Pitfalls in Prescribing for the Elderly

ESTES PARK, COLO. – As a geriatrician with several decades of experience, Dr. Jeffrey I. Wallace is particularly loath to see three things prescribed in older patients: megestrol acetate, oral iron more than once daily, or muscle relaxants.

While he considers those three prescriptions to be especially egregious because the at-best tiny potential benefits are so clearly overshadowed by the sizeable downside risks, other agents on his personal ‘just say no’ list for the elderly include chronic NSAIDs, benzodiazepines, chronic proton pump inhibitors, sedating antihistamines, and first-generation tricyclic antidepressants, said Dr. Wallace at an update in internal medicine sponsored by the University of Colorado, Denver, where he is a professor of medicine.

Learn more about three of the most popular, inappropriate prescriptions for the elderly.

Those agents, with the sole exception of more-than-once-daily oral iron, are among the 53 medications or medication classes included on the recently overhauled Beers list of potentially inappropriate medications in older adults published by the American Geriatrics Society (2012 [doi:10.1111/j.1532-5415.2012.03923.x]). Dr. Wallace has some issues with the list.

"My problem with the Beers list is that most of us have some patients taking a drug that’s on that list because they didn’t respond to the first three drugs we used, yet we can’t get rid of the Beers list drug because they really need treatment. And I’m telling you, there are quality assurance measures that will ding us for that," the physician explained.

He has similar reservations about the STOPP/START criteria developed by an expert panel in Ireland (Int. J. Clin. Pharmacol. Ther. 2008; 46:72-83) and the Healthcare Effectiveness Data and Information Set (HEDIS) list.

"It’s good to be aware of what’s on those lists – the attorneys are aware of them – but if a drug you’re using is on a list and it’s your fourth choice because the first three didn’t work, then you should feel OK," he continued.

Rather than slavishly trying to steer clear of drugs on the Beers or other "potentially inappropriate drug" lists, Dr. Wallace’s preference in his own daily medical practice is to incorporate the "Good Palliative–Geriatric Practice" algorithm (Arch. Intern. Med. 2010;170:1648-54). This tool, developed by Israeli geriatricians in an effort to reduce rampant polypharmacy and inappropriate medications in the elderly, challenges the clinician at multiple points to consider whether an individual patient really needs to be on a particular drug at a given dose. The algorithm has been shown in multiple small controlled trials to improve key outcomes, including hospitalization and mortality.

For example, in a study of 190 patients on a baseline average of 7.1 drugs at six Israeli nursing homes, application of the algorithm in 119 patients led to discontinuation of an average of 2.8 drugs each. The 1-year rates of acute hospitalization and mortality were 12% and 21%, respectively, in the group where the algorithm was applied, compared with 30% and 45% in the control group, making the point that when it comes to prescribing for the elderly, less is often more (Isr. Med. Assoc. J. 2007;9:430-4).

More recently, a study in 70 Israeli geriatric outpatients on an average of 7.7 medications at baseline showed that application of the Good Palliative–Geriatric Practice algorithm resulted in discontinuation of an average of 4.9 drugs, with no significant increase in morbidity or mortality during a mean follow-up of 19 months. A total of 88% of patients who discontinued drugs reported a global improvement in their health (Arch. Intern. Med. 2010;170:1648-54).

Dr. Wallace tries hard to limit older patients to a maximum of six drugs. It can be tough because so many elderly patients have multiple comorbid conditions. But studies show that when elderly patients are on more than six medications, the rate of adverse drug reactions shoots up exponentially. With eight drugs, the chance of a drug-drug interaction is nearly 100%.

Interestingly, he noted, a landmark national study of emergency hospitalizations for adverse drug reactions in the elderly found that only 1.2% of the admissions involved drugs considered high risk because they were on the 2003 version of the Beers criteria or the HEDIS list. Two-thirds of all adverse drug reactions severe enough to lead to hospitalization after an emergency department (ED) visit involved warfarin, diabetes medications, or oral antiplatelet agents (N. Engl. J. Med. 2011;365:2002-12).

