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Journal of Community Health Nursing

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Community-Dwelling Elders' Knowledge of Drug-to-Drug Interactions

Vivian C. Whitehead

Online publication date: 29 April 2010

To cite this Article Whitehead, Vivian C.(2010) 'Community-Dwelling Elders' Knowledge of Drug-to-Drug Interactions',
Journal of Community Health Nursing, 27: 2, 61 — 69
To link to this Article: DOI: 10.1080/07370011003704925
URL: http://dx.doi.org/10.1080/07370011003704925

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 Journal of Community Health Nursing, 27:61–69, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0737-0016 print/1532-7655 online
DOI: 10.1080/07370011003704925

Community-Dwelling Elders’ Knowledge

of Drug-to-Drug Interactions

Vivian C. Whitehead
Toronto, Ontario, Canada

The purpose of this quasi-experimental research study was to determine the effectiveness of an educa-
tion session on community-dwelling elders’ knowledge of drug-to-drug interactions. A total of 82
subjects were divided into experimental and control groups. The pretest/posttest questionnaire was
used to measure the difference in their knowledge. Descriptive statistics were used to organize and
summarize the data collected, and independent t- test was utilized in the data analysis. The results in-
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dicated a significant difference (p = .001) between the mean posttest of both groups. The education
session provided to the experimental group was effective in increasing their knowledge level.

Polypharmacy is very common among elders. It is defined as the concurrent use of a combination
of five or more prescribed, over-the-counter (OTC) and herbal medications (Bergorb, 2006). The
incidence of having at least one chronic disease or condition increases substantially with aging.
Each chronic condition generally results in an elder taking one or more prescribed, OTC, or herbal
medications. Drug-to-drug interactions increase with the number of medications taken. The com-
bination effect of these drugs on an aging body may result in adverse drug reactions or events
(ADRs/Es). Consequently, there is an increased rate of hospitalization, significant morbidity,
mortality, and extra health care costs in the older adult (Buajordet, Ebbesen, Erikssen, Brors, &
Hilberg, 2001; Fick et al., 2003; Pirmohamed et al., 2004).
Approximately 95% of Americans older than 65 years live in the community (of which 52%
live alone), and 5% live in nursing homes (Federal Interagency Forum on Aging Related Statistics,
2006). A descriptive, exploratory study in an age-integrated multifamily housing unit by Prosper
(2000) found that 67% of elderly households in multifamily housing units remain living there un-
til death. Prosper’s study also found that multifamily tenants are living in their homes in the com-
munity at nearly the same rate across all geographic areas: 25% of urban, 24% of suburban, and
2% of rural multifamily households were headed by residents 60 years or older. This study was
supported by other literature that reported that elders claimed that living in the community gives
them more self-determination, a sense of greater well-being, more involvement in their communi-
ties, and less expense associated with care (Lam & Bradley, 2007). The health care system also en-
courages elders to remain in community living not only to promote independence and health, but
to stabilize health care expenses (Coleman, Fox-Grage, & Folkemer, 2003).

Address correspondence to Vivian C. Whitehead, RN, MS, 12 Fernback Avenue, Toronto, Ontario M6H 1W1, Canada.
E-mail: Ted_viv@hotmail.com
 62 WHITEHEAD

However, the vast majority of these elders have no greater access to health care information
than the rest of the public. A number of authors have identified elders’ lack of knowledge about
their medications as a significant cause of morbidity and mortality related to adverse drug effects
(Barat, Andreasen, & Damsgaard, 2001; Budnitz et al., 2006; Cham, Hall, Ernst & Weiss, 2002;
Hussey, 1994; Shepler, Gragan, & Pater, 2006). Consequently, these authors suggested the need
for further study of this issue.
These factors clearly support a need for health care providers to focus their attention toward ed-
ucating elders about the negative consequences of polypharmacy, particularly drug-to-drug
interactions.

