Use, Prescription and Dispensing of Drugs to Elderly Patients with Systemic Arterial Hypertension (SAH) and Diabetes Mellitus (DM) in the City of Amazônia, Brazil

Objective: To analyze the therapeutic process of hypertensive and diabetic elderly assisted in Hiperdia program UBS city of Ariquemes, Rondônia, Brazil. Method: The research model was a quantitative study, cross, which was used pre-structured form. The sample consisted of 196 patients with hypertension and / or diabetes between 60 and 92 years. Results: Predominantly female 66.9%, a consumption of 5.40 per individual medications, and frequent self-medication few physiological parameters described in the charts. Overweight and obesity prevalence in the elderly 78.9%, 67.5% with systolic blood pressure above 140 mmHg and 79.3% with greater than 125 mg glucose / dL. Statistical tests observing pool was applied between the amount of medication and self-medication (p = 0.001) correlation with significance between age and systolic blood pressure (p = 0.003) and body mass and age index (p = 0.018) was observed association between income and acquisition of medication or correlation between age and glucose values. Of the research subjects, 44% reported problems with the drug that can lead to lack of adherence to treatment, and future complications. Conclusions: 1059 drugs were used. 76% of patients acquire medication in at least 02 different sites may favor the therapeutic duplication. Among the most cited DRPs are stomach problems and discomfort, 17.4% have difficulty in recognizing, 15.1% are not taking the drug due to adverse accustomed and 69.4% use at least one self-medication. In the classification of physiological parameters was observed lack of data in the records, and 79.3% had blood glucose levels> 125 mg / dL and 67.5% with SBP> 140 mmHg, it was also observed association between the amount of medication and self-medication and correlation between age and SBP and BMI and age.


INTRODUCTION
The current medicine seeks innovative and humane proposals in the healing process in the field of health education, assistance and policies aimed at promoting health. The importance of observation and individuality of human treatment is becoming more popular, since health involves biological, psychological, social and environmental, as well as habits and lifestyles, promotion and prevention suggest actions aimed at enhancing the patient as the primary contributor of healing itself. (Teixeira, 2007). Improving the quality of life, technological advances, drugs and people's access to health systems in recent years have provided a significant increase in life expectancy. Population aging is a global phenomenon and in Brazil it is believed that by 2025 the elderly population will reach 34 million, causing an increase in demand and use of health services and medicines. (ZAMPARETTI; LUCIANO; GALLATE, 2008). This group of patients is constantly the target of acute or chronic diseases, which leads to the use of several medications at the same time, causing the emergence of Drug Related Problems (DRPs) can cause non-adherence to treatment or inefficiency of the same. The very old body can favor the appearance of unwanted effects, or the failure to obtain therapeutic results, due to the reduction of several physiological mechanisms, including highlight the impaired renal and hepatic function. (CARVALHO, 2010). Pharmaceutical care is considered worldwide as one of the basic elements of primary health care in getting the maximum benefits with minimal risk to the patient. Thus, we value the well -being of the same, generating information on the correct use of medicines, implementing a pharmaceutical care service, where the pharmacist how knowledgeable drugs plays a fundamental role, since currently, the medication is being treated as a simple commodity where the irrational use may bring serious consequences to the individual or collective health. (Araujo et al., 2008). The elderly users of medicines to pharmaceutical care, being a practice developed in the context of pharmaceutical care, aims to provide individual or collective action in order to obtain a better quality of life. However, not intended to intervene in the diagnosis or prescription, which is doctor's competence, but rather to ensure that the patient has an efficient and safe pharmacotherapy avoiding future complications and lower the cost of treatment. (Meneses, SA, 2010). Given that the DRP can lead to non-adherence to treatment and consequently to serious complications for the patient (resulting from chronic diseases that affect this age group) is a pharmacotherapeutic monitoring can identify early cases where the pharmacological treatment is not efficient, and thus facilitate the use of the medication by the patient, ensuring proper dispensing and patient care that makes use of polipharmacies.

