs seem to be the maxNo. 5 S07 RR 07049-11 to Michigan State Univ. 'Prof, of Natural Science, Kedzie Laboratory, Michigan State Univ., East imal number for an elderly person to manage Lansing, Ml 48824. correctly (Lamy & Kitler, 1971). A review of 'Prof, of Social Science, Michigan State Univ., East Lansing, Ml 48824. The Problem
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alcohol, caffeine and nicotine) of elderly individuals.
Measurement of Drug Interactions Because of space limitations it would be impossible to analyze extensively the interactions of the drugs of a number of individuals simultaneously. Typically, due to differences in personal habits, health and medical care, individuals ingest a wide array of drugs. Statistical generalizations regarding type, number and frequency of drug use are more easily arrived at. Therefore, analysis of drug interactions must be examined on an individualized basis. The greater the number of drugs ingested, the greater the opportunity for interactive permutations to develop. Two case studies have been selected to demonstrate potential drug hazards. One case was selected from our study of 55 noninstitutionalized elderly respondents, while the other was selected from investigations and referrals of individuals residing in long-term care facilities. Neither case is atypical. Both individuals were taking at least 10 drugs, were of approximately similar age, and had several chronic ailments in common.
Case Number 1: Overview This 79-year-old married male was living in his own residence and consumed 13 different drugs on a daily basis. He had seven chronic illnesses which included allergy and sinus problems, hardening of the arteries, heart trouble, ulcers, arthritis, and two physical impairments — loss of hearing and back trouble. Despite his chronic illnesses, he had not seen a physician on a regular office visit during the year prior to his being interviewed. However, he was hospitalized on two separate occasions on an emergency basis. In terms of his life condition, he was dissatisfied with cost of medical care, unhappy about his physical health, remorseful about not achieving higher levels of education, and did not like his present family life because his wife had recently been institutionalized and therefore he had to live alone. Also he believed that governmental officials had abandoned him along with other older persons. The respondent's daily drug exposure is listed in Table 1.
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medication errors of patients living at home, has revealed that not less than 25% made errors in the self-administration of their drugs, and in some instances, the figure was as high as 59% (Stewart & Cluff, 1972). In this vein, others have suggested that elderly people who reside in their own households run special drug toxicity risks and need regular reappraisal (Shaw & Opit, 1976). In a previous study of total drug exposure (prescription, over-the-counter and social — alcohol, caffeine and nicotine) of noninstitutionalized elderly, we found that 67% used at least one prescription drug, 65% took at least one over-the-counter drug and 98% consumed a social drug daily (Vener et al., 1979, in press). In terms of range, 24% ingested zero to two drugs, 55% ingested three to five drugs, and 22% consumed six or more drugs, with one individual consuming 13 different drugs. Of those who used drugs, the average of 2.0 prescription, 1.8 over-the-counter, and 1.8 social drugs amounted to a total of 5.6 drugs per individual with males averaging 7.5 and females 4.7. Our sample, which ranged from the upper end of the working to the upper end of the middle class, was purposively selected because of their involvement in peer interaction networks. When medical attention was needed, they had confidence in both their physicians' diagnoses and the drugs he/she prescribed. As previous research has shown regarding the importance of maintaining interaction with peers (Blau, 1973), our respondents' overall satisfaction with their life condition was relatively high despite their average age of 70 years. In contrast to this relatively independent (health, financial and social) group of respondents who were ingesting 2.0 prescriptions per day, we have encountered a number of instances whereby institutionalized elderly were exposed to a larger number of drugs (e.g., up to 18 prescription drugs daily). Some investigators have found that elderly patients in long-term care facilities were taking 3.3 drugs on a daily basis (Kalchthaler et al., 1977) while others found 4.6 (Ingman et al., 1975). In one long-term care institution, 6 of every 10 patients were exposed to major or minor tranquil izers; 3 of 10, sedativehypnotic agents; and 2 of 10, analgesic agents (Ingman et al., 1975). In this report, we wish to explore in detail the interactive hazards of the total drug exposure (prescription, over-the-counter and social —
Table 1. Daily Drug Exposure of a Noninstitutionalized 79-Year-Old Male. Drug
1500 mg .25 mg 25 mg 25 mg 1200 mg 20 mg 300 mg 300 mg 1500 mg 50 mg 100 mg 400 I.U. 750 mg 100 mg 15 mg 10 mg 5 mg 6mg 500 mg 30 I.U. 2 oz 1250 mg
Case Number 2: Overview This 80-year-old female has been living in long-term care facilities since 1971. In 1967 she was widowed and four years later she voluntarily placed herself into a nursing home because of loneliness due to physical isolation. She lived in a rural area and her nearest neighbor resided a mile away. At the time she first entered this facility her physical health was relatively sound and she had no major chronic illnesses. After a year of residence in this original long-term care facility, she became disillusioned with the amount of drugs that she was forced to take and distrustful of the way her pension was being managed. Shortly thereafter she moved to another facility where a number of childhood acquaintances and friends resided. For the first several years she took leadership responsibility in organized social activities. However, within the past several years she has shown a steady decline in both physical and mental health. Presently, she is in a state of extreme lethargy and disorientation and complains of being constipated and frequently is incontinent. She now has four chronic illnesses — hardening of the arteries, high blood pressure, heart trouble and is depressed. She sees a physician once a month who also treats approximately 70 other patients on the day he makes his monthly visit. The 10 drugs thatshe ingests daily and her weekly injection of vitamin B12 are listed in Table 2.
