For many older Americans, their relationship with the most important drugs in their medicine cabinets can be described as "Can't live with 'em, can't live without 'em."
Can't live without 'em, because modern medications are the most effective -- and cost-effective -- treatment we have for most of the chronic diseases (diabetes, hypertension, heart failure, arthritis) that afflict a majority of older people. Without the right drugs, these conditions can quickly become complicated, acute or even deadly, and there is no viable substitute.
Can't live with 'em, because some of the very drugs older patients rely on have the potential to be dangerous, even causing emergency hospitalization. New research from the Centers for Disease Control and Prevention (CDC) shows that about 100,000 people over age 65 are hospitalized on an emergency basis each year, not for a fall or a car accident, but for a dangerous reaction caused by medicine prescribed by their own doctors. Two-thirds of these adverse drug events (ADEs) are unintentional overdoses.
This is the double-edged sword of modern medicine. ADEs hit the elderly disproportionately harder, cost more than $175 billion dollars annually, and can even kill.
Special medication concerns for the elderly
These tragic outcomes are often preventable, yet for years we barely considered the subject. We have my close friend (he died in 2009), colleague, former student and former board president of the American Federation for Aging Research, Mark Beers, M.D., to thank for much of the early progress.
A pioneer, Beers's breakthrough was his premise, namely that elders do not respond to medications, or the same doses of medications, as do younger people and can suffer great harm as a result. In 1991, he published the "Beers Criteria," a roster of drugs with the greatest potential to hurt older patients and one of the most important research outcomes in geriatric medicine. (Twenty years later, the American Geriatrics Society is at work on the third update.)
Yet even use of the Beers Criteria did not end ADEs, and the ER trips continue. If Mark were alive, I know he would be pleased by major new developments that have extended some of his early findings.
Recently, CDC researchers made the startling discovery that just four medications (taken alone or in combination) were to blame for two-thirds of drug-related emergency hospitalizations of older persons. All were common, widely prescribed drugs. (Medications from the Beers Criteria accounted for only slightly more than 1 percent of the emergency admissions.)
The first offender in the CDC research is warfarin, or Coumadin, a blood thinner given for atrial fibrillation to reduce clotting and the associated risk of stroke, which accounted for one out of three hospitalizations. Next comes insulin (by injection, for diabetes) at 13 percent, then oral anti-platelet agents (including aspirin, used for ischemic heart disease) at 13 percent and oral hypoglycemic agents (diabetes pills) at 10 percent of hospitalizations.
For many older adults, these are drugs that they can't live long without. Yet all four are known to have a narrow therapeutic index, the zone between a safe and effective dose and a toxic one.
The same authors had previously identified similar risks with a fifth drug, digoxin. Digoxin has a narrow therapeutic index, but is widely prescribed as the most effective option for patients with congestive heart failure who have not been helped by diuretic and ACE inhibitor treatment.
And, as is often true, the older the patient, the more severe the problem: Nearly half of those hospitalized were age 80 or older.
New guidance on taking your medicine, carefully
Beers Criteria have a successor in the STOPP criteria, or Screening Tool of Older Persons' Potentially inappropriate Prescriptions. Formulated by two geriatricians at the University of Cork in Ireland, STOPP predicted adverse reactions implicated in hospitalizations almost twice as often as Beers. They focus on their own list of drugs, and add the warning that the dangers of the most commonly prescribed "potentially inappropriate medications (PIMs)" for older adults depend on the circumstances. The STOPP criteria include proton pump inhibitors (for uncomplicated ulcers), aspirin (if no history of heart disease), NSAIDs, benzodiazepines (powerful sedatives), diuretics and duplicate prescriptions (a surprisingly big problem). Some of these are over-the-counter drugs, which a doctor may not even know a patient has taken.
STOPP criteria are useful, but also highlight a medical catch-22. Despite the known risks, some of these medications simply cannot be stopped. There is always some risk, and sometimes the benefit outweighs that risk. Should a patient sit back and die of heart failure rather than risk an ADE from digoxin? Should an elderly woman's chronic pain go unrelieved because her medications might increase her risk of falling?
The solution: medication monitoring
The essential (and often missing) piece of the puzzle is medication monitoring. It starts with the realization that only a minority of ADEs can be prevented at the moment the physician writes the prescription. Thereafter, the physician, the patient and everyone else involved in that older patient's life must remain vigilant as long as the patient takes any medication, whether over-the-counter or prescription.
The medication portfolio should be reviewed regularly, at least four times a year, preferably with the help of a well-maintained electronic medical record. But if that's not available, it can be just as effective to bring a paper bag containing all medications to each appointment. Medication monitoring is particularly important during care transitions, such as leaving the hospital or moving to a nursing home.
This vigilance is a matter of life and death. Most ADEs, if caught early, will be less harmful. Because this monitoring is so important, patients and families (as well as caregivers, pharmacists, nurses and anyone else in a position to notice changes or problems) should speak up any time there is a new symptom, particularly soon after starting a new drug. They should ask, and be told, what possible side effects of any new drug look like.
Sadly, medication monitoring is an area in which research has been scanty and few guidelines exist. According to a recent analysis in the Journal of the American Geriatrics Society, fewer than 5 percent of internal medicine or geriatrics textbook chapters discuss medication monitoring.
The bottom line is, the more drugs a person takes, and the longer one stays on them, the more likely it is that an ADE will occur. Today, 40 percent of people over age 65 take between five and nine different prescription drugs. We can't live without most of these drugs, so we must get better at monitoring them.
For more by Richard W. Besdine, M.D., click here.
For more on aging gracefully, click here.