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Overcoming Problems with Polypharmacy and Drug Misuse in the Elderly
HEALTH PROMOTION AND DISEASE PREVENTION
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OVERCOMING PROBLEMS WITH POLYPHARMACY AND DRUG MISUSE IN THE ELDERLY S t e p h e n C. Montamat, MD, a n d Barry Cusack, M D
When medication is prescribed, the desired therapeutic outcome can be adversely affected by factors involving both the patient and the physician. The misuse of properly prescribed drugs by patients may occur, as may the inappropriate prescription of drugs by physicians. Although the elderly rarely abuse illicit chemical dependence on alcohol and licit drugs does occur in this age group due to the careless treatment of symptoms or as a result of psychological addiction.1°56 The prevalence of chronic disorders such as arthritis, cardiovascular disease, and bowel or bladder dysfunction increases with age, often with multiple pathologic conditions in the same patient. In fact, 80% of older Americans have one or more chronic condition^.^' Because most of these diseases as well as nonspecific complaints are potentially responsive to medical therapy, many elderly patients are treated with a variety of medications. Thus, the concurrent or intermittent use of multiple drugs is common in older patients. Even when nonpharmacologic treatments are suitable for a given condition, physicians often prescribe medications. Predictably, the greater the number of drugs prescribed, the greater the risk of inadvertent or intentional misuse of drugs by the patient or caregiver. SCOPE OF THE PROBLEM
Definitions
Polypharrnacy is the prescription, administration, or use of more medications than are clinically indicated in a given patient. Polypharmacy occurs in drug therapy in ambulatory outpatients, hospitalized patients, and also residents of From the Veterans Affairs Medical Center, Boise, Idaho; and the University of Washington, Seattle, Washington
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long-term care institutions. Drug misuse is defined as the inappropriate use of a substance intended for therapeutic purposes.48Forms of drug misuse include overuse, underuse, erratic use, or contraindicated use of a prescribed or nonprescribed medication. The importance of nonprescribed or over-thecounter (OTC) medications is often not appreciated in this context. Drug abuse refers to the nontherapeutic use of any psychoactive substance that in some way adversely affects the user's life.48Abuse of illicit drugs is virtually absent in the community-dwelling elderly; the prevalence of alcoholism is 2% to 5% in males and less than 1%in females over age 65.1° Is Prescribing Appropriate in the Elderly?
Although much of the literature indicates that polypharmacy, drug-drug interactions, the use of contraindicated drugs, and disease-drug interactions are problems of increased significance in older patients, the studies are often less than optimal. Epidemiologic studies are often flawed by nonrandom subject selection, dependence on patient recall, the inability to define the suitability of drug therapy, the absence of dosage information, and lack of outcome analysis. To determine polypharmacy, studies must be able to demonstrate that the increased use of drugs is not warranted. This demonstration requires careful prospective studies that are expensive and seldom performed. Otherwise, polypharmacy may be implied rather than strictly established. Similarly, the potential for drug-drug and drug-disease interactions has been noted in epidemiologic reviews, but the clinical outcomes are seldom evaluated. Thus, the clinician can surmise from such studies that prescribing is suboptimal but not clinically deleterious. Despite these problems, the undoubted evidence of increased drug use42 and adverse drug reactions4' with aging, taken together with documentation of undesirable prescribing practices for older patients,", a 47 indicates problems with geriatric therapeutics and the need for improvement. '
Polypharmacy and Adverse Drug Reactions
Despite the difficulty in assessing the appropriateness of drug usage, considerable data suggest that the number of medications prescribed to the elderly may be detrimental to their health. Polypharmacy may contribute significantly to the incidence of both adverse drug events and medical nonccmpliance. Furthermore, drugs that are commonly implicated in drug-drug interactions are prescribed more often in the elderly." Multiple drug therapy is a risk factor for adverse drug reactions (ADRs).~~ About 10% of geriatric admissions to a medical service are associated with A D R s . ~In ~ addition, ,~~ one fifth of admissions attributed to drug-induced illness are due to nonprescription OTC medications.14 Up to 44% of inpatients and 30% of outpatients suffer from ADRs, but there is controversy whether or not age per se is associated with the incidence of ADRs41Undoubtedly, the most consistent risk factor for ADRs is the number of drugs taken by a patient,41and the elderly are prescribed more medications than the young,42especially when h ~ s p i t a l i z e dThe . ~ ~ incidence of ADRs rises exponentially with the number of drugs taken by the patient,41as shown in Figure 1. Possible reasons for this exponential rise include an increase in severity of disease with disease-drug interactions, an increased incidence of drug interactions, and the use of drugs to treat ADRs.
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no. drugs Figure 1. Relationship between the number of drugs taken concurrently and the incidence of adverse reactions. Note the logarithmic scale on the y-axis. (From Nolan L, O'Malley K: Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. J Am Geriatr Soc 36:145, 1988, with permission, Elsevier Science Publishing.)
