PRESCRIPTION DRUG USE AND ITS IMPACT ON THE ELDERLY’S HEALTH
Erika C. Navarro
B.A., California State University, Sacramento, 2009
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
PRESCRIPTION DRUG USE AND ITS IMPACT ON THE ELDERLY’S HEALTH
A Project
by
Erika C. Navarro
Approved by:
_________________________________________, Committee Chair
Kisun Nam, PhD.
Date: ____________________________
ii
Name of student: Erika C. Navarro
I certify that this student has met the requirements for format contained in the
University’s Format Manual, and that this Project is suitable for shelving in the
Library and credit is to be awarded for the project.
_______________________________, Graduate Coordinator _________________
Teiahsha Bankhead, PhD., LCSW
Date
Division of Social Work
iii
Abstract
of
PRESCRIPTION DRUG USE AND ITS IMPACT ON THE ELDERLY’S HEALTH
by
Erika C. Navarro
This project is undertaken in an effort to develop awareness among the community
regarding the elderly and their impacted health due to the excessive use of prescription
drugs. It is hoped that the information provided here will help in improving the health
conditions of the older adults and improve their quality of life. This project was
developed after reviewing relevant literature regarding the needs and special issues of
the elderly adults. This study employs quantitative research methods that rely on
secondary data analysis obtained from the Sacramento Area Latino Study on Aging
(SALSA), which gathered data from a sample of 1,789 participants. The data was
analyzed using multivariate analysis specifically, multivariate regression analysis to
understand the relationship between the dependent and independent variables. This
project’s findings indicate that the use of prescription drugs among the elderly has an
impact on all areas of their health, although the areas of mental health and physical
iv
abilities showed the strongest negative association.
While other areas, such as
cognitive functioning had a minor effect. Although prescription drugs are prescribed
to treat major ailments and complaints, the health care system lacks a tracking
protocol for prescription drugs for each patient and with multiple care providers; the
use of prescription drugs becomes more complex. The issues of ageism and the
society’s view of the elderly add to the reality of the problem. Further studies that
represent only this population are needed so that future planning and policy changes
reflect the issue of prescription drug use and its effects on the health of the elderly. It
is important to create awareness among the community in order to understand and
advocate for changes that benefit this population in regards to health care and social
services. It is imperative that social and human service professionals increase their
knowledge and awareness on this issue and how it influences the quality of life of the
elderly in order to develop appropriate interventions and treatment plans. Immediate
attention to this issue is due as the elderly population continues to grow and their
needs continue to be unmet.
________________________________________________, Committee Chair
Dr. Kisun Nam, PhD.
____________________
Date
v
DEDICATION
This project is dedicated to the people that have touched my life.
To the very young: my children, who are true miracles and my daily motivation,
Sergio, Daniel, and Sofia~ A ba du
To the young at heart: who instilled in me the love for story tellers and encouraged my
sense of curiosity, discovery, and learning.
To my loving Mamá Sara y Papá Nacho, Mi Yita, Mi Mamá Nacha,
Mi tía Socorro, and to Mica, who taught me about the beauty of life and who shared
their wisdom with me.
To Papá Reyes and Mamá Eliza that are the living links to my history.
This is for you.
~~~~
Este proyecto es dedicado a las personas que han influenciado mi vida.
A los más pequeños: mis hijos, Sergio, Daniel, y Sofia,
quienes son verdaderos milagros y mi motivación diaria
~ A ba du ~
A los jóvenes de corazón: quienes me enseñaron a disfrutar de sus historias y
animaban mi sentido de curiosidad, de descubrir cosas nuevas y el de aprender.
Para mi Mamá Sara y mi Papá Nacho, Mi Yita, Mi Mamá Nacha,
Mi tie Socorro: quienes me ensenaron sobre las cosas bellas de la vida y compartieron
sus sabiduría conmigo.
Para mi Papá Reyes y mi Mamá Eliza quienes son los latentes eslabones con mi
pasado
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ACKNOWLEDGMENTS
First, I want to thank God for allowing me and helping me achieve this goal.
I want to dedicate and acknowledge my husband, Sergio, for all the support, love,
encouragement he has given me since I embarked in this journey. Your respect and
pride in my passions has motivated me to continue to achieve and challenge the status
quo. Know that I love you and cherish you in my life. To my children whose loving
and patient nature allowed me to achieve this goal.
To all my family, in particular to my parents who brought me to this country
hoping to give me a better way of life, and to open the doorway to better opportunities.
I appreciate your love and support.
To my sisters Llecenia and Mari, and my brother Carlos, for supporting me
through my trials and tribulations in the past year with humor and words of
encouragement. Los quiero mucho.
To my fellow students: Rosanna, Elizabeth, Duane, and Maria Leon who
shared in the stress, excitement, frustrations, and jokes that normalized the experience
and kept us moving towards our goal. We did it!
To my teachers and professors, throughout my educational experience, who
always challenged me to reach for my dreams.
A special acknowledgement to my project advisor Dr. Kisun Nam for all his
time, patience, and kindness during the entire process. Thank you for being so
flexible, and supportive
TABLE OF CONTENTS
Page
Dedication.................................................................................................................... vi
Acknowledgments ...................................................................................................... vii
List of Tables ................................................................................................................ x
Chapter
1. THE PROBLEM ...................................................................................................... 1
Background of the Problem .............................................................................. 5
Statement of the Problem ................................................................................. 8
Purpose of the Study ......................................................................................... 8
Theoretical Framework .................................................................................... 9
Definition of Terms .................................................................................... … 11
Assumptions ................................................................................................... 12
Justifications ................................................................................................... 12
Limitations ...................................................................................................... 13
Organization ................................................................................................... 14
2. LITERATURE REVIEW ........................................................................................ 16
Prescription Drug Use .................................................................................... 16
Effects of Prescription Drug Use ..................................................................... 20
Factors Associated with Prescription Drug Use ............................................. 27
Other Issues Related to Prescription Drug Use .............................................. 31
Summary......................................................................................................... 35
3. METHODS ........................................................................................................... 39
Quantitative Research Design ........................................................................ 39
Variables .......................................................................................................... 40
Data Gathering and Analysis .......................................................................... 41
Protection of Human Subjects ........................................................................ 42
4. FINDINGS ........................................................................................................... 43
Overall Findings ............................................................................................. 43
Specific Findings ............................................................................................ 46
5. CONCLUSIONS, RECOMMENDATIONS, AND IMPLICATIONS ................ 55
Conclusions ..................................................................................................... 55
Recommendations .......................................................................................... 57
Recommendations and Implications for Social Work .................................... 59
Appendices ................................................................................................................. 63
Appendix A. Perception of Health when Compared to Others ................................. 64
Appendix B. Daily Living Activities: All Difficulties Combined ............................. 65
References .................................................................................................................. 66
ix
LIST OF TABLES
Page
1.
Table 3.1 Descriptive Statistics for All Independent Variables ..................... 45
2.
Table 3.2 Descriptive Statistics for All Dependent Variables..........................47
3.
Table 3.3 Perception of Health.........................................................................48
4.
Table 3.4 Cognitive Functioning......................................................................50
5.
Table 3.5 Depression........................................................................................51
6.
Table 3.6 Independent Activities of Daily Living: All Difficulties
Combined……………………………...........................................53
x
1
Chapter 1
THE PROBLEM
Prescription drug use is becoming a public health concern, and it is steadily
becoming a major problem among the elderly population in the United States and around
the world. Older adults are the largest and primary group of consumers of prescription
and over-the-counter medications in the United States, and may be particularly vulnerable
to medication side effects and other adverse effects to one or multiple medication
combinations.
The public health threat to our communities is far-reaching and has devastating
consequences. For the elderly the convergence of physiological, psychological, and
psychosocial factors, in conjunction with the environment create a vastly different health
and life experience from those of younger counterparts, when it comes to health care
services and the inevitably overuse of prescription and non-prescription drugs. There has
been a growing public concern about the increasing number of older adults who
inappropriately use prescription drugs, in combination with over-the-counter
prescriptions and herbal remedies, as the number of the population multiplies and the
“baby-boomer” generation reaches their golden years (Lay, 2008).
Pringle (2005)
asserts that prescription drug abuse is a timely health problem with demographic
projections and trends that indicate that older people in this society continue to use more
drugs compare to previous generations. Older persons often are afflicted with at least one
chronic condition, and many have multiple conditions for which they require treatment.
2
Among the most frequently occurring conditions reported are hypertension, arthritis, all
types of heart disease, any type of cancer, diabetes, and sinusitis (National Household
Survey on Drug Abuse, 2009). Furthermore, according to Benshoff (2003) if this trend
continues, by the year 2030 this group in our society (elderly) will double in size to
represent over 72 million individuals or about 20 percent of the population, and about 33
percent of the population that consumes prescription and over-the-counter drugs as part
of their health care treatment. Implicitly, the potential for the inappropriate use of
prescription drugs and the health impact on the elderly becomes a global public health
concern, one that requires immediate attention and prompt interagency and community
collaboration.
Yet, inappropriate prescription drug use and its impact on the elderly health
usually remain undetected, and unidentified as a major issue. Perhaps more intriguingly,
is the fact that the problem is ignored by family members, friends, and even health
providers who usually are aware of the problem until a need for an emergency room visit
is a dire intervention for immediate health care due to complicating medical conditions or
adverse drug reactions.
The area of most significance in this study is the relationship between prescription
drugs and the decline on mental health and physical functioning, due to inappropriate
prescribing of drugs, which can cause substantial morbidity. It also represents a clinical
burden to the individual, their families, and society where prescription drugs and their
inappropriate prescribing, use, and effects have become an important public-health issue
worldwide (Spinewine, Swine, Dhillon,et al, 2007).
3
The population of older adults age 65 and older (as well as the percentage of them
that consume prescription medications) requires medication education in an effort to
increase awareness about the inappropriate use of prescriptions and understanding of the
potential effects of prescription medications on the health of the elderly.
I have long been interested in issues related to older adults and children,
particularly the contrasting and sometimes similar roles of individuals as caretakers,
caregivers, and the recipients of care. My past interactions with several older adults
(differed from the ones I had with my relatives) sparked in me a driving passion to learn
more about the elderly and what aging does to the individual in a holistic way. My intent
is not to undermine the never-ending exciting and always engaging wealth of stories the
elderly have to tell, or the accumulated wisdom resulting from a lifelong journey of
learning experiences, but the cognitive changes and physiological challenges that some of
the elderly experience in unique ways and very differently from their peers.
With the present conditions of our society and economy, it takes extensive efforts
to meet my own health care needs; I can only suspect the struggles that an older adult
experiences in trying to meet their health care needs. Participating in an already highly
structured and bureaucratic health care system is already challenging, it is even more
complex while trying to meet the needs of a partner or other family members as is the
case for the current “baby boomer” generation. Yet, this is exactly what many older
adults are doing alone and with very little support or services.
From personal experience, and with the protection of a pseudonym I present
Lolita’s story who like many elderly living independently often experiences the effects of
4
taking combinations of drugs that cause negative effects on their overall health. Her
story presents the issues of self-disclosure regarding intake of other non-prescribed drugs
or herbal remedies as well, which interfere with the existing drug regimens, and the
stigma associated in disclosing prescription drug usage to their primary care provider or
to emergency room staff.
