Potentially Inappropriate Medication Use, Comorbidity and Quality of Life in Community-Dwelling Older People: A Cross-Sectional Study in Iran

doi:10.21203/rs.3.rs-4615591/v1

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Research Article

Potentially Inappropriate Medication Use, Comorbidity and Quality of Life in Community-Dwelling Older People: A Cross-Sectional Study in Iran

https://doi.org/10.21203/rs.3.rs-4615591/v1

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Background

Multimorbidity, polypharmacy and potentially inappropriate medication use in elderly people are prevalent which affect the quality of life in them. This study investigates the interrelationship between potentially inappropriate medication use, polypharmacy, comorbidity, and the quality of life among elderly people in Iran.

Methods

This cross-sectional study was conducted on 500 elderly people in Isfahan City, Iran. the Beers criteria for Potentially Inappropriate Medication Use in Older Adults, a health-related quality-of-life questionnaire for elderly people, and the Charlson comorbidity index were used for gathering data.

Results

Our findings related to the elderly living in Isfahan community Dewelling showed that the prevalence of PIM = 61.6% and the most common drug category was related to painkillers, the average quality of life score was (0.86 ± 0.08) and the worst category was related to the sleep status of the elderly Was. The average score of CCI = 3.63 ± 1.40 and the most frequent diseases of the elderly were blood lipids, hypertension and diabetes.After adjusting for intervening variables, there was a negative relationship between CCI(B=-0.009(SE = 0.0027), P < 0.001) and PIM(B =- 0.03(SE = 0.007); P < 0.001) was observed with quality of life

Conclusion

Potentially inappropriate medication use and comorbidities in our older population are high and these variables are negatively associated with quality of life in this population. There are few educated family physicians in geriatrics in Iran. Policymakers should pay attention to these issues.

Elderly People

Potentially Inappropriate Medications List

Comorbidity

Polypharmacy

Quality of Life

Due to age-related diseases and disabilities, elderly people take more medications compared to young people (1). Although older people make up 13% of the world's population, they alone use one-third of all medications consumed worldwide (2). Also, the physiological changes of old age affect the pharmacokinetics and pharmacodynamics of medications, which makes this age group exposed to greater risks of medication interactions and side effects(3). Medication interactions and complications have been observed in 26% of them (4).

The simultaneous presence of several diseases and polypharmacy in older people increases the prevalence of potentially inappropriate medication use (PIM) (5). PIMs are known as medications whose health risks outweigh their benefits, provided that they have safer or more effective alternatives (6). The use of these medications brings negative health consequences and increases the burden of treatment costs on the patient and health systems (7). In recent years, the use of PIMs, especially in the older people population, has become a common phenomenon (8).The prevalence of these medications has been reported differently in different countries, in China 34% (5), in India, 15%(9), and 39.6% was reported in France(10). Studies have shown that the prevalence of the use of potentially inappropriate medications has been associated with a decrease in the self-care ability of older people(11), an increase in hospitalization(12), and a decrease in their quality of life in general(13). So with the increase in the use of these medicines the risk of falls and bleeding in the gastrointestinal tract in older people (14).

The consumption of PIMs is also higher in people with comorbidities(15). A study in the United States of America reported that patients who have two or more comorbidities consume more PIMs(16). Other studies have also shown that there is a strong relationship between the number of comorbidities, polypharmacy, and the use of PIMs (17, 18). With the aging of the population, comorbidities have gradually become a great health problem that negatively affects the quality of life of older people (19).The comorbidity index is considered an important factor in checking the survival of people According to statistics, 25 to 50 percent of older people with a chronic disease have comorbidities or associated diseases (20). Also, based on research results, an increase in co-morbidities in a person greatly increases the risk of death(21). Studies have also shown that the increase in comorbidities in old age is associated with a decrease in the quality of life and a decrease in self-care ability (22–24).

