Number of Elderly at Risk for Major Drug–Drug Event Doubles

Marcia Frellick

March 22, 2016

The proportion of elderly patients concurrently using five or more prescription medications increased from 30.6% to 35.8% between 2005-2006 and 2010-2011, new data show.

Results of a study published online March 21 in JAMA Internal Medicine also show the use of five or more medications or supplements of any type among those aged 62 to 85 years increased from 53.4% to 67.1% during the same period.

Moreover, 15.1% (95% confidence interval [CI], 13.2% - 17.1%) of older adults were using medication combinations with the potential for a major drug–drug interaction in 2010 to 2011, up from an estimated 8.4% (95% CI, 7.2% - 9.8%) in 2005 to 2006 (P < .001), according to the study by Dima M. Qato, PharmD, MPH, PhD, from the Department of Pharmacy Systems, Outcomes, and Policy at University of Illinois at Chicago, and colleagues.

"These findings suggest that the unsafe use of multiple medications among older adults is a growing public health problem. Therefore, health care professionals should carefully consider the adverse effects of commonly used prescription and nonprescription medication combinations when treating older adults and counsel patients about these risks," the authors conclude.

Some of the biggest increases in use of prescription medications were seen in statins (33.8% to 46.2%; P < .001), antiplatelets (32.8% to 43.0%; P < .001), nonsteroidal anti-inflammatory drugs (10.1% to 13.7%; P < .001), and proton pump inhibitors (15.7% to 18.5%; P = .05).

Among supplements, the authors note a nearly fourfold increase in use of omega-3 fish oils, despite limited cardiovascular benefit, and a nearly threefold increase in use of vitamin D, "which may be due to increased reports supporting possible cognitive benefits in older adults," the authors explain.

The study included 2351 participants in 2005 to 2006 and 2206 patients in 2010 to 2011, aged 62 to 85 years. In-home interviews and direct medication inspection were performed. Researchers defined medication use as using at least a single prescription or over-the-counter medication or dietary supplement at least daily or weekly.

The authors note that several changes have happened in the last decade that may affect medication use among older adults, including the implementation of Medicare Part D, dozens of new drugs hitting the market, and increasing availability of generics.

Are the Numbers Good or Bad?

In an accompanying invited commentary, Michael A. Steinman, MD, from the Division of Geriatrics in the Department of Medicine, University of California, San Francisco, says the findings are consistent with previous analyses showing the rise in polypharmacy, but what these studies lack is conclusions on whether the increased numbers are good or bad.

He points to the increases in statins and vitamin D as symbolic of the confusion.

"Is this appropriate therapy or overtreatment? Perhaps more important, knowing that the use of multiple medications is common does not tell us what to do about it," he writes.

He says it is time to change the way we monitor polypharmacy and start using systems that would periodically assess benefits, harms, and need of medications. Such a system could help physicians de-prescribe a medication.

One key to change would be more comprehensive, portable lists of all of a patient's medications, including supplements, over-the-counter medications, and alternative therapies. The lists would have to be kept current with the help of engaged patients.

"[T]his list would include not only the drug name, dosage, and schedule but also the indication for each drug, the target symptoms and signs it is meant to address, and how its effectiveness and adverse effects should be monitored. This will provide a common reference point for both the patient and the health care team," Dr Steinman said.

He also suggests a team approach to monitoring, citing the success of warfarin clinics, which have helped dose and monitor patients taking the anticoagulant.

"Pharmacists, nurses, and other health care professionals can be creatively engaged to systematize the process of medication monitoring and follow-up, complementing the role of the physician," Dr Steinman writes.

Many Patients Do Not Tell Primary Care Physicians About Complementary Therapies

The need for patient participation in monitoring all medications and alternative therapies is highlighted by another study also published online March 21 in JAMA Internal Medicine.

Judy Jou, MA, from the Division of Health Policy & Management, and Pamela Jo Johnson, MPH, PhD, from the Center for Spirituality & Healing, University of Minnesota, Minneapolis, found that one third of the US adult population uses a complementary or alternative medication (CAM), but many users do not discuss the CAM with their primary care physician.

The researchers used data from the 2012 National Health Interview Survey and found that of the 7493 respondents who had a primary care physician and had used a form of CAM at least once in the past year, 3094 (42.3%) did not disclose the use of their most used CAM modality.

The number one reason for patients not telling their primary care physician about their CAM treatment was that the physician did not ask (reported by 1759 of the patients [57.0%]). The second most common reason was believing that physicians did not need to know about their CAM use (1432 [46.2%]).

The data make a case for physicians more actively inquiring about patients' use of all medicines, therapies, and treatments, the authors say.

"Incorporating more education about CAM into medical curricula can better equip physicians to initiate conversations," they write.

The National Social Life, Health, and Aging Project is supported by the National Institutes of Health, including the National Institute on Aging, the Office of Women's Health Research, the Office of AIDS Research, and the Office of Behavioral and Social Sciences Research. Dr Steinman is supported by the National Institute on Aging. The study by Jou and Dr Johnson was supported in part by the Integrative Health & Wellbeing Research Program at the Center for Spirituality & Healing, University of Minnesota. One coauthor of the Qato study was chair of the US Food and Drug Administration's Peripheral and Central Nervous System Advisory Committee; was a paid consultant to Pain Navigator, a mobile start-up to improve patients' pain management and IMS Health; and served on an IMS Health scientific advisory board. Dr Steinman reported being a consultant for iodine.com, an Internet start-up. The other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 21, 2016. Article abstract, Commentary extract, Research letter extract

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