The potential of polypharmacy for causing ADRs toxicity was well described in a study of anticholinergic Tennessee Medicaid patients." About 7% of ambulatory patients and 10% of nursing home patients in this study took three or more anticholinergic medications. The authors felt that the physicians did not choose selectively among antipsychotic and tricyclic antidepressant drugs to minimize the risk of anticholinergic toxicity when prescribing them concurrently to nursing home patients. Drugs also may be used to treat symptoms caused by ADRs. The elderly are especially prone to acquire a growing list of drugs due to the treatment of ailments that are actually caused by current therapy. The most prevalent example is the use of psychoactive drugs to treat symptoms of insomnia, anxiety, depression, or psychotic symptoms that may well be due to medications already in use. Possible iatrogenic causes for common geriatric syndromes should be considered so that unnecessary evaluation and treatment can be avoided. The use of psychoactive agents in old age can lead to falls, fractures,47 and confusion.33Larson and colleagues found that almost 12% of outpatients undergoing diagnostic evaluation of suspected dementia were found to have . ~ ~ the offending agents were disconADRs causing cognitive i m ~ a i r m e n tWhen tinued, cognition improved in all of these patients. Sedative hypnotics were most commonly associated with cognitive impairment in this study, especially long-acting benzodiazepines. The drugs most commonly associated with ADRs in the elderly include
psychotropic drugs (especially benzodiazepines), antihypertensive medications (including diuretics), digoxin, nonsteroidal anti-inflammatory agents, systemic steroids, theophylline, and ~ a r f a r i n . ' ~It, is ~~ of , interest ~~ to note that most of these drugs have a narrow therapeutic index (small difference between therapeutic and toxic doses) and readily cause dose-related toxicity. Because the elimination of many of these medications is altered with age, older patients are more likely to suffer from drug-induced illness.14 Furthermore, increased sensitivity to the pharmacologic effects (e.g., sedation from benzodiazepines) is also an important contributor to age-related toxicity. Polypharmacy and Noncompliance
A patient's noncompliance or nonadherence to a medical regimen can prevent the physician and patient from reaching the goals of therapy. Nonadherence results in a lack of therapeutic effect and is associated with 5% to 10% of geriatric medical admissions.1627 Several studies suggest that an increased number of medications is associated with higher rates of nonadherence to prescribed medication^.^^,^^, 52 It is unclear whether age is a risk factor itself," because about one third to one half of patients at any age are likely to be nonadherent.ls Nonetheless, polypharmacy seems to play a role in poor medical compliance in older patients. DRUG THERAPY IN AMBULATORY CARE Polypharmacy
Both prescription and nonprescription drug use increase with age in the ambulatory population.* From 76% to 92% of the elderly use at least one prescription or nonprescription and three out of four office visits to primary care physicians are associated with the continuation or initiation of a prescribed m e d i c a t i ~ n Studies .~~ evaluating outpatient medication use in the United States include two national surveys of prescription drug use based on pharmaceutical marketing data4* and two surveys of distinct elderly popula36 The surveys published by Baum and colleagues were generated t i o n ~ . 30, ~% from data recorded from 1971 through 1982.4, After age 40, the number of drug mentions per year increased substantially with age. (Drug mentions are defined as drugs recorded during a physician-patient contact that reach the patient through formal prescription, hospital ordering, dispensing, sampling, recommendation, or administration. It is therefore a relative value for drug usage, not directly signifying the number of prescriptions given.) In 1981, the elderly averaged approximately 11 drug mentions per person per year. Patients aged 65 or older accounted for 38% of drug mentions for all age groups in 1982 compared with 28% in 1979. Therefore, relative drug consumption in older persons has increased in the recent past. Two surveys have evaluated medication use in populations of ambulatory elderly people. The Dunedin Program in Florida was set up in 1975 to screen a population of retirees for hypertension and other undetected health probl e m ~ . The ~ % average ~~ number of medications was 3.2 in 1978 to 1980 and 3.7 in 1983 to 1985. About one half of the drugs were OTC agents. The upper limit
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of the medication number was 24, and the number increased with age within this population over age 65. The most common indications for drug use were hypertension (38%), analgesia (23%), rheumatism (19%), and vitamin use (18%). Cardiovascular drugs, diuretics, and sedative-hypnotics accounted for over 75% of prescription drugs. Analgesics, nutritional supplements, and laxatives were the most commonly used nonprescription items. The Iowa 65 + Rural Health Study was a project intended to define health and health-related problems of a rural, elderly p o p ~ l a t i o nThe . ~ ~ overall mean number of drugs taken per respondent was 2.8 with means of 1.7 and 1.1 for prescription and nonprescription drugs, respectively. The number of prescription drugs ranged from 0 to 9 for women and 0 to 13 for men, whereas the number of nonprescription medications ranged from 0 to 17 for women and 0 to 9 for men. The most commonly used drugs were very similar to those found in the Dunedin Program, and the most frequently stated indications were cardiovascular disease for prescription medications and musculoskeletal disorders for nonprescription drugs. Both surveys found that approximately 75% of the prescribed medications had directions to be taken daily as scheduled, but the schedule for most of the remaining medications was left to the discretion of the patient. A national survey of physician prescribing habits published in 1973 led investigators to conclude that most prescriptions of psychotherapeutic drugs were warranted.43 This conclusion is predominantly based on patient-derived responses without access to medical records. In the United Kingdom, several studies have been performed that suggest that prescribing rates by family practitioners increase with the age of the patients.42A linear relationship between age and polypharmacy also has been documented in ambulatory patients in A ~ s t r a l i aIn . ~this ~ study, patients taking 10 or more medications were found to be significantly older than a random sample of patients taking
Several studies have attempted to characterize drug misuse in elderly ambulatory pop~lations.~, 15, 50 Bernstein and colleagues surveyed residents for 6 months in the San Francisco area for drug misuse classified by three categories: drug use, drug interactions, and redundancy of compounds from a pharmacologic class.9 Drug use was measured by the appropriateness of the dosage prescribed, indication, and actual patient use. The participants were relatively healthy and well educated. All information was obtained from the patients with no input from their physicians; therefore, the indication for a given medication depended on the patient's knowledge of his or her disease. It should be noted that between 8% and 45% of the elderly do not know the correct purpose of their medication^.^^ In 141 study participants, there were 771 drugs being taken (including alcohol), resulting in an average of 5.5 drugs per person. Misuse events occurred in 62 persons (44%) of which two thirds were due to errors in patient drug use (most often underuse). Fifteen patients (11% of the participants) had an error in drug indication; either they reported the wrong indication for a drug or took a drug that was inappropriately prescribed. An aggregate score for all three major categories of drug misuse correlated with the number of drugs taken by the participants. Patients using psychotherapeutic agents were at greater risk for drug misuse.