Lolita was taken to the emergency room after she suffered a fall while in her
house. She lay on the floor and was unable to get up for about 6 hours; until, her
neighbors aided her. Once triaged at the hospital, she was questioned about her use of
medications. Lolita underreported her use of over-the-counter and prescribed
medications due to her fear of being judged or somehow mistreated while at the hospital.
After the doctors received lab results, it was found that Lolita had high levels of
antidepressants and alcohol in her system, which would have caused her dizziness and
loss of balance and resulted in her falling, and subsequently, her inability to get up on her
own.
Lolita was candidly questioned again on her use of prescription drugs, and at this
time, she admitted to ingesting a combination of drugs, prescribed separately by her
doctors, to deal with the painful grief and loss after her husband’s passing. This had been
her routine for about 5 years, which started soon after her husband’s death. Since that
time, Lolita decreased her social interactions and reported to “like it this way“. She
continued to live on her own until the time of her fall. After this incident, it was
determined that her intake of prescribed and non-prescribed drugs had damaged her liver
and had decreased her cognitive functioning and memory abilities.
5
The ramifications of prescription and non-prescription drug use among the
elderly, and their experiences are systemic and can not be ignored without immeasurable
cost. While receiving health care services, age is certainly the central determinant in how
the elderly, both female and male, experience health changing conditions, disease, and
medical treatment. These services affected by other contributing elements such as sociocultural norms, access to resources, and distribution of power, influences their health care
outcomes, both physical or psychological, in regards to prevention, diagnosis, course, or
treatment of a disease or illness.
It is through my contact with many “Lolitas” and the acknowledgment of the
elderly needs that I embarked on this project. Recognizing the societal perception
regarding prescription drug’s inappropriate use, the behaviors towards the individual that
overuses them, and the role of family members as caregivers; then, a unique display of
elderly experiences is presented. Lolita’s story is just one of the thousands of cases of
elderly who find themselves in the interwoven fabrics of deteriorating health. They find
themselves simultaneously meeting the need to alleviate pain, the misuse of prescribed
drugs, the shame and burden of dependence, the loss of independence and personal
dignity due to their health conditions, and at a crossroads in a broken system with little
social services available.
Background of the Problem
In 2001, the US Congress passed a law declaring that the next 10 years were to be
designated as the “Decade of Pain Control and Research”. Soon after, the Joint
Commission on Accreditation of Health Care Organization (JCAHO) issued new
6
standards that mandated health professionals to consider pain as a “vital sign”, and so
during a health assessment, enquire, measure, and treat pain as they would in regards to
temperature, blood pressure, pulse, and respiratory rate. Currently, all of these standards
are into effect in the health care field and affect all of us, especially the elderly
population. Within the last ten years, health professionals have re-evaluated the way in
which they perceive pain and the impact on the detection of illnesses, and patients have
changed the language with which they advocate for their health care. One cannot ignore
the advances of science and technology in the medical field that have improved our way
of life and the effects on longevity overall. However, we must question ourselves; do we
want to live longer or healthier lives? The answer becomes a personal statement of values
and morals.
Now, the current pharmacopeia includes different products (and in varied
potencies) to alleviate all sort of complaints; all of these resources have made it possible
to ameliorate all types of conditions effectively for many elderly when appropriately
prescribed and managed. However, the key word is “appropriately” for if any of these
products are improperly used other, and sometimes more serious, health problems may
arise. It is important to remember the meaning of “health” according to the World Health
Organization as “a state of complete social, mental, and physical well-being, and not
merely the absence of disease” (Hamdy, 2001, p.2).
As reported by the Administration of Aging (AOA) in 2009, the older population
will continue to grow significantly in the future, specifically between the years 2010 and
2030 when the baby boomer generation reaches age 65 and their health conditions
7
represent decades of alcohol and drug use, and consequences from behaviors from years
past. On the other hand, the number of Americans aged 45 to 64 now will reach the age
of over 65 in the next two decades and their medical and health care needs will reach
levels never seen before for this population during any previous times in our history.
The issue of prescription drug inappropriate use can be easily put into perspective
when we analyze that with the average life expectancy of an additional 18.5 years, a child
born in 2007 could expect to live 77.9 years compared to 47.9 than a child born in 1900.
Much of this increase is due to the reduced death rates for children, young and older
adults, and the increasing advancements in the field of medicine and technology. In
addition, according to the Administration of Aging (AOA) (2009) about 92,000
individuals celebrated their 100th birthday, this was an increase of 147% from the figures
in 1990 of about 37, 000 persons. The consequences of ignoring the problem and
postponing interventions could be detrimental to our entire society and all its members.
While it is true that a myriad of factors contribute to differences in disease
morbidity and mortality, we must not de-emphasize the effect of social roles and norms
that influence the experience of the elderly when participating in the health care system.
For the elderly, economic barriers often influence the attainment of optimal health.
Availability and method of health care delivery is linked to health insurance coverage,
socioeconomic status, and demographics influencing behaviors, progression of a disease
or illness, and treatment. The high incidence of unemployment, economic dependence,
and vulnerability in poor communities with already medically disadvantaged elderly may
increase the likelihood and probability for the elderly to overuse prescription drugs.
8
The health care experience must be examined with particular care when assessing
the experiences of the elderly. Threaded throughout the reviewed literature was the
repeated need for education, empowering the elderly, and linking them to services.
It is hoped that this study will serve as a means for practitioners and social
workers to empower individuals and the elderly to be active participants and advocates in
their health care, as well as raise awareness among the medical community about this
issue and develop new services to assist to the needs of this population.
Statement of the Problem
The abuse of prescription drugs may be an expanding phenomenon in society and poses
more risks than benefits on the elderly health. Areas of specific concern are physical and
neurological that could cause complications or the appearance of conditions such as
cardiovascular disease, hypertension, renal conditions, amongst others; leading to
hospitalizations, injuries, deterioration of body and cognitive functioning, as well as
mental health disorders such as mood and anxiety disorders, depression, and others. The
Sacramento area lacks a system or database specifically designed to address the unique
service needs of the elderly.
Purpose of the Study
This study is undertaken in an effort to better understand, identify, and serve the unique
needs of the elderly in Sacramento County. The findings emphasize a need for greater
awareness among physicians about the risks presented by commonly prescribed
medications as people age and for additional measures to monitor prescription drug use.
The outcomes of this study would provide valuable insight toward creating change within
9
systems while creating an understanding and increasing awareness about the impact of
drugs on the health of the elderly, thus helping the elderly live longer and better quality
lives.
Theoretical Framework
Approaching this project from the Cognitive Behavioral Theory provided structure within
which to incorporate the influence of age, gender, and the experience of older adults and
the magnified stigma and discrimination associated with age and disability. Cognitive
Behavioral Theory aims to replace distorted perceptions that lead to maladaptive
behaviors with new meanings to behaviors that were existent. Further, this approach
aptly incorporates different means of intervention to a variety of issues including
substance abuse, psychological problems, and the adaptation of self-help resources.
Second, this approach allows for individuals to focus on the “here and now” while
providing symptom relief through the use of cognitive restructuring and behavior
orientations, while gradually facing activities or issues which may have been avoided;
and trying out new ways of behaving and reacting.
Third, the Cognitive Behavioral Approach has shown to be an effective tool for
reducing substance use in the elderly and reducing the adverse health effects that are
associated with the use of psychotropic medications such as drug dependence, and other
cognitive impairments.
Finally, Cognitive Behavioral Theory links actions or thoughts to feelings
allowing for the identification of physical or somatic complains to the expressions of
10
feelings or emotions, which are the language of distress in the communication of
symptoms or physiological complaints.
On the micro level of practice, it is important that we remain cognizant of each of
the individual’s needs, abilities, circumstances, lifestyles, and personality traits. It is
relevant for the initial assessment and future interactions as the elderly usually face issues
regarding self-disclosure and trust. On the mezzo level, we need to recognize the
organizational structures that are in place to meet these clients’ needs and the process
used to access those structures. As practitioners, our role in advocacy regarding the
development of procedures and system navigation is key in trying to modify policies and
procedures. As well as in trying to modify treatment plans that change behaviors that are
expressions of repressed feelings or emotions, and improve the individuals well-being.
Lastly, on the macro level, reflection on the existing structures in policy and regulations,
and the interactions of other organizations and their effects of their policies on our
client’s health are crucial. When policies, structures, or regulations become ineffective in
serving the vulnerable or otherwise marginalized populations, we need to analyze the best
way in which to be the best advocate for these clients in regards to their attainment of
social justice.
This project is an attempt to increase awareness on the issue of prescription drug
use and its impact on the elderly health in an attempt and to contribute to the betterment
in the lives of the elderly in their goal to live their lives with quality, decency, and
dignity.
11
Definition of Terms
For the purpose of this project, the following terms are listed and defined:
Elderly as defined by the World Health Organization (2008) "The ageing process is of
course a biological reality which has its own dynamic, largely beyond human control.
However, it is also subject to the constructions by which each society makes sense of old
age. In the developed world, chronological time plays a paramount role. The age of 60 or
65, roughly equivalent to retirement ages in most developed countries, is said to be the
beginning of old age“.
Prescription drug defined as “a drug that is available only with written instructions from
a doctor or dentist to a pharmacist; prescription drug is a licensed medicine that is
regulated by legislation to require a prescription before it can be obtained. The term is
used to distinguish it from over-the-counter drugs which can be obtained without a
prescription” (FDA, 2009).
Prescription Drug Abuse or Substance dependence happens when “an individual
persists in use of alcohol or other drugs despite problems related to use of the substance,
substance dependence may be diagnosed. Compulsive and repetitive use may result in
tolerance to the effect of the drug and withdrawal symptoms when use is reduced or
stopped. These, along with Substance Abuse are considered Substance Use Disorders”
(American Psychiatric Association, DSM-IV TR, 2000).
For clarification, the terms older adults and elderly are interchangeably used in
this project and the terms aim to identify the same population. In addition, the term
12
medication and prescription drug are interchangeably used throughout this project
identifying substances used when prescribed by a physician or practitioner.
Assumptions
In preparation for this project, it was assumed that the number of older adults using
prescription and non-prescription drugs and suffering from health deterioration is
increasing at alarming rates. It was additionally assumed that some of the primary health
issues among the elderly were related to the natural life process and aging, although these
existing conditions might have aggravated with the onset of prescription drugs.
Finally, it was believed that the confluence of age and gender, culture and class
would create unique issues and needs for these older adults. There is also the assumption
that the reader believes that it is the society’s duty to protect those who are most
vulnerable, and agrees that those that conform the elderly population and are
inappropriately, willingly or unwillingly, using prescription drugs are indeed amongst
those more vulnerable.
