Medication, Co-morbidity and Injury in Older Farmers

1. Medication, Co-morbidity and Injury in Older Farmers Don Voaklander School of Public Health University of Alberta

2. Introduction Co-morbidity Medication Use Alberta Study Recommendations Today’s Talk

3. Agriculture is one of the most dangerous occupations in Canada Within the farm population, the older farmer has been identified to be at greater risk Unlike other occupations, farmers continue to contribute to farm operations well beyond the “normative” retirement age Introduction

4. Rates of Work-Related Fatalities by Age (per 100,000 farm population)

5. Work Related Injury Rates by Age (per 100,000)

6. Intervention points with older farmers are difficult Work is self paced Work is part of the farmer’s identity Work styles and habits may be very hard to change or influence Medication monitoring and management may be a plausible intervention point Care of significant co-morbidity may help prevent injury Why Medication Use and/or Co-morbidity Management

7. There are limited analytic studies examining health risk factors for injury in the farming community From Canadian data on farmers aged 60 and older Fatalities related to operation of tractors and other machinery Most common hospitalized injury due to falls Non machinery and machinery related Therefore health risk factor information from numerous fall and motor vehicle collision studies will also be presented Setting the Stage

8. Falls Issues related to a persons ability to balance during walking, climbing and interaction with the environment Driving Like machinery operation, driving is a complex task that requires: Accurate sensory input Rapid information processing Reliable judgment Fast motor responses Setting the Stage

9. Hearing deficit and tinnitus Can prevent awareness of hazardous situations Machinery – extraneous maintenance or blockage problems Avoidance of hazards Sensory awareness of environment Communication of hazards between workers and bystanders Disease Factors Related Farm Injury

10. Muscular-skeletal problems, back pain, arthritis, previous injury Inability to react to a dynamic environment Guarding pain – Decreased mobility Balance issues Gait problems Foot drop or insufficient lift Insufficient strength Insufficient rehabilitation and conditioning Premature return to work Disease Factors Related Farm Injury

11. Disease Factors Related Farm Injury Other Factors Depression No hypothesized reason Lack of self-care? Asthma Hypersensitivity and other allergic reactions may lead to altered reaction to mechanical stressors Also related to depression/injury in other labour sectors Sleep quantity/disturbance

12. Often an array of conditions is involved Generally balance related Walking, climbing Rapid movements Reaction/Reflex Combined with age related declines Sensory awareness, slower reaction time and reflexes, poor vision, muscle strength Disease Factors Related to Falls

13. Vision Vision is declines over time cataracts Poorer at night Incontinence Distraction and/or haste Hypotension Orthostatic Post-prandial Cardiac arrythmias Transient ischemic attacks Disease Factors Related to Falls

14. Peripheral neuropathy Diabetes, alcoholism, malnutrition Arthritis Dementia Avoidance of hazards Gait disorders Parkinsonism Past stroke Chronic inactivity Lost of muscle strength/endurance/coordination Sleep disturbance Disease Factors Related to Falls

15. Vision Hypotension Dementia Muscle strength Joint flexibility Neurological disorders Hearing impairment Hypoglycemia (Diabetes) Disease Factors Related to Motor Vehicle Related Injury

16. Medication reaction with older persons is poorly understood Pharmacokinetics Process of what the body does to the drug Pharmacodynamics Process of what the drug does in the body Polypharmacy Multiple medication use Prescription and over-the-counter Medication Use and Older Persons

17. Four Components Absorption Virtually the same for young and old Distribution Changes in body composition in older persons alter drug distribution Metabolism Slower in older persons Excretion Decreased renal blood flow leads to delayed elimination Pharmacokinetics

18. Little research has been done in this area Few drug trials are conducted with older persons However, there is some evidence that older persons are more sensitive to medications of the same dose when compared to younger persons May be related to altered pharmacokinetics Distribution, metabolism, excretion Pharmacodynamics