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Cartwright surveyed patients of general practitioners in the United Kingdom and found that over one third of the patients were taking medications of which their physicians were unaware.15In addition, these patients were more likely to be using medications with inappropriate indications-31% versus 13% for those patients taking only medications of which their physicians were aware. Shaw and Opit also evaluated the supervision of drug therapy in elderly outpatients and found that 19 of 64 patients (30%) taking long-term prescribed medication had no recorded contact with their family doctors for over 6 months.50 Three of these patients were thought to be suffering from drug toxicity. Other studies have found evidence of increased long-term use of benzodiazepines in older patient^.^' The majority of users over age 65 take hypnotics for over 1year.39This level of use is excessive in view of the increased risk of benzodiazepine toxicity with age3*and recommendations to limit use in elderly patient^.^, l7 These studies underscore the need for close supervision of drug therapy in elderly outpatients. DRUG THERAPY IN HOSPITALIZED PATIENTS
Few studies characterize the effect of hospitalization on the number of drugs taken by elderly patients, but those performed in the United States suggest that the average number is unchanged from admission to discharge.', Beers and colleagues found that 40% of all admission medications were discontinued and 45% of all discharge medications were commenced during the ho~pitalization.~ These major changes in the drug regimen of elderly patients while in the hospital may increase the risk of drug misuse after discharge. Discharge from the hospital may be an important time for clinicians to counsel patients to prevent such drug misuse. Gosney and Tallis surveyed 573 elderly patients admitted to a medical service screening for the prescription of contraindicated or interacting Medications both at admission and during hospitalization were analyzed. Contraindicated or adversely interacting drugs were found in 3.2% of all prescriptions. Twenty-four per cent of the patients were affected by this misprescribing, but only 1.2% suffered adverse consequences. The authors believed that two thirds of the undesirable prescriptions were avoidable and another one fifth were probably avoidable. The study might have shown higher rates of misprescribing if the appropriateness of prescriptions was addressed, but this element is much more difficult to assess. For example, a diagnosis or symptom for which drug therapy is administered may not be recorded. Secondly, when a diagnosis is known, it is not always clear whether one drug is more appropriate than another on the basis of efficacy alone. DRUG THERAPY IN LONG-TERM CARE FACILITIES
Although elderly patients requiring chronic care suffer from the same maladies as their counterparts in the community, some diagnoses are more likely to be encountered in the nursing home population. These include dementia, stroke, depression, and urinary incontinence, all of which are conditions that either alter central nervous system function or require medications resulting in this effect. Symptoms of depression, anxiety, insomnia, and agitation are commonly encountered in the nursing home, and more often than not, drugs are prescribed indiscriminately to treat them.
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The drug use of residents or patients in nursing homes or intermediatecare facilities is easily monitored. Several well-performed studies suggest the misuse of medications in this population usually in the form of indiscriminate use or excessive dosing. Psychotherapeutic agents are the major offenders. Borda and colleagues studied drug use in five Boston hospitals, two of which were dedicated to long-term care.13 Age was again found to be associated with the number of drugs administered, but length of stay also correlated with drug intake. A study based on a large sample of nursing home patients covered by Medicaid and Medicare was published by the Office of Long-Term Care of the Department of Health, Education, and Welfare in 1972.44An average of 6.1 drugs were taken per patient. Nearly one half of all residents were prescribed tranquilizers, which included antipsychotic medications and minor tranquilizers. About one third of the patients were prescribed sedative-hypnotic agents, and 12% received two or more psychoactive drugs. Amitriptyline, the tricyclic with the greatest anticholinergic potency, was prescribed to 38% of those patients receiving antidepressants. A more recent survey does not suggest that this pattern of misuse and overuse has improved over the past 20 years.6Twelve intermediate-care facilities in Massachusetts were monitored for medication use over a 1-month p e r i ~ d . ~ Institutions with a significant percentage of admissions from psychiatric hospitals were excluded to target a typical geriatric nursing home environment. Homes with active nurse practitioner prescribing also were excluded to specifically analyze physician prescribing habits. Patients were found to receive an average of 5.5 drugs given at least once during the monthlong surveillance. Nearly 50% of medication orders were for use as needed (pm). Of the one third of patients with orders written for antipsychotic agents, 58% were for regularly scheduled regimens. The remainder were written as asneeded medications, but only 11% were activated during the month of study. Haloperidol and thioridazine were the most commonly prescribed antipsychotic agents, and the median daily dose from various homes was the equivalent of 65 mg chlorpromazine per patient per day. Forty per cent of patients were prescribed a sedative-hypnotic. Of those actually receiving a sedative-hypnotic, the majority (82%) were by regularly scheduled administration. Diphenhydramine hydrochloride constituted one fourth of the administered sleeping agents. Twenty per cent of all patients received benzodiazepines, and one third of them were taking long-acting drugs, such as flurazepam, diazepam, and chlordiazepoxide, usually as a standing order. Fourteen per cent of the patients used antidepressant medications, with amitriptyline the most commonly received. A study by Ray and colleagues reviewed Medicaid prescription records in Tennessee nursing homes over a 1-year period and found similar prescribing practices by physician^.^^ Interestingly, just 14% of the physicians were responsible for 81% of the antipsychotic medications prescribed. Indices of physician prescription of antipsychotics increased as the size of the nursing home practice increased; many times the majority of antipsychotic prescriptions in a nursing home was directed by a single physician. The number of beds in a nursing home also correlated with antipsychotic drug use. At least one study has characterized drug use in a nursing home. Bergman reviewed drug regimens of residents in a community nursing home and evaluated individual medications for appropriate FDA-approved use and their efficacy or need for the designated use.* Only 4% of drugs were prescribed for an unapproved indication. Although the evaluation of efficacy and need was quite subjective, the investigators concluded that about one fourth of the
