Too many drugs for many older patients

By Christen Brownlee

Older patients are increasingly prescribed multiple drugs that, when combined, can lead to negative side effects and poor health outcomes.  A new Cochrane Library evidence review reveals that little is known about the best ways to avoid inappropriate prescribing of medications for seniors or how to maximize health benefits while minimizing prescriptions.

According to study author Susan M. Patterson, Ph.D., of Queen’s University in Belfast, U.K., inappropriate polypharmacy contributes to around one in 10 hospital admissions. While many appropriately take several drugs to treat the variety of medical problems that can arise with aging, she explains, some are inappropriately prescribed combinations of drugs intended to treat not only the original problem, but from those treatments, and even side effects from side effect drugs.

“It becomes a prescribing cascade,” Patterson said. “Rather than review medications and stop the offending , doctors just prescribe an additional drug.”

Patterson and her colleagues gathered research on studies of interventions aiming to cut down on inappropriate drug combinations for aging patients.

One study examined the benefits of using electronic decision support, a computerized program that automatically reviews a doctor’s notes and suggests ways to avoid medical errors or improve care. Other studies researched the effectiveness of complex pharmaceutical care interventions that typically combined medication review, individual patient counseling, group patient education in the community and clinical case conferences.

Patterson and her colleagues reported that the interventions that appeared to work the best involved pharmacists as part of a multidisciplinary team working together to solve this problem.

However, she notes, it was impossible to judge from these studies whether these changes in care resulted in better patient outcomes. For example, only some of the studies reported a reduction in hospital admissions or adverse drug events. Additionally, the studies reviewed gave little insight on when to best implement interventions—for example, whether it’s more effective to counsel patients once when they’re discharged from the hospital, whenever they are prescribed new drugs, or at scheduled times of the year regardless of whether their care has changed.

“We don’t know enough about the process to say what a best scenario for reducing inappropriate polypharmacy should look like,” Patterson said. “That’s where we need further research.”

Bradley Flansbaum, D.O., director of hospitalist services at Lenox Hill Hospital in New York City, agrees. He notes that most doctors would say they’re more interested in how changes in prescribing affect patients’ quality of life, something that these studies didn’t fully examine. Rather than look at whether patients are experiencing problems such as headaches or constipation from the drugs they’re on, he says, the studies instead used a checklist to measure potentially dangerous interactions. “Not to say that a checklist isn’t important, but do you want a proxy of what you’d like to measure, or to know about the adverse event itself?” he said.

More information: Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD008165. DOI: 10.1002/14651858.CD008165.pub2

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