The importance of quality of life and health status is such that in this century, most health care has focused on improving people's quality of life(25). In the meantime, health-related quality of life (HRQoL) is a suitable indicator for measuring people's overall health. It provides information about people's physical and mental health status and the impact of health status on quality of life(26). This index measures the physical, mental, and emotional dimensions and symptoms related to the disease. The tool also provides a comprehensive assessment of the burden of preventable diseases, injuries, and disabilities (27). Some studies in this field have reported different results. These studies report a lower quality of life with age, gender, educational level, polypharmacy, and co-morbidities (23, 28, 29). However, there may be other factors that affect the quality of life of older people and have not been widely studied so far. More knowledge about these factors will be useful for designing more effective interventions to improve the quality of life(30).

The studies conducted in different countries have reported different information about the prevalence of potentially inappropriate medications, comorbidities, and their effects on the health status of older people. On the other hand, there is little information related to these cases in Iran. According to the latest results of Iran's census in 2015, the population of people 60 years and older was 9.3%(31). Forecasts show that this amount will increase to 32% in 2050 (32). So, investigating the factors affecting the quality of life of older people becomes more important. Therefore, this study was conducted to investigate the relationship between the consumption of PIMs and comorbidity with the quality of life among older people in the health centers of Isfahan City.

This cross-sectional study was conducted in 2023 in the health centers affiliated to Isfahan University of Medical Sciences, Isfahan, Iran.

The study population included all people aged 60 years and older. Other criteria for entering this study included the ability to answer the questionnaire, living in Isfahan City, not suffering from cognitive diseases, and willingness to participate, and the exclusion criteria included incomplete completion of the questionnaires. Data collection was done using questionnaires along with interviews. The researcher aided participants with specialized terms from the questionnaires by clarifying desired words in simple language, and collected data were entered into the questionnaires.

2-1.Sample size and sampling method

A sample size of 500 was estimated by considering a 5% type one error rate and a 90% statistical power to detect a correlation (r = 0.25) between comorbidity and quality of life ⁽²²⁾. A multi-stage cluster sampling with a systematic approach was employed for sample selection. The two main or first-stage clusters were health centers number 1 and 2 in Isfahan. The second stage clusters were health care centers covered by these two main centers. Five health centers were randomly selected from each main center, and a list of elderly people was obtained from each of them. The participants were selected with a systematic sampling method in each selected center.

2-2. Study instruments

2-2-1. Beer’s criteria

Beer's criteria is a specific list of inappropriate medications that should generally be avoided in older people or should be used in a low dose or with caution in older people with a specific disease or syndrome. This criterion is updated every three years since 2012 by the American Geriatrics Society (34). Currently, the latest update of the Beers2019 criteria has stated the potentially unsuitable medications for older people in several groups: 1- Certain medications that should always be avoided in older people. 2- Medications that should not be used in older people with a specific disease or syndrome. 3- Medications that should be used with caution in older people. 4- A list of medication-medication interactions. 5- Medicines that are considered inappropriate based on kidney dysfunction and should be dose-adjusted for each person(35). This criterion was used in previous Iranian studies(28, 36)

2-2-2. Charlson Comorbidity Index

Charlson Comorbidity Index or CCI is an index that predicts the ten-year survival of people with several diseases. In this index, each disease gets a score of one, two, three, or six (37). The score assigned to each disease is based on the severity of the risks associated with each disease. The age of people also affects the CCI score. CCI score for age less than 50 years is zero, age 50-59 years one, age 60-69 years two, age 70-79 years three and eighty years and older four. The score range of this index is from 0-37 in case of age mismatch and from 0-43 in case of age matching. CCI will be calculated from the total age of older people and the score obtained from each disease. Finally, the points are ranked in four degrees of discomfort. Higher scores indicate more comorbidities(38). Charlson Comorbidity Index was used in previous Iranian studies(39, 40)