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prescribed medications were without efficacy or need. As in the study by Ray ,~~ who prescribed the majority of drugs were more and c o l l e a g ~ e sphysicians likely to prescribe inefficacious or unnecessary drugs. Antipsychotic drug use is also widespread in rest homes, with little supervision by physicians or understanding by staff members of the possible side effects from these medication~.~ Extended institutional care appears to be the setting where drug misuse and polypharmacy are most likely to occur in geriatric patients. This increased risk for multiple drug use is associated with patient load, either of the home itself or the physician. Also, in comparison to ambulatory and hospital care, long-term care facilities show the most evidence of inappropriate prescribing, especially with regard to psychotropic medications. Research with more objective measures of appropriate drug prescribing and use is undoubtedly needed in each of these areas of geriatric practice. Factors Leading to Polypharmacy and Drug Misuse
Generally, causes of polypharmacy or drug misuse can be attributed to both the patient and the prescribing physician (Table 1). One of the major influences on drug prescription is the expectation of the patient or physician that medication is required as the definitive solution to an illness. Up to 50% of patients do expect the visit with a physician to result in the prescription of a drug.'= Many times, however, physicians believe that patients expect a prescription even when the patient does not expect one. Usually, the elderly suffer from multiple pathologic conditions, and many of these are amenable to treatment by medical therapy. Unfortunately, these conditions often are chronic in nature, requiring the indefinite use of drugs. Table 1. POTENTIAL CAUSES OF POLYPHARMACY OR DRUG MISUSE
~atiezrelatedfactors 1. Expectation of physician to prescribe medication 2. lnadequate reporting of current medications 3. Failure to complain about symptoms, especially if related to medication 4. Use of multiple, automatic refills without visiting physician 5. Hoarding prior medications 6. Use of multiple pharmacies or multiple physicians 7. Borrowing medications from family members or friends 8. Self-medication with over-the-counter drugs 9. Impaired cognition or vision 10. Economic factors such as high drug costs Physician-related factors 1. Presuming that patients expect prescription of medication 2. Drug treatment of symptoms without sufficient clinical evaluation 3. Treating conditions without setting goals of therapy 4. Communicating instructions in unclear, complex, or incomplete manner 5. Failure to review medications and their possible adverse effects at regular intervals 6. Use of automatic refills without adequate follow-up 7. Lack of knowledge of geriatric clinical pharmacology, leading to inappropriate prescribing practices 8. lnadequate supervision of medications in long-term care 9. Failure to simplify drug regimens as often as possible
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This in itself leads to the accumulation of drug therapy in the elderly. Multiple illnesses also may underlie the association of hospitalization and nursing home placement with polypharmacy. In addition, the severity of illness correlates with the degree of polypharmacy. Upon questioning the patient about exact medication use, physicians may receive an incomplete drug list. Without knowing about pun or OTC medications, the physician may prescribe a drug that the patient is already taking. Aggressive and persistent inquiry into the patient's drug regimen can reduce the risk of duplication. Because of cost, time constraints, or limited mobility, patients may refill a medication many times without visiting the physician for a follow-up. The indication for the medication may resolve, or adverse effects of the medication may occur, leading to the inappropriate use of a once properly prescribed medication. Medicine cabinets may fill with drugs that were discontinued but are kept for possible future need. This provides another opportunity for polypharmacy to occur, with the patient selecting medication for a given problem. With impaired vision or cognition, another drug can be mistaken for the prescribed medication. It is not uncommon for patients to borrow medications from friends or family members for convenience or economic reasons. Finally, patients may obtain their drugs from separate physicians or pharmacies, which reduces the chance of recognizing inappropriate drug regimens. It is easy to understand how such behavior may lead to serious drug interactions or unsuitable treatment. Physicians must realize that these habits occur quite often in patients in their practices. Without an accurate clinical assessment, practitioners may make prescribing errors, including treating the wrong diagnosis, undertreating the correct diagnosis (due to not recognizing its severity), or exposing the patient to unnecessary drug therapy. If it is not recognized that symptoms are due to a current medication, another drug may be added inappropriately to treat the symptom, rather than removing the offending medication. Even if the physician correctly prescribes a medication for a given condition, therapy may be misdirected if goals are not set. Therapeutic end points may be reached without recognition by the physician or patient, resulting in continued therapy that may be unnecessary. This can occur, for example, with anticoagulants treating thrombosis, H,-receptor antagonists treating peptic ulcer disease, or antidepressants treating a major depressive episode. Another common error is to add medications to treat a given condition without an adequate trial of the initial drug. If the physician fails to review medications on a regular basis, he or she may unwittingly allow the accumulation of medications to occur, with the danger of misuse. This problem may be compounded by the use of automatic refills over the telephone without a follow-up of the patient's initial problem. Certain drugs are more commonly implicated in patients with multiple drug therapy, with psychotherapeutic agents, cardiovascular drugs, and diuretics Finally, a lack of knowledge about the principles of geriatric leading the list.28,36 clinical pharmacology can lead to inappropriate prescribing practices, such as excessive dosage, toxic drug combinations, and inappropriate drug selection. PHYSICIAN APPROACHES TO PREVENT POLYPHARMACY AND DRUG MISUSE
