Biomedicine & Aging Pathology 1 (2011) 179–184

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Original article

Drug-related problems in institutionalized elderly in Brasilia, Brazil

Mirna Poliana Furtado de Oliveira 1,∗ , Maria Rita Carvalho Garbi Novaes 2
Faculty of Health Sciences, University of Brasilia, University Campus Darcy Ribeiro, Asa Norte, 70910-900 Brasilia, Distrito Federal, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Before the worldı̌s elderly population increased, there is growing concern about the use of medicines by
Received 12 September 2011 the elders. The continuous use of medicines and polypharmacy exposes such patients to the risk of drug-
Accepted 23 September 2011 related problems (DRP) and the negative outcomes associated with medication (NOM). This study aims
to identify the PRM prevailing in elderly of long-term institutions in Brasilia and correlates it with the
Keywords: socioeconomic and pharmacotherapeutics profile. The research was conducted with 154 elderly residents
Drug-related problems of five long-term institutions of Brasilia. Data were collected between January to December 2007 through
Elderly
a questionnaire adapted from the Dader method, Pharmacotherapeutic Follow-up. Most of the sample
Homes for the aged
Health of institutionalized elderly
consisted of men with a mean age of 74.6 years, with preserved cognitive status, low educational level and
Drug therapy monthly income. The group used an average of four medicines and were cardiovascular and psychotropic
Drug utilization agents used most frequently. Three hundred and eighty-one DRP were identified in the group and an
average of 2.5 DRP for each elderly. Access difficulty, adherence difficulty, lack of medical prescription
knowledge, presence of drugs interactions and self-medication practice were the DRP most frequent in
the group. Results suggest that the socioeconomic and morbidityı̌s profile and the medicines use makes
the group more vulnerable to the emergence of DRP and NOM. The monitoring of medicines use and the
DRP seems an effective way to decrease the number of these problems and ensure safety and efficacy of
pharmacotherapy as well as improving quality of life of the elderly.
© 2011 Elsevier Masson SAS. All rights reserved.

1. Introduction Problems such as errors during the process of prescrib-

Drug-related problems (DRM) are defined as problems related
to using or not using medication [1]. Such concept was used for
the first time by Strand et al. in 1990 [2], but the term was only
incorporated into clinical practice in 1998, with the First Granada
Consensus (Spain). At the time, six DRMs categories (1 to 6) were
created based on medication need, efficacy and safety. That clas-
sification has been improved throughout the years and in the
Third Granada Consensus, which took place in 2007, DRMs were
related to the emergence of NOM. NOMs are defined as patients’
health-related problems, which are not consistent with the phar-
macotherapy objectives and are related to the use or to a problem
with the medication use. They are classified according to the basic
characteristics of all medication to be used: need, efficacy and safety
[1]. Therefore, DRMs are part of the therapeutic process and emerge
before NOMs, which are possible consequences.
∗ Corresponding author. Tel.: +556132977030.
E-mail addresses: mirnapoliana@hotmail.com (M.P. Furtado de Oliveira),
ritanovaes@ig.com.br (M.R. Carvalho Garbi Novaes).
1
Clinic and Hospital Pharmacist. Master in Health Sciences. Teacher and
researcher in the area of Clinic and Hospital Pharmacy.
2
Hospital Pharmacist. Doctor in Health Sciences. Teacher and researcher in the
area of Clinic and Hospital Pharmacy and Human Nutrition.
ing, administering, dispensing, and storing medication, as well
as duplicity and inadequate or contraindicated drugs use, no
adherence to pharmacotherapy might cause severe outcomes to
patients’ health, one NOM, jeopardizing their quality of life besides
increasing their morbimortality [3,4].
The risk of NOMs and DRMs has been frequent in modern
medicine due to the fact that health assistance is centralized in
medication use. Patients making use of polypharmacy have their
risks increased [3–8]. Studies show a positive relation between
the amount of medication consumed and DRMs’ susceptibility and
development, such as increase in developing adverse reactions
[3,8,9].
In the elderly population, due to the increasing numbers of
chronic diseases, polypharmacy and NOMs’ emergence is almost
inevitable [10,11], exposing those patients to negative health
results as well as increasing death risks [3] also, increasing health
care costs [11]. That situation gets worse with aging and worse
clinical situations.
A study done by Correr et al. among institutionalized Brazilian
elderly showed that inadequate medication use in that age bracket,
medication duplicity, overdose and presence of medication inter-
action are the most frequent NOMs in that population and the
study correlated pharmacotherapy inefficacy, giving evidence of
the need of pharmacotherapeutic follow-up [10]. Shmader et al.
showed similar results in 834 outpatient elderly [12]. A study done

