High Frequency of OTC Product Misuse in Older Adults Highlights Areas for Pharmacists to Address

Drug Topics JournalDrug Topics April 2024
Volume 168
Issue 03

Adults aged 65 years and older are the largest group of consumers of OTC medications.

There is a high prevalence of complex OTC misuse in older adults, and pharmacists are poised to help.

Adults aged 65 years and older are the largest group of consumers of OTC medications: according to researchers, almost 50% of this population use an OTC product daily or weekly, and 25% use a combination of 10 or more OTC and prescription medications.1 But because of the nature of these medications, there is little clinical oversight of their use, creating a significant risk to patient safety.

Researchers from the University of Wisconsin-Madison School of Pharmacy and the University of Illinois Chicago School of Pharmacy presented 2 posters1,2 at this year’s American Pharmacist Association Annual Meeting and Exposition on the issues surrounding OTC product use in older adults.

In the first poster,1 investigators noted that adverse drug events associated with OTC products lead to 178,000 hospitalizations each year, with older adults “exceptionally vulnerable to these risks due to age-related factors.” However, little is known about the drivers of product selection and use “especially when symptoms persist after initial, short-term medication use.”

OTC products in a pharmacy. | Image credit: MP Studio - stock.adobe.com

OTC products in a pharmacy. | Image credit: MP Studio - stock.adobe.com

A group of 144 older adults were recruited from 10 community pharmacies in a health system in the Midwest. Participants were given hypothetical symptoms related to either cough, cold, and allergy, pain, or sleep, and were asked to select 1 or more OTC products for self-treatment. Following selection, investigators asked participants to report how they would use the product both at symptom onset and in the event their symptoms persisted or became worse after initial treatment.

OTC selections were evaluated for the following 4 types of misuse:

  • Drug-age, per the 2019 Beers Criteria,
  • Drug-drug, or interactions with medications used at home,
  • Drug-disease, contraindicated with health conditions, and
  • Drug-label, with use deviating from the labeled indications or instructions.

Mean participant age was 73 years. Participants reported, on average, using 11 home medications and having 5 health conditions. Within the group, 79% demonstrated at least 1 type of OTC product misuse when describing how they would use their selected product at symptom onset, with 363 instances of misuse identified within the total group (sample mean, 3.18 per participant); 50% demonstrated misuse in more than 1 category and 94% demonstrated misuse in either drug-drug or drug-label misuse categories.

When describing how they would use their selected products if symptoms worsened or persisted, 78% indicated that they would discontinue use and call their health care provider, use a non-pharmacologic treatment option, or continue using their selection in the same way, while 22% indicated that they would chase their use by increasing either the frequency, dose, or duration, or by adding a new product. Of the 31 participants who responded that way, 23 suggested a change that would contribute to further product misuse: 110 instances of misuse were identified among these 23 participants (sample mean, 4.78 per participant. Further drilling down into this group, 65% demonstrated misuse in more than 1 category, with drug-drug and drug-label misuse having the highest prevalence.

“The results highlight the high prevalence and complexity of OTC misuse in older adults, with nearly [4 of 5] participants demonstrating misuse in 1 or more categories when treating symptoms at onset,” the researchers concluded. “Shedding light on this problem is crucial, as up until now, older adult OTC misuse as not been quantified and is assumed to be non-existent.”

Next steps should include increasing awareness among providers, older adult patients, and caregivers around risks associated with OTC use, as well as identifying interventions that can reduce OTC misuse in older adults without limiting patient autonomy.

READ MORE: OTC Product Roundup: Women’s Health

In a second poster, the same researchers evaluated misuse of high-risk OTC products in older adults and the benefits of a pharmacy-based intervention. Because pharmacies are “ubiquitous sources of OTC accessibility and medication safety expertise, a pharmacy-based intervention was considered important to address OTC medication misuse,” the researchers wrote.2 

The investigators conceptualized a structural redesign of pharmacy OTC aisles with the purpose of reducing OTC misuse for older adults, while encouraging pharmacy interactions around these products. One central feature of this redesign is the use of Stop Signs for high-risk OTC products, and Behind-the-Counter signs for especially high-risk OTCs such as chlorpheniramine, diphenhydramine, and doxylamine. “Stop Signs instruct older adults to consider safer products, while [Behind-the-Counter] signage encourages them to talk to pharmacists for more informed OTC use decisions.”

A randomized controlled trial was designed to determine whether the redesigns reduced misuse of Stop Sign and Behind-the-Counter OTC products. Twenty pharmacies from a large Midwestern health care system were matched and randomly assigned to either the control or intervention groups. A total of 288 older adults were recruited; these participants chose one hypothetical symptom between pain, sleep, and cough, cold, and allergy, selected 1 or multiple OTC products, and described how they would use these products at symptom onset and if symptoms got worse or persisted. Reported OTC use was evaluated for the same types of misuse as in the previous study.

Researchers identified drug-age misuse in 6.8% of cases, with “significantly lower” misuse in intervention sites compared with control sites. Drug-drug misuse—which represented the highest frequency at 20.7%—experienced a similar profile as drug-age misuse in intervention vs control sites. Too few instances of drug-disease and drug-label misuse were noted (3.3% and 5.1%) to make statistical comparisons.

“These findings showcase the first multi-pharmacy intervention to demonstrate effectiveness at reducing the occurrence of various types of OTC misuse for older adults,” the researchers concluded. The use of Stop Signs and Behind-the-Counter signs showed “substantial benefit for reducing high-risk OTC misuse of a variety of types, which is important particularly for vulnerable adults ages 85 to 91.”

Study results also highlighted the complexity of the problem, with adults aged 85 years and older “frequently experiencing multiple types of misuse.”

They concluded, “As the point of sale for most OTC medications, community pharmacies are the natural leverage point for such interventions.”1

Read more of our coverage from the 2024 APhA Annual Meeting & Exposition here.

  1. Chladek JS, Gilson AM, Stone JA, et al. The high prevalence and complexity of over-the-counter medication misuse in older adults. Presented at: American Pharmacists Association 2024 Annual Meeting and Exposition; March 22-25, 2024; Orlando, FL. Poster 1197.
  2. Chui MA, Gilson AM, Chladek JS, et al. Older adult misuse of high-risk over-the-counter medications: benefits of a pharmacy-based intervention. Presented at: American Pharmacists Association 2024 Annual Meeting and Exposition; March 22-25, 2024; Orlando, FL. Poster 1246.
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