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Drug interaction in elderly inpatients in the emergency department of a university hospital DRUG INTERACTION IN ELDERLY INPATIENTS IN THE EMERGENCY DEPARTMENT OF A UNIVERSITY HOSPITALINTERAÇÃO MEDICAMENTOSA EM IDOSOS INTERNADOS NO SERVIÇO DE EMERGÊNCIA DE UM HOSPITAL UNIVERSITÁRIO INTERACCIÓN MEDICAMENTOSA EN ADULTOS MAYORES INGRESADOS EN EL SERVICIO DE URGENCIAS DE UN HOSPITAL UNIVERSITARIO Juliane de Fátima Santos Antunes 1 RN. Resident in the Multi-Professional Program in Aging at the Federal University of Sao Paulo – UNIFESP. São Paulo, SP – Brazil.
Meiry Fernanda Pinto Okuno 2 2 RN. PhD in Nursing. Nurse at the Paulista School of Nursing of the UNIFESP. São Paulo, SP – Brazil.
Maria Carolina Barbosa Teixeira Lopes 3 3 RN. Master´s student in Nursing. Paulista School of Nursing of UNIFESP. São Paulo, SP – Brazil.
Cássia Regina Vancini Campanharo 2 4 RN. PhD in Nursing. Professor at the Nursing Department of the Paulista School of Nursing – Ruth Ester Assayag Batista 4 UNIFESP. São Paulo, SP – Brazil.
Corresponding Author: Juliane de Fátima Santos Antunes. E-mail: [email protected] on: 2015/06/30 Approved on: 2015/10/19 ABSTR ACTObjective: To identify the occurrence of potential drug interactions in prescriptions for elderly patients in the emergency department. Methods: Cross-sectional study with sample of 101 medical prescriptions of the first 24 hours of admission of elderly in the Emergency Room. Analysis of drug interactions was performed by Drugs.com database, which were classified as the potential for interaction: severe, moderate and mild. Results: The number of drug prescriptions ranged 2-14 with an average of 5.8 per prescription. 587 drugs were included. There were identified 7% of severe interactions, 26.8% moderate and 7% mild; 11.3% severe / moderate, 21.1% moderate / mild and 26.8% severe / moderate / mild. Conclusion: This study identified drug interactions in prescriptions for elderly patients in the Emergency Room. They were mainly classified as moderate interactions. It is emphasized the importance of health professionals to take heed to potential interactions, monitoring prescriptions, staff training and monitoring of cases in order to reduce its occurrence. Keywords: Drug Interactions; Aged; Patient Safety; Health of the Elderly.
RESUMOObjetivo: identificar a ocorrência de potenciais interações medicamentosas em prescrições médicas de idosos internados no Serviço de Emergência. Métodos: estudo transversal, amostra composta de 101 prescrições médicas das primeiras 24 horas de internação de idosos na sala de Emergências Clínicas do Pronto-Socorro. A análise das interações medicamentosas foi realizada pela base de dados Drugs.com, classificadas quanto ao potencial de interação em: grave, moderada e leve. Resultados: o número de medicamentos das prescrições variou de duas a 14, com média de 5,8 por prescrição. Foram incluídos 587 medicamentos e identificaram-se 7% de interações graves, 26,8% moderadas e 7% leves; 11,3% grave/moderada, 21,1% moderada/leve e 26,8% grave/moderada/leve. Conclusão: este estudo identificou interações medicamentosas em prescrições médicas de idosos no Serviço de Emergência, classificadas, sobretudo, como moderadas. Ressalta-se a importância de os profissionais de saúde atentarem para as potenciais interações, aprazamento das prescrições, capacitação da equipe e monitoramento dos casos a fim de reduzir sua ocorrência.