Justifications
This project presents an opportunity to actively incorporate the social work tenets of
service, social justice, and the preservation of human dignity and worth with a tangible
end product. In order to “enhance human well-being and help meet the basic needs and
empowerment of people who are vulnerable, oppressed, and living in poverty” (NASW
Code of Ethics, 2008 ) In addition, the Code of Ethics of the National Association of
Social Workers directs social workers to challenge social problems and assist human
13
kind in need. It is obvious the subject is a social problem of vast proportion as the elderly
population increases.
This problem affects people from all occupations and lifestyles, but is more
prominent and devastating among the elderly populations who might already be
oppressed, discriminated against, and perhaps, socio-economically disadvantaged. The
elderly are a vulnerable sector of the mainstream population, and large groups of these
individuals are living alone, are sole caregivers, and are still contributing to their
communities. Their health issues and eventual health complications will have farreaching effects as we continue to ignore the problem.
Further, the NASW code of ethics gives social workers the ethical responsibility
of honoring the right to self- determination. Expanded knowledge on the presented
subject will assist social workers and practitioners to better understand the needs of this
unique population, and enable them to serve them with competency and advocacy
creating a greater chance for social justice to manifest.
Limitations
The following limitations exist in regards to this project. First, the geographic range
presented in this project is limited to the collected data within the Sacramento County. In
addition, the population in question is solely focused on older adults. Therefore, the
ability to generalize these finding to a greater public is unlikely.
Many individuals within the population and these characteristics do not recognize,
or are in denial of the fact that they are abusing prescription drugs, and rarely disclose
14
this information voluntarily; thus, making identifying the problem difficult at the time of
initial contact.
Another limitation of the data set used for this study is that it will only include
participants in the City of Sacramento, California. Thus, while the study‘s findings have
the potential to be used as a teaching tool for all providers working with this population,
there could be some conclusions that are specific to this region. Furthermore, the less
similar a region is to Sacramento, the less this information can be used to generalize or to
apply its findings.
Organization
In preview, Chapter 2 details the themes prevalent in the author’s literature
review: prescription drug use, the effects of prescription drug use, factors associated with
prescription drug use, other issues related to prescription drug use, and a summary on the
chapter. Various insights on these important topics regarding the elderly are included.
Chapter 3 describes the methods used to analyze the data.
Chapter 4 encompasses the results of the Sacramento Area Latino Study on
Aging study (SALSA), a longitudinal study completed in 2008 which data was utilized
for the development of this project.
Finally, Chapter 5 presents conclusions, recommendations, and implications of
the findings of this project for the field of social work. Such findings resulted from the
development of the project and the literature review, as well as from identifying the
implications for future research, study, and program development in order to meet the
15
needs of the future elderly generations and the impact of the continued prescription drug
use on their health.
16
Chapter 2
LITERATURE REVIEW
This chapter will cover the review of the literature on the problem. The different
selection of themes presents relevant information on prescription drug use and its adverse
interactions and concomitant use. It will analyze the effects of prescription drug use on
the elderly’s health (physically and mentally). It will also present possible factors
contributing to the increase in usage of prescription drugs among older adults including,
but not limited to, medical and socioeconomic factors, such as assessment, disclosure and
stigma, socioeconomic and cultural factors, costs, and the role of the media on
prescription drug use.
Prescription Drug Use
Unnecessary use of prescription drugs. The implications of the misuse or
inappropriate use of prescription drugs or medications is a major concern for all
populations, but particularly the elderly. In a study conducted by Zhan and Bierman
(2002), they attempted to find evidence that corroborated the inappropriate use of
medications among the elderly. They evaluated and categorized inappropriate
medication use according to specific criteria, and examined the risk factors for
inappropriate drug use using the criteria set out by Mark Beers developed in 1991. With
the assistance of a panel, they compiled a new list categorizing the drugs into three
categories: drugs that should always be avoided, those that are rarely inappropriate, and
those that have some indications but are often misused (Zhan & Bierman, 2002).
17
According to Zhan and Bierman (2002), the drugs compiled in their list became the most
recent and generally accepted guidelines in the health care field designating prescription
drugs into a scale that implied severity of risk if misused. The results of their study
showed that about 3 percent of the elderly used at least one of the 11 medications that
should always be avoided (barbiturates). About 9 percent used at least one of the eight
that would rarely be appropriate (diazepam), and about 13.3 percent used at least one of
the 14 medications that have some indications, but are often misused (amitriptyline)
(Zhan & Bierman, 2002).
In a different study aimed at finding the frequency in which drugs were prescribed
unnecessarily to the elderly, the researchers Hajjar et al. (2005), found that five most
commonly prescribed drug classes among the elderly population were to alleviate
gastrointestinal, central nervous system (CNS), and cardiovascular conditions. Other
prescriptions were therapeutic nutrients and minerals, and vitamins. Originating from
these five prescription drug classes, antidepressants and benzodiazepines were identified
as commonly prescribed to the elderly and later affected their central nervous system.
Some of the main risks associated with the use of these prescription drugs
included hypertension as a chronic medical condition, the use of multiple prescribing
practitioners within the health care system for an individual, and the consequent use of
nine or more prescriptions that potentially led to prescription drug abuse and secondary
effects on health (Hajjar, et al., 2005).
The use of prescription opioids has increased significantly in the general
population over the past few years according to a recent study (Blazer & Wu, 2009).
18
Blazer and Wu (2009) assert that prescription pain relievers are the medications most
often used among the elderly population, more so than the amount of tranquilizers and
sedatives combined. They also reported that chronic pain has been identified as the most
common reason reported (by both professionals in the medical field and elderly patients)
for the request, prescription, and use of prescription drugs usually for individuals at the
later stage in life (Blazer & Wu, 2009). Some of the most commonly causes of pain
identified were results from musculoskeletal problems, trauma and injury related
problems, digestive problems, and nervous system problems.
They also concluded that after alcohol, opiates were the second most commonly
reported prescription drug of use by adults older than 50 years of age, according to their
study‘s results (Blazer & Wu, 2009). In addition, Blazer and Wu’s (2009) study identified
four prescription drug classes: prescription pain relievers, sedatives, tranquilizers, and
stimulants and the corresponding lists of qualifying drugs in each group setting baselines
as tools to be used for future research.
Adverse drug interactions and concomitant drug use. Many of the prescription
drugs used today are for the prevention and treatment of diseases and other medical
conditions. Health care practitioners, doctors and even dentists prescribe them and the
availability of a wide range of them makes them easy to obtain without the need of a
prescription.
More and more patients, among them the elderly, are also taking natural health
products (such as herbal remedies and dietary supplements). Each of these drugs,
prescription or non-prescription, can interact with other substances causing side effects or
19
adverse reactions. Since elderly patients often have multiple medical conditions that
require them to take multiple drugs, the risks for cases of interactions or adverse side
effects are always latent. According to Hogan and Kwan (2006) with each additional
medication taken, the elderly are at increased risk of adverse drug reactions, side effects,
and drug interactions because their prescription regimens tend to be complex and difficult
to follow correctly and accurately for the individual and for the primary care providers.
Older people commonly use over-the-counter medicines to treat minor
complaints, such as pain from arthritic problems, constipation, colds, allergies, and
gastrointestinal symptoms. These ailments can be treated easily with over-the-counter
analgesics, gastrointestinal preparations, nutritional supplements and respiratory agents
for coughs and colds, but most of these medicines include aspirin or acetaminophen
causing higher risks for an adverse side effect.
When the elderly experience co-morbid conditions and are receiving treatment for
them, but have other habits that include the use of illicit drugs then the potential for
possible drug interaction or concurrent use of alcohol in combination with a prescription
drug and experiencing an adverse effect is highly conceivable.
Significant problems can result from the concomitant use of prescription drugs
and alcohol. Alcohol is a substance that increases the sedative effects of benzodiazepines
and opioids, creating the potential for serious physiological consequences that can lead to
falls, loss of self-control, or even cause death. A study conducted in Pennsylvania by
Pringle, Ahern, Heller, Gold, and Brown (2005) examined the patterns and prevalence of
concomitant alcohol and alcohol-interactive drug use in older people. The authors found
20
that more than 60% of older people referred for prescription drug abuse showed evidence
of alcohol abuse as well. It also showed that alcohol-drug interactions are a factor in at
least 25% of emergency department admissions in hospitals. Other problems such as
stomach bleeding, gastric inflammation, and liver damage were also identified as possible
results of prescription drug overuse (Pringle, et al., 2005).
As the number of older people using prescription drugs without discrimination
continues to grow, the combination of increased prevalence of alcohol and drugs suggests
that health adverse effects and drug interactions due to alcohol concomitant use will also
increase.
Effects of Prescription Drug Use
Physical health. The treatment of chronic pain is identified as the core principle
in the field of medicine, and health professionals seek to ease or ameliorate suffering
from pain and improve individual’s functioning as part of their ethical responsibility.
Identifying the inappropriate medication use among the elderly can be problematic,
especially if home or herbal remedies or other substances that are taken without
prescription interact with prescribed medications; or if they produce adverse effects or
reactions due to simultaneous intake.
The issue of prescription drug use/abuse warrants special attention because it
poses more potential problems for the people in this age group than in younger
populations. More importantly due to the increased rate of adverse drug reactions and
side effects, and the potential for interactions as the number of prescription drugs
consumed among this group of society continues to increase daily.
21
A study conducted by Fu, Liu, and Christensen (2004) aimed at assessing the
connection between improper prescription drug use and the elderly overall health status.
Their study’s findings suggested a “strong evidence of significant adverse effects of
inappropriate medication use on the patient’s health status” (Fu, et al., 2004, p.1934).
Their report states that prescription drug use is the primary cause for adverse drug
reactions and can lead to hospitalizations, more serious injuries, the deterioration of body
functioning (physiological and neurological), and even death. Considering that, elderly
take many more prescribed medications daily compared to other younger age groups this
is an alarming state of affairs (Fu, et al., 2004). Their definition of an inappropriate
medication was defined as “a drug that poses more risk than benefits to the patient” (Fu,
et al., 2004, p.1934), benefits that are often undermined by side effects.
The identified risks of inappropriately using or abusing a prescription drug ranges
from minor weakness to more severe life-threatening events. Furthermore, six chronic
disease conditions were identified as most prevalent: heart and lung disease, cancer,
stroke, and diabetes all based on the International Classification of Diseases, Clinical
Modification codes (Fu, et al., 2004).
In an effort to clarify the definition of “deterioration in health status” it would be
identified as an increase in the number of diseases chronic or due to aging and their
severity. This concept was directly linked to the development of polypharmacy, meaning
multiple use of medications or to their long-term use. The effects of deteriorating health
also indicate the possible impact of other factors such as age and the combination of
lifestyle and social interactions.
22
Some studies suggest that minor co-morbid conditions should not be seen as
causing negative effects on health status in the elderly. However, other indicators such as
frailty, alteration in cognitive function, and insufficiency of renal organs should be
considered as co-morbid conditions according to specific study outcomes related to
adverse drug reactions and the administration of multiple prescription drugs (Laroche, et
al., 2006).
