Abstracts

INTRODUCTION

The demographic and epidemiological scenario in Brazil, characterized by a progressive increase in life expectancy¹1 . Veras R. Envelhecimento populacional e as informações de saúde do PNAD: Demandas e Desafios Contemporâneos. Cad Saúde Pública 2007; 23(10): 2463-6. and the high prevalence of Chronic Non-Communicable Diseases (NCDs)²2 . Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. In: Victora CG et al. Saúde no Brasil: a série The Lancet. Rio de Janeiro: Fiocruz; 2011. p. 61-74., many of them concurrent³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8., entailed the use of various medications.

Polypharmacy (consumption of five or more concomitant medications) constitutes a common practice among the elderly, whose prevalence in Brazilian studies ranges from 5% to 27%⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64.

7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9.

8 . 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.

9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53.

10 . Loyola-Filho AI, Uchôa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22(12): 2657-67.

11 . Carvalho MFC. A polifarmácia em idosos do Município de São Paulo: Estudo SABE - Saúde, Bem-estar e Envelhecimento (dissertação de mestrado). São Paulo (SP): Faculdade de Saúde Pública da USP; 2007.

12 . Marin MJS, Cecílio LCO, Perez AEWVF, Santella F, Silva CBA, Roceti LC. Caracterização do uso de medicamentos entre idosos de uma unidade do Programa Saúde da Família. Cad Saúde Pública 2008; 24(7): 1545-55. ^{- 13}13 . Duarte LR, Gianini RJ, Ferreira LR, Camargo MAS, Galhardo SD. Hábitos de consumo de medicamentos entre idosos usuários do SUS e de plano de saúde. Cad Saúde Colet 2012; 20(1): 64-71.. Among the factors associated with this practice are: being female⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 12}12 . Marin MJS, Cecílio LCO, Perez AEWVF, Santella F, Silva CBA, Roceti LC. Caracterização do uso de medicamentos entre idosos de uma unidade do Programa Saúde da Família. Cad Saúde Pública 2008; 24(7): 1545-55. ^{, 13}13 . Duarte LR, Gianini RJ, Ferreira LR, Camargo MAS, Galhardo SD. Hábitos de consumo de medicamentos entre idosos usuários do SUS e de plano de saúde. Cad Saúde Colet 2012; 20(1): 64-71., aged ≥ 80 years⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 10}10 . Loyola-Filho AI, Uchôa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22(12): 2657-67., presenting a regular self-assessment of health¹⁴14 . Lima-Costa MF, Firmo JOA, Uchoa EA. A estrutura da autoavaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38(6): 827-34., chronic diseases⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 11}11 . Carvalho MFC. A polifarmácia em idosos do Município de São Paulo: Estudo SABE - Saúde, Bem-estar e Envelhecimento (dissertação de mestrado). São Paulo (SP): Faculdade de Saúde Pública da USP; 2007. and number of medical visits in the previous year⁷7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 8}8 . 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.. The growth of the pharmaceutical industry and the marketing of medications can also contribute to increased prescription by health professionals, enabling the use of multiple medications by the elderly⁴4 . Secoli SR. Polifarmácia: interações e reações adversas no uso de medicamentos por idosos. Rev Bras Enferm 2010; 63(1): 136-40. ^{, 5}5 . Rozenfeld S. Prevalência, fatores associados e mau uso de medicamentos entre os idosos: uma revisão. Cad Saúde Pública 2003; 19(3): 717-24..

