In this age of rapidly advancing technology, the pharmaceutical companies have supplied the country with an overwhelming selection of drugs. A visit to the physician's office frequently culminates in the client receiving a prescription for one or more of these sophisticated preparations. Moreover, it has been observed that doctors are treating patients with more drugs, not less, ultimately creating a population highly dependent on a large number of drugs. This trend is compounded by the vast array of drugs also available across the counter to those who self-medicate. The drug-use trend extends to everyone regardless of age. The strong indication is that the young and middle aged of today are more tolerant of drugs and as they grow older they will use even greater amounts than the current elder population.1 The complexities created by this dilemma have yet to be comprehended.
The masked importance of the over-the-counter (OTC) drugs in this medication maintenance ritual relevant, to the elderly client is the subject of this paper. There are two basic issues: the availability and use of OTC drugs in self-medication and the abuse of OTC drugs. In delineating the problems there will be a working definition of OTC drugs; identification of the most commonly used types of OTC remedies; a description of the users; and finally, a discussion of the self-medication risks related to drug abuse and drug interactions.
For the convenience of this discussion the terms nonprescription and over-the-counter will be used interchangeably to refer to those items purchased in drug stores, discount houses, and supermarkets, whose purpose is for alleviation of minor ailments. These drugs do not require the advice or prescription of the physician. They "permit patients to treat a wide range of minor, usually self-limiting problems..."2 Most frequently they are used for relief of pain in muscles, head, and back. Commonly they also include antacids, laxatives, analgesics, and sedatives for prevention or treatment of chronic, often vague and sporadic, symptoms. They are so frequently and commonly used persons ". . .may not perceive themselves as deviating from a state of health even when they seek relief through self -medica ti on."3 When giving a drug history patients often do not include these drugs in what they relate to the doctor because they are not thought of as medications.4,s Yet over-the-counter drugs are a major part of an informal health care system.
The use of OTC drugs is not without risk. Even with intense efforts on the part of the FDA there are still a myriad of useless and unsafe drugs on the shelves of drugstores and medicine cabinets. There arc users who abuse drugs by disregarding directions. There are people who never doubt the value of a drug, subsequently increasing the amount recommended if their body fails to respond to the initial dose. Similarly many, in an attempt to treat a cold or other misery, will experiment and ultimately use whatever they perceive as successful. Finally, there are many drug reactions between prescription and nonprescription drugs, the relative safety of which has been proven independent of other drugs. However, in union with a second drug, dangerous side effects result.
The focus of this paper is upon the drug use among the elderly and their self-medication practices. The reason for such a focus is for better health education programs to this rapidly growing minority group. Of the elderly, 95% live in the community, in varying degrees of self-sufficiency, and are generally responsible for their own medications, however, overuse of OTC drugs by them is not uncommon. Chronic illness creates vulnerability to medication use and misuse in one's search for better health. Moreover, decreased income and mobility renders them more readily susceptible to nonprescription drug advertisements. "While the number of symptoms for which persons perceive it is appropriate to self-medicate appear to be limited, the patent distribution system of nonprescription medicines contains few incentives to assure rational use or to decrease use."3
There is an assumption that everyone uses nonprescription drugs to some extent. Several studies support this notion. It has been reported that the mean number of OTC drugs in a single home is between 1 7.2 and 24. 4.7 The World Health Organization found thai persons average 1.4 different nonprescription drugs a day -for illness or prevention of illness. The healthy persons of any age group were less likely to be consumers.3 However, increased age complicated the statistics. Men under 50 used half as many nonprescription drugs as women the same age. Between the ages of 50 and 64 use by men and women was nearly equal, and once men reached 65 they far surpassed women in the number of OTC drugs ingested.4 Overall though, women and the elderly of both sexes had the highest user rate.3 That's not terribly surprising. Women live longer and make up a greater proportion of the elderly population. But also, all people as an average have two or more chronic conditions once they reach 65 and these conditions, by and large, are medicated at home.8 Those persons use three times more prescription drugs than persons under 65 years of age, and three times more than their healthy peers. In fact, those over 65 consume more than 25% of all prescription drugs. More than half of all adverse drug effects occur in geriatric patients, but ironically, their longevity and better health is, in part, the result of use of medications, some of which are dangerous, or even lethal.'