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Function Prevent cholesterol build-up Regulate heart beat Diuretic Anti-inflammatory Treatment of angina pectoris Heart muscle relaxant Analgesic — gastric distress Cold preventive To prevent ear deterioration To provide minerals and Vitamin D
Enjoyment Enjoyment
Drug Interactions Analysis of the drug interaction of the 79-yearold male exposed to 13 different drugs shows minimal interactive hazards from the prescriptions. He was taking seven prescription drugs daily. His prescriptions indicate that care was taken to avoid potential hazards. For example, the use of Aldactazide as a diuretic was indicated, considering the fact that the respondent was also ingesting digoxin. However, spironolactone, an active ingredient in the drug, has been shown to be a tumorigen in chronic toxicity studies in rats (Physicians' Desk Reference, 1977) and therefore is potentially harmful in itself. The use of Ascriptin (aspirin with aluminum hydroxide) was indicated since the respondent has stomach ulcers and this form of aspirin would be less irritating on the gastric mucosa. When the respondent's total drug intake is examined, potential interactive hazards become evident. Since the respondent has had severe heart disease (hospitalized twice in the year prior to interview on an emergency basis), his intake of caffeine of approximately 1250 mg per day is more than twice the recommended safe level (Long, 1977). His daily intake of alcohol (minimum of 2 fluid ounces) may interact with the aspirin to exacerbate his ulcers, since alcohol potentiates the effects of salicylates. In addition, his high intake of vitamin C (2250 mg)
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Atromid-S (clofibrate) Lanoxin (digoxin) Aldactazide (hydrochlorothiazide + spironolactone) Motrin (ibuprofen) Sorbitrate (isosorbide dinitrate) Pavabid (papaverine hydrogen chloride) Ascriptin (aspirin + aluminum hydroxide) Vitamin C Vitamin Bi Dicalcium phosphate with Vitamin D Cefol Vitamin C Niacin Vitamin Bi Vitamin B2 Vitamin B& Vitamin B12 Folic Acid Vitamin E Alcohol Caffeine
Amount
Table 2. Daily Drug Exposure of an Institutionalized 80-Year-Old Female. Drug
a
Amount 2000 .25 500 30 50
mg mg mg mg mg
75 mg 100 mg 0.4148 mg 0.0776 mg 0.0260 mg 64.8 mg 2400 mg 1 oz 400 mg 100 meg
Function Prevent cholesterol build-up Regulate heart beat Antihypertensive and diuretic Antidepressant Strong tranquilizer Sedative-hypnotic Sedative and antispasmodic Potassium depletion Relief of constipation Enjoyment Treatment for pernicious anemia
once a week
will interact with the aspirin. Aspirin decreases the effect of vitamin C by increasing its urinary elimination from the body, while vitamin C can increase or potentiate the effect of aspirin by slowing its elimination causing aspirin accumulation and toxicity. The ingestion of vitamin C along with aspirin as well as alcohol with aspirin is not an isolated phenomenon. Twenty percent of elderly respondents in our previous study were taking these drugs simultaneously (Vener et al., 1979, in press). Additionally, long-term use of aspirin on its own may be hazardous, (e.g., kidney damage [Goldberger & Talmer, 1975]). Analysis of the drug intake of the 80-year-old institutionalized female indicates that serious health hazards might occur because of her daily prescription regimen. Her lethargic and disoriented state may very well be symptomatic of behavioral toxicity. Reactions to drugs may be varied and present overlapping symptoms such as "insomnia, nightmares, irritability, increased sensitivity to noise, listlessness and restlessness (Davies, 1977). For example, her use of Elavil, a tricyclic antidepressant (amitriptyline) is more likely to cause adverse effects in the elderly. This drug should be avoided if Aldoril (methyldopa and hydrochlorothiazide) is also being taken (Long, 1977). Amitriptyline may cause a dangerous elevation of blood pressure if taken concurrently with methyldopa. Amitriptyline should also be avoided in patients with heart disease, particularly those with disorders of heart rhythm. Amitryptyline taken with a hydrochlorothiazide diuretic may slow its elimination from the body and an overdose could occur.