2-2-3. Quality of life questionnaire

The quality of life questionnaire related to the health of older people or the 15D tool is a general, comprehensive, multidimensional (15 fields), standardized, and self-report questionnaire that examines the condition of vision, hearing, respiratory system, movement, sleep, mouth and teeth, and speech. It deals with excretory status, self-care, mental function, discomforts and symptoms of illness, depression, anxiety, vitality, and sexual activities of older people(41). This questionnaire was translated into Farsi by Heydari et al. (2021), and its psychometric steps were completed. Cronbach's alpha coefficient of the quality of life questionnaire was 0.92% (28). The score of the tool is reported in two ways: single index score and profile measure graph scale. Each area is classified into five levels from "no problem" to "maximum problem". The overall score of 15D is calculated from the average of the total score related to all areas. and the range of the overall quality of life score related to health or any of the areas is between 0-1, the higher the score, the better the physical condition of older people (42).

2-2-4. Other variables

Polypharmacy (number of 5 medications and more used by older person), Demographic variables (age, gender, education, number of doctors visiting elderly people, Disease history).

2-3. Statistical analysis

The data were analyzed using SPSS version 2Data and evaluated with SPSS version 22 (IBM, USA). Numerical variables were reported as means and standard deviations (SD); categorical variables as numbers( percentages). Categorical variables were compared between groups using a chi-squared test and continuous variables using an independent samples t-test or one-way analysis of variance (ANOVA). Pearson correlation coefficient and linear regression were used to evaluate the association between PIM and comorbidity index with quality of life.

2-4. Ethical Consideration

The study received approval from Isfahan University of Medical sciences Ethics Committee (Research Proposal Code:3401529, and Ethical Code: IR.MUI.RESEARCH.REC.1401.291). The informed consent was obtained from all study participants. All steps of study were conducted in strict adherence to the ethical standards of Helsinki Declaration.

The study included 500 elderly people participants aged between 60-90 years. The average age was (66.34 ± 5.67) years, and the mean number of medications consumed was (3.92 ± 2.63). Hyperlipidemia 49.2%, high blood pressure 43.6%, and diabetes 35.4% were the most prevalent diseases among our study population More details about other demographic characteristics of study participants have been presented in Table 1.

According to the findings of this study, the prevalence of potentially inappropriate Medication (PIM) based on the 2019 Beers criteria among participants was 61.2%. The most common category of potentially inappropriate medications related to painkillers at 36.8%, then gastrointestinal medications at 23.6%, nervous system medications at 23.2%, endocrine medications at 10.2%, anticholinergic medications at 1.2%, and cardiovascular medications at 0.6%. There were no cases of anti-thrombosis, anti-infection, and reproductive system medications. The highest consumption of PIMs was related to the age group above 75 years and in the female gender. However, the relationship between the use of PIMs and the increase in age, gender, and education of elderly people participating in this study was not significant. Still, the use of these medications was significant with the number of doctors, so with the increase in the number of doctors, the use of these medications also increased in elderly people. (Table 2)

According to the findings of this study, 36.8% of participants with five or more medications had polypharmacy. There was no significant relationship among polypharmacy, gender, and education. There was a relationship between age and the number of doctors with polypharmacy. The frequency of demographic variables in polypharmacy Pharmacy is listed in (Table 2).

The mean and standard deviation of the Charlson Comorbidity Index score in this study was (3.63±1.40), which had a significant relationship with age and number of doctors, and had an insignificant relationship with the variables of gender and education level. Also, the relationship between the quality of life of elderly people and the variables of age and the number of doctors was significant, and it was not significant with the variables of gender and education level. Table (2) shows the mean and standard deviation of the quality of life score related to the health of elderly people was (0.86 ± 0.08), the strongest area was related to routine self-care and vision status of elderly people, and the weakest area was related to the sleep status of elderly people. Also, the relationship between the mean score of the quality of life in elderly people with age, gender, number of doctors, and the level of education was not significant. (Table 2)

