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

Underestimation of Medication Harms

Observational studies demonstrate that vulnerable older patients are at increased risk of experiencing harm from various medications included in PPO criteria. First, a cohort study using data from a nationally representative sample of community-living Medicare beneficiaries older than 70 years with hypertension found that individuals who received moderate- or high-intensity antihypertensive therapy had an increased risk of a serious fall injury compared with antihypertensive nonusers. Subgroup analysis revealed that among those with a previous fall injury in the past year, the use of moderate- and high-intensity antihypertensive therapy doubled the risk of injury.[18] Second, although inhaled anticholinergic agents were identified as the most commonly underutilized medication using the AOU in a study of frail veterans at time of hospital discharge,[19] they were associated with a markedly increased risk of acute urinary retention in men with chronic obstructive pulmonary disease in a large case-control study.[20] Finally, a cohort study of individuals with DM enrolled in private and Medicare Advantage plans demonstrated that, among persons receiving intensive treatment, those with high clinical complexity, defined as age older than 75 years, dementia, or ESRD, or three or more chronic conditions, had nearly double the risk of severe hypoglycemia as compared with patients with low complexity.[21]

In addition, some medication harms do not receive adequate weight in decision making about appropriateness. Primary or secondary prevention medications, prescribed to decrease the risk of future disease-specific events, may cause immediate non–disease-specific symptoms. These are commonly referred to as "side effects." This term reflects the understanding that these symptoms are an unavoidable consequence of and less important than the primary goal of reducing future risk. However, for many older persons, these effects are not to the side of the primary goal but rather are outcomes as important or more important to avoid than the primary outcome is to achieve. Because of the relegation of these non–disease-specific outcomes as side effects, there is little evidence about their prevalence. One example of the adverse effects of medications on an outcome highly important to older persons is an observational study of community-living men age 65 years and older demonstrating that those who began statin therapy had a steeper rate of decline in physical activity compared with nonusers and chronic users.[22] In a cohort study of nursing home residents hospitalized for acute MI with propensity matching, the prescription of β-blockers post-MI was associated with reduced mortality risk but an increased risk of functional decline.[23]