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Farmacología en Ancianos
Farmacología en Ancianos
Farmacología en Ancianos
Self-Medication in Older
Urban Mexicans
An Observational, Descriptive, Cross-Sectional Study
Fernando Ruiz Balbuena,1 Alfredo Briones Aranda2 and Albert Figueras3
1 Post-degree Department, Universidad de Ciencias y Artes de Chiapas (UNICACH), Tuxtla
Gutiérrez, Chiapas, México
2 Department of Pharmacology, Faculty of Human Medicine, Universidad Autónoma de
Chiapas (UNACH), Tuxtla Gutiérrez, Chiapas, México
3 Fundació Institut Català de Farmacologia, Universitat Autònoma de Barcelona, HU Vall
d’Hebron, E-08035-Barcelona, Spain
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
Self-Medication in Older Urban Mexicans 53
The present study was carried out to fill this gap These 245 inhabitants were identified using a
in the available knowledge. Specifically, the aim of conglomerate sampling technique. Blocks were se-
the study was to quantify and describe the character- lected from an official downtown map provided by
istics of self-medication in a geriatric population in the City Hall. All houses in the chosen blocks were
the urban area of Chiapas, Mexico. visited to identify older adults (aged ≥65 years).
Verbal agreement to participate in the survey was
Methods obtained from all participants before the question-
naire was administered. Sixteen people refused to be
An observational study design was utilized. The interviewed and additional inhabitants were there-
survey was conducted by a specially trained physi- fore obtained to make up the study sample of 245.
cian in a sample of men and women aged ≥65 years
living in the downtown urban area of Tuxtla Guitier- Study Variables
rez (Chiapas, Mexico) during September and Octo-
ber 2006. The downtown area was chosen because it A structured questionnaire was designed to col-
is the city centre; in addition, the streets and houses lect personal data and information relating more
are well established (not newly built) and the popu- specifically to socioeconomic factors, present ill-
lation is not a ‘floating population’ originating from nesses, use of self-medication and ADRs. The Graf-
rural areas. far method as modified by Méndez[11] was used to
classify socioeconomic level; this method classifies
Study Sample populations according to five social layers on the
basis of family members’ professions, monthly in-
In 2006, Tuxtla Gutierrez had 490 455 inhabi- come and living conditions. According to this classi-
tants. Of these, 19 272 were aged ≥65 years and fication, I is the highest socioeconomic level and V
3176 of these lived in the downtown area. The the lowest. Information on chronic conditions was
minimum sample size was calculated using the obtained by asking participants if they had hyperten-
formula proposed by Daniel for populations (see sion, diabetes mellitus, hypercholesterolaemia, joint
equation 1):[10] disease, sleep disorders or depression; the diagnosis
N · Z2 · pq was then confirmed by the results of laboratory tests
n=
d2 · (N –1) + Z2 · pq or a medical record provided by the interviewee.
(Eq. 1) Educational level was categorized as ‘high’, ‘medi-
where n = sample size; N = population size; Z = Z um’ and ‘low’, according to the highest finished
statistic for a level of confidence = 1.96; p = expec- school degree; low educational level included illiter-
ted proportion; q = 1–p (1–0.46) = 0.54, and d = ate participants and those who had not completed
absolute sample error. primary school.
For the purposes of the present survey, an expec- The main variable of the survey was self-med-
ted proportion of self-medicated people of 0.46,[6] an ication. This included all remedies taken by the
absolute sample error of 6.0% and a degree of interviewees on their own initiative (i.e. had not
security of 95% meant 7.7% of the downtown popu- been prescribed) during the previous 30 days, ex-
lation aged ≥65 years (n = 3176) was required for cluding those for topical use. The following infor-
the minimum sample size. This figure represented a mation was identified for each medicine: name, use,
total sample size of 245 inhabitants, which included dosage and administration pattern. Medicines were
an additional 10% for potential losses. grouped according to the Anatomical Therapeutic
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
54 Balbuena et al.
Classification criteria.[12] The interviewer asked the 65–70 years. No difference in sex distribution by
participant to bring all medicines they had taken age group was noted (χ2 = 2.126; p > 0.5; see table
during the past 30 days to the interview; the partici- I).
