Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

Using the simulated patient methodology to assess paracetamol-related counselling for headache

OBJECTIVES

Firstly, to assess paracetamol-related counselling. Secondly, to evaluate the patient's approach as a determinant of counselling and to test the acceptability of the simulated patient method in Slovenian pharmacies.

METHODS

The simulated patient methodology was used in 17 community pharmacies. Three scenarios related to self-medication for headaches were developed and used in all participating pharmacies. Two scenarios were direct product requests: scenario 1: a patient with an uncomplicated short-term headache; scenario 2: a patient with a severe, long-duration headache who takes paracetamol for too long and concurrently drinks alcohol. Scenario 3 was a symptom-based request: a patient asking for medicine for a headache. Pharmacy visits were audio recorded and scored according to predetermined criteria arranged in two categories: counselling content and manner of counselling. The acceptability of the methodology used was evaluated by surveying the participating pharmacists.

RESULTS

The symptom-based request was scored significantly better (a mean 2.17 out of a possible 4 points) than the direct product requests (means of 1.64 and 0.67 out of a possible 4 points for scenario 1 and 2, respectively). The most common information provided was dosage and adverse effects. Only the symptom-based request stimulated spontaneous counselling. No statistically significant differences in the duration of the consultation between the scenarios were found. There were also no significant differences in the quality of counselling between the Masters of Pharmacy and Pharmacy Technicians. The acceptability of the SP method was not as high as in other countries.

CONCLUSION

The assessment of paracetamol-related counselling demonstrates room for practice improvement.

Using the theory of planned behavior to predict self-medication with over-the-counter analgesics

Millions of people worldwide use over-the-counter analgesics on a regular basis; yet little is known about how decisions to self-medicate are made. This study used the theory of planned behavior to explore the influence of beliefs about medicines (Beliefs about Medicines Questionnaire) and individual pain experience as predictors of intent to self-medicate. Both emerged as significant predictors of intent to self-medicate. Furthermore, intent to self-medicate significantly predicted reported use of analgesics. These findings indicate that use of over-the-counter pain medication is more likely when the value of the pain relief is greater than concerns about harm.

Over-the-counter medicines: their place in self-care

Over the last 20 years, there has been a shift in Western countries' healthcare policy to empower patients to exercise self-care by taking greater control in managing their own health, especially in cases where their conditions are deemed minor and self-limiting. In the UK, this has been facilitated by the Department of Health in making more medicines available to the public without the need for a prescription. This article highlights how policy is affecting practice, what attitudes the public and health professionals have toward greater medicine availability, and considers their place in patient management.

Nature and frequency of drug-related problems in self-medication (over-the-counter drugs) in daily community pharmacy practice in Germany

PURPOSE

To quantify drug-related problems (DRPs) in self-medication (over-the-counter [OTC] drug use) identified by community pharmacists (CPs) in Germany at the time the drug is dispensed.

METHODS

One hundred CPs were asked to document 100 consecutive customers presenting symptoms or requesting OTC drugs using a standardized documentation form. The number of 10,000 encounters seemed reasonable to evaluate the set objective. For each encounter, data such as age, sex, and first or repeated request and the availability of a patient file in the pharmacy including drug history were documented. Furthermore, identified DRPs, problem descriptions, and solutions were documented. Data were transcribed electronically, coded, checked for validity, and analyzed.

RESULTS

In total, 109 CPs documented 12,567 encounters identifying DRPs in 17.6% of all cases. Four indications comprised more than 70% of all DRPs: pain, respiratory, gastrointestinal, and skin disorders. Four DRPs were responsible for almost 75% of all DRPs identified: self-medication inappropriate (29.7%), requested product inappropriate (20.5%), intended duration of drug use too high including abuse (17.1%), and wrong dosage (6.8%). If a drug history was available, significantly more cases with wrong dosage (p < 0.05) and drug-drug interactions (p < 0.001) were detected. All patients with identified DRPs were counseled accordingly. Furthermore, the most frequent interventions were referral to a physician (39.5%) and switching to a more appropriate drug (28.1%).

