Use of psychoactive drugs and related falls among older people living in a community in Brazil
Uso de medicamentos psicoativos e seu relacionamento com quedas entre idosos
Flávio Chaimowicza, Teresinha de Jesus Xavier Martins Ferreirab and Denise Freire Assumpção Miguelb
aDepartamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil. bPrograma de Saúde da Família de Campo Belo. Campo Belo, MG, Brasil
Aged#. Accidental falls#. Psychotropic drugs#. Aging health. Mental health. Psychotropic drugs, therapeutic use.
Idoso#. Acidentes por quedas#. Psicotrópicos, efeitos adversos#. Saúde do idoso. Saúde mental. Psicotrópicos, uso terapêutico.
As a result of the changing in mortality and fertility patterns in recent decades in Brazil, it is estimated that the population (65+) will grow from 2.7% in 1960 to 14.0% before 2050, an increase three-times faster than that seen in most developed countries.4 The rising prevalence of chronic diseases and physical disability observed in those countries has also been verified in studies performed in large Brazilian cities.6,12,15
In this age group, neurodegenerative diseases (e.g. Parkinson's or Alzheimer's diseases) and affective disorders (e.g. anxiety, depression) cause a high prevalence of mental health problems, which leads to increased use of psychoactive drugs.6,9,12,15 Signs and symptoms of these conditions in older people are often misinterpreted, sometimes leading to incorrect therapeutic approaches and the related adverse effects.4,5,11
The purpose of this retrospective study is to ascertain whether there is an association between falls and psychoactive medication use in older residents living in a community in Brazil. By including the entire population of one neighbourhood of a small municipality (population of 48,000), it is possible to assume that the conclusions drawn here may be valid for similar municipalities.
Between August and December 1998, using the records of the Family Health Program, all residents of the Arnaldos neighbourhood (Campo Belo, MG) were invited to the community health center to undergo a clinical evaluation. Residents unable to come to the clinic were evaluated in their homes.
A standardized questionnaire was administered, including the following questions:
1. What medications have you been taking lately?
2. Have you used these medications continuously?
3. Did a doctor prescribe these medications?
4. Have you fallen down in the last 12 months?
5. If yes, did you break any bones?
Answers were given by the older subjects themselves and with the aid of their caregivers when necessary.
The data were entered into the statistical program Epi Info 6, version 6.04b, 1997 and analyzed in Epi Info and Minitab for Windows, version 10.2, 1994.* Subjects were grouped according to the use of any psychoactive medication or use of specific agent classes (e.g. antidepressants, benzodiazepines, anticonvulsants). The comparison between dichotomous variables (falls) from independent groups (use of psychoactive medications) was performed using the two-tailed Fisher's exact test (since the expected number of elements in a cell of a 2x2 table was less than five). The relative contribution of intervening factors (gender, age, vision, hearing, and use of psychoactive medication) for a specific response (falls) was analyzed through multiple linear regression. The statistical significance level was established at 0.05.
Among the 1,024 families of the Arnaldos neighbourhood (4,010 individuals; 8.3% of the municipality) there were 161 older people (4.0%), all of which were evaluated in the study (Table 1). Vision and hearing were considered adequate in 115 (71.4%) and 132 (82.0%) subjects, respectively. According to reports given by the subjects and their caregivers, in the 12-month period preceding the study, 27 (16.8%) experienced at least one fall and, of those, 4 (14.8%) had fracture(s).
Table 2 lists the psychoactive medications used regularly by the study subjects. Among the 161 older people, 21 (13.0%) regularly used prescribed anxiolytics, antidepressants and/or anticonvulsants. This number increased to 32 (19.9%) when the central-acting antihypertensive a-methyldopa was included, to 41 (25.5%) when cinnarizin and flunarizin were also considered and totalled 42 (26.1%) when codergocrine was included.
All anxiolytics (except buspirone in one case) were intermediate or long-acting benzodiazepines and were used regularly by 15 (9.3%) individuals. Antidepressants (tricyclics and tetracyclics) were used regularly by four study participants (2.5%), and anticonvulsants by five (3.1%). No subject or caregiver reported use of neuroleptics or drugs to treat Alzheimer's or Parkinson's diseases (except one case of biperiden). The antihypertensive a-methyldopa was used by 13 (8.0%) subjects.
To assess the occurrence of falls, use of cinnarizin, flunarizin and/or codergocrine was excluded from the analysis. There was an association between falls and the use of psychoactive medications (two-tailed Fisher's exact test: p=0.05, Table 3). Multiple linear regression analysis between the response falls and the variables age, gender, vision, hearing and psychoactive drug use revealed that, of all the variables, only psychoactive drug use was independently associated with falls (t=2.45; p=0.02). An independent association was also observed between falls and the variable use of benzodiazepine (t=1.97; p=0.05) or the variable use of benzodiazepine and/or antidepressant (t=2.23; p=0.03). However, no association was found between falls and the variable use of a-methyldopa, when the above-mentioned variables were controlled.