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Furthermore, numerous reports have implicated methyldopa as a common cause of depression and other psychiatric disorders such as insomnia and nightmares. Both mythyldopaand amitriptyline can cause drowsiness as possible side effects. Amitriptyline may also increase the effects of sedatives, sleep-inducing drugs, tranquilizers and cause over-sedation. Since this individual is also taking Thorazine (chloropromazine hydrochloride), a strong tranquilizer as well as several other sedative-hypnotic drugs — sodium butisol (sodium butabarbital), and Donnatal (hyoscyamine sulfate, atropine sulfate, hyoscine hydrobromide, phenobarbital) the present chronic confusional state of this patient may
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be traceable to these drug interactions and/or
side effects. Chloropromazine should be used with caution in the elderly, especially those with impaired heart function. Possible side effects from this drug may include drowsiness, depression, indifference, insomnia and agitation. Chloropromazine may also increase the effects of methyldopa and cause excessive lowering of blood pressure. Lanoxin (digoxin) may cause drowsiness and lethargy as well as confusion and disorientation especially in the elderly. Use of digoxin with hydrochlorothiazide can cause serious digoxin toxicity due to excessive loss of potassium. However, the physician prescribed potassium tablets in order to compensate for this eventuality. Implications
The elderly male living at home, although having more chronic illnesses than the institutionalized female (three of which were the
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Atromid-S (clofibrate) Lanoxin (digoxin) Aldoril (methyldopa + hydrochlorothiazide) Elavil (amitriptyline hydrochloride) Thorazine (chloropromazine hydrochloride) Sodium Butisol (sodium butabarbital) Donnatal — hyoscyamine sulfate atropine sulfate hyoscine hydrobromide phenobarbital Slow-K (potassium chloride) Agoral (phenolphthalein + mineral oil) Caffeine Vitamin Bu (cyanocobalamin)a
94
party would be to periodically observe and/or confer with the patient to assess his/her overall state of being. Finally, it is important to note that the two cases analyzed in this report are not bizarre. We have encountered a number of elderly individuals, both institutionalized and noninstitutionalized, who have ingested larger numbers of drugs. In order to avoid diminishing the importance of the general problem, planners and practitioners should not consider these cases as being exceptional.
References Blau, Z. S. Old age in a changing society. Franklin Watts,
New York, 1973. Butler, R. N. Why survive? Being old in America. Harper and
Row, New York, 1975. Caird, F. I. Prescribing for the elderly. British journal of Hospital Medicine, 1977, 17, 610-613. Carlson, R. I. The end of medicine. Wiley & Sons, New York, 1975. D'Arcy, P. F. Iatrogenic disease: A hazard of multiple drug therapy. Royal Society Health journal, 1976, 96, 277283. Davies, D. M. Textbook of adverse drug reactions. Oxford
Univ. Press, Oxford, 1977. Felstein, I. Later life: Geriatrics today andtomorrow. Penquin
Books, Baltimore, 1969. Goffman, E. Asylums. Doubleday & Co., Inc. Garden City, 1961. Goldberger, L. E., & Talmer, L. B. Analgesic abuse syndrome, a frequently overlooked cause of reversible renal failure. Urology, 1975,5, 728-732. Henry, J. Culture against man. Random House, New York, 1963. Hurwitz, N. Predisposing factors in adverse reactions to drugs. British Medical Journal, 1969, 1, 536-539.
Ingman, S. R., Lawson, I. R., Pierpaoli, P. G., & Blake, P. A survey of the prescribing and administration of drugs in a long-term care institution for the elderly, journal of the American Geriatrics Society, 1975, 23, 309-316.
James, I. Prescribing for the elderly: Check the interaction and cut down your calls. Modern Geriatrics, 1976, 6, 7-14. (a) James, I. Prescribing for the elderly: Why it's best to keep it simple. Modern Geriatrics, 1976, 6, 25-28. (b) Kalchthaler, D. O., Coccaro, E., & Lichtiger, S. Incidences of polypharmacy in a long-term care facility, journal of the American Geriatrics Society, 1977, 25, 308-313.
Lamy, P. P., & Kitler, M. E. Drugs and the geriatric patient. journal of the American Geriatrics Society, 1971, 79,
23-33. Long, J. W . The essential guide to prescription drugs. Harper
& Row, New York, 1977. Martin, E. W. Hazards of medication. J. B. Lippincott Co., Philadelphia, 1971. Petrie, J. C , Durno. D., & Howie, J. G. R. Clinical effects of interaction between drugs. J. C. Excerpta Medica, Amsterdam, 1975. Physician's Desk Reference. 31st. Edition, Medical Economics Co., Oradell, NJ, 1977.