CONCLUSIONS

In nearly one of five encounters, a direct pharmacist-patient interaction about self-medication revealed relevant DRPs. Having access to patient files including data on prescription and OTC drugs may increase patient safety.

A survey on the knowledge, beliefs and behaviour of a general adult population in Malaysia with respect to the adverse effects of medicines

OBJECTIVE

The aim of the study was to explore, in the Malaysian general population: knowledge and beliefs of the characteristics in general of medication-related side effects and side effects associated with different types of medicines; behaviour related to the safe use of drugs before and after taking a medication; and behaviour in the event of a medication-related side effect.

METHODS

A 24-item self-administered questionnaire was developed and used to survey the general public living or working in suburban Kuala Lumpur, Malaysia. Eight hundred questionnaires were distributed, face to face, by researchers using quota sampling. Respondents' knowledge, belief and behaviour were analysed and correlated with demographics, medical history and experience of side effects.

KEY FINDINGS

Six hundred and ten respondents completed the questionnaire giving a response rate of 76.3%. The mean knowledge score for the respondents was 18.4±3.6 out of the maximum possible score of 26. Educational level and experience of side effect had an influence on the knowledge score obtained. Respondents had misconceptions regarding the safety of complementary and alternative medicines (CAMs) and over-the-counter medications. Medication history and previous experience with side effects had a significant influence on the higher behaviour score obtained.

CONCLUSION

The survey has shown moderate results with regard to the knowledge of public regarding safety of medications, and there was evidence of under-estimating the risk of medications, especially CAMs. The misconceptions among the public, and inappropriate behaviour on drug safety-related aspects, is a concern which needs to be addressed in the interventions designed.

Public's views on making decisions about over-the-counter medication and their attitudes towards evidence of effectiveness: a cross-sectional questionnaire study

OBJECTIVE

To explore factors which may influence consumers when making decisions in relation to over-the-counter (OTC) medication.

METHODS

Data were collected from members of the public using a face-to-face interviewer-administered structured questionnaire in 10 shopping centres.

RESULTS

1461 people participated (18.8% males, 81.2% females; ages ranged from under 20 to over 60). Perceived effectiveness, familiarity with the name or brand and safety of the medicine influenced decisions when buying an OTC medicine. Almost all respondents reported that knowledge of effectiveness of OTC medicines was based on previous use. If there was no scientific evidence from drug trials to support effectiveness of a product, but it would not cause harm, two-thirds would still try the product. Over 70% 'agreed/strongly agreed' that people should be able to decide for themselves what OTC medicine they want, irrespective of scientific evidence.

CONCLUSION

There was ambivalence regarding need for evidence of effectiveness when choosing an OTC medicine, with individual autonomy and safety taking precedence over evidence.

PRACTICE IMPLICATIONS

Pharmacists should be aware that patients' expectations in relation to OTC medicines may be in conflict with evidence-based practice.

Parents' decision following the Food and Drug Administration recommendation: the case of over-the-counter cough and cold medication

BACKGROUND

In 2007, the Food and Drug Administration (FDA) recommended against parents administering over-the-counter cough and cold medications (OTC-CCM) to children under 2 years of age because serious and potentially life-threatening side effects can occur. This study examined the impact of FDA's recommendations against giving children under 2 years old OTC-CCM.

METHODS

We asked parents (n= 377) whether they knew of and trusted the FDA recommendations, as well as whether they intended to follow them. We also examined parents' knowledge, perceptions and behaviours with respect to OTC-CCM.