2210-5220/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.biomag.2011.09.007
180 M.P. Furtado de Oliveira, M.R. Carvalho Garbi Novaes / Biomedicine & Aging Pathology 1 (2011) 179–184

with elderly outpatients in Minas Gerais (Brazil) demonstrated
that the most frequent DRMs were related to medication’s effec-
tiveness and need and the authors highlighted the importance of
pharmacotherapy follow-up to solve such problems [13].
Many studies have shown the benefits of pharmacotherapeu-
tic follow-up in different population groups aiming to identify
and prevent DRMs and their consequences [3,4,13–16]. Besides
that, identifying and solving those problems encourage efficacy
improvement as well as improvement to the therapeutic scheme
adherence, and therefore, improvement to quality of life of medi-
cation users [17,18]. In that perspective, this paper aims to identify
problems related to medication (DRM) used in elderly in long-
term institutions in Brasilia and relate their starting point and
worsening to the socioeconomic and pharmacotherapeutic profile
in order to propose strategies for improving quality of the drug
therapy.
using necessary medication or using unnecessary or inadequate
medication).
Data was collected and analysed in Statistical Package for Social
Sciences (SPSS) 15.0 version. Variables were analysed using Chi-
square and student’s t tests taking into consideration significant
results to P ≤ 0.05. Associations between variables were evaluated
through nested log-linear model sequences: of homogenous asso-
ciation, of conditional independency and joint independency. In
order to test the effect on the lack of associations between the vari-
ables for the sequence models, the Chi-square conditional of the
verisimilitude ratio test was used with 5% significance level.
The study protocol was approved by the Research Ethics
Committee of the Federal District Health Secretary (Protocol
125/2005). Volunteer participants have signed the Clearance and
Free Agreement Term. Information secrecy and confidentiality
have been maintained.

3. Results
2. Methods
One hundred and fifty-four elderly were part of the sample,
This study is epidemiological, transversal, descriptive and 51.3% male, 53.9% with discernment, at an average age of 74.6 years
exploratory, done with 154 elderly residing in five long-term old and average time in the institution of five years. Among elderly
institutions in Brasilia. Data was collected between January and without discernment (46.1%), women accounted for a higher rate
December of 2007. The sample was conveniently chosen and (P = 0.0164).
included men and women, 60-years-old or over who were taking As to education level, 46.6% were either not educated or
at least one type of continuous medication. The selection of the attended school for less than a year and 43.9% of the elderly
institutions was done taking into consideration the list from the attended elementary school for up to seven years. Most part of
Federal District Council for Elderly Rights, and invitation was the group received an average of less than two minimum monthly
sent to those which were active. The study took place in those wages (Table 1).
institutions whose directors accepted to participate and signed the Most of the elderly with discernment were independent when
Agreement Term. All participating institutions are philanthropic, performing daily activities such as taking a shower, dressing them-
non-profitable institutions, which have a total of 300 elders. The selves and walking around the institution (83.2%) as opposed to
participating elderly were classified by the institutions’ profes- those without discernment (80.3%) who depended on their care-
sionals in two groups: according to cognitive functioning, with or takers to perform such activities (P < 0.0001). Among the elderly
without discernment. Those able to provide and receive correct with discernment (n = 44), 92.8% took their medication by them-
and coherent information were classified as elderly with discen- selves while 56.3% of those without discernment depended on their
ment. Data was collected through a questionnaire adapted from caretakers to do so.
the Dader Method, 2002 [19] and answered by those classified Among the elderly group, 23.8% had smoked for over 10 years.
as elderly with discernment during an individual interview, com- Most of them were men with discernment (P = 0.0006). Men
plemented with information from their medical prescriptions and were also the most involved with alcoholism (62.5%) (P = 0.0001).
patient charts. Information from the elderly without discernment Regarding physical exercises, most of the elderly were considered
was provided by their caretakers and complemented by analysis sedentary (79.5%) and there was not significant difference between
of their medical prescriptions and patient charts. men and women (P = 0.2111).
The Third Granada Consensus’concept and classification were The following are the main health problems found in the group:
taken into consideration when analysing data related to DRMs systemic arterial hypertension (76.6%), mood or psychiatric disor-
and NOMs [1]. Data was collected from medical prescriptions ders (48.7%), articulatory problems (16.3%), diabetes mellitus type
and patient charts, and complemented with data collected from
interviews with the elderly and their caretakers. Classification for
inappopriate or inadequate medication was done according to the Table 1
Social economic characteristic of institutionalized elderly in Brasilia (n = 154).
Beers’ criteria [20] through analysis of medical prescriptions.
Access to medication was evaluated through analysis of avai- Variables n % Pa
lability of the prescribed medication in the long-term institutions Marital status 0.1140
and in the Federal District’s health centers located near the insti- Single 70 46.7
tutions considering the Federal District’s Essential Medication List Widow/Widower 48 32.0
Separated/Divorced 32 21.3
and the Ministry of Health’s policy on Basic Attention to Health
which focuses on free distribution of medication considered Education Level 0.3254
essential to the Single Health System. None 69 46.6
1 to 7 years 65 43.9
The following are analysed variables: sex, age, education level,
8 to 10 years 11 7.5
monthly salary, time in the institution, marital status, inde- Over 10 years 3 2.0
pendency when performing daily activities, prevailing diseases,
Monthly incomeb 0.2325
smoking, alcoholism and physical activities, medication in use, <2 112 72.7
pharmacotherapy adherence, access to medication, existing DRMs 2–3 33 21.4
(elderly knowledge of prescribed medication, self-medication prac- >4 9 5.9
tice, presence of drug interaction, factors that interfere with a
P means Pearson coefficient according to the Chi-square.
pharmacotherapy adherence) and negative outcomes associated b
Monthly income in Brazilian reais during the data collection period = R$ 415.00
with medication (NOMs) as to the need of pharmacotherapy (not or US$ 233.
 M.P. Furtado de Oliveira, M.R. Carvalho Garbi Novaes / Biomedicine & Aging Pathology 1 (2011) 179–184 181