19. New or improved drug treatments are regularly added to a physicians available treatments Multiple diseases in older individuals predispose them to multiple treatments Can be as high as 12-15 prescription and OTC medications at once On there own, drug side-effects are often predictable but in combination can cause unexpected: Disorientation Confusion Altered balance abilities Hypotension Sedation Polypharmacy

20. Use of any prescription medication Stomach medication Farm stress Heart Medication Altered blood flow/hypotension Anti-depressants Medication and Injury in Farmers

21. Benzodiazepines (falls and MVCs) Commonly used to treat sleep disturbances in older persons Depression/anxiety Restless leg syndrome Dementia Blood pressure drugs (falls) Beta blockers (falls) Altered heart rate Laxatives (falls) Anti-depressants (falls and MVCs) Medication Use and Falls/MVCs

22. Don Voaklander1, Karen Kelly1, Brian Rowe1, Niko Yiannakoulias1, Larry Svenson2, Don Schopflocher2, Will Pickett3 Pain, Medication Use and Injury in Older Male Farmers 1University of Alberta 2Alberta Health and Wellness 3Queen’s University

23. This research was funded by the Canadian Institutes of Health Research Acknowledgement

24. Methods Data sources Data were gathered from 5 provincial registries: Alberta Ministry of Health and Wellness databases Maintains computerized records of all hospital, emergency department, and medical services Data include demographic information, admission and discharge dates, and multiple ICD-9-CM diagnostic and procedure codes All physician claims include up to 3 diagnosis codes (ICD-9-CM for each patent encounter) Alberta Blue Cross Drug Plan Collects information on all reimbursed medications used by Albertans aged 65 and older Alberta Agriculture Farm Fuel Tax Subsidy List List of farmers who received a fuel tax rebate for the use of fuel in farm machinery

25. Methods (cont.) Inclusion criteria Any farm related injury treated in an Alberta ED or admitted to hospital between the April 1, 1997 and March 31, 2000 that was suffered by a farmer identified by linkage between health data and the Alberta Agriculture Farm Fuel Tax Subsidy List. Case definition Hospital/ED visits related to injury from agricultural machinery were identified by the presence in the electronic hospital separation abstract of the ICD9-CM E-code E919.0. Other machinery and non-machinery injuries were identified by the presence of the ICD9-CM E-code for location of injury E849.1 that indicates the injury took place on a farm as well as a concurrent E-code specifying an injury from another machinery type (eg. powered hand tools – E920.1, metal working machines E919.3, etc. or a non-machinery injury (eg. fall from or out of a building E882, butted or gored by animal E906.8). If a person had more than one hospital/ED visit for an agricultural injury during the study period, the case was restricted to the first one.

26. Methods (cont.) Co-morbidity Classifications disorders of the eye (ICD9-CM codes 360-379) incontinence or urinary tract problems (ICD9-CM code 788) nutritional deficiencies (ICD9-CM codes 260-269) Parkinson’s disease (ICD9-CM code 332) osteoarthritis (ICD9-CM codes 715-716) dementia/cognitive impairment (ICD9-CM codes 290 and 331) depression/psychosis (ICD9-CM codes 295-299 and 311) neurotic disorder (ICD9-CM codes 300-309) osteoporosis (ICD9-CM code 733) cerebrovascular disease (ICD9-CM codes 430-438) hypertension (ICD9-CM codes 401-405) cardiovascular disease (ICD9-CM codes 410-414 and 420-429) diabetes (ICD9-CM code 250) cancer (ICD9-CM codes 140-239) gait or balance disorders (ICD9-CM codes 333-334, 342, 359, 365-366,369, 458, 721) any previous injury diagnosis (ICD9-CM codes 800-999)