RESULTS

About 33% of our sample had never heard of the FDA recommendations. Of those who were aware, 32.9% intended to continue administering OTC-CCM, and another 36.7% were not sure what to do. Our results indicate that parents who trust the FDA recommendations are significantly more likely to stop giving OTC-CCM to their children. However, almost half did not trust the FDA recommendations or were not sure whether to trust them. Our results indicate that parents who trust the FDA recommendation are significantly more likely to discontinue using OTC-CCM. Our data also reveal that many parents give more than one drug simultaneously (32.9%), cannot identify the active ingredient(s) (28.9%) or fail to store the medications in a safe place (86.1%).

CONCLUSION

Parents' confidence in the FDA recommendations predicted whether they would continue or stop administering OTC-CCM to their children. Our findings illustrate the urgent need for widespread public education about OTC-CCM products to ensure children's safety.

To give or not to give: Parental experience and adherence to the Food and Drug Administration warning about over-the-counter cough and cold medicine usage

The Food and Drug Administration (FDA) warned against administering over-the-counter cough and cold medicines to children under 2. This study evaluated whether experienced parents show poorer adherence to the FDA warning, as safe experiences are predicted to reduce the impact of warnings, and how adherence can be improved. Participants included 218 American parents (mean age: 29.98 (SD = 6.16), 82.9% female) with children age ≤ 2 who were aware of the FDA warning. We compared adherence among experienced (N=142; with other children > age 2) and inexperienced parents (N=76; only children ≤2). We also evaluated potential moderating variables (amount of warning-related information received, prevalence of side effects, trust in the FDA, frequency of coughs and colds, trust in drug packaging) and quantified the impact of amount of information. Logistic regression assessed the ability of experience alone, and experience combined with amount of information, to predict adherence. 53.3% of inexperienced but 28.4% of experienced parents were adherent (p = 0.0003). The groups did not differ on potential moderating variables. Adherence was 39.5% among experienced parents receiving “a lot of information”, but 15.4% for those receiving less (p = 0.002); amount of information did not affect adherence in inexperienced parents (p = 0.22) but uniquely predicted adherence compared to a model with experience alone (p = 0.0005). Experienced parents were also less likely to mistrust drug packaging (p = 0.03). Targeting FDA information to experienced parents, particularly via drug packaging, may improve their adherence.

Using suitability profiles to better inform consumers' choice of commonly used over-the-counter analgesics

Objective

To quantify the impact of labelled contraindications, precautions and warnings for use on the population that may take commonly used over-the-counter (OTC) analgesics.

Setting

Primary care: data were collected from a general practitioner database in Australia.

Methods

Patient data were audited retrospectively (n = 107553) to determine the number of patients with contraindications, warnings or precautions to the use of OTC paracetamol and the non-steroidal anti-inflammatory drugs aspirin and ibuprofen. The primary outcome measure was the suitability rate (i.e. the proportion of patients with no contraindications, warnings or precautions) of these commonly used analgesics.

Key findings

In this Australian dataset, the proportions of patients who had no contraindications, warnings or precautions to the use of paracetamol or ibuprofen were 98.1 and 76.9%, respectively (P = 0.0001); 83.4% of patients had no contraindications, warnings or precautions to the use of aspirin (P = 0.005 compared with paracetamol).

Conclusion

Of the three OTC analgesics examined, paracetamol is suitable for use by a larger proportion of the general population without the need to seek medical advice.

Simulated patient visits with immediate feedback to improve the supply of over-the-counter medicines: a feasibility study

BACKGROUND

The supply of over-the-counter (OTC) medicines from community pharmacies should be safe and effective, but there is evidence that appropriate practice is not always achieved. The primary objective of this study was to assess the acceptability of simulated patient (SP) visits combined with feedback, delivered by either SPs or pharmacy educators (PEs), as a method for improving the supply of OTC medicines in community pharmacies.

METHODS

This feasibility study used a randomized controlled trial design where participating pharmacies were randomized into two groups (SP or PE, feedback). SP visits were audiotaped and questionnaire data collected from participants post-intervention. Each pharmacy received three covert visits from SPs. Feedback was provided immediately after the first and second visits. Data were collected on information gathering and advice provision. The visits were assessed for minimum standards of practice and appropriateness of outcome.