Table 2
Relation between the number of used medications and age in men and women over 60 in long-term institutions in Brasilia.

Women Men

Age Number of medications Age Number of medications

1 to 3 4 to 6 ≥7 Total 1 to 3 4 to 6 ≥7 Total

60–64 8 5 0 13 60–64 9 3 1 13
65–69 4 4 2 10 65–69 6 9 4 19
70–74 1 4 3 8 70–74 8 2 4 14
≥ 75 12 16 5 33 ≥ 75 12 15 11 38

Total 25 29 10 Total 35 29 20

II (16.2%), respiratory problems (13%), cardiac insufficiency (12.3%) medication due to gastrointestinal discomfort (18.9%), difficulty to
and gastrointestinal problems (11.7%). accept the medication due to deglutition problems (10.1%), diffi-
This study has shown a differenciated medication consump- culty to accept medication due to its bad taste or bad smell and
tion according to the person’s cognitive function and sex. In the uncomfortable way of administering the medicine (2.3%).
group, each elderly with discernment (n = 83) used an average of Self-medication was assessed from the patients’ own self-
five medications while those without discernment (n = 71) used reports. Among the elderly, 20.2% self-medicated themselves and
four medications (P = 0.0080). Men consumed four medications and those with discernment were at a higher proportion.
women, nine medications (P < 0.0001). Medication consumption The analysis of patient charts and the elderly’s and caretakers’
was higher in women with discernment. Statystic analysis showed reports made the identification of 462 NOMs and an average of 3.0
a positive association between the number of medication used and NOMs by each elder. The use of inappropriate medication and the
age (P = 0.045) and the older elders consumed a higher number of lack of necessary medication use were the most common.
medications (Table 2). Among the NOMs, 54.5% of the elderly (n = 84) presented health
Most medications used by the group were antihypertensives, problems due to use of medication considered unnecessary or inap-
antiarrhythmics, hypnotics, sedatives and ansiolitics, antiulcers propriate and 53.3% in the group (n = 82) presented at least one
and antidepressives. The main medications were angiotensin- health problem related to not using medication considered neces-
converting enzyme inhibitors (captopril – 54.6%), thiazid diuretics sary (Table 4).
(hydrochlorothiazide and indapamide – 39.6%), acetylsalicylic acid Refer to Table 5 for the main medication considered inappo-
(29.3%), diazepam (24,0%), nifedipin (15.0%), phenothiazine priate or unnecessary in the evaluated group.
antipsychotics (chlorpomazine and thioridazine – 15%), ranithidin Of the prescriptions, 63.6% (n = 98) presented at least one
(13.0%), beta-blockers (atenolol and propranolol – 12.4%) and clinically significant medication interaction. The main interactions
amitriptyline (12.4%). involved angiotensin-converting enzyme inhibitors (41.2%), thiazid
It was verified that each elder used an average of one psy- diuretics (26.1%), acetylsalicylic acid (23.7%), carbamazepine
chopharmaco and the most consumed were antipsychotics (29.9%), (10.9%), digoxin (10.5%), phenitoyn (7.8%), haloperidol (7.4%),
hypnotics, sedatives and ansiolitics (24%), antidepressives (22.1%) sulphonylureas (6.6%), benzodiazepenes and beta-blockers (5.4%).
andanticonvulsants (14.3%). Only antipsychotics were more con- Regarding the elderly level of information about the used
sumed by women (P = 0.041) and there was no significant difference medication at the time of the study, it was observed that none
between sexes as for the other psychopharmaco classes. of the elderly considered without discernment (n = 71) and 53%
Three hundred and eighty-one drug-related problems were (n = 44) of those with discernment remembered the name, indi-
identified in the group and an average of 2.5 DRM for each elderly. cation or dosage on the medical prescription, totalling 74.7%.
The DRM were the most frequent in the group: access diffi-
culty, adherence difficulty, lack of medical prescription knowledge,
presence of medication interaction and self-medication practice Table 4
Self-reported and/or diagnosed main negative outcomes with medication (NOM) in
(Table 3).
institutionalized elderly in Brasilia.
Adherence was evaluated from information provided by the
health team regarding easiness or difficulty that the elderly pre- Health problems due to not using medications (n = 82)
sented to use the prescribed medication besides the evaluation NOM n %
of medication availability. Among the elderly, 28.6% with discern-
Gastrointestinal discomfort 45 54.9
ment and 29.3% of those without discernment (n = 45) presented Back pain 32 39.0
some type of problem, which jeopardized to the pharmacotherapy Pain in general 28 34.1
adherence. The following were the main identified problems: dif- Dizziness 19 23.2
ficulty accessing the prescribed medication (61.7%), refusal to take Arthritis 15 18.3
Total 139
medication due to depressive states (48.3%), difficulty to accept
Health problems due to using unnecessary or inappopriate medication (n = 84)
Table 3 Sedation, sleepiness 56 66.7
Prevalence of drug-related problems in elderly in five long-term institutions in Muscarinic effects: dry mouth, blurred vision, 55 65.5
Brasilia (n = 154). urinary retention
Dementia, memory loss 53 63.1
Drug-related problems n %
Psychomotor disturbances 53 63.1
Access difficulty 95 61.7 Glycemic level alterations 46 54.8
Adherence difficulty 45 29.2 Dizziness 25 29.8
Self-medication 28 18.2 Orthostatic hypotension 21 25.0
Presence of medication interaction 98 63.6 Depression 14 16.7
Lack of pharmacotherapy knowledge 115 74.7 Total 323