The issue of physical body deterioration among the elderly resonates in the article
written by Kluger and Ressner (2006). They wrote “the legacy of joints wrecked by
years of under treated diabetes--and too many bad hearts and bum livers, and vascular
systems fighting hypertension” (p.2), alluding to the damage to the health and physical
body weakening that the individuals from the baby boomer generation are having to
experience as they age. They often find themselves treating one condition with a
medication, upon the detection and treatment of another, while they deal with the
consequences of abusing recreational drugs as well.
There are different combinations of prescription drugs and other substances that
can cause severe adverse drug reactions, including but not limited to the illegal drugs,
over-the-counter drugs, herbal drugs, that in combination with one or more prescription
drugs can have serious physiological and psychological consequences on the health of
older adults (Schlaerth, et al., 2004).
Veehof, Stewart, Haaijer-Ruskamp, and Meyboom-de Jong (2000) aimed their
work at the exploration of the possible associations between an extension in the longterm use of a drug and the frequency and seriousness of chronic diseases (specifically
23
among the elderly). They found out that the incidence of heart conditions is associated to
the multiple use of medications and to the development of other psychotic or mental
health complaints. The study’s results also presented that heart failure and the overuse of
prescription drugs without a clear indication for its use played an important role on the
deterioration of the elderly health (Veehof, et al., 2000).
Regarding the prevalence of falls and the increase of these incidents among
elderly individuals, Ziere et al. (2005), conducted a study that showed that fall risks
increased for this population paralleled to the number of disabilities, and the presence of
other health conditions (such as hypertension or diabetes). This adds to the fact that some
drugs appeared to have a risk-increasing effect, independent from other factors. All of the
participants in their study were taking at least one prescription drug; however, most of the
participants were taking four or more of them at the time of the study.
Furthermore, the authors presented some possible explanations to their findings.
First, they explained that diuretics can cause dizziness and falls could be a result of the
intake of these drugs. Second, benzodiazepine derivatives might play a major role
affecting the central nervous system, and since prescription drugs are generally
prescribed to be taken on a continuous basis, so the risk factors to the frail health of the
elderly include cognitive functioning due to multiple medications and long-term use, and
the occurrence other chronic health conditions (Ziere, et al, 2005).
Chronic illnesses are long-term illnesses that are rarely cured. Chronic illnesses
such as heart disease, stroke, cancer and diabetes are among the most common and costly
health conditions among the elderly and they compound six out of seven leading causes
24
of death among the elderly population. These chronic health conditions negatively affect
the older persons’ quality of life due to their contribution in the decline in functioning
and the subsequent inability for the elderly to remain an active part of their communities.
Cognitive and physical functioning may be diminishing if illness, chronic disease,
or injury limits physical and /or mental abilities, posing functional limitations affecting
work performance and retirement plans, health and long-term care needs, and the social
well-being of the older population (AOA, 2009).
Many of these chronic conditions could be prevented or modified with behavioral
interventions whether the problem of prescription drug use is voluntary or involuntary,
and if the issue had been identified promptly. Take for example the case of Mr. Jim
Harrison whose case illustrates the gravity of the problem.
At age 73, Mr. Harrison presents several medical problems, as he understands
them: diabetes, Parkinson’s disease, nerves and a heart problem. His medical records
revealed anxiety neurosis, a 30 year old insulin-dependent diabetes mellitus (Type II),
essential tremors for 15 years (Parkinson‘s disease), coronary artery disease with a
coronary bypass 8 years earlier, two myocardial infarctions, right carotid endarterectomy,
and degenerative joint disease. When a drug history (both prescription and nonprescription) was obtained from Mr. Harrison he reported regular insulin, diltiazem
(Cardizem), trihexyphenidyl (Artane), primidone (Mysoline), chlordiazepoxide
(Librium), nortriptyline (Aventyl), vitamin B and C, and enteric coated aspirin (Ecotrin).
His untold story revealed that he was overdosing on prescribed medications and no one
knew it. His use of over-the-counter drugs-mostly laxatives, antacids, and analgesics was
25
causing adverse reactions with his prescribed drugs presenting symptoms of memory los,
functional and cognitive impairment with no prognosis of improvement (Harris, n.d).
Like Mr. Harrison, there are plenty of Americans and people around the world
experiencing more discomfort than relief from their medical and prescription regimens.
As prescription drug user's age, geriatric biology and other life circumstances tend to
constrict the drugs’ hold or effect on their health. According to Brown (2008), the
reduced body mass, slow metabolism, and less efficient liver and kidneys on the elderly
physiological body composition sets grounds for a slower process for the absorption of a
prescription drug and the process needed for it to be assimilated, and then purged from
the body. Thus, the concentration of any drug in the blood can linger for much longer
than for a younger counterpart, even more so when high concentrations of various
substances combine in the circulatory system and other organ, increasing the risks for an
adverse drug reaction or the complication of an existing chronic health condition.
Mental Health. Depressive symptoms and confusion are important indicators of
the general well-being and mental health among the elderly. Older adults that report
many depressive symptoms often experience higher rates of physical illness, increased
function disability, and higher use of health care resources. Elderly individuals are often
prescribed medications to help them deal with feelings of loneliness, loss and grief, and
disrupted life routines that are usually associated with old age. As consequences of the
aging process, issues regarding their activities and productivity, companionship, and
independence can lead to symptoms of severe depression, anxiety, and even suicide.
26
Older people with mental health issues often experience co-occurring physical
illnesses, participate in different clinical settings, and follow their corresponding
interventions. In trying to identify medication errors in the area of mental health care
among older people, a study led by Maidment, et al. (2008) indicated that medical errors
might be more common in older people and their medical interventions due to the
complexity of their medical cases, thus having serious medical consequences.
First, their study suggests that these elderly patients present an additional risk due
to co-occurring conditions of their health status and their most likely multiple use of
prescription drugs (Maidment, et al., 2008). Second, in their findings they present that
due to depression or mild cognitive impairment, elderly patients might be a cohort of
individuals that experience more adverse drug reaction events due to an error in
prescription monitoring from the health professionals (Maidment, et al., 2008). They
point out that “older people with cognitive impairment… may be less able to identify
errors” (Maidment, et al., 2008, p.564), increasing their risk factors for adverse side
effects of prescription drugs, specifically those that included psychotics, and co-occurring
mental and health conditions.
Other prescription drugs commonly used with individuals presenting mental
health problems are opioids like hydrocodone (Vicodin) used to treat pain, and stimulants
(Ritalin) used to treat attention disorders. The National Institute on Drug Abuse (NIDA)
(2008), reported that the elderly are more likely to be prescribed more long-term
medications from these categories in order to treat painful chronic conditions and mental
27
health disorders, as well as more likely to receive multiple prescriptions for different
ailments which could potentially result in the unintentional beginning of an addiction.
The inappropriate use of prescription drugs can lead to addiction, which is another
concern of prescription drug use among the elderly. Benzodiazepines (such as Valium)
and narcotics (such as Librium) are two commonly prescribed medications to treat
anxiety and sleeping disorders and both of these medications could be addictive (NIDA,
2008). Recognizing and treating mental illnesses among older adults is important. The
rate of suicide among older adults is higher than that for any other age group-and the
suicide rate for persons 85 years and older is the highest of all: twice the overall national
rate (SAMHSA, 2009).
Factors Associated with Prescription Drug Use
Medical Factors. Veehof, et al. (2000), designed a study to explore the
connection between prescription drug use and the frequency of chronic diseases. The
study showed that the health professionals responsible for the medical care of the elderly
are not always informed or have an indication of whether or not the older adult is taking
other drugs. Aside from the ones they have prescribed, without the proper indications
and identified this issue as a major factor in the health management of the elderly
(Veehof, et al., 2000).
Determining whether or not an elderly patient is abusing his/her medications takes
a biomedical approach put to practice in trying to find out if this problem affects any
specific elderly person. It has to be determined, and later differentiated, whether the
patient has a biological or psychological disease, such as depression, that is causing the
28
use of a prescription drug or whether the use of a certain prescription drug is needed to
alleviate a biochemical brain disorder such as dementia or delirium. Psychological
distress amongst the elderly can cause addictive behaviors that could be treated with the
same type of medication that they have been using without informing their medical
professionals (Veehof, 2000).
Other possible contributing factors in the use of multiple prescription drugs
among the elderly are elderly not following the instructions in the prescription bottles,
and mixing prescriptions that are contraindicative of each other. Forgetting or getting
confused on how to take their medicines and later trying to make-up for missed doses,
and the reluctance to ask for assistance in understanding their medications for fear of
judgment or embarrassment are also contributing factors affecting prescription drug use.
Often the elderly face a multitude of social and functional struggles that might
hinder their health and lead them to self-medicate on prescriptions drugs prescribed for a
completely different physiological purpose (Mac Isaac, Rivers, and Adamson, n.d.).
When the elderly functional abilities are compromised, and they are no longer
able to continue with their routines, the loss of independence can trigger behaviors that
become disenabling in their desire to keep their autonomy and live independently.
Taking their personal strengths and desires might just be the key to help them develop a
medical or treatment plan to modify their prescription drug regimens and any other
maladaptive behaviors.
Schlaerth et al.(2004) conducted a research study involving participants that came
through an emergency department in Southern California (L.A.) in an attempt to identify
29
the prevalence of drug use by screening persons of the this population about their use.
The study’s results identified the most abused substances to be combinations of
prescription drugs, and illicit or street drugs (specifically benzodiazepines and some
derivate of cocaine and marijuana) in environments where culture and a sense of
belonging forced elderly to continue “experimenting” with varied substances, while still
receiving medical treatment or continuing with their prescription drugs regimens
(Schlaerth, et al., 2004).
Socioeconomic and cultural factors. Most of the studies presented in this chapter
identified their sampling population as cohorts of older adults ranging from 50 and up to
106 years of age (with the age of 50 years as the lower limit defining older adult), who
were participants in the healthcare system, either voluntary such as seeking personal
health care, in a visit to the emergency room, or as an experience in a treatment center.
It was collectively identified that the majority of the elderly consume an average
of five prescriptions daily, but a minimum of one prescription used daily. As the number
of prescription drugs used increased, the probability of experiencing adverse drug
reactions or other effects on the elderly health increased as well, according to a study
conducted by Laroche (2007). Laroche (2007) explained that it is understandable that
persons aged 50 or older take many more medications than younger groups due to the
aging process and the accompanying ailments of age. However, he identified other
factors for prescription drug use including having a poor health status prior to this age,
having a low level of education, being of an ethnicity other than white, and having one or
more existing chronic diseases.
30
The following statistics were obtained from a report presented by the
Administration on Aging (AOA) (2009). They noted that the prevalence of different
chronic conditions differs if these are identified and categorized into gender. It was
reported that women tend to report higher cases of arthritis compare to lower reports
made by men. However, men tend to report higher number of cases of heart disease and
cancer. In the report, it is included that older women usually report more clinically
relevant depressive symptoms compare to the reports made by men. In addition, women
usually experience much more functional limitations compare to those for men.
Issues affecting minority groups in the US indicate that non-Hispanic blacks
reported to have higher levels of hypertension and diabetes compared to those that were
non-Hispanic whites. The Hispanic population reported to have higher levels of diabetes
compared to non-Hispanic whites, but these groups’ shared similar levels of hypertension
and much lower levels of arthritis (AOA, 2009).
