Medication Appropriateness in Vulnerable Older Adults

Healthy Skepticism of Appropriate Polypharmacy

Terri R. Fried, MD; Marcia C. Mecca, MD


J Am Geriatr Soc. 2019;67(6):1123-1127. 

In This Article

Overestimation of Medication Benefits

Lipid-lowering and antihypertensive agents were two of the most common medications identified by the AOU in a study of outpatient veterans 65 years and older.[3] Statins and β-blockers for ischemic heart disease are included in the START criteria.[9] However, in the context of multimorbidity and polypharmacy, these medications may fail to demonstrate expected benefits. Although patients with significant comorbidities are frequently excluded from RCTs, two adequately powered RCTs examined statin use in patients with end-stage renal disease (ESRD) and demonstrated no reduction in a composite of cardiovascular outcomes.[13,14]

Several observational studies also illustrate the reduced benefit of these therapies among vulnerable patients. In a nationally representative cohort age 65 years and older, hypertension was not associated with a higher mortality risk among those with slow gait speed, and higher systolic blood pressure was associated with a lower risk of death among participants who did not complete the walk test, suggesting that frail patients might not derive mortality benefit from antihypertensive treatment.[15] In a cohort study of patients with type 2 diabetes mellitus (DM), those with high comorbidity did not achieve the reduction in cardiovascular risk with more intensive glucose control that was seen in patients with low to moderate comorbidity.[16] In addition, targeting risk factors with multiple medications may not be necessary. In a study examining the association of adherence with multiple preventive therapies and all-cause mortality following myocardial infarction (MI) among Medicare beneficiaries, patients adherent to angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and statins had similar mortality as those adherent to β-blockers in addition to those therapies, suggesting no additional benefit of the β-blockers.[17]