Massive Misprescribing of Inappropriate Drugs to Hospitalized Elderly Patients

The results of a nationwide study published in spring 2008 in the Journal of Hospital Medicine show that nearly half (49 percent) of almost 500,000 hospital patients older than 65 have been prescribed one or more drugs known to be unnecessarily unsafe for older patients.

This study, which was based on data collected from 384 U.S. hospitals, used a device known as the “Beers list” to determine the extent of inappropriate prescribing for those 65 and older. This list, originally developed by consensus by a group of experts geriatric pharmacology in 1991 and updated twice, identifies medications that should be avoided among this age group because they are “ineffective, or pose an unnecessarily high risk, or because a safer alternative is available.” The Beers list and its criteria have been widely adopted as guidelines to avoid potentially inappropriate medication (PIM) use among seniors. Both The Centers for Medicare and Medicaid Services and the National Committee on Quality Assurance have used it to monitor quality of care for older Americans.

Seventy-eight percent of the PIMs prescribed one or more times to these 242,000 hospitalized people (49 percent of the people hospitalized) were drugs for which side effects would be clinically severe if they were to occur. Two or more different PIMs were prescribed for 59,000 patients during their hospitalization and four or more PIMs were prescribed for 10,000 patients during their hospitalization.

These findings are especially disturbing because of the unnecessary adverse reactions that often accompany such misprescribing. Adverse drug reactions cause approximately 100,000 deaths and more than one million hospitalizations a year for the population as a whole. More severe and more frequent side effects occur in older people because they use far more prescription medications and because of reduced ability to clear drugs from the body.

Numerous studies by different groups of researchers have found that inappropriate prescribing is also widespread in different health care settings such as nursing homes as well as among patients living at home but the rates of such inappropriate prescribing are not as high as those found in this hospital study.

The authors of the study found that there was much more prescribing of PIMs in the South (55 percent of hospitals) than in the Northeast (34 percent), and that out of the 384 hospitals an unnamed seven hospitals, with more than 300 patient encounters each, did not have any instances of prescribing PIMs. There were also a number of physicians who rarely or never prescribed PIMs.

The authors divided the PIM drugs into categories based on the kind of side effects they can cause and the categories of drugs. (see box below). The categories included sedation (32 percent), anticholinergic (22 percent, see box), drugs that can lower blood pressure and potentially cause falls and hip fractures (9 percent); drugs that can cause bleeding (3 percent); and other miscellaneous side effects accounting for the other drugs. Some drugs, specifically muscle relaxants, can cause both sedative and anticholinergic side effects.

However alarming the findings of this study are, they probably err on being overly conservative, suggesting that the actual situation is even more serious. That is because the Beers list, while helpful for doctors and patients alike, is relatively short. The list is based on consensus of a group of experts, going through different iterations until there is agreement; it therefore includes only drugs which the entire panel agrees are inappropriate for elders. Thus, drugs that have good evidence of risks that outweigh the benefits but about which not everyone agrees are, so to speak, left on the cutting room floor and are not placed on the list. Although many preventable adverse drug reactions are caused by the PIMs on the Beers list listed in this article, many more are not.

For example, the list was last revised in 2002, two years after the publication of a study showing a four-fold increase in heart attacks in people using the pain-reliever drug Vioxx. In 2001 we had warned Worst Pills, Best Pills News readers not to use rofecoxib (VIOXX) and celecoxib (CELEBREX), a pain medication that also increases patients’ risk of heart attacks. But the 2002 Beers list made no mention of either of these drugs or of valdecoxib (BEXTRA), a third drug that is chemically similar to VIOXX which was removed from the market in 2005 at the request of the Food and Drug Administration.

Most of the 92 drugs listed in the table accompanying this article are either “Do Not Use” drugs in Worst Pills, Best Pills (or www.WorstPills.org) or have restrictions and warning boxes about the particular risks of side effects for older people.

What You Can Do

To exercise more caution than just avoiding the 92 drugs listed in this article that are on the Beers list, we urge you to find out if the drugs you are taking are one of the more than 200 drugs labeled Do Not Use in Worst Pills, Best Pills or on our Web site, www.WorstPills.org. We discuss safer and often more effective alternative for each of the “Do Not Use” drugs.

Table. Beers List: 92 Drugs That Should Be Avoided By Adults Older than  65, According to Beers Criteria

* Do Not Use in Worst Pills, Best Pills
** Limited Use in Worst Pills, Best Pills
*** Last Choice in Worst Pills, Best Pills