Considering the projections presented that indicate that minority populations are
to increase from 5.6 million in 2000 to 8 million in 2010 and then 12.9 million in 2020
(AOA, 2009), increasing awareness regarding preventive health care and appropriate
medication use among these diverse groups is key for the prevention of multiple
prescription drug use and its devastating consequences on health.
In a study designed to understand the needs in treatment for the elderly Lay, King,
and Rangel (2008), state that it was common for all participants to report familial and
relational problems within their families’ environments that had intensified as they aged,
as their health conditions progressed, and as their health deteriorated (Lay, 2008).
31
Social, cultural or religious beliefs directly affect decisions made about health and
disease. For elderly minorities, decisions regarding health care are culturally and
ethnically bound and induce the use of traditional, home, and herbal remedies, in
combination with drugs medically prescribed can definitely add to the problems of over
medication among the elderly, specifically for cultures in Latin America and Asia
(Mollica, 2006).
Several studies have characterized the use of prescription drugs in older
populations from diverse cultural backgrounds not as the overuse of prescribed drugs, but
as self-medication without a practitioner’s advice. Balbuena (2009) identified the
problem as “self-medication” practice that was more popular in women than in men and
often associated with solitude or loneliness (children had left the home), anxiety (losing
independence), abandonment (lack of support system), depression and other common
conditions in the elderly (Balbuena, 2009).
Other Issues Related to Prescription Drug Use
Prescription drug cost coverage and government programs. The cost of
prescription drugs have increased rapidly in the past years, almost at the same rate that
more and more drugs become available to the population in general. The Older
Americans report presented the following figures: in 2008, older adults spent an average
about $5,000 a year in out of pocket health care expenses. Part of that cost, about $2000
per individual was the cost only for prescription drugs (Administration on Aging, 2009).
For the elderly population the lack of prescription drug coverage or health
insurance has created a great hardship, especially so for those less privileged and most
32
vulnerable in regards to their health condition. In January 2006, the federal government
extended coverage under the Medicare program to cover prescription drugs (called Part
D), which also included a subsidy for those that were beneficiaries and had low income
and little assets or other properties. However, not all needs of care are covered under the
Medicare program (which is the most common health insurance program used by older
persons in the United States). Some exceptions include the payment for glasses, hearing
aids, and some regular dental care. It is assumed that some of the vision and hearing
impairments that elderly present, as well as oral health issues are part of the natural
process of aging. However, the elderly experience problems with vision affecting about
17% of them, and 27% of the elderly aged 85 and older have serious trouble seeing at all
(Administration on Aging, 2009).
All of these health conditions and co-morbid illnesses can be prevented, or as last
resort postponed through the practice of early detection, and prompt and immediate
medical treatment; thus, avoiding the costly interventions and consequences of more
serious conditions, and the debilitating effects of multiple prescription regimens on the
health and cognitive functioning of the elderly.
Prescription drugs and the media. Across the United States and other parts of the
world, policies support the concepts of advocacy regarding satisfactory medical care,
self-medication, and patient independence to make choices regarding their health care.
Governments, like in the US, have passed legislation that provides health care subsidies
that help the most disadvantaged in getting the health care they need. As a result,
pharmaceutical companies and the media have also taken a front seat in the promotion
33
and propaganda of “the fountain of youth and health” in a magic bottle and have targeted
the elderly population with their marketing campaigns.
The media in all its forms (internet, radio, television, and press) performs an
important role in the prevalence of this new and empowering wave of health care and
prescription drug choices. According to Datti and Carter (2006) their study’s findings
suggest that the elderly who are exposed to the media’s bombardment on new medicines
or prescription drugs, and their wonderful “condition free” effects were more likely to
visit their physician and inquire about new medications and insisted on their “need” for
them, but only if their physician-patient relationship was comfortable and rapport had
been built.
Good health and great lifestyles are profiles in the commercial advertisements of
medicines and prescription drugs that supposedly enhance the lives of the elderly. They
are presented in all types of media, interplaying in the mind of the elderly when making a
health decision. Adding to drug recommendations received from friends, relatives, and
partners on the benefits and wonders of a certain prescription drug.
Datti and Carter (2006) also suggest that the new changes to Medicare coverage
in the U.S. to integrate the coverage of prescription drug cost might suggest clarification
as why the commercial ads for most new prescription drugs in the market are directly
aimed at the elderly population as the target audience. These strategies create great
possibility for more cases of multiple use of prescription drugs and their already
mentioned consequences on health.
34
Assessment, disclosure and stigma. It is understandable that with aging come
ailments that are a natural part in the process of getting older, and the appearance of pain
and other chronic conditions appear among in the elderly around age 65. Therefore,
medical professionals should be aware of the possibility for the elderly to under and over
report their use of prescription drugs regardless of their current medical or health
condition.
The information obtained from self-reporting is usually subject to a variety of
biases that reflect the elderly values and morals and affects its content by probable
cognitive impairment associated with memory inability to recall detailed information.
In a study conducted by Rockett, Putnam, Jia, and Smith (2006) focused on
modes of reporting among the elderly, it was found that both male and female
underreport their prescription drug use until other assessments and test are performed that
reflected more accurate information on their use of substances. For the elderly, there is a
sense of embarrassment at admitting abusing one or more drugs and they tend to
underreport their use, or refuse urine or saliva drug testing or screenings when admitted
to the hospital, which makes it much more difficult to identify the problem (Rockett, et
al., 2006).
Health professionals should use caution when assessing for unnecessary drug use.
Effective assessment tools are necessary in trying to identify the problem. One tool is the
Medication Appropriateness Index (MAI), which uses a point scale for rating 10 different
criteria regarding drugs, drug interactions, dosage, indications, effectiveness, etc. and
renders reliable results in the assessment and identification of inappropriate use of
35
substances (Hajjar, et al., 2005). Previous sources indicate that there is always a
tendency among the elderly to deny or underreport the use of prescription drugs in the
presence of a health professional, despite the way in which the questions are asked or the
interview/assessment is conducted (Balbuena, 2009).
There is always a certain amount of stigma when reporting certain symptoms of
chronic illnesses, or the use of medications, whether the individual is elderly or not.
Schonfeld, et al. (2010), attempted to examine a pilot program used for the screening of
substances among the elderly in the state of Florida. In regards to prescription
medications disclosure, they point out that the most important indicators reported by the
elderly who were screened during the study were: 1) not disclosing to a physician about
their taking non-prescription drugs and 2) omitting the frequent use of over-the-counter
medications for the relief of pain (Schonfeld, 2010). Because of this study, a program for
screening prescription drug use, depression, and suicide symptoms was designed in an
attempt to accurately assess and address the elderly early stages of prescription drug
misuse and more accurately assess and meet their health care needs.
Full utilization of available services in mental health and medical areas by the
elderly is rare for a variety of reasons, including social stigma, age discrimination, costs
of services, and the stereotypes in society regarding the process of aging, the aged, and
people with mental health issues.
Summary
Several characteristics carried over form study to study. The following is a summary of
the common attributes for the samples found in the research literature. It should be clear
36
that several studies clarified the absence of information from the baby boomer cohort,
which implies the need for further studies and research on the problem.
As the growth of the elderly population continues, the burden of this problem on
the health care system and our society will also increase. Since chronic diseases such as
hypertension, coronary artery disease, arthritis, stroke, cancer, and diabetes mellitus are
commonly identified as people age. It is projected that the number of people with
multiple chronic diseases in the future will also increase.
Some of the factors responsible for increased adverse reactions in elderly patients
are polypharmacy (multiple use of both prescription and over-the-counter medications),
increased risk for drug-drug interactions
Prescription drug use was the most prevalent substance abuse problem among the
elderly, followed by alcohol abuse, over-the-counter medications, and illicit substances
providing the recipe for serious adverse drug reactions.
Some of the symptoms attributed to prescription drugs overuse are difficult to
identify for someone without the proper training, particularly if those symptoms are
confused with symptoms usually attributed to the natural aging process or to the elderly
existing chronic illness or condition. Assessment procedures and tools are still a work in
progress. As research continues to improve the available resources for assessment of the
problem, the issue of disclosure and stigma regarding inappropriate use of prescriptions
and its link to mental health issues among the elderly makes identifying the problem
much more difficult.
37
Socioeconomic and cultural factors play an important role in the origin and
prevalence of the problem. Some chronic conditions seem to affect individuals at
different rates and severity according to gender, socioeconomic, and education variants.
The influence of social, cultural, and faith-based beliefs also interfere in the
administration and successful medical treatment or prescription regimen among the
elderly population.
The elderly face a mixture of mental health issues, but depression plays as the
more prominent mental health condition among those with alcohol and prescription
medication problems. Usually, these future patients will be treated for some or all of
their conditions with drug therapies, as are most health conditions. Prescription drugs are
the single most important intervention in the health care of an individual if practitioner
and patient use them appropriately. However, when used inappropriately prescription
drugs all the therapeutic benefits disappear. Instead, prescription drugs become a health
risk due to the potential of an adverse drug reaction.
It is imperative to recognize that the elderly population seems to be at an
increased risk of adverse side effects, and co-occurring diagnosis of more than one
chronic condition and the impact of prescription drug use in their functioning abilities,
social interactions, and sense of identity.
The inappropriate use of prescription drugs among the elderly can be deteriorating
in regards to physical and cognitive functioning. It is clear that prescription drugs are
utilized to mainly treat pain and relieve other symptoms related to the treatment of
chronic conditions and serious diseases. Nonetheless, the impact of prescription drugs on
38
the health of the elderly is an impending public health problem as the elderly population
increases in the next years. However, the underestimation in the seriousness of this
problem is not to be taken lightly.
Insight into possible alternatives indicates the need for more research in
identifying areas of change, possible improvements in the management of prescription
drug regimens of older patients in an attempt to enhance their overall health, their
functioning and safety, while providing a sense of dignity and self-respect as the elderly
live their lives with honor and personal integrity.
39
Chapter 3
METHODS
In this project, the author hopes to investigate the relationship between
prescription drug use and the effects on the overall health of the elderly. Currently,
limited research examining this relationship exists. By exploring this issue, the author
hopes to promote awareness among social work professionals regarding geriatric issues.
The research design for this study is both descriptive and inferential and aims to examine
and identify the impact of prescription drugs on the health of the elderly.
Quantitative Research Design
This study employs quantitative research methods that rely on secondary data analysis
obtained from the Sacramento Area Latino Study on Aging (SALSA) Study. Data
analysis will be conducted to explore what relationships may exist among the relevant
variables. Previous studies and current literature were used to determine variables and
will help present possible data relationships or their lack thereof.
Multivariate analysis will be used in identifying which independent variables (for
example: age, income, education, etc.) may influence the dependent variables (i.e.,
depression, cognitive functioning, etc.). Specifically, the use of multiple regression
analysis will be used to examine the inter-relationships of three or more categories of
independent or dependent variables and their different attributes in this study.