To avoid the perils of polypharmacy and drug misuse, the physician and patient must communicate effectively. The achievement of efficient and appropriate medical management is difficult, of course, and requires patience and
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diligence on the part of both the physician and the patient. Table 2 includes 10 recommendations to limit polypharmacy. The benefits of reducing drug use have been illustrated in a study from Israel that compared drug use and ADRs in hospitalized patients from two separate 3-year periods of time.34An 11% reduction in the average number of drugs prescribed per patient from 1969 to 1972, to 1973 to 1976 correlated with a 60% decrease in the incidence of adverse effects. No other studies are available to document the effects of lowering drug use in outpatients or the elderly, in particular. The best defense against polypharmacy is to consistently prescribe the least number of drugs possible in a given patient. No prescription or nonprescription medication should be used without scrutinizing the absolute need and possible adverse effects of the medication. Prescribing drugs for symptoms without a diagnosis should be discouraged, although obtaining an exact diagnosis is not always possible. Frank discussion with the patient about the need to limit medications can be helpful, and this conversation may establish a rationale for sometimes trying nonpharmacologic means that are understood by the patient. Ample time should be included in office visits so that detailed verbal and written instructions may be given." Increased clarity of instructions given to patients and discussion of possible adverse effects may help patients understand symptoms targeted for treatment and symptoms due to drug therapy. This alone may diminish the number of drugs used by a patient. Physicians should ensure that their patients are able to distinguish different medication vials, suggesting the use of such identification markings as color codes, if necessary. Patients should be given containers they can easily open and close. ~edicationsprescribed for as-needed use should also be restricted, with regular monitoring of the frequency of their actual use. Problems may arise with increased frequency of use. For example, occasional use of a nonsteroidal anti-inflammatory agent in a hypertensive patient may be harmless, but daily use of this medication may offset control of the patient's blood pressure. The goals of treatment of symptoms using as-needed medication should be mutually agreed upon. This may limit pm use and inappropriate self-treatment by the patient. A useful practice to improve compliance in the elderly is to simplify the drug regimen. Not only should the physician prescribe few drugs, but the
Table 2. GUIDELINES FOR EFFECTIVE PRESCRIBING TO LIMIT POLYPHARMACY AND DRUG MISUSE IN OLDER PERSONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Ask patients to bring in all medicines to office. Restrict prn prescribing for minor symptoms. Select a drug that may treat more than one condition. Check for contraindications and potential drug interactions before prescribing a drug. Start with low doses and titrate the dose according to effect. Monitor for adverse reactions. Educate the patient about the drug therapy. Routinely check and encourage compliance. Periodically simplify the therapeutic regimen and stop drugs if possible. Place realistic limits on the duration of drug prescribing.
Adapted from Cusack B: Polypharmacy and clinical pharmacology. In Beck JC (ed): Geriatrics Review Syllabus. New York, American Geriatrics Society, 1989, p 127, with permission.
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drugs prescribed should require as few daily doses as possible. For example, antihypertensive agents that can be used once or twice daily should be favored over agents requiring three or four daily doses, given equal efficacy and risk of adverse effects. This practice is becoming increasingly possible as more longer-acting agents become available. Cost savings also should accrue from enhanced compliance that may occur with fewer drug doses. Simplification of medication regimens (including OTC medications) should be a part of each patient visit. When possible, physicians should choose the least expensive medications to avoid overburdening the elderly, fixed-income patient with high drug costs, a factor known to reduce ~ o m p l i a n c e . ~ ~ Communication with the patient concerning drug indications, doses and the need for compliance can be greatly enhanced if the patient routinely brings all medications on every office visit. Instead of reviewing the patient's problem list separately, complaints can be elicited at the time of drug review, using the patient's medications to facilitate comprehensive assessment in a concise fashion. Care should be taken to efficiently match drug therapy with diseases. Redundant medications treating the same problem should be discontinued. Treatment of more than one disorder with a single medication, such as coronary artery disease and hypertension with a calcium channel blocker, can increase the efficiency of drug therapy. Once drug therapy has been started, efforts should be directed towards limiting the duration of its use. If a targeted goal of therapy has been reached, the responsible agent should be discontinued. When treating chronic ailments in the elderly, it is tempting to continue therapy even when specific signs or symptoms of disease activity are no longer evident. Where the indication is in doubt due to the absence of signs or symptoms, an attempt should be made to reduce the dose or stop the medicine while monitoring for the return of disease activity. For example, digoxin often can be discontinued in sinus rhythm in ambulatory elderly individuals with a history of congestive heart failure. In one study it was found that all 30 patients taking digoxin in this manner were able to discontinue it without clinical evidence of worsening heart failure.z2Just