An annual or semiannual office visit devoted specifically to a medications review by the patient’s primary care physician or a skilled pharmacist is an excellent way to optimize therapy. Drug plans are willing to pay for it.

An acute hospitalization or trip to the ED provides a good opportunity for another physician to take a critical look at an older patient’s medications.

"I used to get cranky when a hospitalist would take one of my patients who I’ve been taking care of for 10 years and say, ‘Gee, Wallace – this is a dumb drug for this patient; I’m stopping the Fosamax.’ I’d reply, ‘I know the patient; don’t mess with him.’ But more and more, as I look at the literature, I’m thinking that when a patient is in the hospital or the ED, it’s a great time to cut back. I would urge those of you who are hospitalists to do that for reasons of adherence and safety. The data are out there to support you. Just let us know what you’ve done," the geriatrician said.

One of the key means of reducing polypharmacy in the elderly involves avoidance of what’s been called "the prescribing cascade." This cascade occurs when an adverse effect of one drug gets misinterpreted as a new medical condition, for which a second drug is dutifully prescribed.

"This happens all the time," according to Dr. Wallace.

Examples: A patient on hydrochlorothiazide experiences rising uric acid levels, is diagnosed with gout, and put on allopurinol; had he simply been switched to another antihypertensive agent, he’d still be on one drug instead of two for two diseases. Or a patient on chronic daily NSAID therapy develops rising blood pressure as a drug side effect, gets labeled hypertensive, and goes on antihypertensive medications. Or a patient on donepezil or another cholesterase inhibitor reports an increased frequency of urination because of the drug’s effects on the bladder; in response, tolterodine is prescribed.

Three years ago, the cholinesterase inhibitors used in treating dementia were linked to a previously unrecognized increased risk of bradycardia. In a large Canadian study, these medications were associated with a 69% increased rate of emergency department visits for symptomatic bradycardia, a 76% increase in syncope, a 49% greater likelihood of permanent pacemaker implantation, and an 18% increased risk of hip fracture (Arch. Intern. Med. 169: 867-73).

"We didn’t know about this until 2009. I grew up using donepezil in the 1990s when I was a fellow. We were using it all the time and no one thought about bradycardia. It wasn’t in our differential," Dr. Wallace recalled. "I’m sure patients passed out and got pacemakers as an unrecognized drug side effect. My question is this: We think we’re smart, but what else do we not know, especially with newer agents coming along?"

Dr. Wallace reported having no financial conflicts.

ESTES PARK, COLO. – As a geriatrician with several decades of experience, Dr. Jeffrey I. Wallace is particularly loath to see three things prescribed in older patients: megestrol acetate, oral iron more than once daily, or muscle relaxants.

While he considers those three prescriptions to be especially egregious because the at-best tiny potential benefits are so clearly overshadowed by the sizeable downside risks, other agents on his personal ‘just say no’ list for the elderly include chronic NSAIDs, benzodiazepines, chronic proton pump inhibitors, sedating antihistamines, and first-generation tricyclic antidepressants, said Dr. Wallace at an update in internal medicine sponsored by the University of Colorado, Denver, where he is a professor of medicine.

Learn more about three of the most popular, inappropriate prescriptions for the elderly.

Those agents, with the sole exception of more-than-once-daily oral iron, are among the 53 medications or medication classes included on the recently overhauled Beers list of potentially inappropriate medications in older adults published by the American Geriatrics Society (2012 [doi:10.1111/j.1532-5415.2012.03923.x]). Dr. Wallace has some issues with the list.

"My problem with the Beers list is that most of us have some patients taking a drug that’s on that list because they didn’t respond to the first three drugs we used, yet we can’t get rid of the Beers list drug because they really need treatment. And I’m telling you, there are quality assurance measures that will ding us for that," the physician explained.

