Inappropriate Prescribing of Medicines in the Elderly: A Persistent Problem

Long a primary focus of Public Citizen’s Health Research Group, inappropriate prescribing of medications for elderly patients unfortunately remains a dangerous and persistent problem in the U.S. and around the world.

Prescribing a drug is inappropriate when the risks of the drug outweigh its benefits, causing a negative health impact. Such misprescribing typically occurs when a doctor prescribes a drug even when it is contraindicated because of a patient’s age, underlying medical condition or use of other drugs, or when the prescribed dose is too high or the prescribed duration of use is too long. In many cases, especially in the elderly, prescribing is inappropriate because safer alternatives, either other drugs or nondrug interventions, are available.

In the U.S. alone, misprescribing ultimately leads to millions of preventable adverse events and more than 100,000 deaths annually. It wastes billions of dollars within our health care system.

A recently published study documents the scope of inappropriate prescribing in elderly patients in the primary care setting over the last 15 years. The study found that on average, approximately 20 percent of prescriptions for elderly patients in this setting were inappropriate. The study also highlighted some of the most commonly misprescribed drugs.

Systematic review of observational studies evaluating inappropriate prescribing

The study was done by researchers in the Netherlands and published in August 2012 in the free online medical journal PLOS One.

The researchers systematically searched computer databases of all English-language medical journals for relevant studies published from 1950 through March 2012. They only included in their analysis studies of people age 65 or older who received prescriptions in a primary care setting, including outpatient clinics, office practices, general practices and primary care clinics. They excluded studies of patients in nursing homes and other institutional settings.

The researchers limited their analysis to those studies that reported inappropriate prescriptions based on drug and age criteria. (They excluded studies evaluating a single drug, as well as studies evaluating drugs prescribed for a specific patient disease group, such as dementia patients.) Finally, to be included in the systematic review, the studies had to report rates of inappropriate prescribing for specific individual medications.

For included studies, the investigators calculated the median and ranges of overall rates of inappropriate medication prescription for all drugs combined and for each individual drug. (The median represents the middle value from a group of values or numbers: Half of the numbers in the group fall below the median, and half fall above it. The median is one way of evaluating the significance of a group of numbers.)

Overall study results

The researchers found 19 observational studies published between 1997 and 2012 that met their inclusion criteria. Seven studies were conducted in the U.S., eight in European countries (Germany, Holland, Ireland, Italy [two studies], Norway, Portugal and the U.K.), two in Taiwan, and one each in India and Iran.

The prescription drug data and patient clinical information for these 19 studies were obtained from insurance records, national health plan records, medical records or prospective patient surveys. The number of elderly patients included in each study ranged from 100 patients to more than 12 million, and for all studies combined the total was greater than 19 million.

Fifteen of the 19 studies assessed the appropriateness of drug prescriptions using criteria known as the Beers Criteria, which were initially developed in 1991 to assess the appropriateness of medications prescribed to nursing home patients. These criteria were subsequently revised and expanded in 1997 to assess prescribing practices in all geriatric care settings, and they have since been updated, in 2003 and 2012.

The Beers Criteria identify drugs that should not be used in elderly patients regardless of any underlying disease or condition (unconditionally inappropriate drugs for elderly patients) and other drugs that should be avoided in elderly patients who have certain diseases or conditions.

The authors of the systematic review reported that the overall rate of inappropriate medication prescriptions for all drugs assessed across the 19 studies ranged from 2.9 percent to 38.5 percent, with a median of 20 percent. For the seven U.S. studies, the overall rate of inappropriate prescriptions for all drugs ranged from 4.5 percent to 33 percent, with a median of 19.6 percent.

Most commonly misprescribed drugs

According to the PLOS One study, the following four drugs were the most commonly misprescribed in elderly patients in the primary care setting: propoxyphene (DARVON, DARVOCET), doxazosin (CARDURA, CARDURA XL), diphenhydramine (BENADRYL) and amitriptyline (ELAVIL).

Propoxyphene

The study found that the narcotic painkiller propoxyphene, a dangerous drug no longer marketed in the U.S., was the most commonly misprescribed medication.