In this study, a significant relationship was observed between polypharmacy and the use of inappropriate medications, quality of life, and comorbidity of elderly people. Also, based on the results, the relationship between comorbidity and the use of PIMs was significant (P=0.001), so the mean comorbidity score of elderly people who used inappropriate medications was (3.93±1.42), and elderly people who used. They did not have inappropriate medication, their mean comorbidity score was 3.14± (1.22). (Table 3)

There was a significant relationship between the mean quality of life score and PIM consumption among elderly people (P=0.001). The score of the quality of life of elderly people who used PIM compared to other participants who did not use PIM based on demographic variables is given in Table 4. According to the findings, the correlation between the mean score of quality of life and comorbidity based on the Charlson index in elderly people was found to be equal to (r=-0.286 and P=0.001), and the relationship was significant. (Table 4)

Using a linear regression model, it was observed that by controlling the effect of demographic variables, the consumption of PIMs compared with comorbidity has a greater impact on the quality of life of elderly people. Also, by adjusting the effect of demographic variables, comorbidities have a greater impact on the quality of life of elderly people. (Table 4)

Using a linear regression model, after controlling for demographic variables, the relationship between quality of life and PIM use and comorbidity showed that the quality of life of elderly people who did not use inappropriate medication was on average 0.04 higher than that of the other participants. For older people, people who had a higher comorbidity score the mean score of their quality of life was 0.013 lower than that of other elderly people. (Table 5)

Our study showed that the prevalence of the use of potentially inappropriate medications and the increase of comorbidities affect the quality of life in old age. Considering that older people population in Iran is increasing and the problems related to aging will appear more, the need to have a quality life in the old age period is felt more (31).Proper medication treatment, which is one of the most essential components of health, has a significant impact on the quality of life of older people, since older people are more exposed to chronic diseases, and the chances of receiving several inappropriate medications are also higher among them.

The findings of our study showed the prevalence of PIM, based on the 2019 Beers criteria, to be 61.2 percent, which was close to studies conducted in Brazil (43), USA (44), and Pakistan (45). The consumption of these medications in some studies conducted in Turkey(46), France(47), and America (35)were reported as 41.6%, 39.6%, and 47%, respectively, which is lower than our study. The difference in the prevalence of PIM reported in different studies may be due to differences in the characteristics of older people, the type of diseases, different patterns of medication administration, the availability of medications listed in the 2019 Beers criteria, and also the lack of awareness among physicians about the existence of a list of inappropriate medications for older people, which may have led to the difference in the prevalence of PIM.

The most common category of potentially inappropriate medications in our study was painkillers. Since in this study, the use of PIMs increased with the increase in the number of doctors, it can be said that the use of more painkillers was probably due to the prescription of several different types of painkillers by different doctors, and this issue is the necessity of the family doctor plan in our country, and justifies for the better organization of prescribed medicines for older people. Also, one of the most probable factors related to the use of PIMs and comorbidity was the use of five or more medications. The use of several medications leads to the use of more PIMs, and older people who have more comorbidities take more medications. This was consistent with studies that reported the factors affecting PIM and comorbidity among older people. (13, 17, 18)

In this study, the average score of comorbidity was (3.63 ± 1.40) and it had a significant relationship with the use of inappropriate medications so older people who suffered from more comorbidities used more inappropriate medications. The results of other studies also confirmed these findings. and (16, 48). Also, the most common diseases observed among older people were hyperlipidemia, hypertension, and diabetes, respectively, which could be because most of the participants in this study were elderly with the most common cluster of diseases(15). (blood fat, diabetes, and high blood pressure). These comorbidities usually require the use of several medications to manage their conditions. It is also important to remember that in our study, the prevalence of polypharmacy was related to the number of comorbidities.

In this study, the average score of the quality of life- related to the health of older people was good, and the strongest areas were related to routine self-care and vision status of older people, this may be because the average age of older people in this study is low and among the young elderly. are considered to be less vulnerable than other elderly people. Also, the weakest area of the quality of life was related to the sleep status of older people, which is probably due to physical pain that has affected the quality of the sleep of older people. It was used concerning the physical condition of older people.

