Are Seniors Overmedicated?

Although seniors constitute 13% of the population, they consume 30% of all prescription drugs, prompting many seniors and their families to ask, “Why all these pills?”  I’ve seen patients taking as many as 20 different prescription and OTC (over-the-counter) medications.  Are all these drugs really necessary, or, could they be causing more harm than good? The following facts suggest that we should be concerned about this high consumption of medications:

 

  • 25% of Adverse Drug Events [ADE] in those over 80 years of age resulted in admissions to a hospital [Williams]
  • 14-52% of seniors take at least one inappropriate [Beers List] medication [McLeod]
  • For every dollar spent on a drug prescription, it triggers a dollar spent on iatrogenic [physician-induced] illness [Williams]
  • 21-55% non-compliance suggests seniors don’t want to take drugs regularly [Williams, 2002]
  • The ‘benefits’ attributed to drugs need to be interpreted with caution, since up to 39% of people improve regardless of the treatment [known as the “Placebo Effect” - Cochrane 2010; and, Why almost everything you hear about medicine is wrong.  Newsweek 1/24/11.]
  • Polypharmacyis now a recognized problem in geriatrics, and is defined as the use of multiple medications and/or the administration of more medications than are clinically indicated[Am J Geriatr Pharmacother 2007].  Some authors have stated it begins when more than four prescriptions are taken. [see article this website Polypharmacy]
  • 80% of our improved longevity over the past 100 years (from a life expectancy in 1900 of 45yrs to 77yrs today) is due to public health measures, not to drugs or ‘medical miracles’. [CDC –1999.  Ten great public health achievements - US, 1900-1999.  Public health is credited w/ adding 25 of the 30 year increase between 1900 and 1999]


Why are drugs a problem for seniors?
Seniors are not simply ‘older’ adults.  As we age, our metabolism slows down:  the liver and kidney don’t filter toxins as well; our fat is distributed differently which changes drug storage; our brains are smaller and are more sensitive to drugs. This results in frequent problems when taking medicines, particularly an increase in falls and fractures; there is a greater frequency of confusion or delirium, malaise [“don’t feel good”], constipation, indigestion, aching, drowsiness.  [to see a sampling of the published studies on these risks, read Polypharmacy]

Are there any particular drugs that seniors should avoid?
A commonly referenced list of ‘problem drugs’ called The Beer’s List, was first published in 1993 and updated most recently in 2003.  It outlines 48 drugs or classes of drugs which are associated with too frequent side-effects in seniors and are therefore strongly discouraged by Medicare and by the American Geriatrics Society.  The list provides the name of the drug, describes the concern, and whether the risk of a person having the side-effect is high, moderate, or low. CMS (Center for Medicare and Medicaid Services – the administrator and regulator for Medicare/Medicaid) uses the Beer’s List when evaluating the quality of care in nursing homes.  Meaning, if a resident is on one of these drugs, it is a ‘red flag’ to the surveyor to check that the doctor  has documented good reasons why it is prescribed. To see the list of drugs, go to Beers List at Wikipedia or to the following link: www.tahsa.org [Texas Association of Homes and Services for the Aging ]

What do seniors and their families want?
Several studies* have confirmed that, when a serious or incurable condition is present, people want:

  • honest information (including the risk of rare side-effects or bad outcomes),
  • to be kept informed and be involved in making decisions and have a sense of control,
  • to not prolong the dying process when it begins,
  • to honor their loved ones wishes, and
  • to have their pain and other symptoms controlled.

[*Singer et al. JAMA 1999;281(2):163-168.   Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics.   Ziegler. Arch Intern Med 2001 ]

 

What can be done to minimize unnecessary medications?

Based on the evidence, the following are some principles and suggestions to guide medication prescribing for seniors.

For prescribers:

  1. First, do no harm.  [This is from the writings of Hippocrates and should be an obvious principle.]
  2. Start low, go slow. [Because seniors are more sensitive to drugs, when a drug is needed, always start with the lowest dosage and increase it slowly.]
  3. Review all meds regularly.
  4. Stop any drug without known benefit or without a clinical indication.
  5. Use the least ‘toxic’ drug of its class.
  6. Avoid duplicating drugs. [Drugs which have similar purposes.]
  7. Avoid drugs w/ anticholinergic properties.  [e.g. those which make you dry in the mouth]
  8. Follow the prescribing guide whenever possible to treat “one disease, [with] one drug, once-a-day”.
  9. Consider drug side-effects as a cause for symptoms.

[*guideline from article by Dr. C.Williams]


For both physicians and patients, it is important that we:

  1. clarify our goals, because knowing our goal helps in making better decisions:  is our purpose to ‘live’ or ‘be kept alive’?  Do you want ‘quality of life’ or ‘quantity of years’?  [read the website article “Goal-focused care”]  How do you want to die (or to watch your loved one die) and how do you want your family to remember your death (or want to remember theirs)?
  2. start from a position of ‘no drugs’ and add only those with proven benefit to help you live comfortably.  Taking pills is not only a burden for most seniors; it can be lethal.  The evidence is accumulating that seniors live better on fewer pills.
  3. avoid drugs with debatable risks/benefits.  When deciding what’s truly beneficial, if there is debate about its risks/benefits, then the drug is not likely going to help you very much.  Sometimes a trial of one month will help decide:  if you definitely feel better and your family agrees you are significantly improved, then continue; if not, stop it.



Read the website article “Understanding the Risks of Taking a Drug”.  And, for more information about risks and benefits of different drugs or treatments, several websites offer help:

  • Bandolier – the Oxford University’s site [  www.medicine.ox.ac.uk/bandolier/ ].
  • Paling Palettes [www.trci.info ]

 

References:


1. Williams C.  Using medications appropriately in older adults. Am Fam Phys 2002;66:1917-24.
2. McLeod PJ, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997;156:385-91.
3. Fick DM, et al. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003.
4. Buck MD, et al. Potentially inappropriate medication prescribing in outpatient practices:
prevalence and patient characteristics based on electronic health records.
5. Am J Geriatr
Pharmacother. 2009 Apr;7(2):84-92.
6. Cassel E.  The nature of suffering and the goals of medicine.  2004 2nd ed.
7. Hróbjartsson A, Gøtzsche PC (20 January 2010). "Placebo interventions for all clinical conditions".
8.
Cochrane Database Syst Rev 106 (1): CD003974
9. Hospice & Palliative Care Formulary USA, 2nd edition. 2008