pant was then asked to indicate which of these they Half of the participants declared self-medication
had taken on their own initiative. practices (131; 53.5% [95% CI 47.2, 59.7]). No
ADRs were identified in accordance with WHO differences in the proportion of participants declar-
criteria:[13,14] each patient was asked to name any
ing self-medication were found between men (49 of
potential unwanted effects associated with his/her
93 [52.7%; 95% CI 46.4, 58.9]) and women (82 of
medication. When an affirmative answer was given,
152 [53.9%; 95% CI 47.6, 60.0]) [χ2 = 0.04; p =
the interviewer carried out an in situ assessment
0.8479; see table II].
using the Naranjo algorithm.[15]
The relationship between reported self-med-
Data Analysis ication and other social and cultural variables was
analysed. There was a significant difference in re-
The statistical programme EPIINFO version ported self-medication according to marital status.
3.3.2 (Centers for Disease Control and Prevention, Older adults who lived alone (single, divorced or
Atlanta, GA, USA) was used to construct the data- widowed) were significantly more likely to report
base and conduct subsequent statistical analysis of self-medication than married adults (61.1% vs
the variables. The Pearson chi-squared (χ2) signifi- 47.0%, respectively; χ2 = 4.86; p = 0.0274; see table
cance test was used to calculate the independence of II). Additionally, significantly more individuals in
qualitative variables. Both a bivariate and a multi- the illiterate and low-level education subgroup re-
variate analysis (with self-medication as the depen- ported self-medication than in the secondary and
dent variable and adjusting for age, sex, educational
high-school education subgroup (57.6% vs 32.5%,
level, socioeconomic level, marital status and retire-
respectively; χ2 = 8.45; p = 0.0036; see table II).
ment status) were carried out. The level of statistical
Similarly, older people belonging to higher socio-
significance adopted was 0.05.
economic groups (I and II) tended to be less likely to
report self-medication than those belonging to lower
Results
socioeconomic groups (III, IV and V), although the
The survey was conducted in 245 persons (152 significance level was not attained in this case
women [62.0%] and 93 men [38.0%]) aged ≥65 (39.5% vs 56%, respectively; χ2 = 3.54; p = 0.0598;
years (mean = 73.4 years; standard deviation = 8.0). see table II). No significant difference in reported
Almost half of the sample (117, 47.8%) were aged self-medication was observed by working status of
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
Self-Medication in Older Urban Mexicans 55
Table II. Demographic and socioeconomic characteristics of the 245 study participants according to reported self-medication (SM) status
Characteristic SM No SM Total χ2; p-value
n % n % n %
Sex
Women 82 53.9 70 46.1 152 100 0.04; 0.8479
Men 49 52.7 44 47.3 93 100
Marital status
Alonea 69 61.1 44 38.9 113 100 4.86; 0.0274
Marriedb 62 47.0 70 53.0 132 100
Educational level
Illiterate/low 118 57.6 87 42.4 205 100 8.45; 0.0036
Secondary/high 13 32.5 27 67.5 40 100
Socioeconomic levelc
I, II 15 39.5 23 60.5 38 100 3.54; 0.0598
III, IV, V 116 56.0 91 44.0 207 100
Employment status
Unemployed 78 55.3 63 44.7 141 100 0.46; 0.4991
Employed 53 51.0 51 49.0 104 100
a People living alone (single, widowed, divorced).
b Married or de facto couple or living with other family members.
c According to the Graffar classification as modified by Méndez[11] (see Methods section)
the participants (p > 0.05). These relationships were respiratory tract problems (39; 15.9%) and cough
confirmed in a multivariate analysis. (18; 7.3%). Importantly, ‘hypertension’ was the stat-
The 131 participants who reported self-med- ed reason for self-medication by 17 participants (27
ication described taking 246 medicines (table III). medicines, 11.0% of total medicines taken). The
The most frequently cited reasons for taking these indications responsible for the highest proportion of
medications were muscle and joint pain (49 medi- medicines taken per person were gastric complaints/
cines; 19.9% of total medicines taken), upper dyspepsia (1.71 medicines), weakness (1.67) and
Table III. Reasons for taking the 246 medicines reported as self-medication by the 131 study participants
Indications for use n medicines (A) % n people (B) % A/B
Gastric complaints/dyspepsia 12 4.8 7 5.3 1.71
Weakness 20 8.1 12 9.2 1.67
Hypertension 27 11.0 17 13.0 1.59
Upper respiratory tract problems 39 15.9 30 22.9 1.30
Infections 13 5.3 10 7.6 1.30
Diabetes mellitus 9 3.7 7 5.3 1.29
Muscle and joint pain 49 19.9 42 32.1 1.17
Cough 18 7.3 16 12.2 1.13
Headache 17 6.9 16 12.2 1.10
Diarrhoea 10 4.1 10 7.6 1.00
Osteoporosis 8 3.3 8 6.1 1.00
Abdominal pain 7 2.8 7 5.3 1.00
Other 17 6.9 17 13.0 1.00
Overall 246 100 131a 100 1.88
a Some participants took self-medications for more than one indication.