In this study, using a linear regression model, it was observed that the quality of life of older people is related to the use of PIMs and comorbidity so that older people who did not have inappropriate medications in their medication list had better health and quality of life than older people who used inappropriate medications. Also, older people who suffered from more comorbidities had a lower quality of life than other elderly. The results of other studies have also confirmed our findings(23, 24, 28, 29, 33).

This investigation underscores the pressing need to curtail unnecessary PIM consumption and the prevalence of common comorbidities, offering a knowledge foundation for health sector stakeholders aimed at enhancing older people's life quality. The findings inform policymakers to implement effective interventions in medication therapy management, screening for conditions such as hyperlipidemia, hypertension, and diabetes in old age, and establishing a comprehensive family doctor system throughout the country. Additionally, training for doctors on the list of inappropriate medications for elderly people is recommended.

This study does have its limitations; it focused solely on elderly people under the care of health centers, so results may not be universally applicable. Confounding factors such as patient attitudes, prescribing factors, and lifestyles influencing quality of life were not measured or analyzed. Future studies with larger sample sizes and across multiple regions are suggested.

Ethical Consideration

The study received approval from the Isfahan University of Medical Sciences Ethics Committee (Research Proposal Code:3401529, and Ethical Code: IR.MUI.RESEARCH.REC.1401.291). The informed consent was obtained from all study participants. All steps of study were conducted in strict adherence to the ethical standards of Helsinki Declaration.

Acknowledgments

We extend our heartfelt gratitude to all those who assisted with this study, especially older people of Isfahan, who participated patiently and clearly.

Funding

This study was partially supported by the Isfahan University of Medical Sciences.

Conflict of interest

There are no conflicts of interest.

Authors’ contributions

Maryam Shirdozham: Conceptualization, Validation, Investigation, Resources, Writing - Original Draft. Awat Feizi: Methodology, Software, Validation, Formal analysis, Writing - Review & Editing, Supervision. Majid Rahimi: Conceptualization, Methodology, Validation, Resources, Writing - Original Draft, Writing - Review & Editing, Supervision, Project administration, Funding acquisition.

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Table1. Demographic characteristics of study participants

Frequency (%)

Variable levels

Variable

223(44.6)

227(55.4)

Male

Female

Sex

220(44)

156(31.2)

37(7.4)

73(14.6)

10(2)

4(0.8)

Less educated

diploma (12-year formal education)

Associate degree

Bachelor's degree

MSc

Ph.D

Education

233(46.6)

203(40.6)

64(12.8)

1-3

4-6

Number of doctors who visit elderly people participant

150(30)

177(35.4)

218(43.6)

246(49.2)

112(22.4)

86(17.2)

(68(13.6)

39(7.8)

26(5.2)

51(10.2)

14(2.8)

12(2.4)

Heart disease

diabetes

blood pressure

blood fat

Liver fat

Nerve disease

Thyroid disease

Kidney Disease

digestive Disease

Lung disease

cancer

Connective tissue disease

Disease history

Table 2. Frequency distribution of PIM, comorbidity, quality of life, and polypharmacy based on demographic variables in study participants

Variable

PIM Use* n(%)

P Value

Comorbidity score

P Value

quality of life score

P Value

Polypharmacy n(%)

P Value**

Age

<65 years

65-70 years

70-75 years

> 75 years

107(57.8)

105(60.7)

67(65.7)

27(67.5)

0.488

3.40±1.32

3.17±1.20

4.18±1.17

5.25±1.48

<0.001

0.86±0.07

87±0.07

0.87±0.08

0.80±0.1

<0.001

57(30.8)

68(39.3)

41(40.2)

18(45)

0.039

Sex

Male

Female

129(57.8)

177(63.9)

0.167

3.74±1.45

3.54±1.34

0.108

0.88±0.07

0.85±0.08

<0.001

79(35.4)

105(37.9)