STATEMENT OF PURPOSE

The purpose of this research study was to examine the effectiveness of an educational session de-
signed to inform community-dwelling elders regarding drug-to-drug interactions by comparing
the pre- and posttest scores of an experimental and control group.
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CONCEPTUAL FRAMEWORK

Orem’s (1995) General Theory of Nursing was utilized in predicting the phenomena inherent to
this study. In this study, the self-care agent was represented by each of the community-dwelling el-
derly subjects and their ability to independently care for themselves. Self-care is their ability to act
on what they believe and understand to do when they are sick. Orem (1995) explained that
self-care deficit (inability to independently provide self-care) arises when the self-care agency
(the individual’s independent ability to perform self-care activities) cannot meet self-care requi-
sites (actions or measures required to independently provide self-care). Self-care deficit, in this
study, was demonstrated by the elders’ lack of knowledge about their medications and
drug-to-drug interactions. The nursing capabilities of continuing to support, motivate, and influ-
ence these elders in self-care behavior, related to their medications, are paramount to their over-all
therapeutic self-care demands (activities required to meet the self-care requisites).

REVIEW OF THE LITERATURE

With the aging process come the biological, physiological, and circadian changes that naturally
occur in people. Researchers have reported that age-related changes are the most significant pre-
disposing factors in many common diseases experienced by the elderly. There are a plethora of ep-
idemiological studies that confirm the incidence of age-related diseases in elderly people that act
as predictors of polypharmacy issues for this group (Fisher, Wei, Solberg, Rush, & Heirich, 2003).
Researchers have identified three consequences of polypharmacy on the health of the elderly.
They are: medication errors, poor or nonadherence to a drug regimen, and ADRs/Es. The latter
consequence results from drug-to-drug interactions and is the most negative outcome of
polypharmacy on the health of the elderly.
There are three major contributing factors influencing polypharmacy in elders (Conry, 2000;
Frazier, 2005; Larsen, 1999; Rollason & Vogt, 2003). First, 75% of the time when an elderly per-
 ELDERS’ DRUG-TO-DRUG INTERACTION KNOWLEDGE 63

son visits a doctor’s office, he or she leaves with a new prescription for medication. The preva-
lence of potentially inappropriate medication prescribing by physicians remains a serious prob-
lem with community-dwelling elders (Fick et al., 2003; Zhan et al., 2001). Second, elders have
increased accessibility to prescription drugs, herbal, and OTC medication (Fialova et al., 2005).
Research has identified that the inappropriate use of OTC and herbal medications by the elderly
concurrently with prescription medications is another contributing factor in drug-to-drug interac-
tions. Third, only a few health care providers ask whether or not their elderly patients are using
other medications. As well, elders often do not readily volunteer this type of information to their
health care providers. Therefore, many health care providers are not fully aware of the drugs being
taken by the elders they are serving (Cham et al., 2002; Lambercht, Hamilton, & Rabinovich,
2000; Lucas, 2006).
The toxic effect of polypharmacy on an elderly patient has extreme medical safety and eco-
nomic consequences (Fick et al., 2003). There are examples in the literature suggesting that el-
ders’ lack of knowledge about their medications was a predominant contributing factor in their
hospitalization due to morbidity caused by ADRs/Es and drug-to-drug interactions. For example,
a study was done to determine the basic knowledge about the use of OTC pain medications among
elder patients in a hospital emergency department (Cham et al., 2002). The elders reported that ob-
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taining OTC pain medications was easier to access and less expensive than seeing a doctor. As a
result, there is a high potential for inappropriate use and side effects, particularly if people are un-
aware of the risks. This study found a significant gap in patient’s knowledge about OTC pain med-
ication. Another example was reported by Meadows (2006). The author reported that it is not un-
usual for elders to arrive in the hospital or clinic and say that “their doctor gave them a white pill
and that’s all they know” (p. 22). The literature strongly emphasizes the importance of health care
providers, such as pharmacists, nurses and physicians, providing elders with information about
their multiple medications and enhance awareness of their negative effects (Meadows 2006).