Among these factors that contribute to polypharmacy, chronic diseases have greater relevance and association. Although pharmacological treatment is important for the control of chronic diseases, non-pharmacological treatment such as changes in lifestyle, especially diet therapy, it is essential for treating adults and older adults with such illnesses¹⁵15 . Sociedade Brasileira de Cardiologia. Departamento de aterosclerose da Sociedade Brasileira de Cardiologia. IV Diretrizes Brasileiras sobre Dislipidemias e Prevencão da Aterosclerose. Arq Bras Cardiol; 2007; 88(Suppl.1): 1-19. ^{, 16}16 . Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(Suppl.1): 1-51. However, few studies have examined the relationship between polypharmacy and nutritional markers in the elderly, such as nutritional status, body fat, food intake and diet therapy¹⁷17 . Jyrkkä J, Mursu J, Enlund H, Lönnroos E. Polypharmacy and nutritional status in elderly people. Curr Opin Clin Nutr Metab Care. 2012; 15(1): 1-6. ^{, 18}18 . Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults: a cross-sectional study. Drugs Aging. 2011; 28(4): 315-23.. The high prevalence of chronic diseases³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8. in the elderly may require nutritional treatment with the prescription of a diet and of some specific foods¹⁵15 . Sociedade Brasileira de Cardiologia. Departamento de aterosclerose da Sociedade Brasileira de Cardiologia. IV Diretrizes Brasileiras sobre Dislipidemias e Prevencão da Aterosclerose. Arq Bras Cardiol; 2007; 88(Suppl.1): 1-19. ^{, 16}16 . Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(Suppl.1): 1-51, being relevant to study their association with polypharmacy. Therefore, the aim of this study was to investigate the association of nutritional markers, presence of chronic diseases, sociodemographic and health variables with polypharmacy in community-dwelling elderly, and to estimate their prevalence.

METHODOLOGY

This is a cross-sectional study, from a matrix project called The Seniors Project/Goiania, which evaluated health and nutrition in elderly users of the Unified Health System (SUS) in Goiânia (GO)³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8. ^{, 19}19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602. ^{, 20}20 . Pagotto V, Silveira EA, Velasco WD. Perfil das hospitalizações e fatores associados em idosos usuários do SUS. Ciênc Saúde Coletiva 2013; 18(10): 3061-70. ^{, 21}21 . Pagotto V, Silveira EA. Applicability and agreement of different diagnostic criteria for sarcopenia estimation in the elderly. Arch Gerontol Geriatr 2014; 59: 288-294.. This study was approved by the Research Ethics Committee of Universidade Federal de Goiás (CEP/UFG) and everyone who agreed to participate signed an informed consent form (ICF).

In total, 418 seniors were included through a probabilistic sampling, which was proportional to the nine health districts in the city of Goiânia. This sample size was defined by the following parameters: 13% prevalence of diabetes mellitus (outcome of lower prevalence in the matrix study); power of 80%, confidence level of 95%; and ratio of exposed to unexposed 1:2; prevalence ratio of 2. As the prevalence of polypharmacy is superior to the outcome used in the calculation, the sample of The Senior Project/Goiânia is sufficient to ensure the validity of the study, in addition to providing greater statistical power.

Data collection was conducted in the homes of the elderly between November 2008 and March 2009. Sampling procedures in multiple stages, pilot study, staff training, data collection instruments, standardization of anthropometrists, anthropometric techniques²²22 . Lohman TG, Roache, AF. Anthropometric standardization reference manual. Illinois: Human Kinetics Books; 1992. and other methodological information are already described in other publications³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8. ^{, 19}19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602. ^{, 20}20 . Pagotto V, Silveira EA, Velasco WD. Perfil das hospitalizações e fatores associados em idosos usuários do SUS. Ciênc Saúde Coletiva 2013; 18(10): 3061-70..

At the end of data collection, the checking and coding of questionnaires was carried out, followed by a double entry for internal consistency analysis in the software Epi Data version 3.1.

The outcome variable in this study was polypharmacy, defined as the concomitant use of five or more drugs⁴4 . Secoli SR. Polifarmácia: interações e reações adversas no uso de medicamentos por idosos. Rev Bras Enferm 2010; 63(1): 136-40. ^{, 6}6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9.. The variable was dichotomized as yes (use of 5 or more medications) and no (use of 0 - 4 medications). Medication use was assessed by the response of the elderly to the question: "What drugs do you usually take every day?" Furthermore, the elderly were asked to show the recipe and packaging of the drug used, and 100% of them presented both to the interviewer. In the questionnaire, the interviewer would take note of the active ingredient to further classify them according to the reference of the Anatomical-Therapeutic-Chemical Classification System (ATC), a method for classification of pharmaceutical substances (active ingredient) developed by the WHO Collaborating Centre for Drug Statistics Methodology²³23 . WHO Colaboranting Center for drug statistics methodology. Guidelines for ATC classification and DDD assignment. Oslo: World Health Organization; 2007..