27. Methods (cont.) Blue Cross Medication Categories Antihistamines Narcotic Pain Killers NSAIDS Anti-convulsants Anti-depressants Anti-psychotics Anxiolytics, sedatives, hypnotics Anti-Parkinson’s/Movement Disorder Agents Electrolytic, Caloric, Water Balance Visual Impairment Anti-ulcer Agents Corticosteriods Sex Hormones Diabetes Agents Thyroid Medication Anti-coagulants Blood Pressure Agents

28. Methods (cont.) Analysis Cases were matched 1:5 on age, health region and index injury date For a 1 year period prior to the injury date, all medical co-morbidity and medication purchases were tabulated for each case and control Medication use was divided by 4 time periods of use prior to injury: a) 0-30 days, b) 31-90 days, c) 91-180 days, d) 191-385 days. Conditional logistic regression used for unadjusted and adjusted models.

29. Results For the 3-year study period, a total of 282 individuals were identified as having sustained a farm related injury Of the 282 cases, 39 (13.8%) were hospitalized. Ninety-seven (34%) were related to machinery, 55 (20%) were related to animals, 35 (12%) were related to falls, 27 (10%) were struck by an object, 24 (9%) were caught between objects, and 44 (15%) were distributed among other miscellaneous mechanisms. The mean age of cases was 71.4 years (sd5.0) and controls 71.8 (sd4.6).

30. Results (cont.) Cases had been treated significantly more often for: incontinence/urinary tract problems (4.6%vs.2.2%), osteoarthritis (23.4%vs.16.2%), osteoporosis (2.1%vs.0.5%), and previous injury (30.5%vs.23.6%). Cases had been prescribed significantly more narcotic pain killers (25.2%vs.15.0%), non-steroidal anti-inflammatories (NSAIDs) (36.2%vs.24.4%), and significantly fewer anti-convulsants (0.0%vs.1.8%).

32. Discussion Limitations No actual measure of medication consumption. Purchase of medication as a proxy for medication use. No measure of over-counter remedies, alcohol, or other drug use. If co-morbidity is not diagnosed, it does not mean that it does not exist.

33. Discussion (cont.) Strengths Population based approach was used to examine the relationship between medication use and injury. Linkage of the different government databases was successful in identifying a group of farmers where cases and controls could be chosen with the assumption of equivalent exposure. All medication and co-morbidity data taken from the same uniform system. Little chance of systematic bias.

34. Discussion (cont.) Main Relationships The use of sedative class drugs and injury observed. Incontinence/urinary tract disorders also related to injury Strong relationship between the recent use of narcotic pain killers and injury observed. Weaker but significant relationship between the recent use of NSAIDS and injury

35. Discussion (cont.) Explanation Distraction may be related to injury in this active working older population Prostate problems related to injury Pain as well when medication ceased Guarding due to pain - Limits in reaction time and mobility may be related to subsequent injury Premature return to work (de-conditioning) Possible effects of withdrawal from narcotic use.

36. Muscular-skeletal issues, injury and arthritis Return to work should be phased in over a re-conditioning period Do not stop pain or anti-inflammatory medication prematurely Hearing Preserve hearing – PHP and environmental modifications Use hearing aids to maintain sensory awareness Recommendations

37. Benzodiazepines/Sleep New medications available “Z-drugs (zaleplon, zolpidem, zopliclone) Shorter elimination time Less dependence Less tolerance (escalating dosage) Non-pharmacological Strategies Regular bedtime Avoid caffeine and alcohol Exercise Napping less than 30 minutes Sleep area dark and quiet Recomendations

38. Polypharmacy Increase awareness of physicians, nurses and pharmacists in rural areas to educate/alert farmers about potential problems Monitor medication strength Eg: anti-hypertensives Regular check-ups/screening Deal with prostate issues etc. Recommendations

39. Back Pain Hypertension Unspecified symptoms Lumbar sprain/strain Cervical deformity Routine exam Upper respiratory tract infections Acute pharyngitis Thoracic sprain/strain Depressive disorder 10 Most Common Physician Diagnoses for Farm Residents

40. THANK YOU