Adverse events related to medication are especially likely in the elderly. In 1991, Dr. Mark Beers and others developed explicit criteria for inappropriate medication use in the elderly. The original intended patient population was nursing home –based but subsequent updates of the now-famous “Beers list” have been expanded to cover the elderly in general. However, a paper in the Annals of Internal Medicine(2) by Dudnitz, et al in December concluded that medications on the Beers List accounted for few visits to emergency departments for adverse events. Rather, 3 drugs not on the list (warfarin, insulin, and digoxin) accounted for far more emergency department visits for adverse events. In fact, they calculated that the risk for emergency department visits for adverse events due to these 3 medications was 35 times greater than for those medications on the Beers list considered to be almost always inappropriate. Also, nine of the 10 most medications most frequently implicated in emergency department visits for adverse events came from 3 drug categories (oral anticoagulant or antiplatelet agents, antidiabetic agents, and narrow therapeutic index drugs) accounted for 47.5% of the visits.
That paper should not diminish the importance of identifying prescription of potentially inappropriate Beers List drugs in the elderly. Rather, it emphasizes the need to also monitor hi-alert drugs better in the elderly. Hospitals, which should already be assessing use of hi-alert medications as part of their quality improvement and patient safety initiatives, probably already focus on insulin and warfarin which are two of the medications most often implicated in serious medication-related adverse patient outcomes in hospitalized patients.
A good paper “Minimizing Adverse Drug Events in Older Pateients”(3) by Pham and Dickman appears in the December 15, 2007 issue of American Family Physician. At least a third of older persons taking five or more medications will suffer an adverse event each year and many are both predictable and preventable.
We’ve seen an interesting phenomenon in several different settings now. When a computerized system of alerts and reminders is set up to notify physicians when one of their patients is on a drug that is on the Beers List, the physician seldom discontinues the flagged drug in that individual patient. However, the number of new prescriptions for that drug diminishes in the patient population cared for by that physician. When we ask the physicians why they did not discontinue the drug, we usually get a response like this: “This patient has already been on this drug now for some time. It is producing the desired response and the patient is tolerating it very well. Why would I switch them over to another drug that might not work and might have undesirable side effects?” Pretty hard to argue against that argument. In many such cases, the patient indeed has been on the drug for many years before they turned 65 (the typical target age at which the computerized alerts are set to trigger). It may not be necessary to discontinue the drug in such circumstances. However, it should alert the clinician to use the lowest effective dosage in the patient and at least consider whether better alternatives might be present. As people get older, the effects of some drugs may affected by diminishing renal clearance. Fortunately, since we now in most places have ready access to the patients GFR (glomerular filtration rate), we can see when we might need to reduce the dosage of a drug excreted predominantly renally. But there are many drugs that otherwise become poorly tolerated in the elderly. In particular, drugs that have anticholinergic side effects or those that cause orthostatic hypotension are more likely to cause symptomatic adverse effects in the elderly. Temperature regulation also becomes impaired with age and the use of certain drugs may predispose the elderly to heat stroke. So it always makes sense to regularly review the patient’s medication regimen and consider which drugs might be switched to an alternate drug or discontinued all together.
The Pham and Dickman article nicely describes the “brown bag” method of medication review that is useful in managing the older patient. That, of course, consists of having the patient bring all their medication with them on the initial visit and again every 6-12 months for review. This can lead to discontinuation of a medication in about 20% of cases and change in medication in another 29%. We have seen similar outcomes in medication review done in several other settings. CMS, when it rolled out the Medicare Part D drug benefit program, mandated use of Medication Therapy Management (MTM) for certain Medicare recipients. That consists of a review of all a patient’s medications and counseling, usually done with a pharmacist either face-to-face or by telephone. That results frequently in either discontinuation or change in some of the drugs a patient may have been taking. Unfortunately, the CMS mandate is only for those Medicare recipients spending more than $4200 per year on covered medications or some with a certain number of chronic diseases or on a certain number of medications. Some of the smarter Medicare managed care plans have realized that the MTM program is good for both patient safety and the bottom line so they have developed similar programs for even those patients not meeting the mandate criteria. Other organizations may also provide similar services. The Western New York Chapter of the Alzheimer Association has an In-Home Memory Loss and Dementia Care Consultation Service that includes a comprehensive medication review. Quite commonly in this population that medical review will reveal that a patient is on one or more medications that may be causing unwanted consequences. And implementation of the medication reconciliation requirements for hospitals and other healthcare facilities has greatly facilitated such medication reviews in those patients unfortunate enough to have required hospitalization. During medication reconciliation, be it on admission or discharge or transfer, we frequently encounter a drug a patient no longer needs or a duplication of pharmacologic therapy or a problem with dosage of a medication.
The Pham and Dickman article also lists several useful questions to ask during a medication review that are adapted from an article by Hamdy et al(4):
Lastly, the Pham and Dickman article discusses two other medication issues significant in the elderly: underprescribing and nonadherence. Underprescribing is failure to use a medication for which there is a good evidence-based indication. That, of course, is a problem not exclusive to the elderly, though we may have a tendency to mistakenly think that the elderly may not benefit as much from certain interventions. The nonadherence (noncompliance) issue is especially important in the elderly for a variety of reasons, including cost, communication issues, visual or cognitive impairment, etc. Specifically questioning patients or their caregivers about such issues is a very important part of the medication review.
In our October 23, 2007 Patient Safety Tip of the Week on Medication Reconciliation Tools we noted that many of the available medication reconciliation forms that are currently in use lack a field to clarify the indication for which the medication was prescribed. Many medications (eg. beta-blockers, digoxin) may have several indications and you need to know which one applies to your patient. And the dosage of the medication may vary depending upon the indication for use. Similarly, most medication forms and lists fail to include reason for discontinuation. It is important to know if a medication was discontinued because of lack of efficacy, side effect, allergy, or formulary or economic reasons.
So if you are setting up a CPOE (computerized physician order entry) system into your clinic or practice setting, make sure that you include a field for medication indication. Good rules-based alerts and reminders that you might set up as clinical decision support tools take into account not only the drug, but the indication, possible drug-drug interactions, possible drug-disease interactions, possible drug-food interactions, allergies, past adverse reactions, age, size, weight, gender, GFR and other laboratory or physiologic variables, and other items. Managing medications is getting more and more complex in all patients and even more so in the elderly.
Update: See also our Patient Safety Tips of the Week for October 19, 2010 “Psychotropic Drugs and Falls in the SNF” and our What’s New in the Patient Safety World columns for June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” and September 2010 “Beers List and CPOE”.” and September 22, 2009 “