Health of the elderly population and population with intellectual disabilities and their use of medicines and food supplements : doktorska disertacija

Peklar, Jure (author), Kos, Mitja (mentor), Henman, Martin Charles (comentor)

Due to the accelerated ageing of the worldwide population the proportion of elderly (aged 65 and over) people is growing. This will have implications for the planning and delivery of health and social care. Understanding how (older) people manage their pharmacotherapy can help to maximise the benefits of medicines and prevent potential tangible side effects as older people are more vulnerable to adverse drug events due to diminished physiological reserve associated with ageing. This can be exacerbated further by acute or chronic disease and by the effects of the medicines used to treat them. Older people are often prescribed sedative medicines which have been associated with falls, fractures, physical and cognitive impairment, and disability. Frailty as one of more complex geriatric syndrome, develops as a consequence of age-related declines in many physiological systems, resulting in vulnerability to stressors (e.g. infection or hospitalisation) and adverse health outcomes as falls and fractures, mobility and functional declines, hospitalisation, nursing home admissions and death. To test the hypothesis that there is an association between the use of sedative medicines and frailty we used cross-sectional data from the first wave of the Irish Longitudinal Study on Ageing (TILDA). The elderly subgroup in TILDA study cohort included 3,446 participants representative of the community-living population in Ireland. Frailty status was measured using two different methods: phenotype (Fried’s) frailty and frailty index (FI). Cumulative effect of multiple sedative medicines was calculated using the sedative load model which was updated to reflect current knowledge about the sedative effects of medicines. Sedative medicines (most frequently hypnotics and antidepressants) were used by one fifth (19.4%) of participants and was higher in women than in men. Frail participants (4.2%) were significantly older, had more chronic diseases, poorer education and more (ADL and IADL) disabilities but also higher polypharmacotherapy (5 or more medicines) and sedative medicine use. Sedative load was independently associated with both phenotype frailty and FI frailty. The use of medicines with sedative properties in older Irish adults was significant and more prevalent in the subpopulation with the poorest health status. These findings could have important clinical implications with respect to prevention of adverse health outcomes in the elderly. In the ageing population the awareness and willingness of preserving health and intensifying pharmacological treatment with food supplements (FS) is strong. The main purpose of food supplements use is to provide nutrients potentially missing in the food consumed due to the nature of the food intake (e.g. poor quality), specific diet or because of increased need for a specific nutrient due to disease or metabolic malfunction (osteoporosis, anaemia,…), pregnancy or lifestyle activities (increased physical activity). In combination with medicines they may be used to augment treatment needs or to meet separate needs but both may incur risk as well as benefit. We researched the use of food supplements in the Irish community-dwelling population aged 50 years and over alone and in concurrent combination with medicines within the TILDA project, to help us understand better what are the specific factors associated with its pattern. Overall every seventh respondent (14.0%) reported concurrent medicine-FS use. The range of combined use varied from 1 supplement with 19 medicines to 10 supplements with 2 medicines. The most prevalent supplements were calcium with or without D vitamin, omega-3-fatty acids and glucosamine. Combined use was highest in those taking medicines for bone diseases (60.0%; mostly calcium with or without D vitamin) and lowest in those taking medicines for diabetes (15.7%). At least one potential medicine-supplement interaction of any kind was detected in 4.1% respondents. Anticoagulants and NSAIDs were among the most frequently interacting medicines. Overall, potential major interactions were detected in 4.5% of those reported any medicine-FS use. Independent factors for FS use in the TILDA cohort (aged 50 years and over) were being female, employed, non-smoker, having higher education and living alone. Furthermore, factors were having private insurance, three or more chronic conditions and polypharmacotherapy. Similarly were independent factors for overall combined medicine-FS use being female, employed, having private insurance and number of chronic conditions. The variability in FS use in the population showed evidence of unmet need and therefore unrealised benefits among some sub-groups and of exposure to avoidable and potentially serious drug interactions among others. Both of these outcomes may increase in the future as the proportion of the over 50s with multimorbidity, polypharmacotherapy and supplements use grows. Intellectual disability (ID) is a disability characterised by significant limitations in both intellectual functioning and in adaptive behaviours, which covers many everyday social and practical skills. Life expectancy is increasing in this population similarly to the non-ID population. Increasing numbers of people with ID are living in the community and are dependent upon primary health care services (e.g. GP, community pharmacy). All this, however, brings new challenges which need to be addressed at the primary health care level to accommodate the special demands that this population may pose, including the differences in the medicine and food supplement utilisation pattern. Data used in our research was taken from the first wave of the ID supplement to TILDA. To make comparison between the ID population from the Intellectual disability supplement to TILDA and TILDA cohort possible, only the community dwelling subpopulation of person aged 50 years and over with ID were included in the study. It was discovered that ID population was exposed to higher multimorbidity and also pharmacotherapy compared to the non-ID population while food supplement use was almost double. Furthermore, more people with ID reported concomitant medicine and food supplement use and compared to the non-ID population it was more than double. The intensity of medicine use was evaluated using the number of medicines per 100 enrolled participants and was twice as great in the ID cohort (503 versus 251) as in the non-ID cohort. The diversity of medicines used was substantial with the number of different preparations (ATC level 5) per 100 participants being 95.8 (ID) vs. 7.0 (non-ID). In contrast to the greater variety of medicines per participant identified in the IDS TILDA cohort, supplement utilisation illustrated minimal diversity with only 10 types of supplements in use (compared to 134 in the non-ID cohort). The most reported therapeutic class in the non-ID cohort were “Lipid modifying agents” (ATC C10) while in the ID cohort were “Psycholeptics” (ATC N05) with antipsychotics being most prevalent. Long term use of sedative and anticholinergic medicines have been associated with cognitive impairment, increased risk of falls and hospitalisation. This evidence strongly suggests that in particular the ID population studied in this work is exposed to risks and vulnerable to harm from the high levels of medicines and supplements used. Since this population live in the community and it is most appropriate that they continue to be cared for in the community, those Primary Care providers who share responsibility for the provision of medicines and supplements, general practitioners and community pharmacists, should be supported and empowered to collaborate in the care of these diverse populations in need.