RESULTS

Twenty-two pharmacists and 34 medicine counter assistants (MCAs) from 20 community pharmacies in Grampian, Scotland, participated. Sixty SP visits were completed (three per pharmacy) and were well received, particularly by the pharmacists. Similar results were shown across both study groups in terms of information gathering and information/advice provision during consultations. Few SP consultations achieved the minimum standard of practice although most resulted in an appropriate outcome.

CONCLUSIONS

SP visits with feedback were acceptable to pharmacists as a method of improving the quality of consultations for OTC medicines, irrespective of the person giving feedback (SP or PE). The process by which pharmacists and their staff derived their recommendations, in terms of information gathering, could be improved. A large-scale study is needed to assess the effectiveness and cost-effectiveness of SP visits with feedback.

Examining the conspicuousness and prominence of two required warnings on OTC pain relievers

The labeling of over-the-counter (OTC) drugs is critical to their safe and effective use, and certain warnings are meant to be read at the point of purchase (POP). Examples include (i) warnings that alert consumers to the fact that the package is not child-resistant and (ii) warnings that alert consumers to potential product tampering. U.S. law mandates these warnings be "conspicuous" and "prominent" so that it is likely that consumers will read them before leaving the store. Our objective was to quantify the relative prominence and conspicuousness of these warnings. Sixty-one participants reviewed the packages of 5 commercially available analgesics to evaluate the prominence and conspicuousness of these warnings. Evaluated data included (i) the time spent examining the warnings compared with other areas of the label (using a bright pupil eye tracker), (ii) the ability to recall information from the OTCs viewed, and (iii) the legibility of the warnings relative to other elements of the labels (as measured by ASTM D7298-06). Eye-tracking data indicated that warnings were viewed by fewer participants and for less time than other elements of the packages. Recall and legibility data also indicated that the warning statements compared unfavorably with other elements of the labels tested. Evidence presented in this study suggests that 2 required warnings on 5 different OTCs are not prominent or conspicuous when compared with other elements of tested labels.

Over-the-counter medication use in older adults

Use of over-the-counter (OTC) medications is becoming more of a problem in the older adult population as the push to deregulate prescription medications grows. This article summarizes the side effects, adverse reactions, and medication interactions older adults face when using some common OTC medications.

The development of the Self-Medicating Scale (SMS): a scale to measure people's beliefs about self-medication

OBJECTIVE

We describe the development of a reliable and valid measure of people's beliefs about self-medication. To achieve this, student self-medication beliefs and behaviours in response to acute pain were investigated. Specific objectives were to establish the internal reliability plus content and construct validity of this scale.

METHOD

The nine item 'Self-Medicating Scale (SMS)' was developed following one to one interviews conducted with a purposive sample of 10 lay people in 2001 to explore their self-medicating beliefs and behaviour. The SMS was completed by 304 undergraduate pharmacy students in March 2006, along with measures of self-reported over the counter (OTC) analgesic use, pain severity and other non-pharmacological methods of pain relief, using a cross-sectional design. Exploratory factor analysis was conducted on SMS items using Maximum Likelihood extraction and Varimax rotation.

MAIN OUTCOME MEASURE

Factor structure of the SMS and relationships between SMS scales and medication-taking behaviour.

RESULTS

Factor analysis of the SMS revealed three factor structures which were named 'Reluctance', 'Don't think twice' and 'Run its course' (each three item scales with good Cronbach's alpha 0.82, 0.77 and 0.75 respectively). Of the 304 respondents, 93% reported having experienced pain over the past month and nearly three quarters of these indicated that they had self-medicated with OTC analgesics (mean 10.8 doses). Statistically significant differences or associations were found in all three SMS scores and each of the main outcome variables i.e. whether or not analgesics were taken, number of doses of OTC analgesics taken and number of non-pharmacological remedies tried.