Palavras-chave: Interações de Medicamentos; Idoso; Segurança do Paciente; Saúde do Idoso. RESUMENIdentificar la incidencia de potenciales interacciones medicamentosas en las recetas médicas para adultos mayores internados en el servicio de urgencias. Se trata de un estudio transversal en una muestra compuesta de 101 recetas médicas de las primeras 24 horas de internación de adultos mayores en emergencias clínicas. El análisis de las interacciones medicamentosas fue realizado por la base de datos Drugs.com; la interacción medicamentosa fue clasificada según su potencial de interacción como leve, moderada o grave. El número de medicamentos de las recetas variaba entre 2 y 14 con un promedio de 5,8 por receta. Fueron incluidos 587 medicamentos y fueron identificadas 7% de interacciones graves, 26,8% moderadas y 7% leves; 11,3% graves / moderadas; 21,1% moderadas / leves y 26,8% graves / moderadas / leves. Este estudio ha identificado interacciones medicamentosas en las recetas para pacientes de edad avanzada en el servicio de urgencias clasificadas principalmente como moderadas. Es sumamente importante que los profesionales de la salud tengan en cuenta las potenciales interacciones medicamentosas, el plazo de las recetas, la capacitación del personal y el seguimiento de los casos con miras a reducir la incidencia de dichas interacciones. Palabras clave: Interacciones de Drogas, Anciano, Seguridad Del Paciente; Salud del Anciano. REME • Rev Min Enferm. 2015 out/dez; 19(4): 913-918 Drug interaction in elderly inpatients in the emergency department of a university hospital economic and environmental factors. Frailty is a risk factor for Brazil in 2025, according to the World Health Organiza- disability, fal s, hospitalization and death among the elderly. Ac- tion, will be the sixth highest country in the world for the cording to the literature, the number of medications is associ- number of elderly people, around 32 mil ion people. Accord- ated with increased weakness of the elderly.10 ing to the Brazilian Institute of Geography and Statistics (IBGE The weakness can directly affect the lives of the elderly, in Portuguese), and based on the population census, a Brazil- it makes them dependent for activities of daily living (ADLs), ian demographic transition has been observed, with modifi- such as answering the phone, performing household chores, cation of the population structure. In 1980, there was a pre- purchasing groceries, using medication. Apart from the depen- dominantly young population. In 1991 the elderly were 7.3% dence to perform ADLs, the weakness may also be related to of the population in 2000 became 8.6% and in 2010 this per- impairment of homeostatic mechanisms, disabling chronic il - centage reached 10.8 %.1-4 ness, decreased muscle strength, mobility, balance, fal , disabil- The United Nations (UN) classifies elderliness in a different ity, hospitalization and usage of four or more medications.10 way between developed and developing countries. In the first, In Brazil, the establishment of the National Patient Safety older people are those aged over 65, while in developing coun- Program aims to prevent and reduce adverse events related to tries, such as Brazil, are people aged 60 or older.2 assistance in health services, offering quality service and free The increase in life expectancy of the population is ac- from damage to users. Ordinance MS / GM No 529/2013 pro- companied by the prevalence of chronic diseases, which are a vides that a set of basic protocols should be deployed to pa- major cause of disability and dependence among the elderly. tient safety, including the safety protocol in prescription, use About 80% of seniors have at least one chronic il ness and need and administration of medications.11 frequent medical care.5 Emergency services have special characteristics, units with In this population, the occurrence of polypharmacy (the frequent overcrowding of patients and insufficient human and use of several medications at the same time) is constantly seen, physical resources. And when it comes to the specifics of care, due to the exponential increase in the prevalence of chronic it requires specialized team for the appropriate care of patients diseases and the consequences that go along with advancing with diseases, in a quick and with quality manner, considering age, accompanied by high number of prescriptions taught to a aspects such as security and emotional support to patients significant proportion of health professionals.6-7 and family members.12 Patient safety in drug therapy and assis- The elderly consume about three times more medication tance free of risks and failures are worth mentioning mainly by than young people do, due to their various diseases.5 Seniors the use of several drugs, the severity and instability of patients, between 65 and 69 years consume 13.6 medications per year which make them more prone to drug interactions and errors. and those between 80 and 84 years can consume up to 18.4 Nursing is important for drug patient safety, since it is directly medications each year.6 Polypharmacy is considered a risk fac- involved in all stages of the drug regimen, and may play a key tor for drug interactions and adverse reactions. The first oc- role in preventing mistakes.13 curs when the effects of some drugs are modified by anoth- According to the judgment of COREN SP-036 / 2013,14 it is er, altering their effectiveness and can increase it or decrease understood that is private to nurse the medical prescriptions it, beneficial y or harmfully.5,7 Adverse reactions are adverse ef- postponements because of the possibility of drug interactions fects that occur during drug treatment and may be associat- that can result in damage to the therapeutic process of the pa- ed, in the elderly, to the change in the drug's ability to act aris- tient. It is of nurses responsibilities the preparation, administra- ing from changes in physiological functions of these patients, tion, postponements and monitoring of medication adminis- which means, there may be changes in the absorption, distribu- tered, so that they can prevent drug interactions and do prop- tion, metabolism and excretion of medication.7 er planning of medications and their intervals, controlling any Seniors also use more hospital services, treatment with possible harm to the patient and their families.15 longer duration of high cost and their recovery usual y takes Emergency services in the immediate elder care in critical longer and it is more complex, mainly due to chronic diseases condition requires essential clinical reasoning of the physician, and their complications, which creates increased demand for the pharmacist and the nurse on the use of drugs, avoiding pos- emergency services by this population, revealing the need for sible interaction or decrease of the effectiveness of treatment.
further adaptation of that service to the new epidemiological Polypharmacy is common in the elderly, increasing the risk profile of the population.8,9 of drug interactions and adverse reactions16. Given the scarcity One aspect that has also been studied in this population of publications on drug interactions in the elderly in the emer- of older people is the fragility, understood as a multidimen- gency department, this study aims to provide subsidies to im- sional syndrome involving biological, cognitive, physical, social, prove the safety of the population in these services.