• Language: English
• Keywords: stari ljudje, osebe z motnjami v duševnem razvoju, zdravila, uspavala, antidepresivi, polifarmakoterapija, prehranski dodatki, neželeni učinki, kronične bolezni, starostna oslabelost, disertacije
• Work type: Dissertation
• Typology: 2.08 - Doctoral Dissertation
• Organization: FFA - Faculty of Pharmacy
• Place of publishing: Ljubljana
• Publisher: [J. Peklar]
• Year: 2016
• Number of pages: 215 str.
• PID: 20.500.12556/RUL-143776
• UDC: 615.214.065:616-053.9(043.3)
• COBISS.SI-ID: 286666496
• Publication date in RUL: 12.01.2023

Secondary language

• Language: Slovenian
• Title: Zdravje starostnikov in oseb s posebnimi potrebami ter njihova uporaba zdravil in prehranskih dopolnil

Abstract

Delež starostnikov (oseb starejših od 65 let) v svetu narašča zaradi podaljševanja življenjske dobe. To pomembno vpliva na načrtovanje in organizacijo zdravstvenega in socialnega varstva. Dobro razumevanje tega, kako starostniki jemljejo zdravila, lahko izboljša pozitivne učinke zdravljenja oziroma prepreči morebitne znatne neželene učinke zdravil. Starostniki so namreč populacija s povečanim tveganjem za neželene učinke zdravil do katerega pride zaradi zmanjšane fiziološke kapacitete organizma, ki nastanejo ravno zaradi staranja. Dodatno lahko poslabšajo stanje kronične ali akutne bolezni, kot tudi zdravila, ki jih starostnik jemlje ob tem. Starostnikom so pogosto predpisana zdravila s sedativnim učinkom, pri katerih je bila ugotovljena povezanost s padci, zlomi, telesnimi in kognitivnimi okvarami ter invalidnostjo. Starostna krhkost kot eden bolj kompleksnih geriatričnih sindromov, se razvije zaradi učinkov staranja na več fizioloških sistemov, kar vodi v povečano občutljivost na stresne dejavnike (denimo okužbe ali hospitalizacija) in je povezana s padci, zlomi, zmanjšanjem mobilnosti in funkcionalnosti, hospitalizacijo, sprejemom v domove za ostarele in smrtjo. V namen preverjanja hipoteze, ali obstaja povezava med uporabo zdravil s sedativnim učinkom ter starostno krhkostjo, smo uporabili presečne podatke iz prvega leta Irske longitudinalne študije o staranju (TILDA). Subpopulacija starostnikov je vključevala 3446 oseb živečih na domu v Republiki Irski. Stopnja starostne oslabelosti je bila določena z uporabo dveh metod: fenotipska (Friedova) krhkost ter krhkostni indeks (FI). Kumulativni učinek jemanja večih zdravil s sedativnim učinkom je bil kvantificiran s pomočjo modela sedativnega bremena, ki smo ga posodobili, tako da je vključeval zadnja spoznanja o zdravilih s sedativnim učinkom. Zdravila s sedativnim učinkom (najbolj pogosto uspavala in antidepresivi) so bila poročana pri petini (19,4%) vključenih v raziskavo, vendar več pri ženskah kot pri moških. Posamezniki s starostno krhkostjo (4,2%) so bili pomembno starejši, so imeli več kroničnih bolezni, slabšo izobrazbo in več tipov invalidnosti (vsakodnevne aktivnosti/inštrumentirane vsakodnevne aktivnosti). Poleg tega so imeli več polifarmakoterapije (sočasno jemanje petih in več