CONCLUSIONS

These results show that the SMS possesses good internal reliability, plus good content and construct validity indicating that it is a useful measure of self-medication beliefs. More work is needed to extend these findings to the wider general public and with other OTC medications.

Exploring the supply of non-prescription medicines from community pharmacies in Scotland

OBJECTIVE

The objectives of this study were to: (1) explore pharmacy support staff (PSS) opinions of and attitudes towards the supply of non-prescription medicines (NPMs); (2) assess whether NPM supply is compliant with professional and good practice guidelines.

METHODS

This exploratory study was conducted in community pharmacies in Grampian, Scotland, and comprised non-participant observation of NPM consultations, semi-structured interviews with, and a questionnaire of, PSS. Guideline compliance was assessed by a consensus group of practising community pharmacists.

MAIN OUTCOME MEASURES

The percentage of consultations which achieved compliance with professional guidelines was calculated. A total score was also calculated for each consultation to assess compliance with good practice guidelines.

RESULTS

Fifty-seven support staff from 21 pharmacies participated in at least one component of the study. In total, 195 observed consultations were evaluable. Fifty-four participants completed a questionnaire and 95 post-consultation interviews were completed. Most consultations involved product requests and were for self-treatment. Overall, interviewees were satisfied or very satisfied with 78 (83.0%) and 14 (14.9%) of all consultations, respectively. Participants' self-reported scores for the quality of consultation were high indicating that they perceived their consultations to be appropriate. Most PSS were aware of good practice guidelines and thought their use was important/very important, yet few consultations were fully guideline compliant. Non-product consultations were more guideline compliant than product consultations. Just over one third (35.6%) of consultations established whether other medication was being used by the intended recipient of the NPM. Few PSS (21.2%) had read the professional guidelines and as such, compliance with these guidelines was extremely low. The percentage of guideline compliant consultations were 6.6% (n = 5) (sufficient information gathered), 13.2% (n = 10) (adequate advice/information provision), 46.1% (n = 35) (personal involvement of pharmacist), 21.1% (n = 16) (particular care of specific patient groups) and 28.9% (n = 22) (pharmacist involvement with specific NPMs).

CONCLUSION

Few consultations for NPMs in this study were fully guideline compliant. The reasons for non-compliance with good practice and professional guidelines need to be explored. Although failure to comply with professional guidelines could be due to PSS's lack of awareness, this does not explain non-compliance with good practice guidelines.

Natural health product labels: is more information always better?

OBJECTIVE

To explore how the information provided on labels as mandated by the new Canadian natural health product (NHP) regulations impacts consumers' perceptions of risks associated with using NHPs.

METHODS

Six focus groups were conducted in three locations across Ontario. Consumers were asked to react to two labels for a fictitious product called Saturnflower that represented the "old" standards (label 1) and the new standards (label 2). Groups were audio-taped and transcribed verbatim. Qualitative content analysis was used to identify key themes.

RESULTS

The 38 participants criticized label 1 for lacking information about the uses of the product and discussed their frustration at trying to obtain good quality information about NHPs. The lack of risk information on label 1 reinforced their perceptions of NHPs as natural, mild and safe. The majority of participants found label 2 much more informative, but a few were unsettled by the extent of the risk information, questioning if it was necessary.

CONCLUSION

The label requirements of the new NHP regulations were generally viewed positively by the consumers who participated in this study.

PRACTICE IMPLICATIONS

The additional risk information may generate more NHP-related questions for health care practitioners especially with respect to possible interactions between NHPs and conventional medicines.

Reasons for the use of mild analgesics among English students

OBJECTIVE

Mild analgesics such as paracetamol and ibuprofen are amongst the most commonly used over-the-counter (OTC) drugs. However, little is known about what beliefs people hold about them. The present paper examines: (a) the patterns of mild analgesic usage in a sample of university students, (b) their beliefs about the associated risks and the necessity of taking mild analgesics, and (c) the association between beliefs about analgesics and self-reports of their use.