II. THEORETICAL FOUNDATION 2.1 Primary care directed care of the elderly
The Basic Health Units (BHU) are the gateway to all the local health system, where primary needs must be met by approximately 80%. For this to happen healthcare professionals should be able to care and provide services where access and the host are suitable for the population served. The increase in the elderly population has been a major challenge for public health. (PICCINI et al., 2006). The new care model that proposes the Unified Health System (SUS) considers the principle of completeness, where the user is the system of the protagonist. It requires reformulation of care with practices aimed at closer relations between attendant and user, creating bond with the patient, which is not enough to have access to the service, but should allow the achievement of better results. It emphasizes the importance of qualifying this access in order to ensure that these people can be met by the health service, decentralizing the doctor to a multidisciplinary team, enhancing the quality of assistance aimed not only to meet, more listening and dialogue, be able to make decisions and guide or even intervene in accordance with the reality of the region or the patient. (Souza et al. 2008). A major problem for the SUS implementation is related to the qualification of human resources, this area we must turn to a quality service with more humane techniques related to technological advances . Best results are The pharmaceutical care includes educational services in the therapeutic process, standardizing a rational and safe drug therapy, individual levels and collective, with pharmaceutical orientation, promoting the implementation of a follow-up therapeutic drug (SFT), followed by evaluation of the results, being able to identify PRM. This proposal is an enabling strategy, especially for the elderly patient, which in most cases is chronic use of several medications and is more conducive to adverse reactions and drug interactions. (Meneses, SA, 2010). The pharmacist's role is to make the evaluation of the prescription, even for the elderly involves a number of experts, and in some cases occur duplication of medications due to the variety of different brand names with the same active ingredient, when the patient feels good with medication it becomes more adept at handling. By promoting patient adherence to pharmacotherapy, it passes in need of a dwindling number of medication, using fewer health services, improving services and quality of life of patients. (Meneses, SA, 2010).

Tracking Pharmacotherapeutic / Method Dader -Pharmacist Professional practice
The SFT is a practice that requires a lot of dedication and responsibility of the pharmacist in obtaining Pharmacotherapeutic history of the patient, with the purpose to evaluate the health status of the patient, as well as the clinical pharmacology results and identify, prevent and resolve DRPs that are considered adverse clinical outcomes, drug related, interfere with obtaining the expected therapeutic response, or causing undesirable adverse effects. (Santos et al., 2004). The FTS Dader method was developed by researchers at the University of Granada (Spain) in 1999 and is currently being used by pharmacists from various countries to assist in pharmaceutical care and obtaining satisfactory therapeutic results, based on filed concrete procedures, governed by rules acting to describe the status of each patient, where the clinical pharmacist and the doctor in consensus with the patient decide what to do on the data obtained in the interviews conducted by the pharmacist. This is a working tool that allows health care professionals improve the clinical treatment of the patient, solving or preventing the negative results of drug treatment. (CARVALHO, 2010).

Interaction drugs in elderly
Drug interaction (IM) is the process by which modifies the effect of a drug or the appearance of new effects as a result of interactions that may be caused by concomitant use of another drug with food, beverages or environmental chemical agent . These interactions may be classified as pharmacokinetics , affecting the process of absorption, distribution, metabolism or excretion, and as pharmacodynamics, and the change of the drug at its site of action, may cancel or enhance the effect of the drug. (Rossignoli, Guarido;CESTARI, 2006). Pharmacists can help identify drug interactions and guide other health professionals through the dissemination of information on medicinal products. As age advances, the onset may occur in various conditions, contributing to the emergence of such interactions due to constant use of more than one drug. (Rossignoli, Guarido;CESTARI, 2006). Drug interactions can be classified as desirable or undesirable, the first of which can reduce the therapeutic effect or to increase it, causing the appearance of adverse effects, no treatment compliance and jeopardize pharmacotherapy. Now, desirable effects are beneficial to the patient, and associations that can prolong the therapeutic effect, reduce the occurrence of adverse effects, increase patient compliance and treatment efficacy. Thus, a drug can bring benefits or problems to the patient, and the health risk possibility can cause the patient to more complex treatments or prolong hospital stay the same. (Matos et al., 2009). The risk of occurrence of drug interactions increases with age and the number of drugs used, up to 85% in patients who use more than six medications. In elderly 19% of them receive combinations likely to these events, enhancing the problem of pharmacological elderly treatment, and the main drugs involved are often us ed in the treatment of common chronic diseases the oldest patient as digoxin, diuretics, antidiabetic agents, antiarrhythmics , warfarin, Nonsteroidal Anti steroidal drugs (NSAIDs), phenytoin, centrally acting analgesics, and antipsychotics. Some of these drugs have a narrow therapeutic window, depending on the interaction, expose the patient to toxic risk compromising patient safety. (LOCATELLI, 2007).