He has similar reservations about the STOPP/START criteria developed by an expert panel in Ireland (Int. J. Clin. Pharmacol. Ther. 2008; 46:72-83) and the Healthcare Effectiveness Data and Information Set (HEDIS) list.

"It’s good to be aware of what’s on those lists – the attorneys are aware of them – but if a drug you’re using is on a list and it’s your fourth choice because the first three didn’t work, then you should feel OK," he continued.

Rather than slavishly trying to steer clear of drugs on the Beers or other "potentially inappropriate drug" lists, Dr. Wallace’s preference in his own daily medical practice is to incorporate the "Good Palliative–Geriatric Practice" algorithm (Arch. Intern. Med. 2010;170:1648-54). This tool, developed by Israeli geriatricians in an effort to reduce rampant polypharmacy and inappropriate medications in the elderly, challenges the clinician at multiple points to consider whether an individual patient really needs to be on a particular drug at a given dose. The algorithm has been shown in multiple small controlled trials to improve key outcomes, including hospitalization and mortality.

For example, in a study of 190 patients on a baseline average of 7.1 drugs at six Israeli nursing homes, application of the algorithm in 119 patients led to discontinuation of an average of 2.8 drugs each. The 1-year rates of acute hospitalization and mortality were 12% and 21%, respectively, in the group where the algorithm was applied, compared with 30% and 45% in the control group, making the point that when it comes to prescribing for the elderly, less is often more (Isr. Med. Assoc. J. 2007;9:430-4).

More recently, a study in 70 Israeli geriatric outpatients on an average of 7.7 medications at baseline showed that application of the Good Palliative–Geriatric Practice algorithm resulted in discontinuation of an average of 4.9 drugs, with no significant increase in morbidity or mortality during a mean follow-up of 19 months. A total of 88% of patients who discontinued drugs reported a global improvement in their health (Arch. Intern. Med. 2010;170:1648-54).

Dr. Wallace tries hard to limit older patients to a maximum of six drugs. It can be tough because so many elderly patients have multiple comorbid conditions. But studies show that when elderly patients are on more than six medications, the rate of adverse drug reactions shoots up exponentially. With eight drugs, the chance of a drug-drug interaction is nearly 100%.

Interestingly, he noted, a landmark national study of emergency hospitalizations for adverse drug reactions in the elderly found that only 1.2% of the admissions involved drugs considered high risk because they were on the 2003 version of the Beers criteria or the HEDIS list. Two-thirds of all adverse drug reactions severe enough to lead to hospitalization after an emergency department (ED) visit involved warfarin, diabetes medications, or oral antiplatelet agents (N. Engl. J. Med. 2011;365:2002-12).

An annual or semiannual office visit devoted specifically to a medications review by the patient’s primary care physician or a skilled pharmacist is an excellent way to optimize therapy. Drug plans are willing to pay for it.

An acute hospitalization or trip to the ED provides a good opportunity for another physician to take a critical look at an older patient’s medications.

"I used to get cranky when a hospitalist would take one of my patients who I’ve been taking care of for 10 years and say, ‘Gee, Wallace – this is a dumb drug for this patient; I’m stopping the Fosamax.’ I’d reply, ‘I know the patient; don’t mess with him.’ But more and more, as I look at the literature, I’m thinking that when a patient is in the hospital or the ED, it’s a great time to cut back. I would urge those of you who are hospitalists to do that for reasons of adherence and safety. The data are out there to support you. Just let us know what you’ve done," the geriatrician said.

One of the key means of reducing polypharmacy in the elderly involves avoidance of what’s been called "the prescribing cascade." This cascade occurs when an adverse effect of one drug gets misinterpreted as a new medical condition, for which a second drug is dutifully prescribed.

"This happens all the time," according to Dr. Wallace.