zdravil) ter zdravil s sedativnim učinkom. Sedativno breme je bilo neodvisno povezano tako s fenotipsko krhkostjo, kot tudi z krhkostnim indeksom. Uporaba zdravil s sedativnim učinkom je med starostniki na Irskem evidentna, kar še posebej velja za osebe s slabšim zdravstvenim stanjem. Ti izsledki bi lahko pomembno vplivali na pripravo ukrepov z namenom preprečevanja zapletov pri zdravljenju. Ozaveščenost glede ohranjanja zdravja in jemanja prehranskih dopolnil kot dopolnilo zdravljenju z zdravili je pri starajoči populaciji zelo prisotno. Glavni namen jemanja prehranskih dopolnil je zagotoviti potrebna hranila, ki morda manjkajo v vsakodnevni prehrani. Do te potrebe pride zaradi uživanja s hranili siromašne prehrane, posebne diete, ali povečane potrebe po specifičnih hranilih zaradi bolezni, metabolne motnje (npr. osteoporoza, anemija), nosečnosti ali življenjskega sloga (povečana fizična aktivnost). V kombinaciji z zdravili se prehranska dopolnila jemljejo za obogatitev tega zdravljenja ali pa za zadovoljevanje drugih potreb, vendar lahko takšna sočasna raba pomeni tako tveganje za neželene učinke kot doprinos k boljšemu zdravju. V naši raziskavi znotraj TILDA smo ugotavljali uporabo prehranskih dopolnil v populaciji oseb starih 50 let in več živečih na domu v Republiki Irski, tako samostojno kot tudi v kombinaciji z jemanjem zdravil, da bi tako bolje razumeli kateri so napovedni dejavniki, ki so povezani z ugotovljenimi vzorci. Skupno je vsak sedmi posameznik vključen v raziskavo (14,0%) poročal sočasno uporabo zdravil in prehranskih dopolnil. Kombinacije so variirale od enega prehranskega dopolnila skupaj z 19 zdravili, do 10 dopolnil skupaj z dvema zdraviloma. Najbolj poročana prehranska dopolnila so bila kalcij z ali brez vitamina D, omega-3-maščobne kisline ter glukozamin. Sočasno jemanje je bilo najbolj pogosto pri tistih, ki so jemali zdravila za kostne bolezni (60,0%; največ kalcij z ali brez D vitamina), najmanj pa pri tistih, ki so jemali zdravila za zdravljenje sladkorne bolezni (15,7%). Najmanj eno potencialno součinkovanje med zdravili in prehranskimi dopolnili je bilo ugotovljeno pri 4,1% posameznikov, vključenih v raziskavo. Antikoagulanti in nesteroidni antirevmatiki so bili med najbolj pogostimi zdravili, ki so součinkovala. Potencialno pomembne interakcije so bile ugotovljene pri 4,5% tistih, ki so poročali sočasno uporabo zdravil in prehranskih dopolnil. Neodvisni dejavniki pri osebah starejših od 50 let znotraj raziskave TILDA, ki vplivajo na jemanje prehranskih dopolnil, so bili ženski spol, zaposlenost, nekajenje, višja izobrazba, samsko življenje, prostovoljno zdravstveno zavarovanje, tri ali več kroničnih bolezni ter sočasno jemanje petih ali več zdravil (polifarmakoterapija). Podobno so bili neodvisni dejavniki za sočasno jemanje zdravil skupaj prehranskimi dopolnili ženski spol, zaposlenost, prostovoljno zdravstveno zavarovanje in število kroničnih bolezni. Ugotovljena praksa uporabe prehranskih dopolnil kaže na neizkoriščene možnosti, ki