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
56 Balbuena et al.
Table IV. Therapeutic classes of the 246 medicines reported to be taken as self-medication by the 131 study participants
Therapeutic class n medicines %
NSAIDs 89 36.2
Antihistamines 31 12.6
Antihypertensives 22 8.9
Vitamins 20 8.1
Antibacterials 13 5.3
Antacids/anti-ulcer agents 11 5.3
Calcium supplements 9 3.7
Antihyperglycaemics 8 3.3
Mucolytics 8 3.3
Cough remedies 7 2.8
Anti-spasmodics 4 1.6
Anti-parasitic agents 4 1.6
Antidiarrhoeals 3 1.2
Other 17 6.9
Total 246 100
hypertension (1.59) [see table III]. Table IV shows as the stimulus to self-medicating with the treat-
the most commonly used self-medications grouped ment. Twelve participants began the treatment on
by therapeutic class. NSAIDs were the most fre- their own initiative (9.2%; 95% CI 5.5, 12.7) and 10
quently used (36.2% of the medicines reported), participants (7.6%; 95% CI 4.3, 10.9) following a
followed by antihistamines (12.6%), antihyper- recommendation made in the media.
tensives (8.9%) and vitamins (8.1%). These four Finally, it is important to emphasize that 35 pa-
therapeutic classes comprised two-thirds of the tients (26.7% of those who declared self-med-
medicines consumed as self-medication. ication) said they had experienced at least one ADR
When participants who reported self-medication supposedly associated with the drug they were tak-
were asked who induced that practice, the most ing. These 35 patients reported 40 ADRs, the most
frequently reported stimuli were a family member frequent of which were gastrointestinal (heartburn
(40 participants, 30.5% [95% CI 24.7, 36.7]) or a in 12 participants [30.0% of all ADRs] and nausea in
nurse or pharmacist (36 participants, 27.5% [95% CI nine participants [22.5%]; see table V). Both of
21.9, 33.1]). Interestingly, 33 participants (25.2%; these adverse effects appeared mostly after exposure
95% CI 19.7, 30.6) identified previous prescriptions to NSAIDs or antibacterials.
Table V. Suspected adverse drug reactions (ADRs) attributed to medicines taken as self-medication
ADRs n % Suspected medicine (patient’s attribution)
Heartburn 12 30.0 NSAID, antibacterial
Nausea 9 22.5 NSAID, antibacterial, cough remedy
Somnolence 7 17.5 Antihistamine
Dizziness 4 10.0 Antihypertensive, antihyperglycaemic
Asthenia 3 7.5 Antihypertensive, antihyperglycaemic
Malaise 3 7.5 Antihyperglycaemic
Cough 2 5.0 Antihypertensive
Total 40 100
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
Self-Medication in Older Urban Mexicans 57
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
58 Balbuena et al.
ment for pharmacists to keep a copy of the has been reported similarly in other studies.[25] How-
prescription for future inspections. ever, one finding of the present study that should be
Several studies have investigated the association highlighted is that previous prescriptions prompted
between socioeconomic factors and self-medication. self-medication in one-quarter of interviewed pa-
A Danish survey identified social differences in the tients who declared self-medication. This potential
pattern of use of prescription drugs (use was greater misuse of prescriptions some time after they were
in people with lower socioeconomic standing) but initially written emphasizes the need for improved
not in the use of over-the-counter medicines.[22] doctor-patient communication. Unfortunately, these
Another survey conducted in a Spanish population often forgotten parts of the prescription process can
found a significant association between self-med- have deleterious consequences, as in the case of
ication and higher level of education, sex, lower age antibacterials and many other medications.