Examples: A patient on hydrochlorothiazide experiences rising uric acid levels, is diagnosed with gout, and put on allopurinol; had he simply been switched to another antihypertensive agent, he’d still be on one drug instead of two for two diseases. Or a patient on chronic daily NSAID therapy develops rising blood pressure as a drug side effect, gets labeled hypertensive, and goes on antihypertensive medications. Or a patient on donepezil or another cholesterase inhibitor reports an increased frequency of urination because of the drug’s effects on the bladder; in response, tolterodine is prescribed.

Three years ago, the cholinesterase inhibitors used in treating dementia were linked to a previously unrecognized increased risk of bradycardia. In a large Canadian study, these medications were associated with a 69% increased rate of emergency department visits for symptomatic bradycardia, a 76% increase in syncope, a 49% greater likelihood of permanent pacemaker implantation, and an 18% increased risk of hip fracture (Arch. Intern. Med. 169: 867-73).

"We didn’t know about this until 2009. I grew up using donepezil in the 1990s when I was a fellow. We were using it all the time and no one thought about bradycardia. It wasn’t in our differential," Dr. Wallace recalled. "I’m sure patients passed out and got pacemakers as an unrecognized drug side effect. My question is this: We think we’re smart, but what else do we not know, especially with newer agents coming along?"

Dr. Wallace reported having no financial conflicts.

ESTES PARK, COLO. – As a geriatrician with several decades of experience, Dr. Jeffrey I. Wallace is particularly loath to see three things prescribed in older patients: megestrol acetate, oral iron more than once daily, or muscle relaxants.

While he considers those three prescriptions to be especially egregious because the at-best tiny potential benefits are so clearly overshadowed by the sizeable downside risks, other agents on his personal ‘just say no’ list for the elderly include chronic NSAIDs, benzodiazepines, chronic proton pump inhibitors, sedating antihistamines, and first-generation tricyclic antidepressants, said Dr. Wallace at an update in internal medicine sponsored by the University of Colorado, Denver, where he is a professor of medicine.

Learn more about three of the most popular, inappropriate prescriptions for the elderly.

Those agents, with the sole exception of more-than-once-daily oral iron, are among the 53 medications or medication classes included on the recently overhauled Beers list of potentially inappropriate medications in older adults published by the American Geriatrics Society (2012 [doi:10.1111/j.1532-5415.2012.03923.x]). Dr. Wallace has some issues with the list.

"My problem with the Beers list is that most of us have some patients taking a drug that’s on that list because they didn’t respond to the first three drugs we used, yet we can’t get rid of the Beers list drug because they really need treatment. And I’m telling you, there are quality assurance measures that will ding us for that," the physician explained.

He has similar reservations about the STOPP/START criteria developed by an expert panel in Ireland (Int. J. Clin. Pharmacol. Ther. 2008; 46:72-83) and the Healthcare Effectiveness Data and Information Set (HEDIS) list.

"It’s good to be aware of what’s on those lists – the attorneys are aware of them – but if a drug you’re using is on a list and it’s your fourth choice because the first three didn’t work, then you should feel OK," he continued.

Rather than slavishly trying to steer clear of drugs on the Beers or other "potentially inappropriate drug" lists, Dr. Wallace’s preference in his own daily medical practice is to incorporate the "Good Palliative–Geriatric Practice" algorithm (Arch. Intern. Med. 2010;170:1648-54). This tool, developed by Israeli geriatricians in an effort to reduce rampant polypharmacy and inappropriate medications in the elderly, challenges the clinician at multiple points to consider whether an individual patient really needs to be on a particular drug at a given dose. The algorithm has been shown in multiple small controlled trials to improve key outcomes, including hospitalization and mortality.