That, however, is not the entire problem. "Many persons use medicines that are neither prescribed nor suggested by a physician both in absence and presence of illness." There is concomitant use of prescription and nonprescription drugs and commonly patients substitute nonprescription drugs for visits to the doctor, and they also substitute them for prescription drugs.3 It is likely that they don't use prescription drugs and OTC drugs for the same symptoms but Bush3 suggests they may use them for the same illness. There is probably greater awareness of the interaction perils between two prescribed drugs taken simultaneously than there is between OTC drugs. Most people perceive OTC drugs as safe and effective in their limited use and team leach clients about such simple things as aspirin or laxatives. For example, aspirin is, to date, the drug of choice for arthritis and simple pain. It is readily available and inexpensive. Yet, these two qualities often cause persons to disregard it as an unimportant drug, eventually substituting what they consider to be more sophisticated compounds. Tylenol, being newer, often seems to bea logical choice. But Tylenol lacks the antiinflammatory factors so effective against arthritis. Moreover, those who self-medicate with aspirin need to be aware of contraindications and indications of toxicity. ". . .the side effects of aspirin are advantageous in lowering blood sugar and cholesterol and diminishing platelet aggregation."9 But il also has a wide range of interaction effects. It modifies pharmacologic activity of prescription drugs, alters coagulation when used with anticoagulents, and potentiates hypoglycemia when used with chlorpropanimide.3 Even when not in combination with other drugs il also has the untoward side effect of gastric distress and bleeding in a small proportion of users. Aspirin, in high doses, also contributes io insulin hypoglycemia.10
Persons often find themselves in the tenuous position of needing a drug for one condition that is deleterious to another. For example, many elderly have problems related to the bowel (ie, constipation), the stomach, and the circulatory system. Circulatory problems are compounded by sodium. Among the elderly there is a marked incidence of those who consume OTC drugs without knowledge of their sodium content. Bulk laxatives often contain 250 mg of sodium per packet." Baking soda, antacids, and products such as Pepto Bismol, so commonly used for gastrointestinal complaints cause sodium retention, increased pH of the stomach, delaying the absorption of acidic drugs, iron, nutrients, and antibiotic medicines. In addition, those who routinely take digitalis must be cautious in their use of antacids.3
Dependency upon laxatives is another common situation created by routine abuse. Mineral oil has been reported to this author to be consumed in doses as great as one-half of a cup at a time, every day. This consequently leaves the patient in worse condition by retarding gastric emptying and impeding absorption of minerals and fat soluble vitamins. It looms even more threatening as a potentiator of aspiration pneumonia and precursor to loss of vitamin K from malabsorption. Some studies show thai 25% of osteoporotics have such a malabsorption problem.10 More prudent than increasing mineral oil dependency would be increasing dietary bulk, fluid intake, and daily exercise.
The last area to be mentioned here is concern for the diabetic, and the need to be cognizant of sugar in OTC drugs. Small quantities appear in analgesics and antacids.1- A useful listing of sugar free antitussives for persons restricting intake of carbohydrates is available in the Handbook of Non-Prescription Drugs. 3 In it concludes:
Considering all the* possible problems that might be incurred by a self -medical ing diabetic .patient, the pharmacist should thoroughly discuss the siate of the patient's condition. instructions received from the physician, as well as the condition (or which the patient is seeking a remedy. An open line oí communication should be maintained. .. .
As mentioned earlier many elderly persons consume large quantities of prescription drugs with little knowledge of the dangers possible when combined with nonprescription drugs. To return to one of the original examples, antacids, consider what happens when taken at the same time as digoxin, a prescription drug. It will decrease the bioavailability of the digoxin. When taken with tetracycline il will decrease the serum level of the antibiotic. It also has the ability to impair the absorption of phenothiazine unless several hours elapse between the intake of ihe antacid and the prescription drug. Quinidine and antacids taken by the same patient, regardless of the time factor, causes quinidine intoxication. Iron interacts with antacids and the absorption of iron is impaired because of the magnesium or carbonate contained in the antacids. Iron absorption is also markedly decreased when taken in conjunction with tetracycline.14
Alcohol is another common drug which is not considered by many to belong in the drug classification, but the potential interactions between alcohol and prescription drugs are numerous. It interacts with hypnosedatives and causes CNS depression. The same reaction is possible when alcohol is taken with antihistamines, antidepressants, antipsychotics, antimanic drugs, and barbiturates. In addition alcohol and antidepressants together create a risk of paralytic ileus in the consumer.14
Finally, prescripti.on-nonprescription drug dangers are present in antihistamines and antihypertensive drugs. When taken together the blood pressure will increase and cause atropine-like side effects.14
This misuse of OTC drugs alone or in competition with prescription drugs is only the lip of the iceberg. What is seen is millions of elderly Americans, with multiple chronic conditions, living outside the institutional system, responsible for self-medication but the effects of most of the drugs they are using have only been validated on younger persons who have different pharmacodynamics. The hypothesis at this time is that community elderly are having drug reactions, not only from prescribed drugs, but from OTC drugs used in daily maintenance.
