Overprescribing in the Elderly: We Have a Problem

Melissa Walton-Shirley, MD


August 26, 2018

At the European Society of Cardiology (ESC) 2018 Congress, the presenters for the session titled "Drug Prescription in the Elderly" threw around words like "sarcopenia" and "frailty." The initials "GFR" (glomerular filtration rate) got some focus by Christian Funck-Brentano of Paris. "Kidney function is key to drug accumulation and side effects," he said. Muscle wasting and the tendency to fall are almost never mentioned in late-breaking clinical trial presentations, but for patients over age 65, sarcopenia, frailty, and GFR are everything. They predict whether our patients will  break a hip, become confused, or even die.

The panelists meant for us to leave convinced that these terms should never be an afterthought but rather a first consideration when sending an e-script. It worked for me.

Claudio Cenconi from Italy made the  point that the prevalence of heart failure soared between 1988 and 2008, in his presentation "Pharmacotherapy in the Elderly." And the proportion of these patients over 80 years of age increased from 13.3% to 22.4%.[1] The mean number of daily meds per patient has increased from 4.1 to 6.4 over this time, coinciding with an increase in patients with five or more chronic comorbidities (from 42% to 58%).[1] Both systolic and diastolic impairment are common, so understanding this basic milieu of our geriatric patients is salient to nearly all prescriptions.

Drugs used to treat comorbidities produce significant side effects in people with heart failure, not to mention the potential drug-drug interactions. For instance, combining diltiazem and verapamil can lead to worsening heart failure. Most of us understand that glitazones, nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 inhibitors increase heart failure readmissions. Less acknowledged is the correlation of  steroid use with acute myocardial infarction[2] and bronchodilators with adverse outcomes.[3]

Cenconi also emphasized that we can be guilty of underprescribing. For instance, we don't use cardioselective β-blockers for elderly patients with heart failure who have chronic obstructive pulmonary disease as often as recommended.[4,5] We should consider the use of intravenous ferric carboxymaltose (FCM) in symptomatic patients with heart failure with reduced ejection fraction and iron deficiency, a maneuver that increases both exercise capacity and quality of life.[6,7] In his country, "IVFCM is given to less than 5% of eligible patients," he said.

Juan Tamargo, MD, PhD, from Madrid, spoke on polypharmacy.  His first slide was a caricature of two individuals made up entirely of pills and capsules,  each human slightly bent in locomotion, one using a cane. It was an excellent way to illustrate the increasing pill burden we place on our elderly patients: In one analysis, prescriptions rose from 17.8% to 60.4% between 1997 and 2012, with the elderly most affected.[8] The number of patients with more than five prescriptions increased from 8.2% to 15%.[9] To cap it off, it's estimated that 20% of elderly patients receive inappropriate prescriptions.[10]   

Tamargo added that more than 40% of elders self-medicate with complementary and alternative medications,[11] yet most will not disclose this information—often because the physician never asked.[12,13] We're missing a chance to address some important interactions:  St. John's wort is purported to help ease depression but is also an inducer of the cytochrome P450 system, affecting β-blocker, calcium antagonist, digoxin, statin, and warfarin metabolism. Ginseng taken in hope of an improved sense of "well-being," as a cure for erectile dysfunction, or even to help diabetes control can cause hypoglycemia.  Both Ginseng and Gingko biloba (the latter is advertised to help with dementia, tinnitus, and claudication) are known to increase bleeding when used with NSAIDs and anticoagulants. In addition to taking over-the-counter agents that we don't know about, "50% of the time, elders aren't adhering to prescribed meds," Tamargo said.

Perhaps the most salient advice  included the warning to avoid the "prescription cascade." As prescribers, we swore an oath "to do no harm," but when the side effects of one drug are misdiagnosed as symptoms of something else, it can lead to multiple prescriptions. For example, NSAIDs can worsen hypertension, which can trigger a prescription for a calcium channel blocker, which induces a need for a diuretic, which leads  to more meds to improve blood sugar, or to treat insomnia or treat gout.

At the end of the presentations, an audience member made the great point  that the word "deprescribing" was never mentioned. The presenters explained that the point of these lectures was to highlight the problem and prevent the need for deprescribing in the first place.

As physicians and providers, we must work hard to avoid aiding and abetting the negative consequences of polypharmacy. The incidence of orthostasis, falls, fractures, urinary incontinence, cognitive impairment, cost, and hospital admission tightly correlates with the number of medications prescribed.  As with all self-help and addiction programs, the first step is admitting we have a problem. We physicians and providers are addicted to overprescribing, and that is a huge problem.


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