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Drug Therapy in the Elderly: Is It All It Could Be?
N
ow that there is a legal mandate for pharmacists to provide consultant services to skilled nursing facility (SNF) patients, 78 percentl of whom are over 65, it is time to review some of the research dealing with the elderly and to propose further areas of needed documentation. This paper focuses on the ." real world" drug-related problems of the elderly in acute, long-term and ambulatory settings and documents solutions to these problems. The need to move from crisisoriented to prevention-oriented health care delivery leads to some searching questions: Is rational, economic and safe medication usage a reality for the elderly? Can we ascertain and affect the incidence of drugrelated problems in the primary care population segment that uses more drugs per person than any other age group? 2 In our terminology, a drug-related problem may be defined as improper or inappropriate patient drug usage or a desirable drug effect. Using this working definition, a review of some of the pertinent reports focusing on both the institutionalized and the ambulatory elderly patient may lend insight to the magnitude of the problem, to attempted and working solutions and to areas of needed research. Rationality of 'Geripharmacotherapy' While 84-87 percent3, 4 of elderly ambulatory and 95 percents of institutionalized elderly patients are reported to be taking prescription drugs, in 100 consecutive nursing home admissions 64 percent of the patients' primary diagnoses were inaccurate; 84 percent of the secondary diagnoses were either lacking or inadequate.
James W. Cooper Jr., PhD, is associate professor of clinical pharmacy at the School of Pharmacy and on the faculty of gerontology at the University of Georgia in Athens, Georgia 3 0602. This article is based on Dr. Cooper's presentation on September 1 7, 1977, to the Workshop on Pharmacology and Aging, National Institutes of Health, Bethesda, Maryland. References will be sent on request from ths editor of American Pharmacy. American Pharmacy Vol. NS18, No.7, July 1978/353
Drug Therapy in the Elderly: Is It All
It Could Be? By JAMES W. COOPER JR.
The inadequate performance in identifying clinical and therapeutic problems of the chronically ill aged was remarkably consistent, regardless of whether patient referral was from a general or psychiatric hospital, the patient's home or another nursing home.6 If the pre-admission diagnosis is incorrect in so many patients admitted to long-term care facilities, how can the pre-admission drug therapy be rational? Within nursing homes a recent report found that 25 percent of prescribed drugs were not considered effective or needed or given for their FDA-approved use. 7 Another group found that the least men tally impaired and most physically active nursing patients were the most heavily "drugged" with neuroactive substances.8 A recent physician survey demonstrated generalized medical lack of interest in the care of ill aged patients in ins ti tu tions. 9 Drug-prescribing patterns in a 250,000 patient SNF population were reported recently. At the same time a call went out for vigorous promotion of expanded pharmacist in-
volvement in providing drug information and regimen review, as well as reasonable reimbursement for these services.lo
Response to Elderly Inpatient Needs
A manual system for drug utilization review of 10 most commonly used drugs in the SNF (amitriptyline hydrochloride, aspirin, chloral hydrate, chlordiazepoxide, digoxin, hydrochlorothiazide, methyldopa, milk of magnesia, nitroglycerin and thioridazine) has been published. For each drug a purpose for the review, assumptions, required data, data sources, criteria for use, possible problem areas, abstract form and supporting references are provided.11 Professional associations have published monographs on long-term care facility pharmaceutical services12 and monitoring drug therapy,u a manual for pharmacists providing drug information and inservice training 14 and a workbook for development of a pharmacy policy and procedures manual for SNFs.1s Numerous investigators have documented the effectiveness (cost and otherwise) of the consultant or clinical pharmacist in reducing the number of drugs per patient, adverse reactions, medication errors and cost and in improving pharmacist-physician communication as well as elderly patient status. s, 16 - 23
Patient Errors, Compliance and Education
Patient errors of commission and/or omission in the self-administration of drugs in ambulatory elderly patients are common. 24 , 25 Onereport found that 59 percent of an elderly outpatient population with chronic illnesses made errors in the self-administration of prescribed medications and more than 25 percent committed potentially serious errors.26 In another study of ambulatory patients who self-administered drugs in an SNF and in a hospital a 60 percent error rate was seen in those who received drugs without instructions, whereas only a 2.3 percent error rate was seen in instructed patients.2 7 The need for supervision of the el-
25
derly patient receiving long-term drug therapy was recently reemphasized in a study in which 20 percent of randomly selected elderly patients taking medications had no recorded contact with their physician for six months or longer.zs Another survey4 of elderly patients (conducted in their homes) found that many stored their drugs improperly, tended to hoard drugs and did not have enough explicit instructions regarding indications for taking the drugs. Although many drugs were obtained directly from pharmacists, their advice was rarely sought.
