Profile of Prescription Medication in an Internal Medicine Ward

Aging-related loss of resilience associated with the lack of evidence regarding the therapeutic efficacy of medicines can prompt a lack of efficacy of treatments and multiple prescriptions. This work aims to characterize the medication profile of Portuguese older adult inpatients and explore the relationship between hospitalization days and the consumption of medicines. A retrospective data analysis study in older patients who were admitted to a medical internal medicine ward during 2019. The median age of the 616 patients included was 85 years. During the hospitalized period, patients took on average 18.08 medicines. The most prescribed drugs belong to the subgroup of (a) anti-thrombotic agents (6.7%), with enoxaparin being the most prescribed, (b) other analgesics and antipyretics (6.6%), paracetamol being the most frequent, and (c) the Angiotensin Conversion Enzyme Inhibitor (ACE) (6.5%), captopril being the most frequent. The high number of prescriptions in older adults during their hospitalization suggests the need of changing therapeutics to achieve a better efficacy of treatment, which corroborates the hypothesis that the lack of scientific evidence concerning the risk/benefits of many medical therapies in older adults can make it difficult to achieve good clinical outcomes and promote the wastage of health resources.


Introduction
In the last century, the development of health technologies and the improvement in socio-economic conditions have enhanced health and improved life expectancy, which in association with the decrease in fertility has contributed to an aging population [1,2]. Aging is characterized by progressive alterations in psychological, biological (with drug pharmacodynamics and pharmacokinetics alterations), and even social functions and greater susceptibility to disease [3]. Such alterations can cause a decrease in the ability to recover from unhealthy conditions and consequently can increase the consumption of health resources, which includes medicines [4,5]. Recently, it was reported that about four out of 10 older adults consume five or more medicines (polypharmacy) [6]. Pharmacotherapy can improve quality of life, cure, prevent, or relieve symptoms, but in the older population, special care must be taken with the occurrence of adverse drug reactions (ADR) [7]. The increased prevalence of ADR in older adults is not only related to aging-related increases in susceptibility but also the lack of scientific evidence concerning the risk/benefits of many medical therapies of the older adults [8]. Across history, older adults have been systematically excluded from clinical trials [9], and even when they were included, they are younger than the mean age of older adults' population [8]. As a result, sometimes, prescription can occur without adequate clinical data, which can compromise clinical outcomes and the well-being of the patients [8,9].
For this reason, new approaches are needed to improve the therapeutic efficacy of older adults as well as their quality of life. In this context, the knowledge medication profile of older adults is preponderant. This work aims to characterize the medication consumption profile of inpatient older adults, as well as attempt to establish a correlation between the medication profile and the diseases and hospitalization days.

Materials and Methods
A retrospective study was performed to characterize the medication profile among older inpatients of a general internal medicine service of a first-level hospital located in the inner center region of Portugal. All older patients (aged ≥ 65) hospitalized in the internal medicine service for at least 4 days during 2019 were eligible to participate in the study. Older patients hospitalized for less than 4 days were excluded. For patients hospitalized more than once in the internal medicine service, the number of days hospitalized was obtained through the sum of the days of each hospitalization. Data were retrospectively collected from the hospital's electronic medical record and included patient age, patient gender (male/female), patient diagnoses, hospitalization days, and drugs prescribed. The list of all medication, extracted from the electronic records, was converted to the corresponding Anatomical Therapeutic Classification (ATC) code, using the WHO Collaborating Centre for Drug Statistics Methodology's web [10], and patient's diagnoses were classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Statistical and descriptive analysis was conducted using the IBM SPSS software version 25.0 and Microsoft Excel. Spearman's test was used to examine the relationship between age, gender, hospitalization days, the most prescribed pharmacological subgroups, and the number of simultaneous prescribed medicines. Numerical and ordinal data were analyzed using descriptive statistics and presented in frequency and percentage and using mean, median, and quartile values.

Coefficient Value p Value
Hospitalization days R00-R99-Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 0.103 0.010 S00-T88-Injury, poisoning, and certain other consequences of external causes 0.106 0.009 A negative association between age and the medicines belonging to the subgroups A10A (R = −0.111, p = 0.006) and N05B (R = −0.110, p = 0.006). It was also observed a positive association between age and the medicines belonging to the subgroups B05C (R = 0.165, p < 0.0001), C03C (R = 0.171, p < 0.0001), J01C (R = 0.119, p = 0.003) and R03A (R = 0.106 and p = 0.009) ( Table 4). We also observed a positive correlation between the number of hospitalization days and the number of simultaneous prescribed medicines per day (Table 5).

Discussion
This study analyzed the medication profile of Portuguese inpatients at an internal medicine service and concluded that during hospitalization, the inpatients consumed a high number of medicines, suggesting that the high frailly of older adults associated with the lack of prescription guidelines for older adults made it difficult to achieve clinical outcomes and increased the time of hospitalization.
The high average age of the participants included in this study is not surprising, since according to Eurostat, Portuguese have an average life expectancy of 81.5, which is higher than the mean of 27 European Union countries (81.0). However, the increase in life expectancy is not accompanied by health quality; indeed, only 9% of Portuguese older adults are considered healthy, which is a lower number when compared with Austria (58.0%), Germany (38.0%), and France (37%) [11]. This unhealthy state and aging-related loss of resilience and pharmacokinetic and pharmacodynamics alterations that occur in older adults [12] can be a major contribution to the high average number of hospitalized days [13] as well as to the fact that almost 10% of the participants had more than one hospitalization during 2019.
On average, the participants consumed 18.08 medicines during their hospitalization, suggesting a high complexity of the therapeutic treatment that perhaps results from the multiple comorbidities presented by the participants. Similar results were observed by other studies in a long-term care hospitalization setting [14]. There is a lack of evidence for the use of certain medicines in older adults, which greatly limits knowledge about the effectiveness of medication [15] in this age group and leads to the need for a frequent change in medication. The drugs that act on the nervous system are one of the most frequently prescribed drugs among our patients [16]. Indeed, according to the literature, the consumption of these medicines is frequent not only in hospitalized patients but also in nursing home residents [17][18][19]. In our study, we observed a decrease in the consumed anxiolytics with aging, suggesting an attempt to deprescribe it with increasing ages [5,20,21].
Although the relevant information is provided, the data of this study are not representative of all populations, and they cannot be generalized to all hospitalized older adults; the information collected in this study reinforces the need for more scientific knowledge concerning the risk/benefits of polypharmacy in older adults.

Conclusions
The association between a high number of prescribed medicines and the number of hospitalization days observed suggests the need for more scientific evidence regarding therapeutic efficacy in older adults.

Institutional Review Board Statement:
This study obtained the ethical approval (01167) of the hospital on 7 of February 2020 and was carried out according to the European union (EU) general data protection regulation (GDPR).

Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.

Conflicts of Interest:
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.