The following exposure variables were studied: sociodemographic variables (gender, age, skin color, living with a partner, years of education, and socioeconomic status), nutritional markers (nutritional status, waist circumference, body fat percentage, weight gain and loss, being on a diet, daily consumption of fruits, intake of vegetables, daily intake of skimmed and whole milk), chronic diseases and other health conditions (self-assessed health, hospitalization in the previous year).

The economy class variable was categorized as A/B, C, D/E, according to the Brazilian Association of Population Studies (ABEP)²⁴24 . Associação Brasileira das Empresas de Pesquisa (ABEP). Critério de Classificação Econômica Brasil. 2008. Disponível em: http://www.abep.org/novo/Utils/FileGenerateashx?id=12 (Acessado em março de 2009).
http://www.abep.org/novo/Utils/FileGener... , whose classification takes into consideration durable items of household and level of education of household head.

Nutritional status was defined by the Body Mass Index (BMI) from weight and height measured. The elderly were classified as underweight (BMI < 22.0 kg/m²) normal weight (BMI 22.0 to 27.0 kg/m²) and obese (BMI > 27.0 kg/m²)²⁵25 . Lipschitz DA. Screening for nutritional status in the elderly. Prim Care 1994; 21(1): 55-67. ^{, 26}26 . Silveira EA, Kac G, Barbosa LS. Prevalência e fatores associados à obesidade em idosos residentes em Pelotas, Rio Grande do Sul, Brasil: classificação da obesidade segundo dois pontos de corte do índice de massa corporal. Cad Saúde Pública 2009; 25(7): 1569-77.. Waist circumference (WC) was classified according to the cutoff points proposed by the World Health Organization (WHO): increased WC (between 80 - 88 cm for women and 94 - 102 cm for men); greatly increased WC (> 102 cm for men and > 88 cm for women)²⁷27 . World Health Oranization Technical Report Series. Obesity: preventing and managing the global epidemic. Geneva: World Health Organization; 2000. p. 9-11..

The percentage of body fat was assessed using the protocol of the sum of four skin folds. We used the equation of body density of Durnin and Womersley²⁸28 . Durnin JGA, Womersley J. Body fat assessed from total body density and its estimation from skinfold tickness: measurements on 481 men and women age from 16 to 72 years. Br J Nutr 1974; 32(1): 77-97. (1974): D (g/cm³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8.) = 1.1339 - 0.0648 x log (å 4DC) and, for conversion of body density in body fat percentage, the Siri equation²⁹29 . Siri SE. Body composition from fluid spaces and density: analysis of methods. In: Brozek J, Henschel A. Techniques for Measuring Body Composition. Washington: National Academy of Sciences-National Research Council; 1961. p. 223-44. (1961) was applied: %G = (495/D) - 450. To sort the percentage of fat in excessive adiposity, the Gallagher proposition was used³⁰30 . Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto Y. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr 2000; 72(3): 694-701., whose cutoff points for seniors are 42% for women and 30% for men.

For the classification of the daily consumption of fruits, vegetables, skim and whole milk, we analyzed the consumption once a day item from the Food Frequency Questionnaire (FFQ). These variables were classified as yes (consumption at least 1 time a day) and no (does not consume at least 1 time a day). Being on a diet was assessed through the question: "Do you follow a diet or any other food recommendation?"

Chronic diseases were identified through the responses to the question: "Which diseases the doctor has said that you have?" Later, they were classified as chronic or not and categorized numerically: 0 - 1; 2; > 3. Self-assessment of health was assessed by the question: "What do you think of your health in the past month", whose response options were: "very good", "good", "fair", "poor", "terrible"¹⁹19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602..

Data were analyzed using STATA 8.0^(r) software. A descriptive analysis of the types and classes of most commonly prescribed drugs was carried out. To evaluate the association between polypharmacy and the exposure variables, simple Poisson regression was performed with their respective confidence intervals (95%CI). The χ² test for linear trend was also applied. Multivariate analysis was performed hierarchically in three levels: Level 1 - sociodemographic variables; Level 2 - nutritional markers; Level 3 - chronic diseases and other health variables. All variables that showed p-values lower than 0.20 in the bivariate analysis were included in the model.