Total 381 General Total 462

182 M.P. Furtado de Oliveira, M.R. Carvalho Garbi Novaes / Biomedicine & Aging Pathology 1 (2011) 179–184
Table 5
Main inappopriate or unnecessary medication used by institutionalized elderly in
Brasilia, according to Beers’ criteria (Beers 1997) (n = 84).
Drug or therapy class n %
Neuroleptics 46 54.8
Benzodiazepines 37 44.0
Tricyclic antidepressives 19 22.6
Beta-blockers 19 22.6
Nonsteroid Anti-Inflammatory 12 14.3
Methyldopa 8 9.5
Phenytoin 5 6.0
Corticoids 5 6.0
Women accounted for the higher percentage with partial or total
knowledge about the pharmacotherapy (n = 39). Among the men,
40.0% were not able to give any information about the medication
used and that percentage was lower in women (15.2%).
Regarding access to medication, 96.5% of them were available
at the time of the study in the institutions and 80% were available
at the Basic Attention to Health Chain, which supplied the assessed
institutions.
Medication which was not available that way accounted for
12.3% of the monthly income of each elderly (P = 0.0025).
4. Discussion and conclusion
Studies have shown the importance of identifying and mon-
itoring DRMs and NOMs as an effective way to reduce the
morbimortality related to medication and, therefore, costs with
health assistance [3,4,10].
DRMs and NOMs determining factors might be related to the
patient, the therapeutic scheme, the prescriber, the dispenser and
even the health system [1].
Langford et al. proposed that besides polypharmacy, the number
of daily doses, use of medication of low therapeutic index, use of
medication for many health problems and medical therapy changes
are risk factors for the development of DRMs [21].
Acurcio et al. even propose that factors such as complexity of
therapeutic schemes, with various drugs and posologic schemes,
have great influence on the pharmacotherapy adherence and on
the appearance of NOMs [22]. Other studies have showed that such
situation gets worse by the socioeconomic level and by the patients’
health perception and conditions because access and comprehen-
sion of the therapeutic scheme reduce the risk of not following it
[6,23]. Besides that, the high level of medication use increases the
emergence of such problems [3–8].
In the elderly population, all those factors are present in sig-
nificant rates, with some worsening factors such as alterations
in the physiological, biochemical, pharmacokinetics and pharma-
codynamics processes due to the natural process of aging. Such
alterations promote changes in the therapeutic response to medi-
cation, which might reduce efficacy and potentialize adverse effects
[11].
The results of this study suggest that the number of prevailing
diseases added to the decrease of functional capacity, sedentarism,
bad life habits (tabagism and alcoholism), use of multiple med-
ications, low education level and to low monthly income might
be important factors to the emergence of DRMs and NOMs in the
evaluated group, such factors have already been pointed out in
other studies [5,8–10,13]. Socioeconomic and health conditions
as well as the pharmacotherapeutic profile of the studied group
reflect the reality of the elderly population shown in various studies
[3,5,7–10,13,22,24–32].
Morbidity profile of the sample corroborates data from other
studies, which pointed out cardiovascular, neurological, psychi-
atric and articulary diseases as the most prevailing in elder [13,28].
The epidemiologic profile justifies the pattern and the average
of five medications per elderly, also shown by others studies
[5,7,13,23,29–32]. Loyola Filho showed that drugs utilization is pos-
itively related to the female sex, to aging and to a worse health
status [33], which corroborates the findings of this study, Coelho
Filho showed a similar consumption pattern in elderly residing in
Fortaleza, Ceara, Brazil [30].
It is known that the drugs utilization profile is directly influ-
enced by the socioeconomic level and by the elderly’s functional
capacity. According to Nascimento et al., the patient’s education
level negatively affects the use of medication. The less educated
consume more drugs [13]. However, Loyola Filho showed that in
elderly residents of Bambui, Minas Gerais, Brazil, the medication
use is lower among elderly with worse socioeconomic situation
[33]. Coelho Filho et al. also found similar data in elderly in the
Northeast of Brazil [30].
Although Nogueira et al. have shown that the elderly’s func-
tional capacity presents a positive relation to the number of
medications used [34], this study’s results pointed out a higher
level of medication consumption by the elderly considered with
discernment, that is, with preserved functional capacity. That find-
ing might be due to the higher capacity that these elderly possess
to express their problems and, therefore, to be medicated.
