This month we’ve seen a flurry of articles on optimizing medications in the elderly. We’ve previously mentioned our experience with two programs dealing with review of medications in the elderly. One was Medicare’s Medication Therapy Management (MTM) program. The other was a home visit program through the Alzheimer Association. In both cases, patients’ medication lists were reviewed by a pharmacist or a nurse. When medications were identified that were either duplicative or possibly not necessary or possibly causing side effects, contact would be made with the patient’s physician. On the average, a couple medications would be dropped after every such review. Most frequently discontinued medications were those on Beers’ List of potentially inappropriate medications (see our January 15, 2008 Patient Safety Tip of the Week “ “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” and September 2010 “Beers List and CPOE”).and our What’s New in the Patient Safety World columns for June 2008
Now the results of an even more aggressive program addressing polypharmacy in the elderly was published in the Archives of Internal Medicine (Garfinkel 2010). Patients referred for comprehensive geriatric assessments had their medications assessed using the Good Palliative-Geriatric Practice (GP-GP) algorithm, which they had developed and piloted in a previous study of elderly disabled nursing home patients (Garfinkel 2007). The algorithm is very well thought out. Drugs are not discontinued or reduced in dosage in a random fashion but rather only after asking several relevant questions about evidence-based indications and dose levels in this age group, indication in the patient’s current functional or disability status, possible adverse symptoms or signs, etc.
There are a couple basic premises the authors have regarding medications in the elderly. One is that for many drugs we have a good evidence base for deciding when to start a drug but we have no evidence base for when to stop the drug (or when the benefits no longer outweigh the potential harms). Second, the evidence base for the favorable risk:benefit ratio usually comes from studies done on younger patients who often lack the multiple comorbidities seen in the elderly and who have considerably longer life expectancies. Patients in those clinical trials are also less likely to be on many other drugs that might influence either the efficacy or side effects of the study drugs.
They applied the GP-GP algorithm to 70 community-dwelling elderly patients and were able to discontinue drugs by an average of 4.4 drugs per patient overall. Only 2% of patients needed discontinued drugs restarted because of a recurrence of the original indication. Their overall successful discontinuation rate was 81%. No significant adverse events were felt to be attributable to the discontinuation and 88% of the patients reported a global improvement in health (with improvements in subjective clinical, functional, mood and cognitive spheres).
The list of drugs successfully discontinued was long and included not only psychoactive drugs like benzodiazepines and antidepressants and antipsychotic drugs, but also antihypertensives, diuretics, nitrates, statins, beta-blockers, H2 blockers and many others.
Though the sample size in this study was relatively small and the mean followup period was 19.2 months, it certainly demonstrates the feasibility of discontinuing a variety of drugs in the elderly and improving their overall health status. A larger, randomized controlled trial with longer followup might provide more definitive evidence that this approach is a successful one but the results of this study are certainly very encouraging. This will be particularly important since several of the drugs discontinued have been shown to be at least as effective (and in some cases more effective) at preventing the outcomes for the original indications.
The authors did not report cost data in this study but certainly one would expect cost savings for both the individual patients and for society as a whole. The earlier study, which had a control group for comparison, had identified a modest drug cost savings. However, the real question would be whether overall health care costs change with this approach. That is, one would like to see that discontinuation of drugs did not lead over the long run to more frequent hospitalizations, etc. Based on the improvement in global health reported, one might anticipate that discontinuation of drugs may actually lead to fewer hospitalizations over the long run and even bigger cost savings. And their earlier study (the one on the disabled elderly nursing population), though not randomized, did have a comparable control group and actually showed substantial reduction in both acute hospitalizations and mortality compared to that control group.
A key lesson here is that maybe our previous focus on Beers’ List drugs may have been too narrow and that in the elderly any attempt to reduce polypharmacy may lead to more desirable patient outcomes. As we’ve pointed out before, Beers’ List is a consensus-based list of drugs (with good evidence that the drugs could cause harm) rather than a true evidence-based list.
In the earlier paper, they suggested that at least for the elderly disabled hospitalized population, the well-known geriatric recommendation “start low, go slow” should be changed to “stop most, reduce dose”.
One other interesting point raised by the authors is that some of our pay-for-performance (P4P) programs may actually be leading to more aggressive prescribing of preventive medications in this patient population with the unanticipated consequence of worse health outcomes for the elderly.
Several other articles on medication use in the elderly were also published this month. Steinman and Hanlon (Steinman 2010) present a case of a clinically complex older patient and discuss multiple aspects of his medications. They provide a very thoughtful approach to how to assess which medications might be changed, reduced or discontinued, which medications might be underutilized, and how such changes might be accomplished. Part of this article includes a good discussion of the literature and evidence base for the sort of structured medication management approach (using clinical pharmacist, geriatrician, or the PCP). That evidence base, they conclude, is quite scant at this time.
A very thoughtful commentary by Jerry Avorn (Avorn 2010) discusses how healthcare policy changes might improve medication management in the elderly. He proposes reforms in medical school curricula in geriatrics and applied therapeutics, changes in reimbursement to recognize it takes longer to see an elderly patient with multiple comorbidities on multiple medications, better use of EMR’s, and use of expanded Medicare databases to better determine risk:benefit ratios in patients who are historically underrepresented in clinical trials.
Finally, another article focusing on medication and falls (Boyle 2010) has an excellent review of the drugs associated with falls, particularly in the elderly. It concludes the evidence is strong for benzodiazepines, antidepressants, and antipsychotics increasing the risk of falls (and that there is no evidence that some of the newer agents in these categories are any safer with regard to falls). Antihypertensives, particularly diuretics, are associated with a modest increase in fall risk, as do NSAID’s (interestingly, narcotics do not appear to increase the fall risk). The article also describes many of the barriers (both physician and patient barriers) to withdrawal of medications that increase the risk of falls or to avoiding them in the first place.
So it’s been quite a month for good information about medication safety in the elderly!
Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Addressing Polypharmacy
Arch Intern Med. 2010;170(18):1648-1654
Garfinkel D, Zur-Gil S, Ben-Israel J. The War Against Polypharmacy: A New, Cost-Effective, Geriatric-Palliative Approach for Improving Drug Therapy in Disabled Elderly People. Isr Med Assoc J 2007: 9(6): 430-434
Steinman MA, Hanlon JT. Managing Medications in Clinically Complex Elders: "There's Got to Be a Happy Medium". JAMA. 2010;304(14):1592-1601
Avorn J. Medication Use in Older Patients: Better Policy Could Encourage Better Practice. JAMA. 2010;304(14):1606-1607.
Boyle N, Naganathan V, Cumming RG. Medication and Falls: Risk and Optimization. Clin Geriatr Med 2010; 26: 583-605