A number of articles and posts this week have called out the dangers that medications can pose for older adults. This is a topic near and dear to our hearts, and one we have frequently covered on Health AGEnda.
Unfortunately, far too many potentially dangerous drugs are still being prescribed to older people. Even more unfortunately, not giving drugs that are known to cause harm is the easy problem. What’s much more difficult is understanding and dealing with the complexity involved in medication management for elders.
This complexity can arise from a particularly difficult single condition such as Parkinson’s disease or from the often tangled knot of social, financial, and functional barriers that can make a medication regimen totally unmanageable for an older patient. Often, the complexity comes from the numerous medications taken for different, overlapping chronic conditions that create tough treatment trade-off decisions.
How will clinicians help older adults deal with this complexity when the simple practice of not prescribing dangerous drugs still eludes us?
New research published in the Journal of General Internal Medicine and reported on The New York Times Well and AARP blogs gave us bad news on what should be the easier-to-fix problem. Looking at more than six million older adults in Medicare Advantage plans across the country, the study found that one in five older adults were prescribed medications that—because of physiological or other reasons—are deemed potentially harmful in older adults. Five percent of these older adults were receiving two or more of these drugs. These include some common drugs like Valium, which takes a longer time to leave the body for older adults, putting them at risk for confusion and falls.
As with many of the problems in our health care system, geography and regional variation matters. People in the South were 12 times more likely to be prescribed one of these problem medications (I've called home to alert my parents in Texas).
To identify the potentially dangerous drugs, the study used a list of medications embedded in nationally recognized quality measures. This list, in turn, was created in large part from the Beers Criteria, the development of which the Hartford Foundation helped fund more than 20 years ago. We would hope by now that these criteria, updated by the American Geriatrics Society (AGS) in 2012 and now part of nationally used measure sets, would be more widely known.
We obviously have more work to do, including informing older patients and their loved ones about these dangerous drugs. For starters, the AGS’ Health In Aging website has posted a helpful document on Ten Medications Older Adults Should Avoid or Use with Caution.
Beyond more awareness about drugs that might be dangerous, we must begin addressing the larger issues of complexity in medication management for older adults. A recent Wall Street Journal article highlights the inherently complex issues involved with medication management for older diabetes patients. Tightly controlling blood sugar with medications may seem like a worthy goal, but for older adults it can lead to low blood sugar, or hypoglycemia, that can be especially dangerous for older adults at risk for falls.
Vision, dexterity and other functional decline can make insulin injections difficult or memory issues may be an impediment. Regardless, interventions need to be developed that help older adults overcome these barriers to taking their medications through simplification, education, and support. On the other hand, the prescribed regimen has to be appropriate and meet the goals of the patient, not a hemoglobin A1C level that is in all likelihood meaningless without resulting in a better quality of life.
Probably most difficult, clinicians and researchers need to take into account all of the competing chronic conditions and medications that an older adult might have to handle. An illuminating interactive chart on The New York Times online Science section helps us understand the problems with overlapping, multiple chronic conditions, and points specifically to potential drug problems for older adults with Alzheimer’s disease, high blood pressure, and heart disease. The article notes problems such as how diuretics used to treat high blood pressure often increase the need to urinate, but patients with dementia are often already incontinent. Some evidence shows that statins used to lower cholesterol and prevent heart attacks may also have cognitive side effects, which complicates care for dementia patients.
Fortunately, we have bright geriatrician minds working on these issues. The diabetes clinical consensus conference mentioned in the Wall Street Journal was organized by our grantee Jeff Halter and his colleagues at the AGS and American Diabetes Association. Dr. Halter also helped organize a more recent research agenda-setting conference with experts around the country that will help drive the investigation needed in medication management for older diabetes patients.
Dr. Cynthia Boyd, quoted in the Times article on overlapping diseases, and others at the American Geriatrics Society continue to work on guidelines and recommendations that take into account the multiple chronic conditions of older patients.
This work is incredibly important and must continue. At the same time, it is disheartening to see that even the simple concept of preventing the use of unsafe drugs by older adults still seems out of our grasp.