Inappropriate Drug Use in Older Persons
December 15, 2001 4 minutes read
Inappropriate Drug Use in Older Persons
Abstract & Commentary
Synopsis: Drug use in persons older than age 80 with dementia showed drug duplication and potent anticholinergic hazards, while nondemented elderly were mostly exposed to cardiovascular drugs that could aggravate their underlying diseases.
Source: Giron MS, et al. J Am Geriatr Soc. 2001;49:277-283.
As part of an ongoing population study in Sweden, all individuals born in 1912 or earlier living in a certain district were invited to participate in this study, and 1810 enrolled (76% of eligible residents). Women made up 78% of the sample, and 13% resided in institutions. Dementia was established with both the MMSE exam and clinical confirmation when the study began in 1987-1989, with reassessment on all participants every 3 years. Drug data were collected during the follow-up in 1994-1996 through interviews and collection of the actual drug containers.
The mean number of drugs used in the overall sample was 4.6, with a range of 0 to 21. This rose to 4.8 drugs for those aged 90 and older who were not demented, and to 5.8 for that age who were demented. Less than 8% of any of these age groups used no drugs at all, and for institutionalized persons 100% fully used a mean number of 7 drugs.
The most commonly reported drugs used by both demented and nondemented groups were diuretics (39% and 30%), followed by analgesics (27% and 30%). Laxatives were next for demented elderly (28%), but only 13% for nondemented. Hypnotics and sedatives followed in high use for both groups.
Anticholinergic properties were found in 13% of drugs used by demented elderly, most often antipsychotics of low potency, and this group also had the most duplication of more than 1 drug from the same therapeutic/pharmacological class. Duplicate laxative drugs were found in 9% of demented elderly, who also had duplicate anxiolytics to use as needed in 3% of their drugs.
The most common potential drug-drug interactions found were in the use of digoxin with furosemide, where no potassium supplements were used in 69% of demented and 52% of nondemented cases. Another potential problem for 3% of demented elderly was the use of antidepressants and antipsychotics together.
The most common drug-disease interactions involved congestive heart failure, where beta-blockers were used in 12% of nondemented elderly. For patients with peptic ulcer disease, 27% were using systemic glucocorticoids, 18% aspirin, and 9% NSAIDs. For both groups, anticholinergic drugs were commonly used with BPH (14% of nondemented and 29% of demented elderly).
Finally, the average daily drug doses used were compared to maintenance recommendations, and found to be lower in 87% of demented and 75% of nondemented elderly. Only 13% and 18%, respectively, had daily doses exceeding recommendations.
Comment by Mary Elina Ferris, MD
In this population study of older persons with and without dementia, Giron and colleagues found several problems with physician prescribing. Giron et al claim that it is the first published study to evaluate appropriate drug use in this "very old" population, although similar studies have been published for elderly community-dwelling and nursing home residents. Consistent with those previous studies, potentially inappropriate medications were found in double-digit percentages, suggesting poor quality of health care for the elderly.1,2
However, a closer look at the potentially inappropriate categories reveals the weakness of the allegations. Who would be surprised that vital antipsychotic medications have anticholinergic effects? Or that demented male patients older than 80 with BPH would still be prescribed such medications to control behavioral problems? Particularly in these frail older ages, the risks and benefits of any therapy must be balanced for the best effect. Futhermore, the use of multiple medications in a single category may indicate a complex problem rather than a deficiency in care.
The information does provide an interesting perspective on what medications patients are actually taking, since they obtained the data from the patients themselves and not from medical records. The number of drugs used was not surprisingly high (perhaps reflecting more about Sweden than the US), and the fact that lower doses were being prescribed reflects well on the geriatric skill of the practitioners, using the adage "start low and go slow" in prescribing for the elderly. The prevalence of potential disease-drug interactions, particularly with ulcers and ASA/NSAIDS, reminds us once again what has been shown in previous studies, that we need to ask our patients about all the multiple drugs they may be taking at home.3
References
1. Beers MH. Arch Intern Med. 1997;157:1531-1536.
2. Beers MH, et al. Arch Intern Med. 1991;151:1825-1832.
3. Foster DF, et al. J Am Geriatr Soc. 2000;48:1560-1565.
Dr. Ferris, Clinical Associate Professor, University of Southern California, is Associate Editor of Internal Medicine Alert.
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