Therefore, loss of functional capacity, low socioeconomic level,
high prevalence of diseases, and, therefore, higher use of medica-
tions, make this group vulnerable to emergence of DRMs and their
consequences [8,11]. The number and types of prevailing DRMs in
the studied group have already been shown by Nascimento et al.
[13]. According to the authors, lack of use and/or prescription of
unnecessary medicines, use of sub or superdosages, presence of
medication interaction and difficulty with accessing the medicines
are the main DRMs found in outcomes patients monitored by the
School Pharmacy from a University Hospital in Belo Horizonte,
Minas Gerais, Brazil [13].
Adherence to pharmacotherapy accounts for a multifactorial
variable dependent on the number of drugs used, the patient’s
health status, access, family income, level of education, presence
and intensity of adverse reactions, patient’s psychological and
psychiatric status and the emergence of benefic results with the
treatment, among other factors [35].
Studies have shown differents prevalences of adherence in the
elder depending mainly on the concept and on the used assess-
ment methods. Adherence is higher in institutionalized elderly
than in other groups of elderly due to the hospitalization aspect,
constant professional care and the fact that administering medi-
cation is the caretakers’ and not the elderly‘s responsibility, which
eliminates factors such as forgetfulness, lack of information of the
treatment and the option to stop using medication, to alter the
dosage or schedule on their own, common factors in other groups of
elderly. Cintra et al. showed that there is a strong relation between
living alone and no adherence to the therapeutic scheme [29].
According to the authors, elderly who live by themselves present
three times higher chances of no adherence to pharmacotherapy.
The presence of a family member or a caretaker facilitates following
the treatment [29].
Besides that, in the long-term institutions, it is the institution’s
and not the elderly’s responsibility to guarantee access to medica-
tion, which also facilitates adherence to pharmacotherapy in the
group as costs and access problems are minimized, corroborating
Cintra‘s et al. findings in elderly from Campinas, Sao Paulo, Brazil
[29].
Results suggest that even small difficulties with access, high
number of medications prescribed, use of inappropriate medicines
for the age increasing adverse effects and common restrictions for
the age such as motor, visual, listening and deglutition difficulty
are factors which jeopardize adherence to the pharmacotherapy in
 M.P. Furtado de Oliveira, M.R. Carvalho Garbi Novaes / Biomedicine & Aging Pathology 1 (2011) 179–184
the group. Studies have shown positive relation between adverse
effects, no adherence the treatment [29] and the number of medi-
cations and not following the therapeautic scheme [29,36]. Rocha
et al. showed, when studying elderly in Porto Alegre (Brazil), that
the frequency of adherence was higher among patients who used
fewer medications [36].
Besides that, the following factors in studied group jeopardize
adherence to the treatment: high level of psychiatric disorders
reducing the elderly’s functional capacity, dismotivation, depres-
sive state of some and low education level. Such factors might
justify the lack of knowledge of some elderly considered with
discernment in regards to medication being used at the time of
the study. According to Nascimento et al., education level nega-
tively affects comprehension and formulation of concepts provided
during prescription and when administering medication [13]. It
is known that the elderly’s understanding and compliance to
the pharmacotherapy represent important factors to guarantee
adherence [13,35]. Despite the positive relation between these two
variables, in this study, the elderly’s level of information did not
present a significant relation with the education data for both sexes,
even when women were able to give more information on the
medication than men.
In this study, the use of inappopriate medicines to the
elderly population might also represent a complicated factor for
adherence, besides being considered a potential DRM, corroborat-
ing to findings from studies by Correr et al. and by Nascimento
et al. [10,13]. According to Hayers et al., the use of such medica-
tions increases the emergence of adverse reactions and of other
DRMs, increasing health costs [11].
The concepts of inappopriate or inadequate medicines were
defined by Beers et al. as those which present lack of therapeutic
efficacy or an increasing risk of adverse effects that surpasses their
benefits when compared to other medicines [20]. They should be
avoided [37]. According to Nóbrega and Karnikowski, the use of
such medicines is proportional to age. Older age groups tend to use
higher quantities [37].