40
Variables
This study consisted primarily of demographic and descriptive data. For the purpose of
demographic data analysis, frequency distributions will be used which would allow for
management of data for this sample size. An emphasis of this study is the examination of
the possible causal relationship between the independent variables and the dependent
variable. The outcome variable specifically involves the use of prescription drugs among
the elderly.
The operational definitions for the independent and dependent variables in social
research are as follows:
Independent variable: An independent variable is defined as the variable, which
is manipulated. For the purpose of this study, the independent variables are
prescription drug use with three attributes, cognitive functioning, depression,
perception of health with two attributes, and independent and assisted difficulties
with daily living activities with three attributes each.
Dependent variable: A dependent variable is assumed to be caused by the
independent variable. In this study, the dependent variable consists of three
attributes that are as follows: hospitalizations, medical insurance, marital status,
education level, income level, employment or volunteer work, primary language,
generational immigration status, homeownership, household composition, and
age.
Data collected will be used on twelve independent variables that may influence
the dependent variables. Ten variables will be measured on interval scales: for example,
41
medical insurance, marital status, employment status, etc. Two variables will be
measured on nominal scales describing categories: specifically education and income
level. The aforementioned variables will be analyzed to determine their association with
the dependent variables.
The population that participated in this study was older Latino adults, aged 60
years and older, living in the area of Sacramento County that consumed one or more
prescription drugs daily and whose health status was in decline according to their own
perceptions. These older adults were interviewed, from for a period of twelve years,
about their health perception, physical, cognitive, and mental health status. The author
chose to utilize only the baseline dataset for this study. This timeframe was chosen as it
included the most comprehensive data available. This timeframe was selected because it
offered a comprehensive and continuous longitudinal source of medical and health
information from the population relevant to this study.
Data Gathering and Analysis
The SALSA project tracked the incidence of physical and emotional impairment
in elderly Latinos in the Sacramento, California region. The study’s sample size included
1,789 individuals aged 60 years and older.
Access to the SALSA study dataset was obtained online through the ICPSR site.
The study’s data provided all information needed while it protected the anonymity of the
subjects that participated in the study. No other persons were involved in the data
gathering process or analysis.
42
The obtained data from the SALSA study dataset was coded and analyzed using
SPSS version 17.0 software. Descriptive and inferential statistical analysis was
conducted on the data, which will be reviewed in the detail in the subsequent chapter.
Protection of Human Subjects
The protocol for the Protection of Human Subjects was submitted to the Division
of Social Work Human Subjects Committee and it was approved as being “Exempt”.
All information was collected from a secondary source. No subjects were
contacted during the process of this project. A numbering system was used during the
data collection and analysis that ensured for subject anonymity.
Anonymity provisions were adhered to throughout the secondary data collection
and no identifying information was used while data analysis was conducted.
43
Chapter 4
FINDINGS
Prior studies have identified prescription drug use among the elderly as an issue
growing at an alarming rate in the last decade. This study analyzes the data collected by
the SALSA study. The results of this study will provide a description on the responses
provided by 1,789 individuals that participated in the SALSA study, and who provided
their medical and health care related information in relation to their use prescription drug
use. Overall findings will present the frequency distributions of the collected data.
Specific findings, described later in the chapter, will include data analysis that makes an
attempt to answer questions related to the dependent variable, including what other
factors might influence the health outcomes among the elderly.
Overall Findings
Demographic statistics. As stated previously, the sample size for this study was
1,789 participants who were followed over a period of several years. The data analysis
indicates that 60% of the elderly interviewed were married, and about 40% were living as
single individuals. The average age of the participants interviewed was 70 years old,
with the youngest participant being 59 years old and the oldest participant being 101
years old.
Study participants were reported to be 51% first generation Latino immigrants,
and about 49% of the participants claimed to be second-generation Latino immigrants.
There were no additional ethnicities/races reported in the study. There were about 42%
of the participants that spoke English as their primary language and about 58% of the
44
participants that identified Spanish as their primary language. There was no data on
bilingualism or the use of both languages for the sample. Additionally, there was no
information on the category of gender.
Socioeconomic statistics. Other important characteristics of the sample were
socioeconomic identifiers. The participants reported four different levels of school
participation. About 13% of the participants reported having no education, about 58%
reported education less than high school, about 13% reported to have attended high
school, and about 17% reported having attended more than high school education.
There were two identified areas of community engagement among the
participants. About 17% reported to be currently employed and the same percentage
reported to be active with volunteer work in the community. However, about 45% of the
participants earned less than $1,000 a month minimum, the maximum monthly income
reported was more than $2,500 a month by about 14% of the participants. Home
ownership was identified among 67% of the participants and 21% of them reported living
alone in their household.
Regarding medical insurance, about 91% of the participants reported to have
some type of medical insurance, and about 9% reported not having medical insurance.
About 74% of the participants reported having been hospitalized at some point in their
life, and about 26 reported no occurrences of hospitalizations.
Regarding prescription drug use about 75% of the participants reported having
taken at least one prescription drug, about 75% reported taking two or more prescription
drugs daily, and about 5% reported to take more than 2 prescription drugs daily.
45
Table 3.1 Descriptive Statistics for All Independent Variables
Descriptive Statistics: All Independent Variables
.
Drug: Ever taken any prescription
Drug: Number of daily taking prescription
drugs
Drug: Over-prescription drug (2 or more
daily)
75%
Ever hospitalized
Medical insurance
Married
Education
No School
Less Than High School
High school
More Than High School
Currently employed
Volunteer work
First generation immigrant
Monthly income
Less Than $1,000
$1,000-$1,499
$1,500-$1,599
$2,000-$2,499
$2,500 or more
Home ownership
Living alone in household
Spanish-speaking
Age
74%
91%
60%
75%
5%
13%
58%
13%
17%
17%
17%
51%
45%
20%
11%
9%
14%
67%
21%
58%
70.7
(7.14)
Other variables. This study identifies six different variables that are identified as
dependent variables. General perception of health status was identified by 10% of the
participants as poor, 39% of the participants identified it as fair, 32% identified it as
good, 13% identified it as very good, and about 7% rated their perception of health as
excellent. When the participants reported their perception of health against their peers
46
/others, 13% of them reported being worse than others, 28% reported it being about the
same than others, and 59% reported it being better than others.
Regarding their cognitive functioning, the average score for the participants was
84%. An average of 81% reported to have had experienced depression sometime.
Regarding having difficulty with daily activities, 8% reported to have difficulty with
daily activities, 8% reported to have more than two difficulties with daily activities, and
13% reported to have difficulties with all daily activities combined. Additionally, 48% of
the participants reported to have difficulties with independent daily living activities, 47%
reported to have more than two difficulties with independent daily living activities, and
about 72% reported to have difficulties with all independent living activities combined.
Specific findings
The primary question to be answered is what variables may affect or influence the range
of possible of negative health outcomes. Reviewed literature suggested several variables
that may influence negative health outcomes. Included in the range of variables, which
may affect whether an individual’s health is impacted by the use of prescription drugs are
any drugs ever taken, the number of daily drug intake, and the overuse of prescription
drugs. Multiple regression analysis was used to determine possible associations between
the independent variables and the overall health outcomes.
Multivariate analysis was conducted to determine any observed relationships
between the independent and dependent variables.
47
The variables that appear to have an effect on the general health perception of the older
Table 3.2 Descriptive Statistics for All Dependent Variables
Descriptive Statistics for All Dependent Variables
General Perception of Health Status
Poor
Fair
Good
Very Good
Excellent
Perception of Health Compared to others
Worse than others
About the same than others
Better than others
Cognitive functioning
Average score out of 100 possible points
Depression
Difficulty with Daily Living Activities
Have difficulty with any daily living
activities
All difficulties with daily living activities
combined
Number of difficulties with daily living
activities
Difficulty with Independent Daily Living Activities
Have difficulty with any independent daily
living activities
All difficulties with independent daily living activities
combined
Number of difficulties with independent daily
living activities
10%
39%
32%
13%
7%
13%
28%
59%
84%
81%
8%
13%
8%
48%
72%
47%
48
adults and their effects are displayed on table 3.3. Regression results show that all three
independent variables: any drugs ever taken, the number of daily drug intake, and the
overuse of prescription drugs, are statistically significant and positively associated with
the general health perception of health in the elderly.
Table 3.3
Perception of Health
Any Drugs Ever Taken Over-prescription
Number of Daily Drug Intake
Coefficient Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
-0.38 ***
Drug: Over-prescription drug (2 or more daily)
Drug: Number of daily taking drugs
Has ever been hospitalized
-0.07
Medical insurance
0.00
Marital status
-0.11
Education Level
No School
-0.35 ***
Less Than High School
-0.39 ***
More Than High School
-0.04
Current employment
0.19 ***
Volunteer work
0.17 **
First Generation Immigrant
-0.02
Income Level
Less Than $1000
-0.25 ***
$1000-$1499
-0.01
$2000-$2499
0.20 *
$2500 or more
0.37 ***
Home ownership
0.10
Living alone in household
0.06
Spanish Speaking
-0.09
Age
0.01 **
(Constant)
2.69 ***
R-square
p value
sample size
***: p<0.01
**: p<0.05
*: p<0.10
0.18
0.00 ***
1462
0.06
-0.65 ***
0.12
0.06
0.10
0.07
-0.08
-0.09
-0.18
0.06
0.10
0.07
-0.27 ***
-0.06
-0.04
-0.08
0.04
0.06
0.10
0.07
0.11
0.08
0.09
0.07
0.07
0.07
-0.35 ***
-0.40 ***
-0.05
0.24 ***
0.15 **
0.00
0.11
0.08
0.09
0.07
0.07
0.07
-0.33 ***
-0.38 ***
-0.05
0.22 ***
0.15 **
-0.05
0.11
0.08
0.09
0.07
0.07
0.07
0.09
0.09
0.11
0.10
0.07
0.08
0.07
0.00
0.31
-0.26 ***
-0.05
0.17
0.34 ***
0.09
0.05
-0.08
0.01 **
2.56 ***
0.09
0.09
0.11
0.10
0.07
0.08
0.07
0.00
0.31
-0.25 ***
-0.05
0.17
0.32 ***
0.07
0.06
-0.08
0.01 *
2.64 ***
0.09
0.09
0.11
0.10
0.06
0.08
0.07
0.00
0.31
0.17
0.00 ***
1462
0.17
0.00 ***
1462
49
The variables that appear to have the strongest effect to the general perception of the
health status in the elderly are any drugs ever taken, the number of daily drug intake, and
the over use of prescription drugs.
Other potentially influential variables include level of education, with the
attributes of no school and less than high school being the most significant. Furthermore,
the variables for employment and volunteer work show to be of significance, as well as
the variables for income level and age. The table suggests that not having been
hospitalized, being single, high income, high education, and speaking English are
variables positively associated with a general perception of health. The <.05 level of
significance was met in the analysis for all three attributes of the independent variables,
thus the findings remain potentially valid. For further information, the results of
regression analysis for the perception of health compared to others are presented in
Appendix A.
