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Geriatr Gerontol Int 2015; 15: 1242–1248

ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH

Use of medications and functional dependence among Chinese older adults in a rural community: A population-based study Yajun Liang,1,2 Kristina Johnell,2 Zhongrui Yan,3 Chuanzhu Cai,4 Hui Jiang,4 Anna-Karin Welmer2,5 and Chengxuan Qiu2 1

School of Public Health, Jining Medical University, 3Department of Neurology, Jining no. 1 People’s Hospital, 4Xing Long Zhuang Coal Mine Hospital, Yankuang Group, Jining, China; 2Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet-Stockholm University and 5Karolinska University Hospital, Stockholm, Sweden

Aim: To investigate the associations between medication use and functional dependence in Chinese older people living in a rural community. Methods: The cross-sectional study included 1538 participants (age ≥60 years, 59.1% women) in the Confucius Hometown Aging Project in Shandong, China. In June 2010 to July 2011, data on demographics, lifestyle factors, health history, basic activities of daily living (ADL), instrumental ADL, and use of medications were collected through interviews and clinical examinations. Functional status was categorized into no dependence, dependence only in instrumental ADL and dependence in basic ADL. Data were analyzed with multinomial logistic models controlling for potential confounders. Results: Dependence in instrumental or basic ADL was significantly associated with use of antihypertensives and hypolipidemic agents, and basic ADL dependence was also associated with use of sedatives or tranquilizers and cardiac glycosides. An increased number of concurrently used medications was significantly associated with an increased likelihood of dependence in basic ADL (P for trend = 0.016). Compared with non-users of any medication, individuals who concurrently used three or more classes of medications had a multi-adjusted odds ratio of 2.91 (95% confidence interval 1.02–8.28) for dependence in basic ADL. Conclusions: Use of antihypertensives, hypolipidemic drugs, cardiac glycosides and sedatives or tranquilizers, especially use of multiple classes of medications, is correlated with functional dependence among older people in rural China. Geriatr Gerontol Int 2015; 15: 1242–1248. Keywords: China, functional dependence, medications, old age, population study.

Introduction Polypharmacy, usually defined as concurrent use of five or more medical drugs, is increasingly common as people age.1,2 Numerous studies, mostly from highincome countries, have shown a rather high prevalence of polypharmacy among older people. For example, in the USA, approximately 50% of older adults are exposed to polypharmacy;3 in Sweden, polypharmacy is present in 39% of community-dwelling persons aged Accepted for publication 30 September 2014. Correspondence: Dr Chengxuan Qiu MD PhD, Aging Research Center, Gävlegatan 16, S-11330 Stockholm, Sweden. Email: [email protected]

1242 |

doi: 10.1111/ggi.12433

≥65 years, and in up to 57% of those aged 75 years or older.1,4 In addition, a Finnish study suggested that the prevalence of polypharmacy increased from 54% in 1998 to 67% in 2003 among people aged ≥75 years.5 Furthermore, in Sweden, the prevalence of polypharmacy increased by approximately 8% during the period of 2005–2008 in the groups of people aged 60–90 years.6 Polypharmacy has been frequently linked to adverse outcomes among older adults, such as drug–drug interactions, adverse drug reactions, hospital admissions, prolonged length of hospital stay and readmission soon after discharge.7–9 Polypharmacy also has been associated with poor cognitive capacity and mortality in very old adults.10,11 However, reports have not been consistent about the potential association between polypharmacy and functional disability. Some population-based © 2015 Japan Geriatrics Society

Medication use and disability in old age

studies have suggested an association of polypharmacy with disabilities in instrumental activities of daily living (IADL; e.g. cooking, cleaning and running errands) among older adults.10,12 However, a study of nursing home residents in Europe suggested an association between excessive polypharmacy (≥10 drugs) and the reduced likelihood of basic activities of daily living (BADL).13 The Chinese population is aging rapidly and thus, polypharmacy in older people has become a common condition.14 However, data are sparse regarding the use of medications among elderly people in China, especially those living in rural areas.15 Furthermore, few studies have assessed the association between the use of medications and functional dependence in Chinese older adults. We hypothesize that the use of certain medications, and especially the use of multiple classes of medications, could be associated with an increased likelihood of functional dependence in older people, independent of health conditions. Therefore, in the current study, we aimed to assess the associations between use of various classes of medications and functional dependence in BADL and IADL, and to explore the association between exposures to multiple classes of medications and functional dependence in Chinese older people living in a rural area, while taking their health conditions into consideration.

Methods Study population The study population included participants of the Confucius Hometown Aging Project (CHAP), as previously reported.16 Briefly, eligible participants of CHAP were all of the residents who were aged 60 years or older and registered in the Xing Long Zhuang community in June 2010. The community is located approximately 20 km from Qufu, the Hometown of Confucius in Shandong, China. The CHAP was carried out by Jining First People’s Hospital and Jining Medical University in Shandong, China, in collaboration with the Aging Research Center at Karolinska Institutet, Stockholm, Sweden. The primary aim of CHAP was to explore the roles of cardiovascular risk factors and atherosclerosis in aging and health (e.g. cognitive and physical dysfunction). Baseline examination was carried out from June 2010 to July 2011, during which extensive data were collected through face-to-face interviews, clinical examinations and laboratory tests. All assessments were carried out by nurses, physicians and laboratory technicians from a local hospital that provides healthcare services to those residents in the local community. Before the examination, the local research staff for CHAP was trained by specialists and senior researchers from the Aging © 2015 Japan Geriatrics Society

Research Center at Karolinska Institutet. Of all eligible subjects (n = 1743), 205 (11.8%) refused to participate, moved out of the area or had missing data on age, leaving 1538 participants for the current analysis.