METHODS

Through quasi-experimental research study, the following research questions were explored:

1. What is the current drug-to-drug interaction knowledge level of a group of elders

based on their response to the pretest questionnaire as measured by the researcher?
2. Was there a significant difference in the drug-to-drug interactions knowledge pretest
and posttest scores of the control group as measured by the researcher?
3. Was there a significant difference in the drug-to-drug interactions knowledge pretest
and posttest scores of the experimental group after receiving an education session, as
measured by the researcher?
4. Was there a significant difference between the drug-to-drug interactions knowledge
posttest scores of the control and experimental groups as measured by the researcher?

Study Setting and Population

The study was conducted in a senior apartment complex located in the downtown area of a major
city in northeastern United States. The apartment building has approximately 125 apartments,
 64 WHITEHEAD

housing 200 elder residents. Seventy percent of the residents were Spanish speaking and 30%
were English speaking.

Data Collection Procedures

The research proposal received approval from the Institutional Review Board of D’Youville Col-
lege. Permission to conduct the study in the seniors’ apartment complex was then obtained. Two
individuals, a graduate of Spanish literature and an ordinary citizen whose first language is Span-
ish, volunteered to assist the nurse researcher in this study and acted as the interpreters. A general
invitation letter written in English and Spanish was sent to each unit, inviting them to attend the
study. Posters in English and Spanish advertising the research study and information that refresh-
ments and snacks would be offered were also posted in common areas of the apartment building.
Fifty percent of the population responded to the invitation to participate in the study.
Eighty-two percent met the inclusion criteria. The inclusion criteria were developed from the re-
search purpose, identified problem, and the literature reviewed. With the aid of the volunteer assis-
tants, the nurse researcher obtained informed consent from the subjects. The participants were
then provided with the pretest, written in English and Spanish, and randomly assigned and pro-
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vided with an alternate numbered colored card that represented their group. Elders that were ex-
cluded from the study were invited to stay and viewed an educational film on the prevention of
falls in the older adult.

INSTRUMENTATION

The pretest and posttest questionnaire was developed based on examples of applied knowledge
from Bloom’s taxonomy of cognitive processing level. The content of the questionnaire was de-
rived from the review of the literature. The pretest and posttest questionnaires were the same, to al-
low for comparison in determining the differences in the scores. The questionnaire’s level of mea-
surement is ordinal scale. Each question was answerable by choosing either strongly agree, agree,
disagree, or strongly disagree on a four-point Likert scale. Each response category was assigned a
value, with a value of 1 given to the most positive response and a value of 4 to the most negative re-
sponse. The use of the four-point Likert scale made coding of the data easier. The readability of
test questions was assessed by Simple Measure of Gobbledygook and its readability level was at
grade five (Mclaughlin, 1969). Two health care professionals reviewed the questionnaire for con-
tent validity. They both agreed that 9 out of the 10 questions in the questionnaire reflect the issue
of potential drug-to-drug interactions. The one question in dispute was reworded to reflect the
suggestions of the two health care professionals.

TREATMENT OF DATA

The volunteer assistants and the nurse researcher independently coded the answered question-
naires. The research data were analyzed using the Statistical Package for the Social Sciences soft-
ware. Descriptive statistics was utilized to organize the information and summarize the data col-
lected. A t-test statistic was used because there were paired measurements of data. An alpha level
of < .05 was considered to be significant for all statistical analysis.
 ELDERS’ DRUG-TO-DRUG INTERACTION KNOWLEDGE 65

