Bad Medicine

Medications that work wonders in young people can endanger health in the elderly. Yet a new study reveals that doctors prescribe these unsuitable drugs to seniors--even though safer alternatives exist.

Pillboxes rank alongside reading glasses and orthopedic shoes as near-universal accessories for the well-appointed senior. People over age 65 buy nearly a third of all prescription medications sold in the United States. Yet seniors might not be getting what they pay for: A significant number fill prescriptions for drugs considered unsuitable for elderly patients.

Because older bodies process drugs differently than young ones do, medications that work well in the prime of life sometimes wreak havoc on elderly patients (see "Test Patterns" and "Seniors Can Find Standard Meds Hard to Swallow"). In 1991, a panel of geriatrics experts assembled a list of drugs whose potential for unpleasant side effects, such as hallucinations, confusion, and sedation, outweigh their potential benefits in older patients. The offending medicines include pain relievers, muscle relaxants, and antidepressants. The side effects can seriously limit mobility and lead to falls (see "Snap, Crackle Mom"). What's more, doctors might not recognize these conditions for what they are. "Some of these drugs may cause symptoms that we assume are natural in an aging person, when in fact we may be seeing adverse effects of drugs," says Lesley Curtis, a health outcomes researcher at Duke University Medical Center in Durham, North Carolina.

To find out how often seniors take home drugs that could harm them, Curtis and her colleagues collected prescription claims data from a large, national pharmaceutical benefit manager. Of more than 750,000 patients age 65 or older who filed a claim, one in five filled a prescription for a drug on the list, and 15% of those took home two or more, the researchers report in the 9/23 August Archives of Internal Medicine. These figures are striking, Curtis says, because safer alternatives usually exist.

Because this tally does not include individuals who have experienced harmful drug interactions or been prescribed inappropriate dosages, the issue of seniors receiving medications that cause more harm than good probably looms even larger, says internist R. Knight Steel of Hackensack University Medical Center in New Jersey. The problem is, many physicians might not know any better, says geriatrician Diane Chau of the University of Nevada, Reno: Only 4000 doctors in the United States specialize in geriatrics, she says. So elderly patients are often being treated by doctors with little or no training in how to tailor care to their needs.

Yet insisting that all physicians keep abreast of key issues in geriatrics likely won't solve the problem, Chau says, because doctors must concentrate on following advances in their own specialties. "How do you expect dermatologists to keep up with dermatology if they have to read geriatrics publications?" she says. Unfortunately, most physicians fail to consult geriatricians when prescribing medication to elderly patients. "My husband is an endocrinologist, and people don't hesitate to consult him for diabetes management," Chau says. "I rarely, rarely get consulted."

Perhaps the solution lies in reminding doctors that geriatrics is a specialty--and that elderly patients present as many physiological challenges as do newborns, for example. "I can't go into a neonatal unit and prescribe medication to a 4-pound child," Steel says. And medications can have as many unexpected consequences in the frail or disease-weakened organ systems of the elderly as they do in children's developing bodies. "There would be [at least as many] prescription errors if all doctors started writing pediatrics prescriptions," says Chau.

Pharmacists could also help by pestering doctors to cease prescribing the troublesome drugs, says Steel. For instance, if pharmacists were required to telephone the doctor each time a patient over 65 filled a prescription for one of these medications, the doctor would presumably tire of the calls and start prescribing safer alternatives, he says. In addition, "the patient would be told, 'I have to call the doctor, because this is on the list of drugs you shouldn't get,' " Steel says, which might encourage the patient to discuss the prescription with the doctor.

Other approaches Steel proposes include censure by state medical boards for physicians who prescribe too many inappropriate medications, or having Medicare refuse to pay for drugs deemed risky in the elderly. But the simplest and likely the most effective solution, he says, would be to implement a computer program for pharmacists, similar to one in use in Canada, that identifies inappropriate prescriptions. More than 10 years have passed since the list was compiled, and the problem persists. "It's time to stop talking about it and time to do something about it," Steel says. With any luck, the contents of Grandma's ubiquitous pillbox will suit her a little better in the future.

Caroline Seydel is a science writer in Redondo Beach, California, where she specializes in avoiding doctors' offices altogether.