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A Third of Older People May Take Potentially Inappropriate Medicines

Almost 30 percent of seniors in managed care plans may have been given potentially inappropriate medications by their doctors, according to a study published in the February Journal of the American Geriatrics Society.

Almost a third of all senior citizens are taking medications that are on a controversial list of potentially inappropriate drugs, says Steven Simon. (Photo by Graham Ramsay)

“There’s good evidence that prescribing for the elderly is a bigger problem than for young people,” said lead author Steven Simon, HMS assistant professor of ambulatory care and prevention.

Solving the problem may require further education of physicians and patients to disseminate the most recent information on potentially inappropriate drugs. But it also will require clinical studies to better define which medications really do cause adverse outcomes in older people. The current list of more than 50 drugs that expert panels have labeled “potentially inappropriate for the elderly” is based on literature reviews.

Simon and his colleagues analyzed automated pharmacy data from 10 different HMOs in nine different states, selecting a random sample of 157,517 members who were 65 years or older. Using data from Jan. 1, 2000, to June 30, 2001, the study looked for 33 of the potentially inappropriate drugs and found that they had been prescribed to 28.8 percent of the sample. The results are consistent with similar studies that did not use HMO-generated data.

The findings could be indicative of several problems. Doctors might not be aware of the potential hazards of these drugs, the expert panels’ determination of their inappropriateness might not translate into significant adverse outcomes, or patients might prefer these drugs to safer but more expensive alternatives.

Drug costs may be a significant factor, Simon speculated, noting that most HMOs limit coverage of prescription expenses for seniors. “There are good alternatives to these medications in terms of effectiveness and side effects, but the trouble is the cost,” he said. “These medications are perceived as tried and true, and they are inexpensive since almost all of them have generic versions.”

The findings are only a first step in this line of research, Simon explained. More work is needed on why these medications are prescribed and what their outcomes are. As of now, there is no conclusive evidence that the drugs harm elderly people. “What we don’t have a good understanding of is, are these 28.8 percent of older people at a higher risk than their counterparts? Do they have more hip fractures? Do they have a higher mortality rate?”

“There’s good evidence that prescribing for the elderly is a bigger problem than for young people.”

Simon and his colleagues have several recommendations for limiting prescriptions of potentially inappropriate medications. Intensive educational outreach programs for doctors could increase awareness of the controversial drugs. A second possibility involves using computerized prescribing processes so computer programs can flag potentially harmful drugs. Another possible deterrent could be made via insurance company regulations: if physicians needed special permission from the companies to prescribe these medications, said Simon, they might hesitate before recommending them. But Simon has no solution for the high expense of some of the drugs. “Even with new legislation,” he said, “the issue of out-of-pocket expenses is a problem.”

In the study, Simon and his colleagues divided the 33 medications into three categories. The first included drugs that can be harmful when prescribed for the wrong health problem. Antihistamines, for example, are often prescribed to elderly patients as sedatives, but their only safe uses for this population are as treatments for allergies or urticaria. The second category included medications that are only considered appropriate in rare circumstances, and the third included medications that should always be avoided because of known risks.

Of the elderly surveyed, 5 percent had been prescribed medications that according to the expert panels should always be avoided; 13 percent received medications that are rarely appropriate; and 17 percent received at least one medication that is often misused. Seven percent had taken propoxyphene, an analgesic medication “considered rarely appropriate in the elderly and a drug that has a long history of limited efficacy and potential for toxicity,” according to the study.

—Rebecca Tinkelman

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