III. METHODS
In order to meet the therapeutic process of hypertensive and diabetic elderly assisted in Basic Health Unit carried out a quantitative research, the patients treated in Hiperdia program neighborhood UBS Sector 06, the city of Ariquemes, Rondonia, Brazil. This unit carried out the service 08 close quarters, assisted by two teams of the Family Health Strategy (ESF) which in addition to other functions to assist people with arterial hypertension (HBP) and Diabetes Mellitus (DM). Of the 08 districts were selected 03 for the research. It is inferred that the population of the districts involved have some similar characteristics, such as socioeconomic conditions, in addition to these neighborhoods are those who hold the largest number of patients assisted by Hiperdia Program at UBS said the context of care. The availability of staff to work with the provision of data for the accomplishment of this study was also major item for the election of the target population. The study population of elderly accompanied by Community Health Workers (CHWs) who attend the monthly group Hiperdia assisted by UBS, neighborhoods Sector were selected 06, Sector 08 and Sector 11, totaling 410 patients of which 315 are hypertensive and 95 diabetic , of these 196 patients were analyzed, using as age inclusion criteria less than 60 years, assisted by CHWs, who attend the group, be found in the residence within two attempts and agreed to participate, as exclusion criteria, patient They did not meet the inclusion criteria. Data collection started after the project was approved by the Research Ethics Committee (CEP) of the Faculty of Education and Environment (FAEMA) on the opinion substantiated 704.163.Todos patients were informed about the study and signed the Term consent Form (ICF). Data collection lasted 78 days. The interviews were conducted during the group meetings and throu gh home visits to patients registered who did not attend the meetings, which are the majority. It is clarified that the data collection process occurred through the application of a form that was divided into three parts: demographic data relating to the identification, gender, income, education, marital stay; user perception about medication which quantified the drugs presented by patients through label, box, blister or revenues, as well as those mentioned by patients used without prescription, order acquisition and difficulties; It was obtained in the third step records data such as weight, height, body mass index (BMI) values of BP and blood glucose. Also in this instrument we have been addressed DRP involving the acquisition, use orientation, amount of drugs for the same condition and quantity of drugs with self-medication. How important addition was applied statistical test to establish an association between the user's income and the acquisition of medication, amount of medicine with selfmedication and acquisition. Were also established correlation between age, systolic blood pressure (SBP), diastolic blood pressure (DBP) blood glucose and BMI. Finally the SBP, glucose and BMI were classified in order to observe the degree of risk of patients. higher levels of education may better understand the prescription, find it easier to understand the pathology and medicines used, literacy contributes to a reduced risk offered by inadequate drug treatment and prevent late complications caused by chronic diseases. (SANTOS, OLIVEIRA; COLET, 2010). Second Kings and Ventura (2013) low levels of education reflects directly on the patient's quality of life to b e related to a low financial income, as well as the above study, it was observed that levels of education are influences of early work primarily in crops by need of assistance in family income. According to Bos and Bos (2004), the impact of income mainly the elderly patient with chronic disease, is a very significant influence on the choice of health used being public or private system, seniors with lower incomes are more dependent on the public system. They found that individuals with higher levels of education tend to use more private system due to greater awareness of the public system and demand for more sophisticated alternatives, which corroborates with our research. Regarding marital status a study in Montes Claros in Minas Gerais noted that married seniors showed no difficulties in medication due to the assistance of the spouse when one partner has some difficulty. (Silva et al., 2010).  (Pereira et al.,  2012). There was a higher incidence among women of hypercholesterolemia, gastric disorders and depression compared to men have also been observed that use of these five treatments for prostatic hyperplasia. Table 2 shows the main morbidities according to gender. It found that patients using 01-13 medications comprises a total 1059 medicines for the entire group studied (Table  3), an average of 5.4 medications per patient, ranked 177 in pharmaceutical specialties, and 845 are of continuous use and 214 of occasional use, were classified in the occasional group all drugs that were not administered daily even being frequently used.