Adverse Reactions and Interactions In patients more than 60-70 years old, the risk of drug reaction is 1.5 times that in adults 30-40 years old.29 The elderly have also been shown to have a higher frequency of hospital admissions due to adverse reactions than younger patients.3o The most comprehensive study of inpatient drug use and adverse reactions is yielding published data concerning the relationship of age to hospitalized patient adverse reaction rate.3I A study of seven nursing homes found that almost 25 percent of the patients risked a potential drug interaction.s With the pharmacist consultation, however, the incidence of adverse reactions and potential interactions in the elderly
26
may be reduced. Probably digoxin toxicity was found to be decreased from 19 percent to 10 percent in elderly inpatients by pharmacist prediction of digoxin toxicity using pharmacokinetic principles.32
Drug-Related Problems and Hospitalization Looking at only adverse reactions and interactions appears to be merely the tip of the iceberg. Almost one third of the patients (65 or older) admitted to two small community hospitals were found to have drugrelated problems that influenced their need for admission.33 Fully two thirds of the problems of these elderly patients were classified as misuse of drugs (poor compliance, covert multiprescriber usage, dietary indiscretion/inadequacy with drug therapy and therapeutic ineffectiveness or inappropriateness of prescribed therapy). The remaining problems were caused by adverse response to preadmission drug therapy.
Why Patient Needs Are Not Met We are just beginning to realize the scope of elderly patient problems with drug therapy. However, the problem of patient errors in selfadministration of drugs was documented more than IS years ago (1962). The lack of specific training in clinical pharmacology and geria-
tries in many medical schools has brought specific recommendations from the American Geriatrics Society,34 and current health care legislation is addressing the lack of sufficient general clinical training in pharmacy schools. That there is no specific accreditation requirement for geriatric experience in baccalaureate or PharmD programs is a paradox -the skilled nursing facility is the first area in which the clinical involvement of the pharmacist is mandated. Long-term care clinical education programs are expanding, however, in the nation's pharmacy schools.3s The time lag in advancing medical science findings to the "standard of care" level for elderly patients is a further concern, e.g., predicting creatinine clearance and digitalis and aminoglycoside dose requirements based on the elderly patient's decreasing renal function. We know very little about bioavailability in drugs in aged ill patients. Pharmacokinetic changes in distribution, metabolism and excretion are beginning to receive attention. Today 90 percent of our elderly are out in the community. Planners should use the virtually untapped resources of the nation's pharmacists in planning elderly patient home health or day care pilot programs.