Additional regressions were used to identify the relationship between the
independent variables and the impact on the elderly cognitive functioning. Table 3.4
shows the effects of the associated independent variables with the decline of cognitive
functioning. The relationship between the attributes for the variable of prescription drug
use and cognitive functioning presents statistically significant relationships. The multiple
regression results show that level of education, income, being first generation immigrant
and age have large effects, marital status and primary language (Spanish) minor effects.
All the independent variables have explained a 35 % of the variation in the cognitive
functioning scores of the elderly.
50
The <.05 level of significance was met in the analysis for all three attributes of the
dependent variables, thus the findings remain potentially valid.
Table 3.4
Cognitive Functioning
Any Drug Ever Taken
Over-prescription Drug Number of Daily Drug Intake
Coefficient
Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
-0.06 ***
0.55
Drug: Over-prescription drug (2 or more daily)
-0.41 ***
1.09
Drug:Number of daily drug intake
-0.37 *** 0.35
Ever hospitalized
1.59 ***
0.52
1.59 ***
0.52
1.62 *** 0.52
Medical insurance
2.02 **
0.89
2.02 **
0.88
2.10 **
0.88
Married
-0.12
0.63 -0.12
0.63
-0.09
0.63
Education Level
No School
-12.68 ***
1.05 -12.67 ***
1.05
-12.62 *** 1.05
Less Than High School
-4.47 ***
0.76 -4.46 ***
0.76
-4.43 *** 0.76
MoreThan High School
1.20
0.85
1.20
0.85
1.20
0.85
Current employment
1.64 **
0.66
1.65 **
0.66
1.63 **
0.66
Volunteer work
1.99 ***
0.64
1.98 ***
0.64
1.98 *** 0.64
First generation immigrant
-0.33
0.61 -0.35
0.61
0.41
0.62
Income Level
Less Than $1000
-2.79 ***
0.84 -2.77 ***
0.84
-2.76 *** 0.84
$1000-$1499
-0.93
0.84 -0.92
0.84
-0.92
0.84
$2000-$2499
-0.59
0.98 -0.60
0.98
-0.60
0.98
$2500 or more
-1.15
0.93 -1.15
0.93
-1.18
0.93
Home ownership
3.08 ***
0.60
3.07 ***
0.60
3.05 *** 0.60
Living alone in household
1.79 **
0.72
1.79 **
0.72
1.80 **
0.72
Spanish-speaking
-0.16
0.67 -0.16
0.67
-0.14
0.67
Age
-0.33 ***
0.04 -0.33 ***
0.04
-0.33 *** 0.04
(Constant)
108.89 ***
2.88 108.87 ***
2.88
108.97 *** 2.88
R-square
P value
Sample size
0.35
0.00 ***
1465
0.35
0.00 ***
1465
0.35
0.00 ***
1465
***: p<0.01
**: p<0.05
*: p<0.10
Depression scores were used to analyze the relationship between prescription drug
use and the mental health status of the elderly. Here again, the relationship type is
51
indicated as having the most influence on the health outcome. Additionally, community
engagement through volunteer work or employment demonstrated a strong effect; minor
effects were demonstrated by medical insurance, level of education and level of income.
Table 3.5
Depression
Any Drug Ever Taken
Overprescription Drug Number of Daily Drug Intake
Coefficient Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
2.13 ***
0.71
Drug: Over-prescription drug (2 or more daily)
Drug: Number of daily taking drugs
Ever hospitalized
1.06
0.68
Medical insurance
0.71
1.16
Married
-0.42
0.81
Education Level
No School
2.69 **
1.35
Less Than High School
1.85 *
0.97
MoreThan High School -1.10
1.09
Current employment
-1.89 **
0.84
Volunteer work
-2.55 ***
0.82
First generation immigrant 0.23
0.79
Income Level
Less Than $1000
2.68 **
1.08
$1000-$1499
0.66
1.08
$2000-$2499
-1.45
1.25
$2500 or more
-1.64
1.19
Home ownership
-1.08
0.78
Living alone in household
0.79
0.93
Spanish-speaking
0.84
0.86
Age
-0.09 *
0.05
(Constant)
12.80 ***
3.71
R-square
p value
sample size
0.11
0.00 ***
1403
***: p<0.01
** : p<0.05
* : p<0.10
0.11
0.00 ***
1403
2.33 ***
1.40
1.14
1.21
-0.43 **
0.68
1.14
0.81
1.17 **
1.07
1.05
-0.51 *
0.48
0.68
1.14
0.81
2.68 *
1.88
-1.09 **
-2.16 ***
-2.44
0.12 **
1.36
0.98
1.09
0.84
0.82
0.79
2.57 *
1.79
-1.09 **
-2.09 ***
-2.45
0.26 **
1.36
0.98
1.09
0.84
0.82
0.79
2.75
0.85
-1.28
-1.47
-0.99
0.86
0.79 *
-0.08 ***
13.57 ***
1.08
1.08
1.25
1.19
0.78
0.93
0.87
0.05
3.71
2.74
0.88
-1.26
-1.39
-0.95
0.78
0.79 *
-0.08 ***
13.26 ***
1.08
1.08
1.25
1.19
0.78
0.93
0.86
0.05
3.70
0.11
0.00 ***
1403
52
In this case, regression results show that all three independent variables: any
drugs ever taken, the number of daily drug intake, and the over-prescription drug use are
statistically significant and positively associated with depression on the mental health of
the elderly. All independent variables have explained 11% of the variation on
depression. In this case, it seems that age had little association with overall health
outcomes of depression. However, the <.05 level of significance was met which suggests
that this results are still valid. Table 3.5 represents these results in detail.
The author also analyzed the relationship between the occurrences of difficulties
with independent and regular daily living activities. The results of the analysis for all
combined difficulties with regular daily activities are presented in Appendix B. The
results of difficulties with independent daily living activities are as follows.
Table 3.6 demonstrates the relationship type indicated for all difficulties with
independent daily activities combined. Regression analysis shows the independent
variables of age, ever been hospitalized, and income as having the strongest effect.
Noted as having a minor effect were having medical insurance, being married, living
alone in the household, and primary language (Spanish). All independent variables have
explained 15 % of the variation in all difficulties with independent daily activities
combined in the elderly. The results suggest that owning a home, having a companion in
the household, being employed or a volunteer, earning more than $2,000 monthly, and
speaking English are positively associated with having fewer difficulties with
independent daily living activities. The significant relationship was supported by a <.05
level of significance suggesting that these results are valid.
53
The results of regression analysis indicated that all the independent variables had
strong effects on the all attributes of the dependent variables or aspects of health on the
Table 3.6 Independent Activities of Daily Living: All Difficulties Combined
Any Drug Ever Taken
Overprescription Drug Number of Daily Drug Intake
Coefficient
Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
1.84 ***
0.40
Drug: Over-prescription drug (2 or more daily)
Drug: Number of daily taking drugs
Ever hospitalized
1.28 ***
0.40
Medical insurance
-0.10
0.65
Married
-0.52
0.48
Education Level
No School
0.66
0.78
Less Than High School
0.50
0.55
More Than High School
-0.29
0.61
Current employment
-1.16 **
0.47
Volunteer work
-1.65 ***
0.46
First generation immigrant -0.48
0.47
Income level
Less Than $1000
2.20 ***
0.62
$1000-$1499
0.37
0.63
$2000-$2499
-0.21
0.71
$2500 or more
-0.49
0.68
Home ownership
-0.57
0.45
Living alone in household
-0.42
0.54
Spanish-speaking
-0.60
0.51
Age
0.18 ***
0.03
(Constant)
-8.61 ***
R-square
p value
Sample size
0.07 *
0.00 ***
1458
***: p<0.01
** :p<0.05
* :p<0.10
2.19
2.83 ***
0.85
1.28 ***
0.30
-0.60
0.40
0.65
0.48
1.50 ***
1.19 ***
0.07
-0.67
0.29
0.40
0.65
0.48
0.66
0.54
-0.25
-1.38 ***
-1.55 ***
-0.53
0.79
0.55
0.61
0.47
0.46
0.47
0.57
0.47
-0.24
-1.31 ***
-1.59 ***
-0.38
0.78
0.55
0.61
0.47
0.46
0.47
1.88 ***
-0.39
-0.64
0.46
0.61
0.58
1.85 ***
-0.35
-0.52
0.46
0.61
0.58
-0.50
-0.41
-0.62
0.18 ***
0.45
0.54
0.51
0.03
-0.46
-0.48
-0.60
0.19 ***
0.45
0.54
0.51
0.03
-7.73 ***
2.16
-8.31 ***
2.15
0.07 *
0.00 ***
1458
0.08 *
0.00 ***
1458
54
elderly. The analysis of data and its findings indicate the need for future research that
would provide detailed information on the problem of prescription drug use. Such
information could offer evidence that could be used to generalize across greater
populations.
55
Chapter 5
CONCLUSIONS, RECOMMENDATIONS, AND IMPLICATIONS
Conclusions
The purpose of this study was to provide an assessment of the elderly population
and the impact that prescription drug use is having on their health. Additionally, it aimed
to examine other factors that influenced the overall health outcome and the negative
effects on their daily life.
Previous studies have offered conflicting findings regarding the relationship
between the use of prescription drug use and the impact on the health of the elderly.
Overall, however, most current literature, as well as the results of this study, suggests that
the element of age is one of the factors that contributes to deterioration of health,
however it is not the only negative factor. In addition, consistent with most current
literature, this study found that the median age for elderly with health complications
averages about 65 years old. Additionally, this study’s findings indicate that the
majority of the elderly take more than one prescription drug daily, an important indicator
of polypharmacy as was identified in current literature.
Demographics reported in this study regarding the participants are consistent with
the demographics of the general populations studied in previous research. Specifically,
the average age of participants in this study fell within the varying ranges of what current
literature indicates as the highest.
56
The ethnic demographics of participants in this study did not accurately reflect the
general population of the Sacramento County (US Census Bureau, 2009). Participants
were identified as 100 % of Latino background, while this group represents about 33% of
the population in the Sacramento County. Additionally, it could be consider a limitation
of this study the omission of gender for the sample. The author believes that both the
lack of identification of other ethnicities and gender might be limitations for this study.
Clearly, while older people of Latino background were over-represented in this
study related to the overall County population, the findings in relation to age can make
the results of this study valid and applied to broader regions of the country and across
populations. Data analysis suggests a relationship regarding prescription drug use and
health outcomes. However, the magnitude and actual association of the relationship
exceeded the scope of this study. Prior studies have made note of a concern regarding the
increase of prescription drug (with or without a doctor’s recommendation) and the impact
it has on the overall health perception among the elderly. Data collection that uses
variables that can be coded at an interval level would allow for further investigation of
these findings and perhaps provide a better explanation for the representation of people of
other ethnic backgrounds and the degree to which ethnicity impacts health outcomes.
The majority of this study’s participants were identified as elderly and over the
age of 55. This report is slightly higher than the findings from previously conducted
studies. In this study, the participants reported to be about the same average age than
those who have participated in other studies. The consistency in the identification of
elderly persons in respect to age makes the findings in the study reliable.
57
Data analysis suggests the number of prescription drugs taken daily as having the
strongest influence on the overall health of the elderly. However, the magnitude and
nature of the relationship is not explained in this study. Regression analysis proved
useful in explaining the magnitude and relationship of the study.