IV. RESULTS AND DISCUSSIONS
In 2008 a study of elderly entered into a support group in Porto Alegre / RS found a total of 5.34 medications per patient data similar to those presented in this study. (COLET; MAYORGA; AMADOR, 2008). Among the drugs observed a higher intake of antihypertensive (241) since 92.9% of patients are hypertensive and many of them use more than one drug of this class, analgesics (136) due to reports of frequent headaches and muscle aches diuretics (125) to aid in reducing hypertension, antidiabetics (96) greater incidence of type 2 diabetes drugs most frequently used are shown in Table 3, and losartan, hydrochlorothiazide and dipyrone the most widely used drugs.
Regarding the use of polidrugs there was a finding that 53% of patients using 05 to 10% drugs and 4 make use of more than 10 drugs (Figure 1). These findings are commonly found in Brazilian literature and other countries, as the elderly are constantly affected by concurrent disorders in different organs or systems, making them easy targets for the use of several drugs at the same time. (Aguiar et al., 2008). It also noted the occurrence of major polimedications among women a proportion of 63.6% of women use 05 or more medications, and among patients of male 44.6% of them use more than 05 drugs. A study by Pereira et al. (2012) with hypertensive and diabetic patients in Minas Gerais observed increased use of drugs among women due to increased demand for health services for them. It is inferred that the concomitant use of several medications may favor the emergence of DRPs, especially in elderly patients, hindering adherence to treatment due to several daily doses, use of drugs with low rates therapeutic and other factors can also lead to events of rise undesirable adverse including hospitalizations for drug interactions. In a study conducted in Tubarão, Santa Catarina, it was observed that cardiovascular problems such as hypertension, endocrine as diabetes, central nervous system and depression are the main contributors to the polimedications. (GALLATE; SILVA; TIBURCIO, 2010).

International Journal of Advanced Engineering Research and Science (IJAERS)
[ Vol -5, Issue-8, Aug-2018]  https://dx.doi.org/10.22161/ijaers.5.8.15  ISSN: 2349-6495(P) | 2456-1908(O) www.ijaers.com Page | 112 On the acquisition of medication of 196 patients 18 (9.2%) to buy all medication because they cannot get any by the public, 16 (8.2%) acquire exclusively by the Popular Pharmacy Program (PFP), 13 (6.6% ) patients can take all medications at UBS, and most (149), ie 76% for all drugs used takes the medication in two or more locations, namely UBS through the public system, the PFP or buy in private pharmacies at least one of the drugs, among all patients 25 (12.8%) reported getting at some point without taking the medication when not found in public, for lack of financial condition or do not have the prescription with which can acquire the People's Pharmacy. In Table 4 one can see the profile of acquisition of the patients' medication Hiperdia group. When comparing the acquisition of the drug with the income was not observed in the statistical analyzes significant differences in acquisition among even groups because it is a population where the majority receive up to minimum wage and attends the same group of health care.  Given that 42.3% of the population is illiterate as shown in Table 1, the purchase of medicines in various locations can contribute to therapeutic duplication due to the wide variety of medicinal and pharmacological associations existing in the market.

4.3
Elderly patients and self-medication It was found that among respondents 30.60% of patients acquire neither medication use without medical supervision since 136 (68.4%) reported the use of at least one self-medication, as shown in Figure 2.   Figure 4 shows the use of self-medication.

Fig.4: Demonstration of the use of non-prescription medicines
In a study carried out with elderly people in the south of Brazil, 80.5% of the patients were self-medicated, and analgesics were the most used therapeutic class, considering simple health problems and because they are over-the-counter, according to the authors, selfmedication can cause problems for the elderly, since the choice is not always appropriate to the symptomatology, and by the use of polipharmacies, which may cause adverse reactions or undesirable drug interactions. (CASCAES; FALCHETTI; GALATO, 2008).
It was found association between the amount of medication used and self-medication, according to the analysis of Figure 5, it was noted that there is association () between the variable amounts of medications and selfmedication. The most significant values are between 03 to 08 drugs with a higher proportion of self-medication, among patients with more than 10 medications it is possible to note that patients use more than 03 selfmedication.