Future Service and Research Specific questions need resolution. Can we affect planning and funding agency attitudes as well as practitioner attitudes toward the elderly patient's perceived or unrealized needs? Can the accuracy of diagnoses and subsequent rationality of "geripharmacotherapy" be improved? If therapeutic acumen is increased, can effective drug distribution, utilization and review be developed? Can the adverse reaction rate be affected in ambulatory and· institutionalized elderly populations? Can elderly patient hospital admissions due to drug-related problems be reduced? These questions are presented as a challenge to the health care professions to find meaningful solutions to the specific problems of our nation's elderly patients. o American Pharmacy Vol. NS18, No.7, July 1978/354
ow that there is a legal mandate for pharmacists to provide consultant services to skilled nursing facility (SNF) patients, 78 percentl of whom are over 65, it is time to review some of the research dealing with the elderly and to propose further areas of needed documentation. This paper focuses on the ." real world" drug-related problems of the elderly in acute, long-term and ambulatory settings and documents solutions to these problems. The need to move from crisisoriented to prevention-oriented health care delivery leads to some searching questions: Is rational, economic and safe medication usage a reality for the elderly? Can we ascertain and affect the incidence of drugrelated problems in the primary care population segment that uses more drugs per person than any other age group? 2 In our terminology, a drug-related problem may be defined as improper or inappropriate patient drug usage or a desirable drug effect. Using this working definition, a review of some of the pertinent reports focusing on both the institutionalized and the ambulatory elderly patient may lend insight to the magnitude of the problem, to attempted and working solutions and to areas of needed research. Rationality of 'Geripharmacotherapy' While 84-87 percent3, 4 of elderly ambulatory and 95 percents of institutionalized elderly patients are reported to be taking prescription drugs, in 100 consecutive nursing home admissions 64 percent of the patients' primary diagnoses were inaccurate; 84 percent of the secondary diagnoses were either lacking or inadequate.
James W. Cooper Jr., PhD, is associate professor of clinical pharmacy at the School of Pharmacy and on the faculty of gerontology at the University of Georgia in Athens, Georgia 3 0602. This article is based on Dr. Cooper's presentation on September 1 7, 1977, to the Workshop on Pharmacology and Aging, National Institutes of Health, Bethesda, Maryland. References will be sent on request from ths editor of American Pharmacy. American Pharmacy Vol. NS18, No.7, July 1978/353
Drug Therapy in the Elderly: Is It All
It Could Be? By JAMES W. COOPER JR.
The inadequate performance in identifying clinical and therapeutic problems of the chronically ill aged was remarkably consistent, regardless of whether patient referral was from a general or psychiatric hospital, the patient's home or another nursing home.6 If the pre-admission diagnosis is incorrect in so many patients admitted to long-term care facilities, how can the pre-admission drug therapy be rational? Within nursing homes a recent report found that 25 percent of prescribed drugs were not considered effective or needed or given for their FDA-approved use. 7 Another group found that the least men tally impaired and most physically active nursing patients were the most heavily "drugged" with neuroactive substances.8 A recent physician survey demonstrated generalized medical lack of interest in the care of ill aged patients in ins ti tu tions. 9 Drug-prescribing patterns in a 250,000 patient SNF population were reported recently. At the same time a call went out for vigorous promotion of expanded pharmacist in-
volvement in providing drug information and regimen review, as well as reasonable reimbursement for these services.lo
Response to Elderly Inpatient Needs
A manual system for drug utilization review of 10 most commonly used drugs in the SNF (amitriptyline hydrochloride, aspirin, chloral hydrate, chlordiazepoxide, digoxin, hydrochlorothiazide, methyldopa, milk of magnesia, nitroglycerin and thioridazine) has been published. For each drug a purpose for the review, assumptions, required data, data sources, criteria for use, possible problem areas, abstract form and supporting references are provided.11 Professional associations have published monographs on long-term care facility pharmaceutical services12 and monitoring drug therapy,u a manual for pharmacists providing drug information and inservice training 14 and a workbook for development of a pharmacy policy and procedures manual for SNFs.1s Numerous investigators have documented the effectiveness (cost and otherwise) of the consultant or clinical pharmacist in reducing the number of drugs per patient, adverse reactions, medication errors and cost and in improving pharmacist-physician communication as well as elderly patient status. s, 16 - 23
Patient Errors, Compliance and Education
Patient errors of commission and/or omission in the self-administration of drugs in ambulatory elderly patients are common. 24 , 25 Onereport found that 59 percent of an elderly outpatient population with chronic illnesses made errors in the self-administration of prescribed medications and more than 25 percent committed potentially serious errors.26 In another study of ambulatory patients who self-administered drugs in an SNF and in a hospital a 60 percent error rate was seen in those who received drugs without instructions, whereas only a 2.3 percent error rate was seen in instructed patients.2 7 The need for supervision of the el-
25
derly patient receiving long-term drug therapy was recently reemphasized in a study in which 20 percent of randomly selected elderly patients taking medications had no recorded contact with their physician for six months or longer.zs Another survey4 of elderly patients (conducted in their homes) found that many stored their drugs improperly, tended to hoard drugs and did not have enough explicit instructions regarding indications for taking the drugs. Although many drugs were obtained directly from pharmacists, their advice was rarely sought.