SETTING

A convenience sample of 333 students studying at a large English University were approached on the University campus. Of these, 291 agreed to participate, yielding an 87% response rate.

METHOD

This study employed a cross-sectional design, with all participants completing the same questionnaire concerning their use of mild painkillers, such as paracetamol and ibuprofen, and beliefs about their use.

MAIN OUTCOME MEASURE

Four questions asked about their patterns of mild analgesic use in the past month, specifically (a) have they taken analgesics, (b) how often did they take analgesics when they had symptoms, (c) did they take more than a single dose of 1-2 tablets at one time, and (d) did they exceed the maximum dose.

RESULTS

Almost all of the 291 participants reported symptoms in the past month, with over two thirds treating with mild analgesics, and one sixth exceeding the maximum dose. Only 17% indicated that there were short-term risks of using mild analgesics, although half indicated that there were long-term risks. The risks that were identified generally did not conform with current medical thinking. Perceptions of risks were not generally associated with self-reports of analgesic usage. Rather, respondents who thought analgesics were more necessary were more likely to report taking analgesics, report taking more analgesics, and report exceeding the maximum dose.

CONCLUSION

These results indicate the need for caution in current moves to encourage self-medication. If people are unaware of the risks of drugs such as paracetamol or ibuprofen, then they may only contact health professionals after they experience adverse effects.

Effect of reading additional safety information on planned use of over-the-counter analgesics

OBJECTIVES

This study was used to test the effect on planned safe use of over-the-counter (OTC) analgesics of adding information about the potential for nonsteroidal anti-inflammatory drug (NSAID) interaction with antihypertensive medications, the potential for interaction of alcohol and acetaminophen, and NSAID ceiling effects to the Federal Drug Administration's (FDA's) OTC analgesics pamphlet.

DESIGN

A randomized posttest-only double-blind experimental design was used to test an intervention with a comparison group reading the FDA pamphlet, and treatment group reading the pamphlet with added information.

SAMPLE

Participants included 137 adults.

INTERVENTION

Participants read the treatment or the comparison pamphlet.

RESULTS

Both groups responded with similar planned use of OTC analgesics. The majority were likely to read the label before taking an OTC analgesic, but were unlikely to give acetaminophen to a family member using antihypertensive medication.

CONCLUSIONS

Reading additional information about OTC analgesics resulted in no greater intention to safely use analgesics. Responses indicated reluctance to use OTC analgesics, and the potential need for increased health teaching regarding use of OTC analgesics with antihypertensive medication. Public health teaching should include the importance of treating pain and selecting the safest OTC analgesics for the clinical situation.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Use of self-prescribed nonprescription medications and dietary supplements among assisted living facility residents

OBJECTIVE

Describe the prevalence of self-prescribed use and misuse as well as users' opinions concerning nonprescription medications and dietary supplements in assisted living facilities.

DESIGN

Descriptive cross-sectional study.

SETTING

Two assisted living facilities (ALFs) in Oregon and Washington State.

PARTICIPANTS

Convenience sample of 45 ALF residents.

INTERVENTION

Chart reviews and face-to-face interviews.

MAIN OUTCOME MEASURES

Prevalence and types of use of self-prescribed over-the-counter (OTC) medications and dietary supplements; misuse of these products, and participants' opinions concerning use of these products.

RESULTS

Among 29 women and 16 men with a mean (+/- SD) age of 84.8 +/- 6.9 years and a mean of 9.9 +/- 6.4 years of education, 84.4% were using selfprescribed OTC medications and dietary supplements at the time of this study. A mean of 3.4 products was used per participant. Nutritional supplements were most frequently used (32% of products), followed by gastrointestinal products (17%), pain relievers (16.3%), herbals (14.4%), topical products (12%), and cold/cough products (8.5%). Potential misuse was identified in 23 (51%) of the participants. Problems in the use of products included duplication (70%), potential drug/disease/food interactions (20.8%), and other inappropriate use (9.1%). The majority (76%) of the participants believed the products were helpful in maintaining health, 56% of them wanted more product information, 49% sought product information from family and friends, 40% turned to their physicians and nurses for information, and 11% asked pharmacists for advice.