0.568

Education

Less educated

Diploma

Associate

Degree

Bachelor's degree

MSc

Ph.D

135(61.4)

99(63.5)

24(64.9)

41(56.2)

5(50)

2(50)

0.84

3.69±1.4

3.48±1.45

3.54±1.16

3.69±1.36

4.1±1.37

4.5±1.73

0.414

0.85±0.09

0.87±0.07

0.88±0.07

0.87±0.07

0.87±0.05

0.93±0.01

0.09

220(40)

156(31.2)

37(7.4)

73(14.6)

10(2)

4(0.8)

0.190

Number of Doctors

1-3

4-6

101(33)

156(76.8)

49(76.6)

<0.001

3.24±1.19

3.77±1.39

4.59±1.60

<0.001

0.88±0.07

0.86±0.07

0.81±0.09

<0.001

23(9.9)

65(32)

35(54.7)

<0.001

* Potentially Inappropriate Medication

Continuous data as mean±SD and categorical data as frequency (percentage). *obtained from chi-square test or independent samples t-test/ANOVA.

Table 3. The relationship between polypharmacy and PIM, comorbidity and quality of life in study participants

Variable

PIM Use*

Yes n(%) No n(%)

P Value

Comorbidity

P Value

Quality of Life

P Value**

Polypharmacy

Yes

168(91.3) 16(8.7)

138(43.7) 178(56.3)

<0.001

4.3±1.41

3.22±1.22

<0.001

0.75±0.15

0.79±0.16

0.005

* Potentially Inappropriate Medication

Continuous data as mean±SD and categorical data as frequency (percentage). *obtained from chi-square test or independent samples t-test.

Table 4. Relationship between Determinants of PIM in study participants

P Value*

Potentially inappropriate medication )PIM(

Variable

<0.001

n=194

Yes

n=306

Mean

0.89±(0.07

0.84±0.07

<0.001

0.04

0.726

0.84±0.07

0.85±0.07

0.85±0.08

0.81±0.09

0.9±0.06

0.9±0.07

0.8±0.11

<65 years

65-70 years

70-75 years

> 75 years

age

0.02

<0.001

0.9±0.07

.89±0.07

0.87±0.07

0.83±0.07

Male

Female

sex

<0.001

0.03

0.07

0.01

0.38

0.88±0.08

0.90±0.07

0.91±0.05

0.90±0.06

0.91±0.04

0.92±0.01

0.83±0.08

0.85±0.06

0.86±0.08

0.85±0.07

0.83±0.03

0.93±0.01

Secondary school

diploma

Associate degree

Bachelor's degree

MSc

P.H.D

education

<0.001

0.007

0.12

0.90±0.07

0.89±0.06

0.84±0.09

0.85±0.07

0.80±0.09

1-3

4-6

Number of doctors

Continuous data as mean±SD and categorical data as frequency (percentage). *obtained from independent samples t-test or chi-square test.

Table 5. Relationship between PIM and comorbidity with Quality of life

P Value

Standardized coefficient

95% confidence

Regression coefficient (standard error)

Predictors

<0.001

- 0.135

- 0.060

(- 0.055 _ , - 0.026)

(- 0.044 _ , - 0.016)

- 0.044(0.007)

- 0.03(0.007)

Unadjusted

Adjusted

PIM(Use versus not Use)

<0.001

- 0.117

- 0.074

(- 0.018 _ , - 0.018008)

(- 0.004 015 _ , - 0.004)

- 0.013(0.025)

- 0.009(0.0027)

Unadjusted

Adjusted

Comorbidity

Adjustment was made for confounding variables including , age, sex, education, number of physician visiting elderly people

No competing interests reported.

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Editorial decision: Revision requested
01 Jul, 2024
Editor assigned by journal
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Submission checks completed at journal
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Potentially Inappropriate Medication Use, Comorbidity and Quality of Life in Community-Dwelling Older People: A Cross-Sectional Study in Iran

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