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same), was not taking any tranquilizers, antidepressants or sedative-hypnotics and was able to care for himself and remained active in his network of lifelong friends. The apparent greater use ofthesedrugs in long-term care facilities may be due to the increased pathology of the patients and/or a tendency on the part of physicians working with institutionalized individuals to prescribe more drugs under controlled conditions. In addition, the desire of officials to maintain operational efficiency by controlling the behavior of their patients with disparate needs and dispositions may also be involved. The use of drug therapy among the elderly should proceed with caution. Multiple pathology of the aging leads to polypharmacy which in turn may lead to a greater number of iatrogenic reactions which frequently are treated with even a greater number of drugs. This cycle can be broken by a greater awareness on the part of health professionals, policy-makers and others who work on behalf of the aging. Drugs prescribed for the elderly should be as simple as possible and be of relatively short duration (Caird, 1977). A physician explaining why he is prescribing certain drugs to elderly patients or their relatives, in itself, often results in more simple and rational prescribing behavior (Whitehead, 1975). However, in long-term care facilities, as in all total institutions, patients find it difficult to establish and maintain social contacts with individuals from the outside world (Goffman, 1961). Health problems also limit contacts with outsiders as well as loss through death of friends and relatives. Therefore, consideration should be given to the feasibility of utilizing a third party whose prime function would be to act on behalf of the institutionalized elderly patient in lieu of concerned relatives and/or friends. Periodically, this third party would confer with the physician to discuss the patient's medical condition and to explain the rationale for the drugs being prescribed. In order to avoid conflict of interest, thethird party should in no way be associated with the long-term care facility in which the elderly patient resides. For example, representatives of state departments of social services or individuals from concerned gerontological organizations could be designated for such a function. Even the best longterm care facilities primarily focus upon the business of medical care, feeding and asepsis (Henry, 1963). Unfortunately, the emotional condition of the patient's mind is often of lesser concern. An additional function of the third
Rabin, D. L. Use of medicine: A review of prescribed and nonprescribed medicine use. USPHS, DHEW, Publ. HSM 73-3012, Reprint Series, 1972. Shaw, S. M., & Opit, L. J. Need for supervision in the elderly receiving long-term prescribed medication. British Medical Journal, 1976, 1, 505-507. Stewart, R. B., & Cluff, L. E. A review of medication errors and compliance in ambulant patients. Clinical Pharmacology and Therapeutics, 1972, 13, 463-468.
Vener, A. M., Krupka, L. R., & Climo, J. J. Drug exposure and health characteristics of noninstitutionalized retired individuals. Journal of the American Geriatrics Society, 1979. (in press) Whitehead, A. World Medicine, 1975, Sept. 24, 26 (As cited in Atkinson, L, Gibson, I. J. M., & Andrews, J. The difficulties of old people taking drugs. Age and Aging, 1977,6, 144-150).
Miami University, Oxford, Ohio, has been authorized by the Ohio Board of Regents to offer the degree, Master of Gerontological Studies. A multidisciplinary, administration oriented program, the degree is offered through the Department of Sociology and Anthropology. Further information may be obtained from: Dr. Mildred M. Seltzer, Director Graduate Program in Gerontology Scripps Foundation Gerontology Ctr. Miami University Oxford, OH 45056
Dr. Theodore Wagenaar, Director
Graduate Program, Sociology and Anthropology Miami University Oxford, OH 45056
GERONTOLOGICAL SOCIETY ANNOUNCES ITS 1979 RESEARCH FELLOWSHIP PROGRAM The Gerontological Society invites applications from social and biomedical researchers with extensive backgrounds in aging for fellowships in governmental offices on aging and organizations involved in the field of aging. Fellows' interests will be matched'with the agencies' needs. The stipend will be $3,000 for a 3 month full-time or 6 month half-time placement. In addition, travel and per diem expenses are covered for work related activities. Deadline is March 9, 1979. For more information write to: Gerontological Society (West Coast Project Office), 2728 Durant Avenue, Berkeley, California 94704. This program is based on tentative approval by the Administration on Aging, Health, Education and Welfare. Final notification is pending.
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MASTER OF GERONTOLOGICAL STUDIES
Hazards of Drug Use Among the Elderly1 Lawrence R. Krupka, PhD,2 and Arthur M. Vener, PhD3
90