CONCLUSION

The use of nonprescription medications and dietary supplements among ALF residents was high, and simultaneous use of multiple products with the same active ingredient was the most prevalent problem. The residents turned to family and friends, physicians, nurses, and ALF staff for information on these products more frequently than they did to pharmacists.

Approaches to appropriate drug prescribing for the older adult

When prescribing for the older adult, the office-based physician walks the fine line between introducing the drugs that are considered best practices for each disease that the person has and acknowledging that as the number of drugs increases, the risks of adverse drug reactions, drug-drug interactions, or drug-disease interactions increase considerably. Establishing the clinician-patient partnership to develop goals of care is the first step in the process. Avoiding drugs that are likely to be associated with adverse outcomes (the Beers Criteria list) is an important next step, as is awareness of the prescribing cascade. It is also important, however, to not be overly pessimistic. Quality of care and quality of life may be greatly enhanced by careful use of prescription and over-the-counter medications in the older adult.

Selecting nonprescription analgesics

Worldwide, there has been an emerging patient demand for access to efficient drugs without consulting a doctor and obtaining a prescription. As a result, there has been an expanding movement of prescription-only drugs to over-the-counter (OTC) status. An increasing number of drugs are becoming available OTC, empowering patients to treat themselves. Where the principle of empowering individuals to treat themselves can fail is when consumers lack the knowledge to do so safely. This potentially applies to the self-selection of analgesic drugs by consumers. When used inappropriately, these drugs pose significant risks. The nonsteroidal antiinflammatory drugs (NSAIDs) are associated with many adverse reactions, interactions, and contraindications in a number of patient groups, even at OTC doses. In particular, in the elderly, the high incidence of cardiovascular and gastrointestinal disease, coupled with age-related decline in renal function and multiple medication use, all warrant extra caution with the use of NSAIDs and make paracetamol the simple analgesic drug of first choice. Despite the possibility of hepatotoxicity in overdose, paracetamol represents a better all-round option for most patients requiring OTC analgesic therapy.

Switching of Prescription Drugs to Over-the-Counter Status

Prescription medicines are increasingly being switched to over-the-counter (OTC, nonprescription) status in the developed world, with the support of government policy. These changes may provide greater choice for individuals and offer potential savings in government spending on health while expanding the market for pharmaceutical companies. However, there is concern regarding the safety of these reclassifications. Elderly people are the largest consumers of prescription and OTC medicines and are more vulnerable to drug adverse effects and the risks of multiple or inappropriate medications. Commonly purchased agents such as NSAIDs have recognised adverse effects which have been shown to be more common in the elderly. Furthermore, all sedatives, including antihistamines, have a propensity to cause falls in older people. As many doctors do not ask patients about OTC medicine use, problems related to use of these drugs may go undetected. Furthermore, the increased availability of OTCs may result in a delay in patients consulting medical practitioners for potentially serious conditions, although this has not so far been investigated. In the UK, the recent switch of a low-dose HMG-CoA reductase inhibitor (statin) to OTC status has caused concern. Although there might theoretically be some benefits from improved access to medications used in primary and secondary prevention of heart disease, the actual outcomes of use of this reduced dose of the statin will be difficult or impossible for patients or practitioners to monitor. OTC drug use implies a mutual responsibility for communication between patients and health professionals that in practice is not always achieved. Epidemiological research is needed to investigate patterns of OTC use and evaluate the potential risks of OTC medicines in elderly people. Governments, regulatory bodies, professionals and the drug industry have a responsibility to ensure that robust systems are in place if the increased use of OTC medicines by elderly people is to be safe and effective.