The use of those medicines by the studied group might jus-
tify the high number of health problems and, therefore, the higher
level of drugs consumption. Correr et al. uses the term “iatrogenic
cascade” to describe the situation of successive and increasing use
of drugs to treat health problems caused by the use of other drugs
[10]. According to Nóbrega and Karnikowski and Chaimowicz et
al., the use of benzodiazepenes, neuroleptics, beta-blockers and
metyldopa, considered inappropriate medicines according to Beers’
criteria, might potentialize fall risk in elderly due mainly to the
fact that they cause sedation and orthostatic hypotension [37,38].
Correr et al. concluded that the use of inappropriate medicines
potentialize DRMs’ risks related to safety [10], corroborating this
study’s findings, in which the prevalence of health problems and
complaints were very high (54.6%).
Another finding in this study is that non-treated health prob-
lems migh be a result of adverse effects from medication used in
the group and/or medication interactions found. Besides that, the
presence of such problems might justify self-medication among
the elderly even if access to medication is extremely controlled
by the institutions. Besides, in the studied population, educa-
tion level and socioeconomic conditions limit the practice even
more.
Many factors determine self-medication such as simple symp-
toms, difficulty to acces health services, medicines and professional
care, socioeconomic level, health status and the patient’s age,
besides the increasing availability in the pharmaceutical market
[26,27,39]. A study done by Bortolon et al. with elderly women
residing in Brasilia (Brazil) showed 30.8% self-medication and there
was no significant relation between this practice and low educa-
tion level or family income [26]. Cascaes et al. showed a higher
183
percentage in elderly in the south of Brazil (80.5%) [27]. Arrais
et al. also showed that the profile for self-medication is different
between the sexes [39]. Women aged 15 to 45 tend to be the biggest
consumers of medication without medical prescription while that
practice were more common in men aged 56 to 65 [39]. On the other
hand, Cascaes et al. did not show a significant relation between the
practice of self-medication and sex, age, education, marital status,
having a health plan or using various medications [27].
Risks related to self-medication in the studied group must be
considered even if its prevalence is lower in other studies done
in Brazil [26,27,39]. Consequences related to self-medication are
very different and some possible ones are increasing adverse reac-
tions and emergence of drugs interactions which might jeopardize
the pharmacotherapy efficacy and safety besides representing an
important DRM [10,26]. In the elderly, that possibility increases
because of body type and physiological and biochemical variations
which follow aging.
Polypharmacy and lack pharmacotherapeutic follow-up, com-
mon situations in the studied group, might also corroborate the
findings of this study that 63.6% of the medical prescriptions pre-
sented at least one drug interaction of clinical importance. Similar
occurrence and profile were found by Bleich et al. in adults and
elderly in Cascavel, south of Brazil (66.6%) [25] and by Codagnone
Neto et al. in another city in the south of Brazil [40]. However,
Cruciol-Souza and Thomson showed important lower percentages
(49.7%) in hospitalized patients in a university hospital in the south
of Brazil [41]. According to researchers, most patients presented
drugs interactions considered moderate to severe which could
worsen the patient’s clinical state [41].
Presence of drugs interactions is an important DRM which
requires continuous monitoring [11] and the results might be used
as a way to improve the quality of health assistance [40].
In the studied group, the presence of drugs interactions added
with drug utilization profile could also be associated to worsen-
ing the patient’s health status and loss of their functional capacity.
Besides that, it might reflect the prescribers’ difficulty in introduc-
ing a rational therapeutic scheme and deficiency in medical plus
pharmaceutical assistance to the elderly.
Access to health assistance, related to either medical care or
medicines, is considered a determining factor to adherence to the
pharmacotherapy [42]. Access to medicines is also considered a
multifactorial variable which is directly influenced by age, educa-
tion level, health conditions, relation to the basic health unit, family
income, and others factors [42].
In the studied group, although the percentage of elderly with
problems with medicines access is small, lack of medication in the
Basic Attention to Health Chain (20% at the time of data collecting)
added to the low monthly income, with most retired elderly earn-
ing the minimum wage, represent limiting factors to access and,