jih za izboljšanje zdravstvenega stanja le-ta ponujajo na eni strani, ter nevarnost za nastanek potencialnih interakcij na drugi strani. Prisotnost obeh (neugodnih) možnosti se bo v prihodnje verjetno le povečala, saj delež oseb starih 50 let in več z večimi kroničnimi boleznimi in polifarmacijo ter uporabo prehranskih dopolnil, narašča. Motnje v duševnem razvoju so opredeljene s pomembno okrnjenimi intelektualnimi zmožnostmi in prilagodljivega vedenja, ki jih uporabljamo v vsakdanjem življenju. Pričakovana življenjska doba oseb z motnjami v duševnem razvoju se podaljšuje in postaja podobna tisti, ki jo dosega populacija brez motenj. Vse več ljudi s temi motnjami živi na domu in se poslužuje storitev izvajalcev primarnega zdravstvenega varstva kot so družinski zdravniki in lekarniški farmacevti. To prinaša nove izzive nosilcem primarnega zdravstvenega varstva, da kar najbolje zadovoljijo posebne potrebe te populacije, vključno z drugačno prakso jemanja zdravil in prehranskih dopolnil. Podatki, ki smo jih uporabili pri raziskovanju, izhajajo iz prvega leta »ID suplementa« k TILDA študiji. Da smo lahko primerjali populacijo iz obeh študij, smo v populaciji z motnjami v duševnem razvoju upoštevali le tiste posameznike, ki so živeli na domu (torej niso bili institucionalizirani) in so bili stari 50 let in več. Ugotovili smo, da so imeli posamezniki z motnjami v duševnem razvoju več kroničnih bolezni ter so poročali jemanje večih zdravil kot posamezniki brez motenj, ob tem pa je bila poraba prehranskih dopolnil skoraj dvojna. Več kot podvojeno je bilo tudi sočasno jemanje zdravil in prehranskih dopolnil. Nivo intenzivnosti zdravljenja z zdravili je bila ocenjena s številom zdravil na 100 posameznikov vključenih v posamezno kohorto in je bila v primeru populacije z motnjami v duševnem razvoju dvojna (503 proti 251). Raznovrstnost poročanih zdravil (ATC 5) v tej populaciji je bila bistveno višja v primerjavi s populacijo brez motenj in je znašala kar 95,8 proti 7,0. V nasprotju s tem, pa je bila raznovrstnost poročanih prehranskih dopolnil zelo omejena, saj smo jih identificirali le 10 različnih vrst, medtem ko jih je bilo v populaciji brez duševnih motenj 134. Najbolj poročana skupina zdravil je bila v populaciji brez duševnih motenj »zdravila za spreminjanje ravni serumskih lipidov« v drugi pa »psiholeptiki«, kjer so prevladovali antipsihotiki. Dolgotrajno jemanje zdravil s sedativnim in/ali antiholinergičnim učinkom je povezano z zmanjšanjem kognitivnih funkcij, povečanim tveganjem za padce in hospitalizacijo. Tako je še posebej populacija z motnjami v duševnem razvoju izpostavljena povečanemu tveganju za neželene učinke zdravil in prehranskih dopolnil. Ob tem, da ta populacija živi v običajni skupnosti in že uporablja storitve v primarnem zdravstvu, bi bilo najbolje, da izvajalci primarnega zdravstva, torej družinski zdravniki in lekarniški farmacevti, dobijo možnost dodatnega izobraževanja, da bi skupaj kar najbolje skrbeli za posebne potrebe te populacije.