as it is important to define therapeutic end points for beginning a medication, it is equally important in a trial of drug therapy to define signs or symptoms whose return suggests that the drug is necessary. There are many other factors to consider to prevent polypharmacy and drug misuse. Repeat prescriptions should be limited, especially for pun medications. Indications such as insomnia, musculoskeletal pain, or constipation should be reviewed before a vicious cycle of chronic and inappropriate pharmacologic therapy is begun. The physician should recommend use of only one pharmacy. Patients under the care of other physicians are more likely to receive redundant medications; therefore, the primary care physician should be notified of any additional medications at the time they are prescribed. Consultants should be encouraged to allow the primary care physician to actually prescribe the medication. Multiple refills over short periods of time should signal drug misuse, such as hoarding, lending, or illicit selling, and they should be addressed by the physician. Other Practical Methods to Reduce Polypharmacy and Drug Misuse
Other recommendations have been made for reducing drug misuse in the elderly beyond the patient-physician interaction. The increased use of clinical
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pharmacists has been shown to reduce drug consumption with cost savings in a nursing home.54Pharmacists can enhance compliance by providing more comprehensive instructions to patients as well as reducing adverse effects by increased surveillance of drug regimen^.'^ Home health aides and visiting nurses also can assist in this capacity. There have been novel methods for increased monitoring such as the use of prescription booklets12and the use of computerized medication records that signal possible drug interaction^.^', 53 In the authors' Veterans Affairs Medical Center where the patient's medications are dispensed by a central pharmacy, the patient's record is supplemented by a drug profile that is updated at each visit. This profile includes the list of medications with dosage, number, date of last refill, and the option of discontinuing or refilling the prescription. Pertinent laboratory information also is included. Data on the effectiveness of this method to reduce drug use and prevent misuse are not available, but clinical experience suggests that it is helpful. Educational Methods. The need for knowledge of geriatric clinical pharmacology is obvious for all practitioners who evaluate and treat older patients. This area has been ignored in the past but is now slowly gaining attention and corrective action at the level of medical school education. It has been shown that office-based physician education programs can be employed to reduce drug usage by implementing academically based "detailix~g."~Another controlled outpatient trial including patients (mean age 61.2) taking 10 or more drugs resulted in a significant reduction of prescriptions at 4 months by means of a combination of written reminders and educational instructions to physic i a n ~By . ~ 12 ~ months, however, there was no difference between the control and intervention groups. Also, drug manufacturers will be required by the Food and Drug Administration to include information concerning use by the elderly in the package insert of any new product. It is hoped that an increase in the availability of information and attention to proper drug use in the elderly will help improve physician prescribing habits, particularly in the nursing home setting. LEGISLATIVE REGULATION OF DRUG USE
As part of the Omnibus Budget Reconciliation Act (OBRA) in 1987, federal legislation has established regulations for the use of antidepressants, anxiolytic and hypnotic agents, and neuroleptics in Medicare- and Medicaid-certified nursing homes.29Table 3 lists irregularities in the use of these agents that should be reported to the attending physician or director of nursing by a licensed pharmacist. Implementation of these guidelines for psychotherapeutic drug monitoring began in October 1990. A recent study of neuroleptic drug use in 60 nursing homes was conducted by reviewing extant data from 1976 to 1985.23One half of neuroleptic use was found to be "ineligible" according to Health Care Financing Administration guidelines. In those cases, antipsychotic drugs were used without specific psychiatric diagnoses or documentation of psychotic or agitated features of dementing illness. Therefore, it appears that enforcement of the guidelines will lead to greater scrutiny of psychoactive drug use in Medicare and Medicaid nursing home residents. As a part of the OBRA legislation in 1990, a national drug utilization review (DUR) program is to be implemented for the review of drug use in all Medicaid patients by October 1992." Each state will be required to form a DUR board that includes physicians and pharmacists. DUR will be conducted both retro-
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Table 3. IRREGULARITIES IN DRUG USE IN NURSING HOME RESIDENTS DEFINED BY THE HEALTH CARE FINANCING ADMINISTRATION Drug Class
Irregularities
Antidepressants
Use of antidepressants for less than 3 days More than two changes of an antidepressant within a 7-day period Use of antidepressants in excess of listed daily maximal doses
Anxiolytics/hypnotics
Continuous use of hypnotic drugs for more than 30 days Use of two or more hypnotic drugs at the same time Hypnotic or anxiolytic drugs administered in excess of the listed maximum doses
Neuroleptics
Use of antipsychotics for less than 3 days, with the exception of intermittent use to control acute episodes of agitation Use of two or more antipsychotic drugs at the same time Use of anticholinergic therapy with antipsychotic drugs in the absence of extrapyramidal side effects Neuroleptic agents administered in excess of the listed maximum doses
Adapted from Health Care Financing Administration: Medicare and Medicaid: Requirements for long-term care facilities. Federal Register 54:5316, 1989.
spectively and prospectively. Retrospective DUR will be performed by the review of prescriptions with special emphasis on costly and high-risk drugs. Prospective DUR will be initiated by pharmacist screening of current prescriptions in order to inform physicians of therapeutic duplication or drug interactions. Although DUR will become law, there is no rigorous scientific evidence that DUR actually improves health care and lowers expenditures; however, it does appear a reasonable starting point in the attempt to formally ensure improved prescribing practices.
