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“Inappropriate medication use is a major patient safety concern, especially for the elderly population.” This is the first sentence of a study published in the December 12, 2001 issue of the Journal of the American Medical Association. This study adds to the growing body of research results dating back to 1980 that verifies once again the fact that millions of elderly people are being given dangerous drugs when safer and more effective ones are available.
The authors of the study...
“Inappropriate medication use is a major patient safety concern, especially for the elderly population.” This is the first sentence of a study published in the December 12, 2001 issue of the Journal of the American Medical Association. This study adds to the growing body of research results dating back to 1980 that verifies once again the fact that millions of elderly people are being given dangerous drugs when safer and more effective ones are available.
The authors of the study were from the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services, Johns Hopkins University, and the University of Rochester. Among the objectives of the study was to determine the prevalence of potentially inappropriate prescribing involving older adults living in the community (i.e., not in institutions) in 1996. A list of 33 inappropriate drugs, developed by a seven member expert panel, was used for the study.
The drugs were classified in three categories: drugs that (1) should always be avoided, (2) are rarely appropriate, and (3) have some valid uses but are often mis-prescribed in the elderly. The authors used the latest available national estimates from the 1996 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of health care use, including drug use, for prescribing information to determine the prevalence of inappropriate prescribing.
In 1996, 21.3 percent of older adults living in the community received at least one of these potentially inappropriate drugs. Using the three classifications determined by the expert panel about 2.6 percent of elderly patients used at least one of the 11 drugs that should always be avoided by the elderly. Over 9 percent of elderly patients used at least one of the eight drugs that are considered rarely appropriate. For the 14 drugs the expert panel classified as having some use in elderly patients but were often misprescribed, 13.3 percent of patients received at least one of these drugs.
The three tables below list the 33 drugs according to three categories defined by the expert panel. Also, in the right hand column are our recommendations for the use of these drugs from the first edition of Worst Pills, Best Pills published in 1988 unless otherwise noted. Overall, we had listed 64.6 percent, 21 of the 33 drugs, as Do Not Use. For the drugs that the expert panel recommended to Always Avoid, Table 1, we listed 82 percent, 9 of the 11, as Do Not Use drugs. We disagreed with the expert panel on meperidine (DEMEROL), a narcotic painkiller, and we have not evaluated propantheline (PRO-BANTHINE), though we do not disagree with the expert panel’s recommendation on this drug.
Table 2 lists the drugs the expert panel classified as Rarely Appropriate, of these eight drugs, we listed seven, or 88 percent, as Do Not Use. The exception is the drug metaxalone (SKELAXIN), a muscle relaxant, that we have not evaluated.
The expert panel listed 14 drugs as having Some Indications, or uses, in the elderly in Table 3. Of these, we listed five (36 percent) as Do Not Use in Worst Pills, Best Pills. Another three of these drugs are listed as Limited Use and one as a Last Choice drug. All the other five drugs had boxed warnings in the FDA-approved labeling and, in Worst Pills, Best Pills we wrote about adverse reactions, especially directed at older adults. Limited Use drugs are those that published studies indicate should only be used as a “second-line” (alternative) drug if another drug does not work, or the evidence shows that it is more dangerous than another drug but not so much so that it merits being listed as Do Not Use.
The authors estimate that in 1996 almost one million elderly patients living in the community received at least 1 of the 11 drugs that the expert panel classified as Always Avoid. This is an alarming number that we think is a gross underestimate of the extent of inappropriate prescribing to the elderly. The authors point out that they did not assess drug-disease interactions, drug-drug interactions, and drug administration-related problems, such as too high a dose of a drug for an older patient. They also note that given the rate of introduction of new drugs on the market that are rarely studied in the elderly that it is likely that recently released drugs may be potentially inappropriate for use in elderly patients. Of course we agree with this statement; that is one reason why we research and write Worst Pills, Best Pills News.
There is another reason we believe that this study represents only a fraction of inappropriate prescribing in the elderly. This list of potentially inappropriate drugs only contained 33 products. In the 1988 edition of Worst Pills, Best Pills, we listed 104 drugs as Do Not Use, by the 1993 edition this number had increased to 116, and then skyrocketed to 160 in the most recent edition of the book. We are in the process of preparing a supplement to the book that should be ready this spring that reviews drugs approved since the last edition. This supplement contains at least 20 more drugs that will be listed as Do Not Use.
The majority of the 33 drugs in this study have been on the market for years and are not heavily promoted to health professionals or directly to consumers. Why then are they still being prescribed? Years ago, these drugs were heavily advertised and the use of these products became ingrained in the prescribing practice of many physicians. A lot of new physician’s prescribing habits are picked up on the job from older colleagues. The editorial that accompanied this study summed up the situation by saying “Their [the 33 drugs] continuing use is testimony to the triumph of habit over evidence in shaping drug prescribing choices.” We agree.
What You Can Do
Your best chance of avoiding drug-induced death or illness is to read Worst Pills, Best Pills News and the book Worst Pills, Best Pills.