REME • Rev Min Enferm. 2015 out/dez; 19(4): 913-918 Drug interaction in elderly inpatients in the emergency department of a university hospital Table 1 - Socio-demographic and economic characteristics of pa- To identify the occurrence of potential drug interactions tients in the emergency room, from March to June, Sao Paulo, 2014 in medical prescriptions for elderly patients admitted to the Emergency Room.
Age (years)(Average ± DP) Cross-sectional study conducted at the Sao Paulo Hospi- tal. The sample was obtained by convenience and composed of 101 prescriptions for the elderly within the first 24 hours of admission in the Clinical Emergencies subdivision of the Emer- gency Room area in the period from March to June 2014.
Inclusion criteria were 60 years of age or older, be at least for 24 hours admitted to the emergency room and with pre- scriptions dated the day data was collected. Prescriptions for patients with only one item were excluded. Data collection was performed by full transcript of prescriptions for individu- al files. The recorded variables were: socio-demographic, date of hospitalization, medical history, drug name, dosage, dosage form and route of administration.
Illiterate/High School Incomplete The analysis of drug interactions (DI) was performed based on data available at Drugs.com database, pairing up all existing drugs on the prescriptions and obtaining a list, which were clas- sified according to the potential drug interactions in: severe, which may present a risk of death and / or require some ur- Monthly family income (reais) gent medical intervention to minimize these risks or their seri- Below minimum wage ous adverse effects; moderate, which can enhance the patient's 1 to 2 minimum wage value clinical conditions and / or require exchange of drug therapy; 3 to 5 minimum wage value and mild, classified as interactions with minimal clinical effects Individuals depending from family income (Average ± SD) and may increase the frequency or severity of side effects but Presence of caregiver without the need to change in drug therapy.17 Data were analyzed using descriptive statistics and pre- sented in tables. The study was conducted after review and approval by the Ethics Committee of the Federal University of * Values expressed as number (%) and mean (SD).
Sao Paulo (CAAE: 28238814.8.0000.5505).
The time of the day, dosage form and route of administra- tion of the prescribed drug in the emergency room are shown in Table 2 (Table 2).
In this study there was a predominance of female patients After analyzes made based on data available at Drugs.com with white skin color, retirees or pensioners, low education lev- database, potential drug interactions have been identified as, el, most had family income between one and two minimum five (7%) serious interactions; 19 (26.8%) moderate interactions wages and had a caregiver (Table 1).
and five (7%) mild. Some prescriptions had more than one in- The most frequent items of personal medical history teraction: eight (11.3%) severe and moderate; 15 (21.1%) mod- found in the elderly were hypertension (65.3%), diabetes mel i- erate and mild; 19 (26.8%) severe, moderate and mild. Table 3 tus (36.6%) and cardiovascular disease (27.7%).
shows the DIs classified as serious according to the Drugs.com The number of drug prescriptions ranged from two to site (Table 3).
14; the average per prescription was 5.8 drugs of the total of Table 4 shows the DIs classified as moderate as found in 101 prescriptions. 587 drugs were included, the most com- Drugs.com website (Table 4).
mon being omeprazole (7%), simvastatin (5.5%) and enoxa- Table 5 shows the DIs classified as mild as found in Drugs.
parin (5.4%).
com website (Table 5).
REME • Rev Min Enferm. 2015 out/dez; 19(4): 913-918 Drug interaction in elderly inpatients in the emergency department of a university hospital Table 2 - Period, dosage form and route of administration of medi- cations prescribed to elderly patients admitted in the emergency Table 3 - Frequency of drug interactions classified as severe found room, from March to June, Sao Paulo, 2014 on the prescriptions of elderly patients in the emergency room, from March to June, Sao Paulo, 2014 Diltiazem hydrochloride Potassium chloride Tramadol hydrochloride Tramadol hydrochloride Tramadol hydrochloride Route of administration Table 4 - Frequency of drug interactions classified as moderate found on the prescriptions of elderly patients in the emergency room, from March to June, Sao Paulo, 2014 Acetylsalicylic acid Amlodipine besylate Acetylsalicylic acid Acetylsalicylic acid Acetylsalicylic acid Acetylsalicylic acid Table 3 - Frequency of drug interactions classified as severe found on the prescriptions of elderly patients in the emergency room, Acetylsalicylic acid from March to June, Sao Paulo, 2014 Acetylsalicylic acid Acetylsalicylic acid Acetylsalicylic acid Enoxaparin sodium Acetylsalicylic acid Amiodarone hydrochloride Amiodarone hydrochloride Amiodarone hydrochloride Amiodarone hydrochloride Amlodipine besylate Formoterol fumarate Tramadol hydrochloride * Frequency < 1.4% were included in the Others category.
