Caution urged when prescribing for elderly

Washington -- A new study by Duke University researchers seems like déjà vu all over again in its finding that large numbers of elderly Americans are receiving prescriptions for medications that are believed to be potentially dangerous for them.

The study found that over the course of a year, one in five of the more than three-quarters of a million elderly patients studied filled a prescription for at least one drug determined to be inappropriate by a panel of geriatricians and others.

Two drugs, amitriptyline and doxepin, accounted for 23% of those prescriptions, said the researchers.

Some drugs impact elderly people differently, largely because of slower metabolism. "Drugs tend to stick around much longer in an older person's body than they do in a younger person's," said the study's lead author Lesley Curtis, PhD, assistant research professor at the Duke Center for Clinical and Genetic Economics.

Side effects such as dizziness and sleepiness may linger from evening into the next day for older people, thus increasing their risk for falls and other accidents. The potential problems are often exacerbated by multiple medications taken for several chronic conditions.

Dr. Curtis and colleagues used a large outpatient prescription claims database of a national pharmaceutical benefit manager to see which of the 765,423 subjects 65 or older had filled prescriptions for medications that met criteria first developed in 1991 by Mark H. Beers, MD, and associates for determining which drugs older people should avoid.

The Beers list was updated in 1997 and 2003 and is thought to be the "gold standard of drugs that should never, or almost never, be prescribed for older patients," said Daniel Perry, executive director of the Alliance for Aging Research, a nonprofit group based in Washington, D.C.

"We've encouraged a broader dissemination of the Beers list by the Dept. of Health and Human Services so any physician or pharmacist knows that those drugs are considered inappropriate for people in that age group," he said.

The latest Beers update was published in the Dec. 8, 2003, issue of the Archives of Internal Medicine, and the Duke study, which checked for drugs on the 1997 update, was published in the Aug. 9/23, 2004, issue of the same journal.

The question is, why are such drugs still commonly prescribed for elderly patients, said Roseanne Leipzig, MD, PhD, professor of geriatrics and adult development at Mount Sinai School of Medicine in New York City.

"Here we are 13 years after the first Beers list was published, and some of this information has still not hit prime time," she said. "Clearly there is a problem with the dissemination of the message."

Solutions in sight?

"Perhaps because most physicians in practice today had little or no training in geriatric medicine, they may simply not be aware of the advances in this rapidly growing field," wrote Knight Steel, MD, a professor of geriatrics at the New Jersey Medical School, in an editorial that accompanied the study.

Or, "Is there too great a willingness to prescribe drugs on the part of the physician and too great an expectation on the part of the patient to receive them during an office visit?" he asked.

Cost may be a driving factor, said Dr. Leipzig. The generics that are often prescribed are older and cheaper than drugs more recently developed that might have fewer side effects. Many elderly patients were probably without drug coverage at the time of the study. And while more suitable generics may be available, the time it takes to track down alternatives could pose a problem for physicians who are continually running short of time, she said.

Many patients may have taken the drugs for years and insist on continuing to take them while the threat of adverse reactions grows. "Old drugs tend to be a matter of habit, demand and sloppy health care," said Perry.

Encouraging pharmaceutical companies to test these drugs more frequently on people older than 70 would be a positive move, he added. Although such testing would be difficult and expensive given the multiple chronic conditions of many members of this population, incentives could be offered to manufacturers as they have been used to encourage the testing of more drugs in children.

Dr. Leipzig would like to see a systemwide approach to solving the prescribing problem. "To me it's the first thing that should be dealt with on a nationwide basis. Older people are so much more likely than younger people to have an adverse event with drugs. They are so much more likely to be using drugs. They are set-ups," she said.

One safeguard could be to have pharmaceutical benefit managers more closely question the prescribing of a drug to an older patient. For certain drugs, like amitriptyline, the evidence of possible harm is compelling enough that concerns could be raised, she said, although "I wouldn't say this for every drug on the Beers list."

Pharmacists could also serve as physicians' allies in the quest to cut inappropriate prescriptions, she said. "Pharmacists could be incredibly helpful. But it is also a matter of getting physicians to recognize that they are part of a team.

"Pharmacists don't always get the nicest reception when they call a doctor. But they should, because they are providing help."