RESULTS

On the first day of the study, the volunteer assistants and the nurse researcher considered the sub-
jects’ request to increase the duration of time to answer the questionnaire from the original plan of
30 mins, to 45 min to an hour due to poor vision and hearing deficits. As the subjects handed in
their pretest, they were given the dates of when to return for their respective sessions. A majority
of the subjects strongly expressed their uncertainty about being able to attend on the dates se-
lected. They acknowledged that they were aware of the duration of the study, as they had all re-
ceived and read the letter of invitation. Their interest in the research topic was sufficiently high
that they did not want to miss the initial session and hoped that there could be some flexibility in
the schedule to meet their needs.
The nurse researcher decided to alter the original schedule, realizing the high probability of
losing 90% of the subjects if no revisions were made. Subsequently, the original plan of adminis-
tration of the education session and the posttest to the second day and third day, respectively, fol-
lowing the pretest to the experimental group, and posttest to the control group on the seventh day
was modified. The subjects in the experimental group agreed to come back on the second day fol-
lowing the pretest for the education session and posttest. The control group agreed to come back
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on the third day for the posttest. This change in schedule influenced the number of the conve-
nience sample to increase from the original target number of n = 72 to n = 85.

Experimental Group

All the 41 participants in the experimental group returned on the second day for education session
and posttest. A total of 12 participants spoke Spanish and answered the questionnaire in Spanish,
and 29 participants spoke English and answered the questionnaire in English.

Control Group

Only 41 out of 44 subjects in the control group came back on the third day and completed the
posttest. As a result the size of the overall convenience sample was reduced to n = 82. A total of 18
participants spoke Spanish and answered the questionnaire in Spanish and 23 participants spoke
English and answered the questionnaire in English.

Analysis of Demographics

The oldest subject was an 88-year-old woman. The majority of the participants were women and
married. The overall number of Spanish-speaking participants in this study was 30 (21%). The
overall number of English speaking participants in this study was 52 (86%).

Spanish- and English-Speaking Subject Posttest Results

The difference in the mean posttest score between the Spanish-speaking participants in the control
group and the experimental group was 11.5556. The difference in the mean posttest score between
the English-speaking participants in the control group and the experimental group was 7.4992.
The difference in the mean posttest score between the two groups was significant at p = .002. See
 66 WHITEHEAD

Table 3 for the summary of the difference in the mean posttest result of Spanish and English
speaking subjects in both groups.

Research Questions

Question number 1. The mean pretest score of the control group was 20.1707. The mean
pretest score of the experimental group was 19.4874. A paired t-test result of p value of 0.6 indi-
cated that there was no significant difference between the groups’ pretest scores. The score deter-
mined their baseline drug-to-drug interactions knowledge level and denotes a consistent lack of
knowledge in both groups.
Question number 2. The mean pretest score of 20.1707 and mean posttest score of 20.1220
of the subjects in the control group who did not receive the education session showed no signifi-
cant difference. A paired t-test result was p value of 0.8.
Question number 3. The mean pretest score (19.4872) and mean posttest score (29.5128)
of the experimental group indicated a significant statistical difference. A paired t-test showed a p
value of .001. This group received the education session. This indicated that the education session
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resulted in an improvement in the subjects’ knowledge of drug-to-drug interactions. See Table 1

for the summary of the difference between the mean pretest and posttest scores of control and ex-
perimental groups.
Question number 4. The mean posttest score (20.1220) of the control group and the mean
posttest score (29.4634) of the experimental group showed a significant statistical difference. The
result was p value of .001 and a 95% confidence interval of difference –10.75770, –7.92522.
This indicated that the education session designed to inform the community-dwelling elders re-
garding drug-to-drug interactions was very effective in improving their knowledge. See Table 2
for the summary of the difference between the mean posttest scores of control and experimental
groups.

CONCLUSIONS

The pretest results of the experimental and control group and the posttest results of the control
group indicated lack of knowledge of drug-to-drug interactions, which meant that they were expe-
riencing self-care deficit. The mean posttest score of the subjects in the experimental group who
demonstrated self-care deficit and received the education session, showed that they were able to
gain knowledge about the potential drug-to-drug interactions. The nurse researcher’s action en-
hanced the elders’ self-care by continuing to promote and maintain independence and overall ther-
apeutic self-care demand.
The plethora of literature that reported (a) drug-to-drug interactions to be the most noteworthy
consequences of polypharmacy on the health of the elderly; (b) the elders’ lack of knowledge; (c)
their lack of knowledge as a significant cause of extra health care cost due to increased rate of hos-
pitalization, morbidity, and mortality; and (d) the need for health care professionals to be available
to disseminate health care information and resources in the community were confirmed in this
study’s results. It was evident from the result of this study that community-dwelling elders require
 ELDERS’ DRUG-TO-DRUG INTERACTION KNOWLEDGE 67