REME • Rev Min Enferm. 2015 out/dez; 19(4): 913-918 Drug interaction in elderly inpatients in the emergency department of a university hospital Table 5 - Frequency of drug interactions classified as light found on After an examination on the website Drugs.com, we iden- the prescriptions of elderly patients in the emergency room, from tified potential drug interactions as: five (7%) severe, 19 (26.8%) March to June, Sao Paulo, 2014 moderate and five (7%) mild; eight (11.3%) severe / moderate; 15 (21.1%) moderate / mild, and 19 (26.8%) severe / moderate / Acetylsalicylic acid mild. Another study showed that there was also a prevalence of Acetylsalicylic acid moderate interactions (65%), followed by severe (24%) and mild Acetylsalicylic acid (9%).20 In relation to severe DIs, the most common was between Acetylsalicylic acid aspirin and enoxaparin sodium, with a frequency of 25.5%. As Acetylsalicylic acid evidenced in another study, DI between aspirin and enoxaparin sodium was also one of the most common, in about 10% of pre- Amlodipine besylate scriptions.21 According to the website Drugs.com, this interac- tion may cause the complications of increased bleeding, head- aches, dizziness or weakness and even blood in the urine and feces during treatment.17 Another study, conducted in Swiss hospitals with elderly patients, found that those with polyphar- macy who used vitamin K antagonists showed higher risk of bleeding than patients without polypharmacy.22 In the case of DIs moderate, mostly were related to the use Piperacillin sodium of omeprazole and simvastatin. This association may increase the effects of simvastatin, increasing the risk of side effects such as liver damage, kidney and skeletal muscle degradation. It is important to monitor for fever, chil s, joint pain, nausea and vomiting, fatigue, jaundice of the skin or eyes, rash that could be signs and symptoms of hepatic injury.23 * Frequency < 1.4% were included in the Others category.
As for mild DIs, it is unusual for the DI to cause damage or require any change in drug therapy. It was observed that the most frequent DI was the association between aspirin and fu-rosemide (7.9%). Some drug interactions may be clinical y rel- In this study, there was a predominance of female patients evant in all patients.23 In another study, mild DI accounted for with while skin color, retirees or pensioners, low education, the 9% of prescriptions.20 average age was of 75 years old, the majority had household Whereas polypharmacy is common in the elderly popula- incomes between one and two minimum wages and had a tion22-24, this study draws attention to the nurses for the post- caregiver. Similar data were observed in a study in the service ponement of medical prescriptions in order to avoid medica- of emergency of a municipality of Belo Horizonte, where 13% tions to be administered simultaneously that can interact and/ of cases corresponded to people aged 70 or more and most or interfere with the effectiveness of treatment.
matched the female population.9 Low income can directly in- In addition, this study contributes to the literature on terfere in the access to health and education, and food and so- the subject, emphasizing the importance of physicians, nurs- cial care, which can compromise the quality of life for seniors es and pharmacists tuned to reduce drug interactions and ad- of this research.18 verse events.
Multiple diseases accompany the aging process. In this study the most common personal medical history were sys- temic arterial hypertension, diabetes mellitus and cardiovascu-lar disease, as observed in another study in Sao Paulo.19 This study identified the occurrence of possible drug in- The number of drug prescriptions ranged from two to 14, teractions in medical prescriptions for elderly patients in the while the average for prescription drugs was 5.8. 587 drugs were Emergency Room of the Sao Paulo Hospital, being most of included, and the most prescribed were omeprazole, simvas- them identified as moderate.
tatin and enoxaparin. In a study looking at potential drug pre- Therefore, we emphasize the importance of health profes- scriptions for patients admitted to an Intensive Care Unit, we sionals to be aware of the potential drug interactions, the post- identified more variation in the number of drugs, between 5 ponement of judicious prescriptions, staff training and moni- and 22, with an average of 10.9 medications per prescription.20 toring of cases of adverse effects and interactions, in order to REME • Rev Min Enferm. 2015 out/dez; 19(4): 913-918 Drug interaction in elderly inpatients in the emergency department of a university hospital 12. Oliveira GN, Vancini-Campanharo CR, Okuno MFP, Batista REA. Acolhimento reduce its occurrence. However, some limitations of this study com avaliação e classificação de risco: concordância entre os enfermeiros e o should be highlighted, such as the small sample size and the protocolo institucional. Rev Latino-Am Enferm. 2013;21(2):500-6. [Cited 2015 Jun 06]. Available from: http://dx.doi.org/10.1590/S0104-11692013000200005 fact that it was conducted at a single center.
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