Adverse Reactions and Interactions In patients more than 60-70 years old, the risk of drug reaction is 1.5 times that in adults 30-40 years old.29 The elderly have also been shown to have a higher frequency of hospital admissions due to adverse reactions than younger patients.3o The most comprehensive study of inpatient drug use and adverse reactions is yielding published data concerning the relationship of age to hospitalized patient adverse reaction rate.3I A study of seven nursing homes found that almost 25 percent of the patients risked a potential drug interaction.s With the pharmacist consultation, however, the incidence of adverse reactions and potential interactions in the elderly
26
may be reduced. Probably digoxin toxicity was found to be decreased from 19 percent to 10 percent in elderly inpatients by pharmacist prediction of digoxin toxicity using pharmacokinetic principles.32
Drug-Related Problems and Hospitalization Looking at only adverse reactions and interactions appears to be merely the tip of the iceberg. Almost one third of the patients (65 or older) admitted to two small community hospitals were found to have drugrelated problems that influenced their need for admission.33 Fully two thirds of the problems of these elderly patients were classified as misuse of drugs (poor compliance, covert multiprescriber usage, dietary indiscretion/inadequacy with drug therapy and therapeutic ineffectiveness or inappropriateness of prescribed therapy). The remaining problems were caused by adverse response to preadmission drug therapy.
Why Patient Needs Are Not Met We are just beginning to realize the scope of elderly patient problems with drug therapy. However, the problem of patient errors in selfadministration of drugs was documented more than IS years ago (1962). The lack of specific training in clinical pharmacology and geria-
tries in many medical schools has brought specific recommendations from the American Geriatrics Society,34 and current health care legislation is addressing the lack of sufficient general clinical training in pharmacy schools. That there is no specific accreditation requirement for geriatric experience in baccalaureate or PharmD programs is a paradox -the skilled nursing facility is the first area in which the clinical involvement of the pharmacist is mandated. Long-term care clinical education programs are expanding, however, in the nation's pharmacy schools.3s The time lag in advancing medical science findings to the "standard of care" level for elderly patients is a further concern, e.g., predicting creatinine clearance and digitalis and aminoglycoside dose requirements based on the elderly patient's decreasing renal function. We know very little about bioavailability in drugs in aged ill patients. Pharmacokinetic changes in distribution, metabolism and excretion are beginning to receive attention. Today 90 percent of our elderly are out in the community. Planners should use the virtually untapped resources of the nation's pharmacists in planning elderly patient home health or day care pilot programs.
Future Service and Research Specific questions need resolution. Can we affect planning and funding agency attitudes as well as practitioner attitudes toward the elderly patient's perceived or unrealized needs? Can the accuracy of diagnoses and subsequent rationality of "geripharmacotherapy" be improved? If therapeutic acumen is increased, can effective drug distribution, utilization and review be developed? Can the adverse reaction rate be affected in ambulatory and· institutionalized elderly populations? Can elderly patient hospital admissions due to drug-related problems be reduced? These questions are presented as a challenge to the health care professions to find meaningful solutions to the specific problems of our nation's elderly patients. o American Pharmacy Vol. NS18, No.7, July 1978/354