TABLE 1
Summary of the Difference Between the Mean Pretest and Posttest Scores
of Control and Experimental Groups

Pretest Score Posttest Score t-Test

Control group (n = 41) 20.1707 20.1220 0.8

Experimental group (n = 41) 19.4874 29.5128 .001

TABLE 2
Summary of the Difference Between the Mean Posttest
Scores of Control and Experimental Groups

Posttest

Control Group Experimental Group

(n = 41) (n = 41) t-Test
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20.1220 29.4634 0.000

TABLE 3
Summary of the Difference in Mean Posttest Result of Spanish
and English Speaking Subject in Both Groups

Experimental Difference in Mean

Control Group Group Posttest Score t-Test

Spanish (n = 18) Spanish (n = 12) 11.5556

English (n = 23) English (n = 29) 7.4992
.002

assistance from health care professionals in learning and better understanding their medications
and the possibility of drug-to-drug interactions.
Barkay and Tabak (2002) reported that there is a correlation between the degree of autonomy and
the degree of participation in different activities by elders. The nurse researcher and the volunteer as-
sistants’ flexibility in our schedule, adhering to the elders’ request regarding schedule and/or dura-
tion of time to answer the questionnaire, was an important factor in their participation in this study.
The tool that was developed and the content of the education material that was prepared and
presented in the language and terminology that the elders are familiar with, clearly contributed to
their increased knowledge. The use of images (visuals), body language (gesturing), and the tone of
voice appropriate to the hearing ability of the majority of the elders, also assisted considerably in
their understanding of the words used in the presentation.
 68 WHITEHEAD

RECOMMENDATIONS

Incidents of elders selling and/or sharing their medications were reported by the social worker of
the study setting. The prevalence of these practices appeared undeniable as the researcher and vol-
unteer assistants, during the study, witnessed these incidents. Future studies need to be conducted
to determine what precipitating factors influence elders, from various cultural and ethnic back-
grounds, to sell and commonly share medications amongst themselves.
In spite of the fact that the documents used in this study were translated into the Spanish lan-
guage and the volunteer assistants and the nurse researcher verbally invited every Spanish-speak-
ing elder that we had occasion to meet, only 36% of the 70% of the total Spanish speaking popula-
tion responded to the study, and only 21% joined the study. An appropriate next step in future
studies would be to examine what factors hinder the majority of this population to join activities
that could improve their health.
There is a need to replicate this study in a qualitative method or focus groups to draw upon the
Hispanic community elders’ beliefs, views, experiences and reactions regarding participation in a
health promotion program. The findings will assist in developing strategies to encourage and em-
power them to increase their participation.
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The volunteer assistant and the nurse researcher discovered that the City’s Public Health De-
partment dispatches a physician and a nurse, once a month for 4 hr, to provide basic nursing ser-
vices at the Senior Building (e.g., blood pressure, blood sugars, weight, dentition checks, and mo-
bility assistive device requirement). However, only a few residents take advantage of this service.
Therefore, it is the nurse researcher’s recommendation that the public health care providers in-
crease their visits, maintain consistency in their visits, and expand their services to education of
these elders in health promotion particularly about polypharmacy and its effects.
Finally, the significant difference in the mean posttest scores of the Spanish-speaking subjects
in the control and experimental group indicated that the Spanish speaking subjects require assis-
tance in learning about health maintenance or improvement. The nurse researcher strongly believe
that Spanish-speaking elders will greatly benefit from health literacy programs such as group or/
and one-to-one education sessions that are presented in Spanish.

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