therefore, to adherence to the prescribed treatment. Similar access
conditions were revealed by Paniz et al. in a study that took place
in 41 towns in the northeast and south of Brazil [42].
Low prevalence of problems related to access to medicines
among institutionalized elderly (3.5%) is due to the fact that it is
the institutions’ and not the elderly’s or their family’s responsibility
to guarantee access to medication. Besides that, the increas-
ing number of medicines in the Health Single System’s list plus
federal government programmes such as the Popular Pharmacy
have improved medication access for the general population in all
regions of the country.
Therefore, this study’s results allow us to conclude that socioe-
conomic, morbidity and use of medication profile as well as the
elderly’s health habits, directly influence the pharmacotherapy
quality making the elderly more vulnerable to drug-related prob-
lems (DRPs) on and to NOMs, jeopardizing the elderly’s quality of
life and increasing health assistance costs.
184 M.P. Furtado de Oliveira, M.R. Carvalho Garbi Novaes / Biomedicine & Aging Pathology 1 (2011) 179–184
In that scenario, there is a consensus that follow-up the emer-
gence and the worsening of such problems might be successfully
developed integrating clinical pharmacists and the elderly’s mul-
tiprofessional assistance team, prescribing balanced and rational
medication, and promoting improvement of the quality of the phar-
macotherapy and the users’s quality of life [4,8,13,16]. However, do
so more studies are necessary, particularly in relation to DRPı̌ and
NOMı̌s risks in elder population [3,4,10] as well as more invest-
ments in professional training and health politics with integral and
multiprofessional assistance.
Disclosure of interest
The authors have not supplied their declaration of conflict of
interest.
Acknowledgements
The authors would like to thank the long-term institutions’s
directors, their professionals and patients for their cooperation
during the study.
References
[1] Comite de Consenso. Tercer Consenso de Granada sobre Problemas Relaciona-
dos con Medicamentos (PRM). Ars Pharm 2007;48(1):5–17.
[2] Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. Drug-related prob-
lems: their structure and function. Drug Intell Clin Pharm 1990;24:1093–7.
[3] Hajjar ER, Cafiero AC, Hanlon JT. Polypharmarcy in elderly patients. Am J Geriatr
Pharmacother 2007;5(4):345–51.
[4] Hanlon JT, Lindblad CI, Gray SL. Can clinical pharmacy services have a positive
impact on drug-related problems and health outcomes in community-based
older adults? Am J of Geriatr Pharmacother 2004;2(1):3–13.
[5] Galato D, Silva ES, Tiburcio LS. Estudo de utilização de medicamentos em idosos
residentes em uma cidade do sul de Santa Catarina (Brasil): um olhar sobre a
polimedicação. Ciência & Saude Coletiva 2010;15(6):2899–905.
[6] Luz TCB, Loyola Filho AI, Lima-Costa MF. Percepções de capital social e
subutilização de medicamentos por motivos financeiros entre idosos. Cad
Saúde Pública Rio de Janeiro 2011;27(2):269–76.
[7] Marin MJS, Rodrigues LCR, Druzian S, Cecilio LCO. Diagnósticos de Enfer-
magem de idosos que utilizam múltiplos medicamentos. Rev Esc Enferm USP
2010;44(1):47–52.
[8] Medeiros-Souza P, Santos-Neto LL, Kusano LTE, Pereira MG. Diagnosis and con-
trol of polypharmacy in the elderly. Rev Saúde Pública 2007;41(6):1049–53.
[9] Nguyen JK, Fours MM, Kotabe SE, Lo E. Polypharmacy as a risk factor for adverse
drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother
2006;4(1):36–41.
[10] Correr CJ, Pontarolo R, Ferreira LC, Baptistão SAM. Riscos de problemas rela-
cionados com medicamentos em pacientes de uma instituição geriátrica. Braz
J Pharmaceut Sci 2007;43(1):55–62.
[11] Hayes BD, Klein-Schwartz W, Barrueto Jr F. Polypharmacy and the geriatric
patient. Clin Geriatr Med 2007;23:371–90.
[12] Schmader K, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, et al. Effects
of geriatric evaluation and management on adverse drug reactions and subop-
timal prescribing in the frail elderly. Am J Med 2004;116:394–401.
[13] Nascimento YA, Carvalho WS, Acurcio FA. Drug-related problems observed in
a pharmaceutical care service, Belo Horizonte, Brazil. Braz J Pharmaceut Sci
2009;45(2):321–30.
[14] Galato D, Alano GM, Trauthman SC, Vieira AC. A dispensação de medica-
mentos: uma reflexão sobre o processo para prevenção, identificação e
resolução de problemas relacionados à farmacoterapia. Braz J Pharmaceut Sci
2008;44(3):465–75.
[15] Romano-Lieber NS, Teixeira JJV, Farhat FCLG, Ribeiro E, Crozatti MTL,
Oliveira GSA. Revisão dos estudos de intervenção do farmacêutico no uso
de medicamentos por pacientes idosos. Cad Saúde Pública Rio de Janeiro
2002;18(6):1499–507.
[16] Vieira FS. Possibilidades de contribuição do farmacêutico para a promoção da
saúde. Ciencia & Saúde Coletiva 2007;12(1):213–20.