Ethical consideration The CHAP protocols were approved by the ethics committee at Jining First People’s Hospital of Jining Medical University, Shandong, China. Research within CHAP had been carried out according to the principles expressed in the Declaration of Helsinki. Written informed consent was obtained from participants, or from informants, in the case of cognitively impaired persons. Research within CHAP was carried out in compliance with Human Subjects Research Committee requirements.

Data collection and definitions Data on demographics (e.g. age, sex, and education), lifestyle factors (e.g. smoking and alcohol consumption), a wide range of self-reported medical conditions (27 health conditions, such as hypertension, diabetes, hypercholesterolemia, stroke, heart disease, chronic obstructive pulmonary disease, bone fracture, kidney disease and tumor) and use of medications 2 weeks before the interview were collected after a questionnaire that was developed from the World Health Organization STEPwise approach to Surveillance17 and the Study on Global Ageing and Adult Health.18 Smoking status was dichotomized as never versus ever (current or former) smoking. Alcohol consumption was assessed based on the frequency and amount of alcohol intake in a typical drinking day, and was dichotomized as no versus yes. Global cognitive function was assessed with a Chinese version of the Mini-Mental State Examination (MMSE). Cognitive impairment was defined using the education-specific cut-offs of the MMSE score that has been validated in the Chinese population; that is, MMSE score ≤17 for individuals without formal education, ≤20 for those with 1–6 years of education (primary school) and ≤24 for those with ≥7 years of education (middle school and above).19 Medications were preclassified into 14 classes in the questionnaire, which is largely in accordance with the Anatomic Therapeutic Chemical classification system; that is, antihypertensives, antidiabetic agents, hypolipidemic agents, aspirin phenacetin and caffeine (APC) or aspirin, antibiotics, corticosteroids, antithyroid drugs, sex hormones (e.g., hormone replacement therapy), sedatives or tranquilizers, analgesics other than APC or aspirin, anti-asthmatics, cardiac glycosides, anti-acid drugs, and antidepressants. During the interview, the examining physician classified the medications | 1243

Y Liang et al.

into the corresponding classes according to participants’ report of use of medications. Physical functional status was evaluated by trained physicians using the Katz ADL for BADL and Lawton IADL scales.20 The BADL scale included five basic selfcare activities of bathing, dressing, toileting, transferring and feeding. Participants were asked about whether they were able to carry out those activities. Dependence in BADL was defined as being not able to carry out at least one of the five items in the Katz ADL scale. The Lawton IADL scale included eight items; this is, telephoning, shopping, cooking, housework, washing clothes, transportation, using medications and managing finances. Dependence in IADL was defined as being able to carry out all five items of the Katz ADL scale, but being not able to carry out one or more items of the Lawton IADL scale.

Statistical analysis Characteristics of the study participants by functional dependence were compared using analysis of variance for continuous variables with a normal distribution or a χ2-test for categorical variables. Functional status was categorized, according to a hierarchical indicator that combines IADL and BADL scales, into no functional dependence (reference), dependence only in IADL, and dependence in BADL. Multinomial logistic regression analyses were carried out to estimate the odds ratio and 95% confidence interval of functional dependence asso-

ciated with use of individual classes of medications and multiple medication classes. We report the results from three models; that is, model 1 was controlled for age, sex, education, ever smoking and alcohol consumption, model 2 was additionally controlled for number of diseases, and model 3 was further controlled for cognitive impairment. IBM SPSS Statistics 22 for Windows (IBM SPSS, Chicago, IL, USA) was used for all analyses.

Results The mean age of the participants was 68.6 years (SD 4.9), and 59.1% were women. The overall prevalence of functional dependence was 15.3% for only IADL dependence and 2.3% for any BADL dependence. Compared with people who were functionally independent, participants with functional dependence were older, and the proportion of women was the highest in those with only IADL dependence (P < 0.001). Functionally dependent people, compared with the independent people, were less educated, more likely to smoke and less likely to drink alcohol (P < 0.05). In addition, those with functional dependence had on average more diseases and a lower MMSE score, and had higher prevalence of cognitive impairment and use of multiple classes of medications (P < 0.01; Table 1). Table 2 shows the association between use of various classes of medications and functional dependence. After controlling for demographics and lifestyle factors, use of antihypertensives, hypolipidemic agents and analgesics

Table 1 Characteristics of study participants by functional status Characteristics† No. participants Mean age, years (SD) Women, n (%) Mean education, years (SD) Ever smoking, n (%) Alcohol intake, n (%) Mean no. diseases‡ (SD) Mean MMSE (SD) Cognitive impairment, n (%) No. medication classes§, n (%) 0 1 2 ≥3

Total sample

Functional dependence No Only IADL

Any BADL

P

1538 68.6 (4.9) 909 (59.1) 4.0 (3.4) 465 (30.3) 284 (18.6) 3.9 (2.7) 26.3 (4.4) 92 (6.0)

1266 68.0 (4.7) 718 (56.7) 4.3 (3.4) 396 (31.3) 249 (19.8) 3.8 (2.7) 27.1 (3.6) 41 (3.2)

236 71.2 (5.2) 173 (73.3) 2.1 (2.8) 54 (23.0) 31 (13.2) 4.5 (2.8) 22.8 (5.6) 43 (18.2)

36 70.9 (4.7) 18 (50.0) 3.2 (3.6) 15 (41.7) 4 (11.1) 5.4 (2.8) 21.8 (7.0) 8 (22.2)

Use of medications and functional dependence among Chinese older adults in a rural community: A population-based study.

To investigate the associations between medication use and functional dependence in Chinese older people living in a rural community...
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