In 1978, Public Citizen unsuccessfully petitioned the former Department of Health, Education, and Welfare to ban propoxyphene because it was the leading cause of prescription drug-related deaths, was highly addictive and had significant neurologic toxicities while offering little analgesic benefit, being no more effective than aspirin or acetaminophen.

In 2006, Public Citizen again petitioned the government — this time, the Food and Drug Administration — to ban propoxyphene. Our petition cited new data documenting fatal cardiac toxicity with propoxyphene use. The Beers Criteria also listed this drug as inappropriate for prescribing to elderly patients. The drug was belatedly removed from the U.S. market in 2010, long after such action was taken by the U.K. and the European Union.

Doxazosin

Doxazosin, used to treat high blood pressure, was found to be the second most commonly misprescribed medication in elderly patients.

Doxazosin belongs to a class of antihypertensive drugs known as alpha blockers. WorstPills.org lists all drugs in this class as Do Not Use drugs for the treatment of hypertension because there are safer, more effective and cheaper alternatives.

In March 2000, the National Institutes of Health announced that it had stopped one part of a large high blood pressure study because doxazosin proved to be less effective than thiazide diuretic chlorthalidone (HYGROTON) in reducing some forms of cardiovascular disease. The study, called the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), found users of doxazosin had 25 percent more adverse cardiovascular events and were twice as likely to be hospitalized for congestive heart failure as users of chlorthalidone.

Overall, the ALLHAT study demonstrated that chlorthalidone was superior to doxazosin for blood pressure control, drug compliance and reduction of cardiovascular complications. In addition, chlorthalidone and other similar diuretic drugs are much less expensive than doxazosin.

Finally, elderly patients are particularly susceptible to two other adverse events caused by doxazosin. The first is orthostatic hypotension (a sudden drop in blood pressure with standing) leading to syncope (fainting, loss of consciousness) that occurs most commonly with the first dose of the drug or with any subsequent dose increase. The second is aggravation of urinary incontinence, particularly in women.

Diphenhydramine

Diphenhydramine was found to be the third most commonly misprescribed drug in the elderly.

Diphenhydramine is an antihistamine drug found in a variety of prescription and over-the-counter products, including anti-allergy drugs, sleep aids, decongestants and cold medicines. However, in addition to blocking histamine, the drug interferes with the action of the chemical acetylcholine in the nervous system, which can cause a wide range of side effects known as anticholinergic effects. Diphenhydramine’s anticholinergic effects pose significant risk of adverse events in elderly patients, including confusion, drowsiness, constipation, urinary retentions, dry mouth and impaired sweating, which can lead to heat-induced injury and death.

Amitriptyline

The fourth most commonly misprescribed medication in the elderly identified by the researchers was the tricyclic antidepressant amitriptyline. WorstPills.org lists this drug as a Do Not Use drug because it has more adverse effects than any other member of this family of drugs. The Beers Criteria also listed this drug as inappropriate for prescribing to elderly patients because of these risks of significant adverse side effects.

Amitriptyline has significant anticholinergic effects and frequently causes orthostatic hypotension. Older adults are especially sensitive to the harmful anticholinergic effects of amitriptyline. Mental side effects that are commonly seen with this drug in the elderly include confusion, delirium, short-term memory problems, disorientation and impaired attention.

Study implications

The authors of the study concluded that “[d]espite intensified efforts to scrutinize and improve the quality of medication prescription among elderly persons in the primary care setting, inappropriate medication prescriptions are still too common.” We strongly agree.

Such inappropriate prescribing practices remain a serious threat to the health and welfare of elderly patients. Many of the most commonly misprescribed drugs can cause confusion, altered levels of consciousness and an increased risk of falls, all of which can lead to injuries, decreased independence and death.

A negative health impact of prescription drugs is highly likely if the risks of a drug outweigh its benefits. This is especially true for the elderly, who use more prescription drugs than younger people. It is our hope that by being better-informed health care consumers, readers can be more vigilant about the drugs they are prescribed and, in conjunction with their doctors, avoid unsafe drugs.