Prevalence of neuropsychiatric disorders in older Brazilians
Some studies have shown that in Brazil, as well as in many other countries, the population aging process has been associated with an increase in the prevalence of mental and affective disorders.9
In one municipality of the State of S. Paulo, the prevalence of dementia almost reached 40% in the 85+ age group.8 In a random sample (n=625) of older people in a municipality of the State of Minas Gerais,6 33% of the sample participants complained of "anxiety", whereas 32% reported "depression". Other large community-based studies also revealed a high prevalence of these disorders among random samples of older people. In Rio de Janeiro, the prevalence of "mild depression" ranged between 20% and 35%15 and in S. Paulo 23% of the women studied were considered possible cases of "psychiatric disorders".12
Sleep disorders are also highly prevalent among older people (41% in one study mentioned above),6 not only because of their association with dementia, anxiety and depression, but also due to age-related co-morbidities and changes in sleep patterns.9 Delirium episodes in older people are provoked by diverse causes, such as erysipelas or heart failure and frequently are not diagnosed.5 Psychotic symptoms such as agitation, delusions, hallucinations and aggressive behaviour often prove to be extremely difficult for families to cope with and are among the most common causes of institutionalization.
Use of psychoactive drugs and falls
Since older people are more vulnerable to adverse effects of psychoactive drugs,1,11 their use requires accurate diagnosis and knowledge of age-related pharmacokynetics and pharmacodynamics. However, underdiagnosis of mental and affective disorders in older people is as common as their inadequate diagnosis and treatment.5,9
As presented in Table 4, many of the psychoactive drugs used by older residents of Arnaldos neighbourhood increase the risk of falls11 by acting on the cardiovascular system (orthostatic hypotension) or the central nervous system (impairment of vision, proprioception, balance, coordination and cognition, lethargy, psychomotor slowing, ataxia and delirium). This study demonstrated that, controlling variables such as age, gender, vision and hearing, the use of these drugs is independently associated with falls.
The incidence of falls increases with age. Approximately one-third of the older subjects living in the community suffer a fall each year, and nearly 5% of those suffer fractures ¾ 20% to 40% of which occur in the femur.2 After a femur fracture, 25% of them die within six months; two-thirds of those surviving experience persistent leg pain or swelling and only a minority regain pre-fracture functional levels. So there is an increasing risk of institutionalization.2 In this study, the incidence of falls was less than expected (16.8%) while that of fractures was more than expected (14.8% of those who had fallen). This is partly explained by memory bias: retrospective studies can underestimate the incidence of falls but not of fractures by 13% to 32%, depending on the elapsed time.2
The data gathered here suggest that improper prescription practices may be common. The drugs of choice to treat chronic anxiety disorders and sleep disorders in older patients are azapirones and short-acting benzodiazepines, respectively1,10 but all except one resident (a buspirone user) were being prescribed long-acting benzodiazepines. Antidepressants, besides being apparently underutilized, belong to agent classes that do not represent the best options for older individuals.7
Drugs of disputed therapeutic efficacy (cinnarizin, flunarizin and codergocrine), some of that may cause secondary parkinsonism,3 were widely prescribed, even though the only drug used to treat Parkinson's disease is not appropriate for older patients. Since no antipsychotic drugs or drugs to treat Alzheimer's disease were being used by this population, it is important to consider whether the psychiatric manifestations of these common conditions were being treated with benzodiazepines or even barbiturates.
The population of Arnaldos neighbourhood must be considered a young population since older residents account for less than 4% of the total. However, it seems that some of the public health problems characteristic of aged populations are already present in this community. The increasing prevalence of neuropsychiatric problems related to aging, coupled with the difficulties in accurately diagnosing and correctly treating these conditions may be responsible for the high level of psychoactive drug use.
The retrospective nature of this study does not allow causal inferences, but evidence of the independent association between use of psychoactive drugs and falls has been consistently demonstrated in studies performed in so-called "aged populations".
By Studying the entire population of older residents of the Arnaldos neighbourhood the findings reported here have a significant external validity. Addressing the problems of Campo Belo and other similar municipalities should not only be cost-effective ¾ considering the high costs of treatment and rehabilitation of fractures ¾ but, more importantly, should contribute to improving the disability-free life expectancy and quality of life of the older population.
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Departamento de Clínica Médica
Faculdade de Medicina da UFMG
Av. Alfredo Balena, 190
30130-100 Belo Horizonte, MG, Brasil
Submitted on 19/8/1999. Reviewed on 2/6/2000. Approved on 26/7/2000.
*Minitab Inc. 3081 Enterprise Drive. State College, PA 16801-3008, USA.