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dase inhibitors and sedatives. Of 185 doctors The elderly (65 and older) comprising 10% surveyed only 17% had accurate knowledge of of the population consume 22 to 25% of all these drug interactions (Petrie et al., 1975). prescription drugs in the U.S. (Butler, 1975; The problem of multiple drug use among the Rabin, 1972). In the United Kingdom, the elderly elderly has serious implications because of representing 12% of the population, consume as pharmacokinetic (differences in absorption, dismuch as 30% of the National Health Service tribution, metabolism and excretion) and funding for drugs (Carlson, 1975). pharmacodynamic (alterations of action at Multiple pathology, a common phenomenon receptor sites) considerations (James, 1976b). among the elderly, fosters the practice of poly- Attention has been directed to the iatrogenic pharmacy in attempts to treat several disorders hazards of drugs to geriatric patients (D'Arcy, simultaneously (James, 1976a). The number of 1976). Such potentially harmful, commonly drugs prescribed for hospitalized individuals prescribed medicines include antidepressants, rises with the age of the patient (Hurwitz, 1969). antirheumatics, cardiac glycosides, diuretics, Adverse drug reactions accelerate with in- barbiturates and tranquilizers. Geriatric patients creased drug exposure. When six to ten drugs often have decreased renal and liver function are taken, typically, 7.4% of the recipients have resulting in a narrowing of the safety margin adverse drug reactions (Martin, 1971). Hospital between the therapeutic and toxic doses. For patients who were given one to five drugs had an example, although phenobarbital is frequently adverse drug reaction incidence of 18.8%, prescribed as a sedative for young people it whereas patients ingesting six or more pre- may be especially hazardous for the older pascribed drugs, had an incidence of 81.4% tient. Large doses of the drug can result in stupor Games, 1976a). A reduction in the number of and coma. The failure of the liver to metabolize drugs prescribed for older individuals has been the drug adequately and/or the inability of the recommended to lessen the number of drug kidney to excrete the drug into the urine eninteractions (Caird, 1977). hances potential drug toxicity. Furthermore, In a study of 138 patients living in an extended brain impairment (stroke) in a geriatric patient care facility, 30 patients had prescriptions for 38 may result in increased susceptibility to the "non-recommended" drugs (Ingman et al., effects of phenobarbital, wherein a decreased 1975). Furthermore, a study of physicians in dosage would have the same impact as a larger Scotland showed that they were generally un- dose (Felstein, 1969). aware of the potential interactions involving five In the U.S., only 4 to 5% of the elderly live in groups of drugs — adrenefgic neurone blockers, institutionalized settings (i.e., nursing facilities). warfarin, antidiabetic agents, monamine oxi- Thus, the overwhelming majority of older people have minimal supervision with respect to their overall exposure to drugs. Several investigators 'This research was supported by the NIH Biomedical Research Support Grant, have argued that three drugs seem to be the maxNo. 5 S07 RR 07049-11 to Michigan State Univ. 'Prof, of Natural Science, Kedzie Laboratory, Michigan State Univ., East imal number for an elderly person to manage Lansing, Ml 48824. correctly (Lamy & Kitler, 1971). A review of 'Prof, of Social Science, Michigan State Univ., East Lansing, Ml 48824. The Problem
Vol. 19, No. 1, 1979
91
alcohol, caffeine and nicotine) of elderly individuals.
Measurement of Drug Interactions Because of space limitations it would be impossible to analyze extensively the interactions of the drugs of a number of individuals simultaneously. Typically, due to differences in personal habits, health and medical care, individuals ingest a wide array of drugs. Statistical generalizations regarding type, number and frequency of drug use are more easily arrived at. Therefore, analysis of drug interactions must be examined on an individualized basis. The greater the number of drugs ingested, the greater the opportunity for interactive permutations to develop. Two case studies have been selected to demonstrate potential drug hazards. One case was selected from our study of 55 noninstitutionalized elderly respondents, while the other was selected from investigations and referrals of individuals residing in long-term care facilities. Neither case is atypical. Both individuals were taking at least 10 drugs, were of approximately similar age, and had several chronic ailments in common.
Case Number 1: Overview This 79-year-old married male was living in his own residence and consumed 13 different drugs on a daily basis. He had seven chronic illnesses which included allergy and sinus problems, hardening of the arteries, heart trouble, ulcers, arthritis, and two physical impairments — loss of hearing and back trouble. Despite his chronic illnesses, he had not seen a physician on a regular office visit during the year prior to his being interviewed. However, he was hospitalized on two separate occasions on an emergency basis. In terms of his life condition, he was dissatisfied with cost of medical care, unhappy about his physical health, remorseful about not achieving higher levels of education, and did not like his present family life because his wife had recently been institutionalized and therefore he had to live alone. Also he believed that governmental officials had abandoned him along with other older persons. The respondent's daily drug exposure is listed in Table 1.