RESULTS

The final sample of The Senior Project/Goiânia consisted of 418 elderly, 66% females, 48.5% aged 60 - 69 years and 46.9% belonged to class C. The prevalence of polypharmacy was 28.0% (95%CI 23.1 - 32.5) and was significantly higher in eutrophic and obese females (32.7%), aged 75 - 79 years, in the presence of 2 chronic diseases and/or 3 chronic diseases and terrible self-assessed health (Figure 1). The average intake of medications was of 3.7 (± 2.4), with a maximum of 12 drugs per individual. Most used drug classes were: cardiovascular (49.2%), alimentary tract and metabolism (18.0%) and central nervous system (12.2%) (Figure 2).

The variables that were associated with polypharmacy in the bivariate analysis were: female gender (OR = 1.76; 95%CI 1.14 - 2.73) (Table 1), terrible self-assessed health (OR = 2.86; 95%CI 1.63 - 5.08), hospitalization in the previous year (OR = 1.57; 95%CI 1.07 - 2.31), presence of two chronic diseases (OR = 3.20; 95%CI 2.12 - 4.83) and three or more chronic diseases (OR = 3.85; 95%CI 2.29 - 6.48) (Table 2).

Regarding nutritional markers, the bivariate analysis also showed an association between polypharmacy and nutritional status in the eutrophic (OR = 2.28; 95%CI 1.07 - 4.86) and obese (OR = 2.67; 95%CI 1.28 - 5.55) categories; greatly increased waist circumference (OR = 2.24; 95%CI 1.29 - 3.89); being on a diet (OR = 2.19; 95%CI 1.48 - 3.23); daily intake of skimmed milk (OR = 1.70; 95%CI 1.10 - 2.63) (Table 2).

After hierarchical multivariate analysis (Table 3), the following factors remained associated with polypharmacy: being female (OR = 1.76; 95%CI 1.21 - 2.65), aged 75 - 79 years (OR = 1.98; 95%CI 1.03 - 3.79), being eutrophic (OR = 2.17; 95%CI 1.11 - 4.27) and obese (OR = 2.41; 95%CI 1.24 - 4.70 ), being on a diet (OR = 2.09; 95%CI 1.49 - 2.92), terrible self-assessed health (OR = 1.96; 95%CI 1.25 - 3.09), presence of two chronic diseases (OR = 2.76; 95%CI 1.92 - 3.96) and three or more chronic diseases (OR = 2.73; 95%CI 1.77 - 4.20).

DISCUSSION

The use of medicine is a common practice among the elderly, given that, in this study, 72% used one or more drugs and the prevalence of polypharmacy was 28%. These findings are superior to studies already developed in Brazil⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 10}10 . Loyola-Filho AI, Uchôa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22(12): 2657-67., but similar to the results of Bambuí Project⁹ 9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53.and Porto Alegre⁷7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9.. Some factors may contribute to the high consumption of drugs, such as low frequency of use of non-pharmacological treatments for chronic diseases and/or other health problems, as well as easy access to medications⁷7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9.. In addition to these factors, in some cases, in an attempt to alleviate symptoms or have faster response compared to non-pharmacological therapies, practitioners prescribe drugs in a distorted or impulsive manner, which can contribute to the unnecessary use of drugs and increase the number of drugs consumed by the elderly⁵5 . Rozenfeld S. Prevalência, fatores associados e mau uso de medicamentos entre os idosos: uma revisão. Cad Saúde Pública 2003; 19(3): 717-24.. One of the consequences of the use of multiple drugs is the increased risk of Adverse Drug Reactions (ADR), which in turn, increases the morbidity and mortality among the elderly⁴4 . Secoli SR. Polifarmácia: interações e reações adversas no uso de medicamentos por idosos. Rev Bras Enferm 2010; 63(1): 136-40..

The most frequently used medications were the ones that act on the cardiovascular system, followed by those that act on the digestive system, metabolism and central nervous system, which is consistent with findings of previous studies⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64.

7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9.

8 . 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.

9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53.