About 91% of the study sample participants were identified as having medical
insurance. Data analysis did not find this variable to have an impact on the overall health
of the participants. Reviewed literature studies did not address the issue of participants
residing at assisted living or homes of care. Future studies would be encouraged to
examine the outcomes and variables related to those participants who may have the same
issues as the population studied, but are not self-sufficient to continue living alone. The
author would suspect that the relevance and significance would be greater than the
findings reported in this study.
Recommendations
Increased prescription drug use among the elderly is a current and relevant health
for this community. This is not an isolated problem and must be addressed in
conjunction with other concerns affecting this population, and the review of services
available for the elderly as they age. Attention to this issue for future research studies is
encouraged for all professionals.
Prior studies have generally found that the presence of a chronic or medical
condition makes it difficult to identify any underlying prescription drug use issues among
the elderly. The review of the literature included some indication that with the existence
or absence of disclosure, medical findings that were conclusive for health outcomes had a
58
higher relationship compared to those that did not fully disclose their prescription drug
use. However, the scope of this study did not allow for determining the degree to which
non-disclosure might impact future health outcomes. This study did not evaluate whether
or not pre-existing medical conditions are factors in the intake of prescription drugs.
However, work experience has indicated that those older adults who live alone are
unlikely, whether they have a medical condition or not, to identify any over-use of
prescription drugs. Prior studies had similar findings. The presence of non-disclosure is
a major reason for prescription drug misuse and is been cited as a primary reason for
adverse drug reactions that affect the overall health of the person.
While data analysis suggests that the use of prescription drug use negatively
affects the overall health of the elderly it would be useful to further study any possible
relationships between pre-existing medical conditions and related medications, and their
associated variables to determine if any groups of elderly are not fully experiencing
adverse side effects masked by the continued use of their prescription drugs, and thus not
being used effectively.
Consistent with other previous studies, this study found that depression was the
most affected part of the overall health by the use of prescription drugs, followed by
difficulties with independent daily living activities, and the decline in cognitive
functioning. However, specific physiological effects have not been studied with the same
depth or distinction so that a clear picture of this issue is not reflected. While this study
did distinguish between the differences in physical, mental, and executive functioning,
specific physical complaints were not included in this study.
59
Regarding current literature reports in prior studies, their findings show
significant association between the type of prescription drugs and health outcomes. This
study found some relationship between the number of prescription drugs taken daily and
difficulties with activities of daily living. Multiple regression analysis facilitated some
illumination of this relationship deserving of more in depth analysis.
This study appears to be consistent with findings from other studies, and presents
similar comparing statistics with other study findings that provide a certain level of
consistency. In the review of literature, the effects of prescription drug use tend to be
similar across populations. Having data collected over a longer period with an ethnically
diverse sample could be included, and then compared to national findings would be
desirable.
Recommendations and Implications for Social work
The findings of this research have a great relevance to the social work profession. It
supports the need for social work professionals to be educated about the issues of the
aging population. Future work with the elderly and their caregivers regarding prescription
drug use can be improved. There is need for further research aimed at expanding the
understanding of the health care system in which elderly and their families are served.
Fuller comprehension of the health care system may offer social workers and other
human service providers with a clearer and efficient context in which to work with this
population. All professionals working with this population would be able to develop
more appropriate responses at all environmental levels when dealing with this problem.
60
Among future efforts to improve and understand the systems and services used in
providing services for the elderly, certain procedures can be enhanced. Presently, a
system exists that identifies drug interactions for an individual, only if one pharmacy is
used to fill his/her prescriptions. If a similar system were implemented across a county, it
would provide a more efficient and effective way to track the medications used by a
single individual.
From a social work perspective, this seems an effective approach at trying to
identify the participation of the individual in various systems or environment.
Additionally, having an updated medical history, including medication history, would
provide information for more comprehensive service plan, in the case of interventions.
Concerning future studies, involving a more representative and large enough
sample size would allow for validity testing, as well as the ability to generalize the study
findings to much broader populations, thus making studies more useful. This study
involved a large sample size, but over-represented only an ethnic group and limited its
validity in trying to generalize its findings to larger populations. The use of prescription
drugs continues to be regarded as a standard health care logistical component; however,
this study does not yield results useful for medical practice. This study aims at creating
awareness about the issue for those that actively work with the elderly population. Future
research would encourage the incorporation of both quantitative and qualitative methods
of research, to gain a better understanding of the holistic role that human and social
service providers play in the life of the elderly.
61
In addition to understand and provide better services and planning to this
community, the general attitude of ageism must also be addressed. This bias against the
elderly reflects a sense of uneasiness with a significant portion of the population. Ageism
embodies a negative view of the elderly and their function in society. As much value
must be given to the concerns of the elderly as has been given to the concerns of the
younger populations.
It is necessary to begin with the premise that the elderly are a valuable part of
society, to also acknowledge that the increase in prescription drug use is a significant
problem and education about the issue is the first needed step among social work
undergraduate and graduate students, health care professionals, and family members and
caregivers.
Medical professionals and social workers (specifically medical social workers)
can assist the elderly with ensuring the appropriate use of the prescription drugs. Ensure
that they follow the directions, and that they are aware of the potential interactions.
Social workers can also be advocates for patients and call on appropriate agencies
and organizations for immediate attention to prescription drug use or misuse as a public
health issue, to raise awareness among the healthcare community, and involve society
and social services agencies participation in the creation of programs, services, and
resources for this population. Perhaps as important is their participation in the
development of policies that would protect an already vulnerable and growing elderly
population.
62
As identified in the NASW Code of Ethics it is the social worker’s responsibility
to assist clients, in this case the elderly, in procuring quality of life. In doing so, social
workers should understand the needs of this population, and gaps in the availability of
services. Future studies should focus on gathering specific information that discerns
details on prescription drug use relevant to the elderly. Several studies provide statistical
information on prescription drug use across the US population, however studies are
needed to isolate or disaggregate the information to provide details focusing only on the
characteristics of the elderly population. This is not to say that the rest of the population
is not affected by this problem; but an attempt has to be made in order to identify
specifics for this population separate from its younger counterparts.
There seems to be a need for appropriate and reliable screening and assessments
tools that would identify prescription drug use as a problem for the elderly. There is not a
single baseline across the healthcare or human services community to identify this
problem in this particular part of the population. Efforts in research and further studies
should focus their attention on the development of a screening tool for prescription drug
use. Further studies in this area are urgently needed. The elderly is a growing community
that will live even longer thanks to the advantages of technology and the advancements in
the healthcare fields. However, as a society we have to be ready to provide this
community with appropriate services and resources that are able meet the underlying
effects of such advancements and their future needs at all levels of their environment.
63
APPENDICES
64
APPENDIX A
Perception of Health when Compared to Others
Appendix A
Perception of Health when Compared to Others
Any Drug Ever Taken
Overprescription Drug Number of Daily Drug Intake
Coefficient Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
-0.13 ***
0.04
Drug: Over-prescription drug (2 or more daily)
-0.22 ***
0.08
Drug: Number of daily taking drugs
-0.15 *** 0.03
Ever hospitalized
Medical insurance
Married
Education Level
No School
LessThan High School
MoreThan High School
Current employment
Volunteer work
First Generation Immigrant
Monthly Income
Less Than $1000
$2000-$2499
$2500 or more
Home ownership
Living alone in household
Spanish Speaking
Age
(Constant)
-0.04
-0.14 **
-0.08 *
0.04
0.07
0.05
-0.04
-0.16 **
-0.08 *
0.04
0.07
0.05
-0.03
-0.14 **
-0.07
0.04
0.07
0.05
-0.04
-0.04
-0.02
0.08 *
0.16 ***
0.01
0.08
0.06
0.06
0.05
0.05
0.05
-0.04
-0.04
-0.02
0.10 **
0.15 ***
0.02
0.08
0.06
0.06
0.05
0.05
0.05
-0.03
-0.03
-0.02
0.09 *
0.15 ***
-0.01
0.08
0.06
0.06
0.05
0.05
0.05
-0.12 **
0.12 *
0.13 **
-0.02
-0.03
-0.03
0.01 ***
1.99 ***
0.05
0.06
0.06
0.04
0.05
0.05
0.00
0.21
-0.11 **
0.11 *
0.12 **
-0.02
-0.03
-0.03
0.01 ***
1.94 ***
0.05
0.06
0.06
0.04
0.05
0.05
0.00
0.21
-0.11 **
0.11 *
0.11 *
-0.03
-0.02
-0.02
0.01 ***
1.98 ***
0.05
0.06
0.06
0.04
0.05
0.05
0.00
0.21
R-square
p value
Sample Size
0.06
0.00 ***
1465
*** : p < 0.01
** : p < 0.05
* : p < 0.10
0.06
0.00 ***
1465
0.07
0.00 ***
1465
65
APPENDIX B
Daily Living Activities: All Difficulties Combined
Appendix B
Daily Living Acitivities
All difficulties Combined
Any Drug Ever Taken Overprescription Drug Number of Daily Drug Intake
Coefficient Std. Error Coefficient Std. Error Coefficient Std. Error
Drug: Ever taken
0.25 *
Drug: Over-prescription drug (2 or more daily)
Drug: Number of daily taking drugs
Ever hospitalized
0.30 **
Medical insurance
0.09
Married
-0.19
Education Level
No School
0.65 ***
Less Than High School
0.28
More Than High School
0.26
Current employment
0.00
Volunteer work
-0.28 *
First generation immigrant
-0.26 *
Income level
Less Than $1000
0.10
$1000-$1499
0.00
$2000-$2499
-0.21
$2500 or more
0.06 ***
Home ownership
-0.20
Living alone in household
-0.07
Spanish-speaking
0.19
Age
0.05 ***
(Constant)
-3.71 ***
R-square
p value
Sample Size
*** : p < 0.01
** : p < 0.05
* : p < 0.10
0.07 ***
0.00 ***
1458
0.13
0.77 ***
0.26
0.12
0.21
0.15
0.29 **
0.12
-0.20
0.12
0.21
0.15
0.39 ***
0.27 **
0.05
-0.23
0.25
0.18
0.20
0.16
0.15
0.15
0.63 **
0.28
0.26
-0.03
-0.25 *
-0.25 *
0.25
0.18
0.20
0.15
0.15
0.15
0.60 **
0.25
0.27
-0.02
-0.26 *
-0.19
0.25
0.18
0.20
0.15
0.15
0.15
0.20
0.20
0.23
0.22
0.14
0.17
0.16
0.01
0.68
0.08
-0.20
0.08
0.06 ***
-0.19
-0.05
0.18
0.06 ***
-3.62 ***
0.15
0.20
0.19
0.22
0.14
0.17
0.16
0.01
0.67
0.07
-0.20
0.10
0.06 ***
-0.17
-0.07
0.17
0.06 ***
-3.70 ***
0.14
0.20
0.19
0.21
0.14
0.17
0.16
0.01
0.67
0.07 ***
0.00 ***
1458
0.08 ***
0.00 ***
1458
0.08
0.12
0.21
0.15
66
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