SUMMARY
Polypharmacy, the inappropriate use of multiple drug regimens, has a significant impact on the health of elderly individuals. Drug use increases with age, but suitability of therapy is sometimes difficult to define. In ambulatory and hospital care, there is some documentation of poor prescribing practices by physicians and drug misuse by patients. Sound data suggest that polypharmacy and drug misuse are highly prevalent in long-term care facilities. Psychotherapeutic agents are the most commonly misused drugs by physicians in this setting. Polypharmacy is associated with factors such as the number and severity of illnesses, hospitalization, number of physicians seen, number of pharmacies used, and possibly increased patient age. Methods to prevent polypharmacy and drug misuse have not been well studied. There is a need for intensive research to define effective methods to strengthen prescribing practice of physicians for elderly patients, to promote cooperation among health care personnel in ensuring optimal drug use by patients, and to enhance the role of patients as responsible partners in drug therapy. The authors are confident, however, that drug misuse and polypharmacy can be reduced in
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older persons by the use of current knowledge of risk factors associated with polypharmacy and by improved communication between the physician and patient. References 1. Alexander N, Goodwin JS, Currie C: Comparison of admission and discharge medications in two geriatric populations. J Am Geriatr Soc 332327, 1985 2. Avorn J, Dreyer, P, Connelly K, et al: Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study. N Engl J Med 320:227, 1989 3. Avorn J, Soumerai SB: Improving drug-therapy decisions through educational outreach-a randomized controlled trial of academically based "detailing". N Engl J Med 3081457, 1983 4. Baum C, Kennedy DL, Forbes MB, et al: Drug use and expenditures in 1982. JAMA 253:382, 1985 5. Baum C, Kennedy DL, Forbes MB, et al: Drug- use in the United States in 1981. JAMA 251:1293, 1984 6. Beers MH, Avorn J, Soumerai SB, et al: Psychoactive medication use in intermediatecare facility residents. JAMA 260:3016, 1988 7. Beers MH, Dang J, Hasegawa J, et al: Influence of hospitalization on drug therapy in the elderlv. 1 Am Geriatr Soc 37679, 1989 8. Bergman HD: Prescribing of drugs i n a nursing home. Drug Intel1 Clin Pharmacy 9:365, 1975 9. Bernstein LR, Folkman S, Lazarus RS: Characterization of the use and misuse of medications by an elderly, ambulatory population. Med Care 27654, 1989 10. Blazer DG: Alcohol and drug problems in the elderly. In Busse EW, Blazer DG (eds): Geriatric Psychiatry. Washington, American Psychiatric Press, 1989, p 489 11. Blazer DG, Federspiel CF, Ray WA, et al: The risk of anticholinergic toxicity in the elderly: A study of prescribing practices in two populations. J Gerontol38:31, 1983 12. Bliss MR: Prescribing for the elderly. BMJ 283:203, 1981 13. Borda I, Tick H, Slone D, et al: Studies of drug usage in five Boston hospitals. JAMA 202:506, i967 14. Caranassos G. Stewart RB. Cluff LE: Drutl " induced illness leading " to hosvitalization. JAMA 228:713, 1974 15. Cartwright A: Medicine taking by people aged 65 or more. Br Med Bull 46:63, 1990 16. Col N, Fanale JF, Kronholm P: The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 150:841, 1990 17. Consensus Conference. Drugs and insomnia. JAMA 251:2410, 1984 18. Cooper JK, Love DW, Raffoul PR: Intentional prescription nonadherence (noncompliance) by the elderly. J Am Geriatr Soc 30:329, 1982 19. Cusack B: Polypharmacy and clinical pharmacology. In Beck JC (ed): Geriatrics Review Syllabus. New York, American Geriatrics Society, 1989, p 127 20. Cypress BW: Drug utilization in office visits to primary care physicians: National Ambulatory Medical Care Survey, 1980. Department of Health and Human Services Publication (PHs) 82-3320. Washington, Public Health Service, 1982 21. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med 100:258, 1984 22. Filner B, Williams TF: Health promotion for the elderly: Reducing functional dependency. In Hamburg DS, Nightingale EO, Kalmar V, et a1 (eds): Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, Background Papers. DHEW Publication No 79-55071A. Washington, US Government Printing Office, 1979, p 365 23. Fleg JL, Gottlieb SH, Lakatta EG: Is digoxin really important in treatment of compensated heart failure? A placebo-controlled crossover study in patients with sinus rhythm. Am J Med 73:244, 1982 24. Garrard J, Makris L, Dunham T, et al: Evaluation of neuroleptic drug use by nursing
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home elderly under proposed Medicare and Medicaid regulations. JAMA 265:463, 1991 -. . -
25. Gosney M, Tallis R: Prescription of contraindicated and interacting drugs in the elderly patients admitted to hospital. Lancet 2:564, 1984 26. Greenlaw CW, Zellers DD: Computerized drug-drug interaction screening system. Am J Hosp Pharm 35567, 1978 27. Gryfe CI, Gryfe BM: Drug therapy of the aged: The problem of compliance and the roles of physicians and pharmacists. J Am Geriatr Soc 32:301, 1984 28. Grymonpre RE, Mitenko PA, Sitar DS, et al: Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc 36:1092, 1988 29. Hale WE, May FE, Marks RG, et al: Drug use in an ambulatory elderly population: A five-year update. Drug Intell Clin Pharmacy 21:530, 1987 30. Health Care Financing Administration: Medicare and Medicaid; requirements for long-term care facilities. Federal Register 54:5316, 1989 31. Helling DK, Lemke JH, Semla TP, et al: Medication use characteristics in the elderly: The Iowa 65' Rural Health Study. J Am Geriatr Soc 35:4, 1987 32. Hulse RK, Clark SJ, Jackson JC, et al: Computerized medication monitoring system. Am J Hosp Pharm 33:1061, 1976 33. Kendrick R, Bayne JRD: Compliance with prescribed medication by elderly patients. Can Med Assoc J 127:961, 1982 34. Larson EB, Kukull WA, Buchner D, et al: Adverse drug reactions associated with global cognitive impairment in elderly persons. Ann Intern Med 107:169, 1987 35. Levy M, Kleffer-Hemo D, Nir I, et al: Drug utilization and adverse drug reactions in medical patients. Is J Med Sci 13:1065, 1977 