Assessment of physical appearance and physiological parameters
With aging, care is taken to minimize the risks of Cardiovascular Diseases (CVD), among the predisposing factors are smoking, hypertension, dyslipidemia, DM, total and central obesity. (FERREIRA et al., 2010). In the analysis of the charts it was possible to verify that 38.73% of the patients were classified as overweight, 28,17 with degree I obesity, 7.04 degree II obesity and 4.93% degree III obesity, totalizing 78.9% of overweight patients , according to BMI values shown in Figure 6. According to Ferreira et al (2010), a study carried out in Goiânia observed the prevalence of obesity in 76.2% of elderly patients, again being women with a higher incidence (83.3% %), the prevalence of type 2 DM was associated with high mortality rates, since most diabetics were overweight or obese.  Costa (2004), in a survey conducted in Belo Horizonte / MG, about the harmful factors to health of the elderly, reports that income, education and other aggravating factors of health, but healthy eating is related to cultural habits, but poverty defines the access to vegetables and fruit due to low purchasing power, in addition, much of the old income is spent on drugs. Also it was observed that elderly people with less education were more sedentary lifestyle and had less healthy eating habits. reported at least one problem with the drug (Figure 7), the most common are shown in Figure 08 were hardly be cited by 31 4% of patients, 40.7% reported stomach problems observed in this case the use of hypoglycemic drugs and NSAIDs, 17.4% reported having difficulties in recognizing the medication which makes the pharmacological treatment a health risk patients can be serious consequences for short and long term depending on the type of medication and therapeutic index, 15.1% due to discomfort come to be without taking medication noting non-adherence to treatment, 3.5% difficulty swallowing also 3.5% They reported a lack of satisfactory results as control of BP and blood glucos e and 4,6% reported dry cough.

Fig.7: (a) Number of seniors with DRP (b) Main DRP cited by Seniors
The DRP and bring discomfort to the patient may impair the pharmacological treatment leading to non-compliance with treatment or undesirable consequences such as hospitalizations, studies have reported that the risk of drug interactions increases with the amount of medication 06 drugs leads to a risk 85%, 08 drug interaction potential of up to 100% on these facts the monitoring of prescriptions and monitoring of elderly patients is indispensable. (LOCATELLI, 2007).
Regarding the direction of the medication the elderly reported that the doctor is the main advisor, when do not understand how to take their medication mainly seek help with children or family house that pushes through private pharmacies get some medicine. Permanent education and adoption of collaborative strategies among physicians, pharmacists, nurses and CHWs can contribute to a more humane and promising service, adopting measures and updated programs or lists of the main interactions and side effects can assist in the identification of drug interactions to reduce risks to health of the elderly and possible hospitalization patients. (Matos et al., 2009).    Pink and Franken (2007) highlight the importance in monitoring hypertensive patients, especially elderly people who have higher levels than younger patients due to high prevalence of coronary, cerebral and heart disease, the BP control helps reduce the risk of pathological events that may compromise the health and welfare of the elderly. When applied Pearson correlation statistical test to verify the correlation between age, PAS and blood glucose observed that age and systolic blood pressure is statistically correlated positively (p = 0.003), showing that the larger the higher age are the values of SBP, not correlation between SBP and glucose (p = 0.393) or between glucose and age (p = 0.174), noting that were not correlated patients with two logs or more glucose and PA, observed 40 patients with more than two glycemic and 152 history with more than two PA history, which may compromise the results, it is suggested a more detailed follow-up of these physiological parameters in order to obtain more satisfactory results. BMI at pressure levels and the age of patients, there was a significant positive correlation was also correlated with age (p = 0.018) and no association with blood pressure levels (p = 0.334) for this analysis was analyzed history 142 elderly.

FINAL CONSIDERATIONS
After analysis of the results was observed using 1059 medicaments, 76% acquire medication in at least 02 different places may promote therapeutic duplication, the physician is the main guiding medication use, among the cited MICs are stomach problems and malaise, 17.4% have difficulty in recognizing, 15.1% are not taking the drug due to adverse accustomed and 69.4% use at least one self-medication. Regarding income observed similarity in the mode of acquisition, the classification of physiological parameters was observed lack of data in the records, and 79.3% had blood glucose levels> 125 mg / dL and 67.5% with SBP> 140 mmHg, also noted it is association between the amount of medicines and self-medication and correlation between age and SBP and BMI and age. The application of the SFT can assist in achieving safer and more effective drug therapies, deployment strategies that can promote greater patient adherence to medication and monitoring of physiological parameters. Therefore, it is inferred that this study may support public policies of attention and promoting the health of the elderly facing the aging not as a disease but a natural process of life.