For example, in a study of 190 patients on a baseline average of 7.1 drugs at six Israeli nursing homes, application of the algorithm in 119 patients led to discontinuation of an average of 2.8 drugs each. The 1-year rates of acute hospitalization and mortality were 12% and 21%, respectively, in the group where the algorithm was applied, compared with 30% and 45% in the control group, making the point that when it comes to prescribing for the elderly, less is often more (Isr. Med. Assoc. J. 2007;9:430-4).

More recently, a study in 70 Israeli geriatric outpatients on an average of 7.7 medications at baseline showed that application of the Good Palliative–Geriatric Practice algorithm resulted in discontinuation of an average of 4.9 drugs, with no significant increase in morbidity or mortality during a mean follow-up of 19 months. A total of 88% of patients who discontinued drugs reported a global improvement in their health (Arch. Intern. Med. 2010;170:1648-54).

Dr. Wallace tries hard to limit older patients to a maximum of six drugs. It can be tough because so many elderly patients have multiple comorbid conditions. But studies show that when elderly patients are on more than six medications, the rate of adverse drug reactions shoots up exponentially. With eight drugs, the chance of a drug-drug interaction is nearly 100%.

Interestingly, he noted, a landmark national study of emergency hospitalizations for adverse drug reactions in the elderly found that only 1.2% of the admissions involved drugs considered high risk because they were on the 2003 version of the Beers criteria or the HEDIS list. Two-thirds of all adverse drug reactions severe enough to lead to hospitalization after an emergency department (ED) visit involved warfarin, diabetes medications, or oral antiplatelet agents (N. Engl. J. Med. 2011;365:2002-12).

An annual or semiannual office visit devoted specifically to a medications review by the patient’s primary care physician or a skilled pharmacist is an excellent way to optimize therapy. Drug plans are willing to pay for it.

An acute hospitalization or trip to the ED provides a good opportunity for another physician to take a critical look at an older patient’s medications.

"I used to get cranky when a hospitalist would take one of my patients who I’ve been taking care of for 10 years and say, ‘Gee, Wallace – this is a dumb drug for this patient; I’m stopping the Fosamax.’ I’d reply, ‘I know the patient; don’t mess with him.’ But more and more, as I look at the literature, I’m thinking that when a patient is in the hospital or the ED, it’s a great time to cut back. I would urge those of you who are hospitalists to do that for reasons of adherence and safety. The data are out there to support you. Just let us know what you’ve done," the geriatrician said.

One of the key means of reducing polypharmacy in the elderly involves avoidance of what’s been called "the prescribing cascade." This cascade occurs when an adverse effect of one drug gets misinterpreted as a new medical condition, for which a second drug is dutifully prescribed.

"This happens all the time," according to Dr. Wallace.

Examples: A patient on hydrochlorothiazide experiences rising uric acid levels, is diagnosed with gout, and put on allopurinol; had he simply been switched to another antihypertensive agent, he’d still be on one drug instead of two for two diseases. Or a patient on chronic daily NSAID therapy develops rising blood pressure as a drug side effect, gets labeled hypertensive, and goes on antihypertensive medications. Or a patient on donepezil or another cholesterase inhibitor reports an increased frequency of urination because of the drug’s effects on the bladder; in response, tolterodine is prescribed.

Three years ago, the cholinesterase inhibitors used in treating dementia were linked to a previously unrecognized increased risk of bradycardia. In a large Canadian study, these medications were associated with a 69% increased rate of emergency department visits for symptomatic bradycardia, a 76% increase in syncope, a 49% greater likelihood of permanent pacemaker implantation, and an 18% increased risk of hip fracture (Arch. Intern. Med. 169: 867-73).

"We didn’t know about this until 2009. I grew up using donepezil in the 1990s when I was a fellow. We were using it all the time and no one thought about bradycardia. It wasn’t in our differential," Dr. Wallace recalled. "I’m sure patients passed out and got pacemakers as an unrecognized drug side effect. My question is this: We think we’re smart, but what else do we not know, especially with newer agents coming along?"

Dr. Wallace reported having no financial conflicts.