10 . Loyola-Filho AI, Uchôa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22(12): 2657-67. ^{- 11}11 . Carvalho MFC. A polifarmácia em idosos do Município de São Paulo: Estudo SABE - Saúde, Bem-estar e Envelhecimento (dissertação de mestrado). São Paulo (SP): Faculdade de Saúde Pública da USP; 2007. ^{, 19}19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602.. These findings are consistent with the epidemiological profile of Chronic Noncommunicable Diseases (NCDs) in Brazil²2 . Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. In: Victora CG et al. Saúde no Brasil: a série The Lancet. Rio de Janeiro: Fiocruz; 2011. p. 61-74. and the high prevalence of cardiovascular risk factors among the elderly in this study, as discussed above³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8.. Older people commonly complain of insomnia, anxiety and confusional states, contributing to high rates of prescription drugs acting on the central nervous system⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64.. The consumption of drugs that act on the digestive tract observed in this and other studies⁷7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 8}8 . 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. may be related to the need to alleviate symptoms in the gastric mucosa caused by excessive use of drugs as a result of polypharmacy itself. It is noteworthy that some drugs can cause gastric symptoms, such as anti-inflammatory drugs, which cause irritation and gastric ulcer, and anticholinergics, which reduce the motility of the gastrointestinal tract⁴4 . Secoli SR. Polifarmácia: interações e reações adversas no uso de medicamentos por idosos. Rev Bras Enferm 2010; 63(1): 136-40.. In this study, the profile of chronic disease and the predominant drug classes demonstrate that polypharmacy in the elderly may be related to long-term treatments, suggesting a continuity of practice in later years, which requires attention and continuous monitoring by health professionals.

Women had 1.76 times higher prevalence of polypharmacy than men, corroborating results from other studies⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 12}12 . Marin MJS, Cecílio LCO, Perez AEWVF, Santella F, Silva CBA, Roceti LC. Caracterização do uso de medicamentos entre idosos de uma unidade do Programa Saúde da Família. Cad Saúde Pública 2008; 24(7): 1545-55.. Considering the current demographic and epidemiological scenario, women have a high prevalence of diseases, longer life expectancy than men¹1 . Veras R. Envelhecimento populacional e as informações de saúde do PNAD: Demandas e Desafios Contemporâneos. Cad Saúde Pública 2007; 23(10): 2463-6. and a different attitude towards the disease, as they report signals and symptoms with higher frequency and use more health services, being, therefore, more subject to medicalization⁷7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. _.

This study also supports the majority of epidemiological studies that demonstrate significant increase in the use of drugs with advancing age⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 10}10 . Loyola-Filho AI, Uchôa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22(12): 2657-67., with a higher prevalence of polypharmacy in the 75 - 79 years age group. However, a low prevalence of polypharmacy was observed in the 80 years or older age group. With increasing life expectancy, the 80 years or more age group, has been considered a distinct age group. It is suggested that future research investigate the medicinal practices in this age group.

Among the variables related to health status, a terrible health self-assessment and the presence of two or more chronic diseases had statistically significant associations with polypharmacy, as described in previous studies⁶6 . Coelho-Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saúde Pública 2004; 38(4): 557-64. ^{, 7}7 . Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública 2005; 39(6): 924-9. ^{, 9}9 . Loyola-Filho AI, Uchôa E, Firmo JOA. Estudo de base populacional sobre o consumo de medicamentos entre idosos: Projeto Bambuí. Cad Saúde Pública 2005; 21(2): 545-53. ^{, 11}11 . Carvalho MFC. A polifarmácia em idosos do Município de São Paulo: Estudo SABE - Saúde, Bem-estar e Envelhecimento (dissertação de mestrado). São Paulo (SP): Faculdade de Saúde Pública da USP; 2007. ^{, 14}14 . Lima-Costa MF, Firmo JOA, Uchoa EA. A estrutura da autoavaliação da saúde entre idosos: projeto Bambuí. Rev Saúde Pública 2004; 38(6): 827-34. ^{, 19}19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602.. This is an expected result, given that the elderly who have multiple illnesses can use multiple drugs and consequently self-assess their health as poor/terrible. Self-assessment of health expresses the perception of the subject based on interpretations of physical, cognitive and emotional health, as well as their expectations and their references for comparison¹⁹19 . Pagotto V, Nakatani AYE, Silveira EA. Fatores associados à autoavaliação de saúde ruim em idosos usuários do Sistema Único de Saúde. Cad Saúde Pública 2011; 27(8): 1593-602.. Thus, the routine use of medications, including timetables, route of administration, drug and correct dose and the amount of medications consumed can contribute to a feeling of lack of health and consequent poor/terrible health self-assessment. The presence of multiple diseases, potential drug interactions or adverse effects may enhance the self-reported poor/terrible health. These findings reaffirm the need for health professionals to use non-pharmacological treatments and in health education activities, which, in turn, may contribute to the reduction of polypharmacy and to a better health perception.