and smoking habit.[23] Our survey, conducted exclu- The last noteworthy finding of the present survey
sively in an elderly population in a society with was the high proportion of older adults who self-
fewer economic resources than the abovementioned medicated and complained of having experienced an
European countries, revealed a significant relation- ADR attributed to the medicine/s they had decided
ship between self-medication and several variables, to take. One-quarter of participants who self-medi-
such as living alone, lower education level and
cated complained of at least one adverse effect while
lower socioeconomic level, but not employment sta-
taking their medication. This proportion was higher
tus. These discrepancies among the published stud-
than the 15% reported in the study conducted in
ies could be explained both by the different study
Spain.[8] Most suspected ADRs reported in the pre-
designs and the different populations analysed (i.e.
sent survey were mild symptoms that could be easily
all age samples vs older adults only). However, in
identified even by people who are not health profes-
keeping with our findings, a study conducted in the
sionals. However, the number of ADRs identified in
north of Brazil found that 37% of elderly people
the present survey could have been an underestimate
who took at least one drug as self-medication lived
in the outskirts of the city, an area with a lower since some symptoms attributed to medicines are
socioeconomic level.[20] A significant association difficult to identify, particularly if they are confused
between self-medication and low socioeconomic with symptoms usually attributed to the aging pro-
level was also found in a study conducted in Mexico cess or to the patient’s chronic illness.[26] Considera-
in 2006.[24] tion of the most frequently reported suspected ADRs
in the present survey revealed a pattern similar to
Studying the factors that induce self-medication
that found in a study conducted in a geriatric unit of
is difficult because of potential interactions among
a Brazilian hospital, where acute gastritis was re-
them. Social pressure and the growing profile of
ported by 22.7% of all self-medicating patients and,
medicines in the media interplay with recommenda-
as in the present survey, was largely caused by
tions from friends or relatives, making analysis dif-
NSAIDs.[27]
ficult. In our survey, patients were asked in an open-
ended way to describe who or what prompted them Participation in the present survey was refused by
to commence self-medication. The results showed only 16 people. This high participation rate might be
that the main alleged instigators of self-medication explained by the fact that the interviewer was a
in elderly people living in an urban area of Chiapas medical doctor whose visits could have been seen as
were relatives, friends, nurses and pharmacists, as a way to receive free health assistance at home.
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
Self-Medication in Older Urban Mexicans 59
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)
60 Balbuena et al.
12. WHO Collaborating Centre for Drug Statistics Methodology. 26. Ramos CA, Milian VP, Fonseca LJ, et al. Determinación de
Anatomical Therapeutic Chemical (ATC) classification index. polifarmacoterapia en pacientes geriátricos de un consultorio
Oslo: WHO Collaborating Centre for Drug Statistics Method- médico de la familia en Cienfuegos. Rev Cubana Farm 2000;
ology, 1993 34: 170-4
13. Delamothe T. Reporting adverse drug reactions [letter]. BMJ 27. Passarelli MC, Filho WJ, Figueras A. Adverse drug reactions in
1992, 304: 465
an elderly hospitalized population: inappropriate prescription
14. Lindquist M. The need for definitions in pharmacovigilance. is a leading cause. Drugs Aging 2005; 22: 767-77
Drug Saf 2007; 30: 825-30
15. Naranjo C, Busto U, Sellers EM, et al. A method for estimating
the probability of adverse drugs reactions. Clin Pharmacol Correspondence: Dr Albert Figueras, Servei de Farmaco-
Ther 1981; 36: 239-45
logia Clínica, Hospital Vall d’Hebron, Passeig Vall
16. Santana VO, Bembibre TR, García NR, et al. Efectos sobre la
salud del anciano en cuanto alteraciones en la medicación. Rev d’Hebron, Barcelona, 119-129, E-08035, Spain.
Cubana Med Gen Integr 1998; 4: 316-9 E-mail: afs@icf.uab.es
© 2009 Adis Data Information BV. All rights reserved. Drugs Aging 2009; 26 (1)