ABSTRACT
Objectives: - To evaluate determinants of prescribing for the elderly in primary care such as diagnoses types, sources and availability of medications.
Design: - Cross sectional study of elderly patients in primary care.
Setting / Institution: -Training primary care center in Riyadh (AL Rabwah primary care center)
Subjects: - 100 elderly patients randomly selected from Rabwah primary care center 
Main Measures: - Number of concomitant diseases, diagnoses, number, types and sources of medications for elderly in primary care.
Results: - The study showed 51% of patients are being followed up in primary care center, 56% of patients had two and more diseases, and 31% of patients are on three or more medications. 61% of patients get their medications form primary care center and 95% of elderly medications may be available in primary care center. 
Conclusions: - Most of elderly patients depend on primary care center for their health care.
Well-organized elderly care system need to be in effect urgently in primary care settings coupled with appropriate educational programs for the health care team members.

Key words: Health, Prescribing, Elderly, primary care.

Introduction:

The global increase in people aged 60 years and above had attracted the attention of the world to the magnitude of the problems of providing health care for the elderly⁽¹⁾. The proportion of geriatric population in developed countries reached between 12 and 18% of total population and expected to increase in coming years^(2,3), a phenomenon known as the "baby boomers" in the west. Similar changes noticed in developing countries⁽⁴⁾, and Saudi Arabia is not an exception. In Saudi Arabia studies on general population in primary health care PHC showed an average of 3.2 ± 0.04 drugs per prescription and an average of 1.8 ± 0.3 drugs per patient. Higher numbers are expected to be found in the elderly population which composes about 20.7% of patients attending PHC ^(5.6).

Traditional teaching suggests that a prescription should be safe, necessary, effective and economical. 

Since increasing number of elderly patients, a group with special medical needs, will be seen in PHC, the objective of the present study was conducted to evaluate the essential drugs list available now ⁽⁷⁾ taking into consideration the needs of this age group. 

Subjects and methods:
 
This is a cross sectional study that was conducted in Riyadh. During April-July 2001.

The study population was elderly patients aged 60 years and above, who were registered in a training (Rabwah) primary health care (PHC) center. 

A pilot study was conducted in King Fahad PHC center and relevant changes in questionnaire were made after ward. The final questionnaire completed included the following: -

1. Demographic data such as age, gender, level of education and place for follow up of disease. 

2. Health variables such as number of concomitant diseases, diagnoses, number, types, sources and availability of medications used by patient, whether patient is using any medical appliances and information related to it, i.e. devices like diabetes kits.

The population in the area covered by Rabwah PHC center is 27,042 of whom 85% were registered in the center. The elderly account for 2671 (9.8%) in this populace.

The study sample is composed of 100 registered elderly patients 50 male and 50 female patients selected randomly. This number represents 3.7% of the elderly population living in Rabwah. 

Physicians working in Rabwah PHC center interviewed all patients. 
The data was entered and analyzed in a personal computer using "Data Star Software for data entry "Systat" Software-version 9" for statistical analysis .

Results:

The total number of elderly patients involved in the study was 100 out of which (50%) were females. The overall mean age was 66.8 year ± 5.8. (Between 60 to 85 years) (Table 1). Fifty one percent of patients are followed up in PHC center, while 49% of patients are being followed up in both PHC and hospital. 

Forty four percent of patients were found to have one disease while 32% of patients had two diseases. Patients who had three diseases or more accounted for 24%. Table 2 shows that more than half the sample size (56%) represented with at least two or more diseases.

Table 1: Age - sex distribution of the elderly participants

Age group  (year)

No. of patients (M=50, F=50) Male (%)        Female (%)

Total  (100)

60-69	28 (56%)	38 (76%)	66 (66%)
70-79	19 (38%)	11 (22%)	30 (30%)
≥ 80	3 (6%)	1 (2%)	4 (4%)

 

Table 2: Number of diseases by sex in elderly patients involved in the study

Age group  (year)

No. of patients (M=50, F=50) Male (%)        Female (%)

Total  (100)

One disease	21 (42%)	23 (46%)	44 (44%)
Two diseases	11 (22%)	21 (42%)	32(32%)
Three diseases   or more	18(36%)	6(12%)	24(24%)

The diagnosis most commonly seen in elderly patients was endocrine and metabolic diseases mainly diabetes mellitus followed by diseases of cardiovascular system CVS mainly hypertension. Musculoskeletal and joint diseases represented only 9% (Table 3). Forty three percent of patients are using only one medication (Table 4).

Table 3: Classification of diseases by gender in elderly patients involved in the study.

Diseases

No. of patients (M=50(F=50) Male (%)       Female (%)

Total (100)

Endocrine and Metabolic disease	23 (46%)	19 (38%)	42 (42%)
Cardiovascular system	13 (26%)	21 (42%)	34 (34%)
Musculoskeletal and joint diseases	5 (10%)	4 (8%)	9 (9%)
Respiratory system diseases	3 (6%)	4 (8%)	7 (7%)
Digestive system disorder	2 (4%)	0	2 (2%)
Others	4 (8%)	2 (4%)	6 (6%)

Table 4: Number of medications by gender for elderly patients involved in the study.

No. of medication

No. of patients (M=50)(F=50) Male (%)        Female (%)

Total (100)

One medication	17 (34%)	26 (25%)	43 (43%)
Two medications	12 (24%)	14 (28%)	26 (26%)
Three medications	8 (16%)	4 (8%)	12 (12%)
Four medications	7 (14%)	2 (4%)	9 (9%)
Five or more	6 (12%)	4 (8%)	10 (10%)

Almost one third of patients are on three or more medications. 

Type: Forty five percent of elderly patients are on drugs for Diabetes, 34% of patients on drugs for hypertension, 11% of patients on drugs for musculoskeletal and joints disease mainly non-steroidal anti-inflammatory drugs NSAID, 4% of patients on drugs for gastrointestinal tract GIT mainly antacids and ulcer healing drugs (Table 5) .Of the above medications 35% were prescribed by physicians in PHC center, 43% by physicians in both hospital and PHC center and 22% by physicians in other places. 

Table 5: Types of drugs used by patients involved in the study:

Type of drug	No. of patients  (n = 100)	(%)
Endocrine system  (Insulin, OHA.. etc.)	45	(45%)
CVS (Beta blockers,  diuretics.. etc)	34	(34%)
Musculoskeletal and  joint disease  (NSAIDs.. etc)	11	(11%)
GIT (ulcer healing  drugs, antacids,.. etc)	4	(4%)
Respiratory system  (ventolin, Becotide..   etc)	4	(4%)
Eye, ear and others	2	(2%)

Sources: The sources from which elderly patients in the study get their medications were PHC center (61 percent) hospital (8 percent); both hospital and PHC center (30 percent) and only 1% of patients get their medications from other places. Indicating that PHC center is the main source of medications. 

Availability: On questioning these elderly patients about availability of their medications 5% of patients indicated that their medications are always not available in PHC center, 70% of patients indicated that their medications are some times available in PHC center, while 25% of patients indicated that their medications are always available in PHC center.

Discussion:

This study has shown that the health care for the majority of elderly patients is provided by PHC center that agree with previous publications ⁽⁸⁾ .
More than half the sample size had two or more diseases with endocrine and metabolic the commonest encountered diseases, which is expected in this age group. The prevalence of diabetes is known to increase with age; therefore it is not an unexpected finding in this study that diabetes mellitus was at the top of the list of metabolic diseases seen in elderly patients. This also explains why the medications for diabetes were the most common drugs used by elderly in PHC.