The final question is: Is the patient aware of the OTC drug dangers? Many take more than one potent drug a day. "Since most every drug affects not one, but many physiologic systems, chances are good that any two drugs will interact in at least one system."5 Finding the elderly, assessing their needs, capabilities and resources, then tailoring the medication regimens to their individual situations, consistently and repeatedly is a challenge. But also there is a need to approach patient teaching in a more imaginative, thoughtful style, perhaps slowing down, asking for feedback, and using visual aids in conferences with the patients. This request came from a study of elderly who said the main key to successful teaching for them was "plan with us, not for us and we'll not make so many mistakes."15
- 1. Basen MM: The elderly and drugs - problem overview and program strategy. PHR 92:43-18, January February 1977.
- 2. F DA: Commentaries. Safety efleciiveiiess ol over-the-counter drugs: The FDA's OTC drug devices. Pediatrics 59(2):309-31 1, February 1977.
- 3 Bush P. Robin D: Who's using ? on -prescribed medicines? Medical Care 1 1(2): 101 1-1023. December 1976.
- 4. Stewart R, Giuli LE: Studies on the epidemiology of adverse drug reactions VI: t'tili/ation and interactions of prescription and non- prescript ion drugs in outpatients. Johns Hopkins Med J 129:319-331, 197!.
- 5. Hussar DA: Drug interactions: Good and bad. Nuis 6(9):61-65, September 1976.
- 6. Plant J: Educating the elderly in safe medication use. Hospitals 51:97-98, April 1977.
- 7. Johnson RE, Pope C, Campbell W, et al: Reported use of nonprescription drugs in health maintenance. Am J Hosp Pharm 33:1249-1254, December 1976.
- 8. Lenhart D: The use of medications in the elderly population. NCNA:I35-144, March 1976.
- 9. Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics, 5th ed. New York, MacMillon, 1975, pp 331-333.
- 10. Burnside I: Nursing and the Aged. New York, McGraw Hill Book Co. 1976, ? 373.
- 11. Inglefinger FJ: The handbook of non-prescription drugs. Nurs J Med 297:48-49. July 1977.
- 12. Thomas K: Diabetes Mellitus in elderly persons. NCNA 11:157168. March 1976.
- 13. Chalmers RK, Cormier JF: Antitussives, in Handbook of NonPrescription Drugs. Washington, DC, American Pharmaceutical Association, 1973.
- 1 4. Avery GS: Drug interactions that really matter: A guide to major important drug interactions. Drugs 14:132-146, 1977.
- 15. Schwartz D: Self medication for elderly outpatients. Am J Nurs 75:1808-1810, October 1975.
- Alfano G: There are no routine patients. Am J Nurs 75: 1804-1807, October 1975.
- Brand F, Smith R, Brand PA: Effect of economic barriers to medical care on patients' noncompliance. PHR 92:72-78, January/ February 1977.
- Brickner P, Janeski J, Rich G, et al: Home maintenance for the homebound aged. Gerontol 16:25-29, February 1976.
- Burnside I: Listen to the aged. Am J Nurs 75:1801-1803, October 1975.
- Cantor M. Mayer M: Health and the inner city elderly. Gerontol 16:17-25. February 1976.
- Eisdorfer C: Issues in health planning for the aged. Gerontol 16:1216, February 1976.
- Kennedy RD: Teamwork in geriatric medicine. Physiotherapy 62:158-159. May 1976.
- Kovar MG: Health of the elderly and the use of health services. Public Health Reports 92:9-20, January /February 1977.
- Sadik F, Bauguess CT, Fincher J: O-T-C- Products for the Symptomatic Relief of Bronchial Asthma. J Am Pharm Assoc N515:247-250. May 1975.
- Salzman C, Shader R, VanDerkolk BA: Clinical psychopharmacology and the elderly patient. ? Y J Med 76:71-77. January 1976.