As for nutritional markers, it was observed that, with increasing BMI, the prevalence of polypharmacy also increases. A review study¹⁸18 . Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults: a cross-sectional study. Drugs Aging. 2011; 28(4): 315-23. demonstrated the existence of association between polypharmacy and nutritional status, but with controversy, because, in some studies, polypharmacy was associated with weight loss and, in others, with obesity. However, studies¹⁸18 . Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults: a cross-sectional study. Drugs Aging. 2011; 28(4): 315-23. show greater consistency in the association between polypharmacy and obesity, corroborating the findings of this research. The hypothesis for this association is based on the knowledge that obesity is a risk factor for the occurrence of comorbidities such as diabetes and hypertension, as well as hampering the control of blood glucose and blood pressure levels³3 . Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de Fatores de Risco Cardiovascular em Idosos Usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol 2010; 95(5): 621-8., and therefore, the use of medications is necessary¹⁵15 . Sociedade Brasileira de Cardiologia. Departamento de aterosclerose da Sociedade Brasileira de Cardiologia. IV Diretrizes Brasileiras sobre Dislipidemias e Prevencão da Aterosclerose. Arq Bras Cardiol; 2007; 88(Suppl.1): 1-19. ^{, 16}16 . Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(Suppl.1): 1-51.

The reduction in BMI, regardless of the use of drugs, leads to the lowering of blood pressure and blood glucose. Thus, the non-pharmacological treatment including diet therapy (or nutritional treatment) is an important therapeutic approach to control these chronic diseases¹⁵15 . Sociedade Brasileira de Cardiologia. Departamento de aterosclerose da Sociedade Brasileira de Cardiologia. IV Diretrizes Brasileiras sobre Dislipidemias e Prevencão da Aterosclerose. Arq Bras Cardiol; 2007; 88(Suppl.1): 1-19. ^{, 16}16 . Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(Suppl.1): 1-51 _. In this research, there was an association between diet and use of polypharmacy, which may indicate that the elderly received dietotherapeutic prescription due to the presence of chronic diseases, that is, received pharmacological and non-pharmacological treatment. It is noteworthy that the elderly were not asked about the dietotherapeutic prescription, therefore, this was a self-reported information. It is noteworthy that the elderly who participated in this research are the users of the Unified Health System (SUS), and the primary health care network in the municipality is composed of a multidisciplinary team, including nutritionists, who perform individual consultations and health and nutrition education groups. This may have facilitated the access of seniors to information about the importance of using diet to treat diseases.

The dietary intake variables did not remain significantly associated with polypharmacy after adjustments in the final multivariate regression. It is, however, relevant information that this research presents, because other data that evaluated the association between dietary intake and polypharmacy were not located.

Due to the cross-sectional design, this study is not adequate to test relationships between causes and effects, since they presuppose guarantee that selected variables precede the outcome in time. However, it can be observed that there is an association between polypharmacy and the variables described above, which in itself reflects important links between the patient characteristics and use of medications. On the other hand, some measures were taken to ensure the quality of information: training and standardization of evaluators, pilot study and calibration of equipment. Data on medications were also carefully collected to ensure the accuracy and validity of results.

CONCLUSION

This study showed an association between polypharmacy and eutrophic and obese females in the 75 - 79 years age range, who were on a diet, had a poor health self-assessment, and presented two, three or more chronic diseases.

Studies like this are important because they signal reflections on the need for reorientation of pharmaceutical care and the adoption of non-pharmacological treatments among the elderly population. In addition, they guide the actions of all health professionals to make drug therapy more efficient in internal and external contexts of SUS. Nutritional guidelines aimed at improving eating habits for the control of diseases, education for the family, carers and the elderly themselves about the effects of polypharmacy and the qualification of the professionals as to prescription are possibilities of prevention of polypharmacy and hence of possible drug interactions.

It is recommended that further studies on polypharmacy are developed with an emphasis on nutritional aspects, mainly cohort, to advance and enhance non-pharmacological strategies that are effective and accessible to the elderly.

REFERENCES

Publication Dates

History