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medication errors of patients living at home, has revealed that not less than 25% made errors in the self-administration of their drugs, and in some instances, the figure was as high as 59% (Stewart & Cluff, 1972). In this vein, others have suggested that elderly people who reside in their own households run special drug toxicity risks and need regular reappraisal (Shaw & Opit, 1976). In a previous study of total drug exposure (prescription, over-the-counter and social — alcohol, caffeine and nicotine) of noninstitutionalized elderly, we found that 67% used at least one prescription drug, 65% took at least one over-the-counter drug and 98% consumed a social drug daily (Vener et al., 1979, in press). In terms of range, 24% ingested zero to two drugs, 55% ingested three to five drugs, and 22% consumed six or more drugs, with one individual consuming 13 different drugs. Of those who used drugs, the average of 2.0 prescription, 1.8 over-the-counter, and 1.8 social drugs amounted to a total of 5.6 drugs per individual with males averaging 7.5 and females 4.7. Our sample, which ranged from the upper end of the working to the upper end of the middle class, was purposively selected because of their involvement in peer interaction networks. When medical attention was needed, they had confidence in both their physicians' diagnoses and the drugs he/she prescribed. As previous research has shown regarding the importance of maintaining interaction with peers (Blau, 1973), our respondents' overall satisfaction with their life condition was relatively high despite their average age of 70 years. In contrast to this relatively independent (health, financial and social) group of respondents who were ingesting 2.0 prescriptions per day, we have encountered a number of instances whereby institutionalized elderly were exposed to a larger number of drugs (e.g., up to 18 prescription drugs daily). Some investigators have found that elderly patients in long-term care facilities were taking 3.3 drugs on a daily basis (Kalchthaler et al., 1977) while others found 4.6 (Ingman et al., 1975). In one long-term care institution, 6 of every 10 patients were exposed to major or minor tranquil izers; 3 of 10, sedativehypnotic agents; and 2 of 10, analgesic agents (Ingman et al., 1975). In this report, we wish to explore in detail the interactive hazards of the total drug exposure (prescription, over-the-counter and social —
Table 1. Daily Drug Exposure of a Noninstitutionalized 79-Year-Old Male. Drug
1500 mg .25 mg 25 mg 25 mg 1200 mg 20 mg 300 mg 300 mg 1500 mg 50 mg 100 mg 400 I.U. 750 mg 100 mg 15 mg 10 mg 5 mg 6mg 500 mg 30 I.U. 2 oz 1250 mg
Case Number 2: Overview This 80-year-old female has been living in long-term care facilities since 1971. In 1967 she was widowed and four years later she voluntarily placed herself into a nursing home because of loneliness due to physical isolation. She lived in a rural area and her nearest neighbor resided a mile away. At the time she first entered this facility her physical health was relatively sound and she had no major chronic illnesses. After a year of residence in this original long-term care facility, she became disillusioned with the amount of drugs that she was forced to take and distrustful of the way her pension was being managed. Shortly thereafter she moved to another facility where a number of childhood acquaintances and friends resided. For the first several years she took leadership responsibility in organized social activities. However, within the past several years she has shown a steady decline in both physical and mental health. Presently, she is in a state of extreme lethargy and disorientation and complains of being constipated and frequently is incontinent. She now has four chronic illnesses — hardening of the arteries, high blood pressure, heart trouble and is depressed. She sees a physician once a month who also treats approximately 70 other patients on the day he makes his monthly visit. The 10 drugs thatshe ingests daily and her weekly injection of vitamin B12 are listed in Table 2.
92
Function Prevent cholesterol build-up Regulate heart beat Diuretic Anti-inflammatory Treatment of angina pectoris Heart muscle relaxant Analgesic — gastric distress Cold preventive To prevent ear deterioration To provide minerals and Vitamin D
Enjoyment Enjoyment
Drug Interactions Analysis of the drug interaction of the 79-yearold male exposed to 13 different drugs shows minimal interactive hazards from the prescriptions. He was taking seven prescription drugs daily. His prescriptions indicate that care was taken to avoid potential hazards. For example, the use of Aldactazide as a diuretic was indicated, considering the fact that the respondent was also ingesting digoxin. However, spironolactone, an active ingredient in the drug, has been shown to be a tumorigen in chronic toxicity studies in rats (Physicians' Desk Reference, 1977) and therefore is potentially harmful in itself. The use of Ascriptin (aspirin with aluminum hydroxide) was indicated since the respondent has stomach ulcers and this form of aspirin would be less irritating on the gastric mucosa. When the respondent's total drug intake is examined, potential interactive hazards become evident. Since the respondent has had severe heart disease (hospitalized twice in the year prior to interview on an emergency basis), his intake of caffeine of approximately 1250 mg per day is more than twice the recommended safe level (Long, 1977). His daily intake of alcohol (minimum of 2 fluid ounces) may interact with the aspirin to exacerbate his ulcers, since alcohol potentiates the effects of salicylates. In addition, his high intake of vitamin C (2250 mg)
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Atromid-S (clofibrate) Lanoxin (digoxin) Aldactazide (hydrochlorothiazide + spironolactone) Motrin (ibuprofen) Sorbitrate (isosorbide dinitrate) Pavabid (papaverine hydrogen chloride) Ascriptin (aspirin + aluminum hydroxide) Vitamin C Vitamin Bi Dicalcium phosphate with Vitamin D Cefol Vitamin C Niacin Vitamin Bi Vitamin B2 Vitamin B& Vitamin B12 Folic Acid Vitamin E Alcohol Caffeine
Amount
Table 2. Daily Drug Exposure of an Institutionalized 80-Year-Old Female. Drug
a
Amount 2000 .25 500 30 50
mg mg mg mg mg
75 mg 100 mg 0.4148 mg 0.0776 mg 0.0260 mg 64.8 mg 2400 mg 1 oz 400 mg 100 meg
Function Prevent cholesterol build-up Regulate heart beat Antihypertensive and diuretic Antidepressant Strong tranquilizer Sedative-hypnotic Sedative and antispasmodic Potassium depletion Relief of constipation Enjoyment Treatment for pernicious anemia
once a week
will interact with the aspirin. Aspirin decreases the effect of vitamin C by increasing its urinary elimination from the body, while vitamin C can increase or potentiate the effect of aspirin by slowing its elimination causing aspirin accumulation and toxicity. The ingestion of vitamin C along with aspirin as well as alcohol with aspirin is not an isolated phenomenon. Twenty percent of elderly respondents in our previous study were taking these drugs simultaneously (Vener et al., 1979, in press). Additionally, long-term use of aspirin on its own may be hazardous, (e.g., kidney damage [Goldberger & Talmer, 1975]). Analysis of the drug intake of the 80-year-old institutionalized female indicates that serious health hazards might occur because of her daily prescription regimen. Her lethargic and disoriented state may very well be symptomatic of behavioral toxicity. Reactions to drugs may be varied and present overlapping symptoms such as "insomnia, nightmares, irritability, increased sensitivity to noise, listlessness and restlessness (Davies, 1977). For example, her use of Elavil, a tricyclic antidepressant (amitriptyline) is more likely to cause adverse effects in the elderly. This drug should be avoided if Aldoril (methyldopa and hydrochlorothiazide) is also being taken (Long, 1977). Amitriptyline may cause a dangerous elevation of blood pressure if taken concurrently with methyldopa. Amitriptyline should also be avoided in patients with heart disease, particularly those with disorders of heart rhythm. Amitryptyline taken with a hydrochlorothiazide diuretic may slow its elimination from the body and an overdose could occur.
