Drug compliance and unreported drugs in the elderly.

A random sample of 46 general practitioners of the Unitá Sanitaria Locale in Torino recruited 802 elderly outpatients and collected information about complaints and current drug treatment. Within a week each patient received a home interview and details were collected on drug compliance and use of drugs other than those reported by the general practitioners. On average, each patient was taking 3.6 drugs, of which 2.9 were correctly reported by the general practitioners and 0.7 were unreported. Among the most prescribed therapeutic groups there were drugs with a narrow therapeutic index (cardiovascular drugs, diuretics, psychotropic agents) and substances whose efficacy has never been fully documented ("cerebroactive-vasoactive" agents). Age and number of complaints were positively and significantly correlated with number of prescribed drugs. Nearly half of the sample (44.4%)--more frequently women and people with higher education--were taking one or more drugs not detected by the general practitioners, often benzodiazepines taken over a long period for anxiety or insomnia. Full compliance occurred for 81.5% of the prescriptions and 59.9% of patients were correctly taking all prescribed drugs. Compliance was lower for prescriptions of the general practitioners compared with other doctors' prescriptions (eg, hospital doctor, private doctor) and probability of taking correctly all the prescribed drugs decreased with the number of medicines concurrently taken. The most common reason for noncompliance was fear of side effects.

Change in prescribing patterns of general practitioners in Italy before and after the Reform Drug Act. A case study of changes in the city of Turin.

As of 1 January 1994, the introduction of a new classification of the drugs to be reimbursed by the National Health Service was approved by the Italian parliament in order to limit expenditure on pharmaceutical agents. This has set off a 'cultural revolution', unprecedented in Italy. The criteria that inspired the expert group charged with attributing drugs to different classes (Class A: essential, free of charge drugs; Class B: drugs to be paid for 50% by the patient; Class C: drugs to be paid entirely by the patient) were principally scientific rather than merely economic or administrative. Expectedly, the creation of Class C (drugs not reimbursed by the National Health Service on account of their insufficiently proven clinical effectiveness, or their unfavourable cost/benefit ratio with respect to therapeutically equivalent agents) has provoked remarkable changes in general practitioners' prescription options, particularly given the fact that many of these drugs were among the most prescribed in Italy. A database including the prescriptions of about 940 general practitioners, dispensed through the 280 community pharmacies of the city of Turin, has been analysed for a comparative sample of time periods in 1993 and 1994, in order to quantify the changes that occurred and to qualify them with respect to more relevant therapeutic groups and sentinel drugs.

[Health status of the very old at the USSL I in Turin. Epidemiological study in the area of the USSL I in Turin]. / Le condizioni di salute dei "grandi anziani" nella USSL Torino I. Studio epidemiologico nel territorio della USSL I di Torino.

The aims of the study were: a. to describe the socioeconomic conditions of a randomized sample of over 75 years elderly of Torino USL; b. to evaluate the impact on doctors of a better knowledge of patients and c. to evaluate the feasibility and the results of a collaborative teamwork with doctors, nurses and social workers. Social workers or nurses evaluated the functional abilities of the elderly with the ADL and IADL scales, the cognitive function with the Mini Mental State and depressive symptoms with the Care Scale. 40 General Practitioners were randomized in two groups and each randomly selected 5 men and 5 women over 75 years, among their patients. Half of the doctors (experimental group) were offered a WHO textbook on drug prescription for the elderly and three monthly meetings with nurses and social workers, to globally evaluate the patients situation and define necessary interventions. 340 patients were recruited for the study (mean age 81 years). No differences were observed in the outcomes of the experimental and control group. An overall improvement of diagnostic skills and reduction of drug prescription was observed in both groups, but the impact of the latter was larger in the experimental group.

Drug use by the elderly in Italy.

OBJECTIVES: To evaluate drug consumption in the elderly aged 75 years or more living at home. DESIGN: Cross-sectional study. SETTING: Old-old (i.e., > or = 75 y) people living in central Turin, a city in northern Italy. PARTICIPANTS: Thirty-four general practitioners (GPs), with 50 or more old-old people in their patient list, randomly chosen among the GPs working in the Unità Socio-Sanitaria Locale I (Local Health Unit I) of Turin; 261 old-old people (135 men and 126 women) randomly selected from the practice records. METHODS: Data were collected by the GP through a structured questionnaire during an office visit and by a social worker in a home interview within 14 days of the GP visit. GPs were asked to record every diagnosis and drug currently taken by the patient; social workers were trained in the administration of a structured questionnaire exploring sociodemographic variables, drug use (following the medication inventory strategy), disability, cognitive functions, and depressive symptoms. RESULTS: Nearly all subjects (95% of the women and 91% of the men) were taking at least 1 drug. The overall number of drugs recorded was 917 (47.1% for men and 52.9% for women), of which 172 (18.8%) were not reported by the GP but were recorded during the social worker's visit. The mean number of drugs was 3.2 for men and 3.8 for women, with a statistically significant difference (p = 0.02), while the mean number of diagnoses was 2.3 and 2.6, respectively. The study of correlates of drug consumption showed a strong association with number of diagnoses at univariate analysis (p < 0.0001, with a linear correlation coefficient of 0.64). No multivariate model showed a clear superiority over the simple one containing only the number of diagnoses in predicting the total number of drugs taken. Cardiovascular, nervous system, and alimentary tract drugs were the most frequently used. A total of 107 subjects (41%) were taking at least 1 unreported drug. CONCLUSIONS: Our study shows high drug consumption among old-old people, with nearly 20% of drugs taken not reported by the GP. These results emphasize the need for an essential therapeutic approach in old-old people, prescribing only drugs of scientifically proven efficacy. Furthermore, the GP must make more effort when collecting a drug history from old-old patients.

[The elderly and drugs: the possible role of a home visit in improving a "difficult relationship". I. The results of an epidemiological study of drug prescription and use by the elderly conducted in the area of local health unit No. 1-23 in Turin]. / Anziani e farmaci: possibile ruolo di una visita a domicilio nel miglioramento di una "relazione difficile". Parte I: risultati di uno studio epidemiologico sulla prescrizione e l'uso dei farmaci nell'anziano condotto nel territorio dell'U.S.L. 1-23 de Torino.

A random sample of 46 general practitioners of the Unità Sanitaria Locale in Torino recruited 802 elderly outpatients and collected information about complaints and current drug treatment. Within a week each patient received a home interview and details were collected on drug compliance and use of drugs other than those reported by the GP. On average, each patient was taking 3.6 drugs of which 2.9 were correctly reported by the GP and 0.7 were un reported. Among the most prescribed therapeutic groups there were drugs with a narrow therapeutic index (cardiovascular drugs, diuretics, psychotropic agents) and substances whose efficacy has never been fully documented ("cerebroactive/vasoactive"). Age and number of compliants were positively and significantly correlated with number of prescribed drugs. The most common reason for non-compliance was fear of side-effects.