[17] Lyra-Júnior DP, Kheir N, Abriata JP, Rocha CE, Santos CB, Pelá IR. Impact
of Pharmaceutical Care interventions in the identification and resolution of
drug-related problems and on quality of life in a group of elderly outpa-
tients in Ribeirão Preto (SP), Brazil. Ther Clin Risk Management 2007;3(6):
989–98.
[18] Lyra-Júnior DP, Rocha CE, Abriata JP, Gimenes FRE, Gonzalez MM, Pelá IR. Influ-
ence of Pharmaceutical Care intervention and communication skills on the
improvement of pharmacotherapeutic outcomes with elderly Brazilian out-
patients. Patient Educ Couns 2007;68(2):186–92.
[19] Machuca M, Fernández-Llimós F, Faus MJ. Método Dáder. Guia de Seguimento
Farmacoterapêutico. 3rd ed. GIAF-UGR; 2003.
[20] Beers MH. Explicit criteria for determining potentially inappropriate medica-
tion use by elderly. Arch Intern Med 1997;157:1531–6.
[21] Langford BJ, Jorgenson D, Kwan D, Papoushek C. Implementation of a self-
administered questionnaire to identify patients at risk for medication related
problems in a family health center. Pharmacotherapy 2006;26(2):260–8.
[22] Acurcio FA, Silva AL, Ribeiros AQ, Rocha NP, Silveira MR, Klein CH, et al. Com-
plexidade do regime terapêutico prescrito para idosos. Rev Assoc Med Bras
2009;55(4):468–74.
[23] Teixeira JJV, Cano FG, Sanches ACC, Carniel TA, Schneider DSLG. Inquérito far-
macoepidemiológico de pacientes de meia idade e idosos em três comunidades
de Cascavel, PR - Brasil. Verificação evolutiva do conhecimento terapêutico.
Braz J Pharmaceut Sci 2008;44(2):297–303.
[24] Blanski CRK, Lenardt MH. A compreensão da terapêutica medicamentosa pelo
idoso. Rev Gaúcha Enferm Porto Alegre (RS) 2005;26(2):180–8.
[25] Bleich GW, Bleich A, Chiamulera P, Sanches ACC, Schneider DSLG, Teixeira JJV.
Frequency of potential interactions between drugs in medical prescriptions in
a city in southern Brazil. Sao Paulo Med J 2009;127(4):206–10.
[26] Bortolon PC, Medeiros EFF, Naves JOS, Karnikowski MGO, Nobrega OT. Análise
do perfil de automedicação em mulheres idosas brasileiras. Ciência & Saúde
Coletiva 2008;13(4):1219–26.
[27] Cascaes EA, Falchetti ML, Galato D. Perfil da automedicação em idosos partic-
ipantes de grupos da terceira idade de uma cidade do sul do Brasil. Arq Catar
Med 2008;37(1):63–9.
[28] Chaimowicz F. A saúde dos idosos brasileiros às vésperas do século XXI: prob-
lemas, projeções e alternativas. Rev Saúde Pública 1997;31(2):184–200.
[29] Cintra FA, Guariento ME, Miyasaki LA. Adesão medicamentosa em idosos
em seguimento ambulatorial. Ciência & Saúde Coletiva 2010;15(Supl. 3):
3507–15.
[30] Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamen-
tos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública
2004;38(4):557–64.
[31] Danilow MZ, Moreira ACS, Villela CG, Barra BB, Novaes MRCG, Oliveira MPF.
Perfil epidemiológico, sociodemografico e psicossocial de idosos institucional-
izados do Distrito Federal. Com Ciências Saúde 2007;18(1):9–1.
[32] Flores VB, Benvegnú LA. Perfil de utilização de medicamentos em idosos da
zona urbana de Santa Rosa, Rio Grande do Sul, Brasil. Cad. Saúde Pública
2008;24(6):1439–46.
[33] Loyola Filho AI, Uchoa E, Firmo JOA, Lima-Costa MF. Estudo de base populacional
sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde
Pública Rio de Janeiro 2005;21(2):545–53.
[34] Nogueira SL, Ribeiro RCL, Rosado LEFPL, Franceschini SCC, Ribeiro AQ, Pereira
ET. Fatores determinantes da capacidade funcional em idosos longevos. Rev
Bras Fisioter 2010;14(4):322–9.
[35] Leite SN, Vasconcellos MPC. Adesão à terapêutica medicamentosa: elementos
para a discussão de conceitos e pressupostos adotados na literatura. Ciência &
Saúde Coletiva 2003;8(3):775–82.
[36] Rocha CH, Oliveira APS, Ferreira C, Faggiani FT, Schroeter G, Souza ACA, et al.
Adesão à prescrição médica em idosos de Porto Alegre, RS. Ciência & Saúde
Coletiva 2008;13(Sup):703–10.
[37] Nobrega OT, Karnikowiski MGO. A terapia medicamentosa no idoso: cuidados
na medicação. Ciência & Saúde Coletiva 2005;10(2):309–13.
[38] Chaimowicz F, Ferreira TJXM, Miguel DFA. Uso de medicamentos psicoa-
tivos e seu relacionamento com quedas entre idosos. Rev Saúde Pública
2000;34(6):631–5.
[39] Arrais PSD, Coelho HLL, Batista MCDS, Carvalho ML, Righi RE, Arnau JM. Perfil
da automedicação no Brasil. Rev Saúde Pública 1997;31(1):71–7.
[40] Codagnone Neto V, Garcia VP, Santa Helena ET. Possible pharmacological
interactions in hypertensive and/or diabetic elderly in family health units at
Blumenau (SC). Braz J Pharmaceut Sci 2010;46(4):795–804.
[41] Cruciol-Souza JL, Thomson JC. A pharmacoepidemiologic study of drug inter-
actions in a brazilian teaching hospital. Clinics 2006;61(6):515–20.
[42] Paniz VMV, Fassa AG, Facchini LA, Bertoldi AD, Piccini RX, Tomasi E, et al. Acesso
a medicamentos de uso contínuo em adultos e idosos nas regiões Sul e Nordeste
do Brasil. Cad Saúde Pública, Rio de Janeiro 2008;24(2):267–80.