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Furthermore, numerous reports have implicated methyldopa as a common cause of depression and other psychiatric disorders such as insomnia and nightmares. Both mythyldopaand amitriptyline can cause drowsiness as possible side effects. Amitriptyline may also increase the effects of sedatives, sleep-inducing drugs, tranquilizers and cause over-sedation. Since this individual is also taking Thorazine (chloropromazine hydrochloride), a strong tranquilizer as well as several other sedative-hypnotic drugs — sodium butisol (sodium butabarbital), and Donnatal (hyoscyamine sulfate, atropine sulfate, hyoscine hydrobromide, phenobarbital) the present chronic confusional state of this patient may
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be traceable to these drug interactions and/or
side effects. Chloropromazine should be used with caution in the elderly, especially those with impaired heart function. Possible side effects from this drug may include drowsiness, depression, indifference, insomnia and agitation. Chloropromazine may also increase the effects of methyldopa and cause excessive lowering of blood pressure. Lanoxin (digoxin) may cause drowsiness and lethargy as well as confusion and disorientation especially in the elderly. Use of digoxin with hydrochlorothiazide can cause serious digoxin toxicity due to excessive loss of potassium. However, the physician prescribed potassium tablets in order to compensate for this eventuality. Implications
The elderly male living at home, although having more chronic illnesses than the institutionalized female (three of which were the
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Atromid-S (clofibrate) Lanoxin (digoxin) Aldoril (methyldopa + hydrochlorothiazide) Elavil (amitriptyline hydrochloride) Thorazine (chloropromazine hydrochloride) Sodium Butisol (sodium butabarbital) Donnatal — hyoscyamine sulfate atropine sulfate hyoscine hydrobromide phenobarbital Slow-K (potassium chloride) Agoral (phenolphthalein + mineral oil) Caffeine Vitamin Bu (cyanocobalamin)a
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party would be to periodically observe and/or confer with the patient to assess his/her overall state of being. Finally, it is important to note that the two cases analyzed in this report are not bizarre. We have encountered a number of elderly individuals, both institutionalized and noninstitutionalized, who have ingested larger numbers of drugs. In order to avoid diminishing the importance of the general problem, planners and practitioners should not consider these cases as being exceptional.
References Blau, Z. S. Old age in a changing society. Franklin Watts,
New York, 1973. Butler, R. N. Why survive? Being old in America. Harper and
Row, New York, 1975. Caird, F. I. Prescribing for the elderly. British journal of Hospital Medicine, 1977, 17, 610-613. Carlson, R. I. The end of medicine. Wiley & Sons, New York, 1975. D'Arcy, P. F. Iatrogenic disease: A hazard of multiple drug therapy. Royal Society Health journal, 1976, 96, 277283. Davies, D. M. Textbook of adverse drug reactions. Oxford
Univ. Press, Oxford, 1977. Felstein, I. Later life: Geriatrics today andtomorrow. Penquin
Books, Baltimore, 1969. Goffman, E. Asylums. Doubleday & Co., Inc. Garden City, 1961. Goldberger, L. E., & Talmer, L. B. Analgesic abuse syndrome, a frequently overlooked cause of reversible renal failure. Urology, 1975,5, 728-732. Henry, J. Culture against man. Random House, New York, 1963. Hurwitz, N. Predisposing factors in adverse reactions to drugs. British Medical Journal, 1969, 1, 536-539.
Ingman, S. R., Lawson, I. R., Pierpaoli, P. G., & Blake, P. A survey of the prescribing and administration of drugs in a long-term care institution for the elderly, journal of the American Geriatrics Society, 1975, 23, 309-316.
James, I. Prescribing for the elderly: Check the interaction and cut down your calls. Modern Geriatrics, 1976, 6, 7-14. (a) James, I. Prescribing for the elderly: Why it's best to keep it simple. Modern Geriatrics, 1976, 6, 25-28. (b) Kalchthaler, D. O., Coccaro, E., & Lichtiger, S. Incidences of polypharmacy in a long-term care facility, journal of the American Geriatrics Society, 1977, 25, 308-313.
Lamy, P. P., & Kitler, M. E. Drugs and the geriatric patient. journal of the American Geriatrics Society, 1971, 79,
23-33. Long, J. W . The essential guide to prescription drugs. Harper
& Row, New York, 1977. Martin, E. W. Hazards of medication. J. B. Lippincott Co., Philadelphia, 1971. Petrie, J. C , Durno. D., & Howie, J. G. R. Clinical effects of interaction between drugs. J. C. Excerpta Medica, Amsterdam, 1975. Physician's Desk Reference. 31st. Edition, Medical Economics Co., Oradell, NJ, 1977.
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same), was not taking any tranquilizers, antidepressants or sedative-hypnotics and was able to care for himself and remained active in his network of lifelong friends. The apparent greater use ofthesedrugs in long-term care facilities may be due to the increased pathology of the patients and/or a tendency on the part of physicians working with institutionalized individuals to prescribe more drugs under controlled conditions. In addition, the desire of officials to maintain operational efficiency by controlling the behavior of their patients with disparate needs and dispositions may also be involved. The use of drug therapy among the elderly should proceed with caution. Multiple pathology of the aging leads to polypharmacy which in turn may lead to a greater number of iatrogenic reactions which frequently are treated with even a greater number of drugs. This cycle can be broken by a greater awareness on the part of health professionals, policy-makers and others who work on behalf of the aging. Drugs prescribed for the elderly should be as simple as possible and be of relatively short duration (Caird, 1977). A physician explaining why he is prescribing certain drugs to elderly patients or their relatives, in itself, often results in more simple and rational prescribing behavior (Whitehead, 1975). However, in long-term care facilities, as in all total institutions, patients find it difficult to establish and maintain social contacts with individuals from the outside world (Goffman, 1961). Health problems also limit contacts with outsiders as well as loss through death of friends and relatives. Therefore, consideration should be given to the feasibility of utilizing a third party whose prime function would be to act on behalf of the institutionalized elderly patient in lieu of concerned relatives and/or friends. Periodically, this third party would confer with the physician to discuss the patient's medical condition and to explain the rationale for the drugs being prescribed. In order to avoid conflict of interest, thethird party should in no way be associated with the long-term care facility in which the elderly patient resides. For example, representatives of state departments of social services or individuals from concerned gerontological organizations could be designated for such a function. Even the best longterm care facilities primarily focus upon the business of medical care, feeding and asepsis (Henry, 1963). Unfortunately, the emotional condition of the patient's mind is often of lesser concern. An additional function of the third
Rabin, D. L. Use of medicine: A review of prescribed and nonprescribed medicine use. USPHS, DHEW, Publ. HSM 73-3012, Reprint Series, 1972. Shaw, S. M., & Opit, L. J. Need for supervision in the elderly receiving long-term prescribed medication. British Medical Journal, 1976, 1, 505-507. Stewart, R. B., & Cluff, L. E. A review of medication errors and compliance in ambulant patients. Clinical Pharmacology and Therapeutics, 1972, 13, 463-468.
Vener, A. M., Krupka, L. R., & Climo, J. J. Drug exposure and health characteristics of noninstitutionalized retired individuals. Journal of the American Geriatrics Society, 1979. (in press) Whitehead, A. World Medicine, 1975, Sept. 24, 26 (As cited in Atkinson, L, Gibson, I. J. M., & Andrews, J. The difficulties of old people taking drugs. Age and Aging, 1977,6, 144-150).
Miami University, Oxford, Ohio, has been authorized by the Ohio Board of Regents to offer the degree, Master of Gerontological Studies. A multidisciplinary, administration oriented program, the degree is offered through the Department of Sociology and Anthropology. Further information may be obtained from: Dr. Mildred M. Seltzer, Director Graduate Program in Gerontology Scripps Foundation Gerontology Ctr. Miami University Oxford, OH 45056
Dr. Theodore Wagenaar, Director
Graduate Program, Sociology and Anthropology Miami University Oxford, OH 45056
GERONTOLOGICAL SOCIETY ANNOUNCES ITS 1979 RESEARCH FELLOWSHIP PROGRAM The Gerontological Society invites applications from social and biomedical researchers with extensive backgrounds in aging for fellowships in governmental offices on aging and organizations involved in the field of aging. Fellows' interests will be matched'with the agencies' needs. The stipend will be $3,000 for a 3 month full-time or 6 month half-time placement. In addition, travel and per diem expenses are covered for work related activities. Deadline is March 9, 1979. For more information write to: Gerontological Society (West Coast Project Office), 2728 Durant Avenue, Berkeley, California 94704. This program is based on tentative approval by the Administration on Aging, Health, Education and Welfare. Final notification is pending.
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MASTER OF GERONTOLOGICAL STUDIES