36. Mandolini A: The social contexts of aging and drug use: Theoretical and methodological insights. J Psychoactive Drugs 13:135, 1981 37. May FE, Stewart RE, Hale WE, et al: Prescribed and nonprescribed drug use in an ambulatory elderly population. South Med J 75:522, 1982 38. McMillan DA, Harrison PM, Rogers LJ, et al: Polypharmacy in an Australian teaching hospital. Preliminary analysis of prevalence, types of drugs and associations. Med J Aust 145:339, 1986 39. Meyer TJ, Van Kooten D, Marsh S, et al: Reduction of polypharmacy by feedback to clinicians. J Gen Intern Med 6:133, 1991 40. Montamat SC, Cusack BJ, Vestal RE: Management of drug therapy in the elderly. N Engl J Med 321:303, 1989 41. Morgan K, Adllosso H, Ebrahim S, et al: Prevalence, frequency, and duration of hypnotic drug are among the elderly living at home. BMJ 296:601, 1988 42. Morrow D, Leirer V, Sheikh J: Adherence and medication instructions-review and recommendations. J Am Geriatr Soc 36:1147, 1988 43. Nolan L, O'Malley K: Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. J Am Geriatr Soc 36:142, 1988 44. Nolan L, O'Malley K: Prescribing for the elderly: Part 11. Prescribing patterns: Differences due to age. J Am Geriatr Soc 36:245, 1988 45. Parry HJ, Balter MB, Mellinger GD, et al: National patterns of psychotherapeutic drug use. Arch Gen Psychiatry 28:18, 1973 46. Physician's Drug-Prescribing Patterns in Skilled Nursing Facilities. Publication (05) 76-50050. Washington, Office of Long-Term Care, US Department of Health, Education, and Welfare, 1976 47. Proceedings of the Drug Utilization Review Workshop. Clin Pharmacol Ther 50(5 Part 11), 1991 48. Ramsay LE, Tucker GT: Drugs and the elderly. BMJ 282:125, 1981 49. Ray WA, Federspiel CF, Schaffner W: A study of antipsychotic drug use in nursing homes: Epidemiologic evidence suggesting misuse. Am J Public 70:485, 1980 50. Ray WA, Griffin MR, Schaffner W: Psychotropic drug use and the risk of hip fracture. N Engl J Med 316:363, 1987 51. Shaw SM, Opit LJ: Need for supervision in the elderly receiving long-term prescribed medication. BMJ 1:505, 1976 52. Shelowitz PA: Drug use, misuse, and abuse among the elderly. Med Law 6:235, 1987 53. Shorr RI, Bauvens SF, Laudefield CS: Failure to limit quantities of benzodiazepine hypnotic drugs for outpatients-placing the elderly at risk. Am J Med 89:725, 1990
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54. Stewart RB, Cluff LE: A review of medication errors and compliance in ambulant patients. Clin Pharmacol Ther 13:463-468, 1972 55. Tallis RC, Edmond ED, O'Halloran A: A computer system to prevent prescriptions of contraindicated drugs. Br J Pharmaceut Pract 6:223, 56. Thompson JF, McGhan WF, Ruffalo RL: Clinical pharmacists prescribing drug therapy in a geriatric setting: Outcome of a trial. J Am Geriatr Soc 32:154, 1984 57. Vestal RE, Jue SG, Cusack BJ: Increased risk of adverse drug reactions in the elderly: Fact or myth? In O'Malley K, Waddington JL (eds): Therapeutics in the Elderly. Amsterdam, Elsevier Science Publishers, 1985, p 97 58. Whitcup SM, Miller F: Unrecognized drug dependence in psychiatrically hospitalized elderly patients. J Am Geriatr Soc 35:297, 1987 59. Williamson J, Chopin JM: Adverse reactions to prescribed drugs in the elderly: A multicentre investigation. Age Ageing 9:73, 1980
Address reprint requests to Stephen C. Montamat, MD Research and Development (151) VAMC 500 W. Fort Street Boise, ID 83702
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OVERCOMING PROBLEMS WITH POLYPHARMACY AND DRUG MISUSE IN THE ELDERLY S t e p h e n C. Montamat, MD, a n d Barry Cusack, M D
When medication is prescribed, the desired therapeutic outcome can be adversely affected by factors involving both the patient and the physician. The misuse of properly prescribed drugs by patients may occur, as may the inappropriate prescription of drugs by physicians. Although the elderly rarely abuse illicit chemical dependence on alcohol and licit drugs does occur in this age group due to the careless treatment of symptoms or as a result of psychological addiction.1°56 The prevalence of chronic disorders such as arthritis, cardiovascular disease, and bowel or bladder dysfunction increases with age, often with multiple pathologic conditions in the same patient. In fact, 80% of older Americans have one or more chronic condition^.^' Because most of these diseases as well as nonspecific complaints are potentially responsive to medical therapy, many elderly patients are treated with a variety of medications. Thus, the concurrent or intermittent use of multiple drugs is common in older patients. Even when nonpharmacologic treatments are suitable for a given condition, physicians often prescribe medications. Predictably, the greater the number of drugs prescribed, the greater the risk of inadvertent or intentional misuse of drugs by the patient or caregiver. SCOPE OF THE PROBLEM
Definitions
Polypharrnacy is the prescription, administration, or use of more medications than are clinically indicated in a given patient. Polypharmacy occurs in drug therapy in ambulatory outpatients, hospitalized patients, and also residents of From the Veterans Affairs Medical Center, Boise, Idaho; and the University of Washington, Seattle, Washington
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long-term care institutions. Drug misuse is defined as the inappropriate use of a substance intended for therapeutic purposes.48Forms of drug misuse include overuse, underuse, erratic use, or contraindicated use of a prescribed or nonprescribed medication. The importance of nonprescribed or over-thecounter (OTC) medications is often not appreciated in this context. Drug abuse refers to the nontherapeutic use of any psychoactive substance that in some way adversely affects the user's life.48Abuse of illicit drugs is virtually absent in the community-dwelling elderly; the prevalence of alcoholism is 2% to 5% in males and less than 1%in females over age 65.1° Is Prescribing Appropriate in the Elderly?
Although much of the literature indicates that polypharmacy, drug-drug interactions, the use of contraindicated drugs, and disease-drug interactions are problems of increased significance in older patients, the studies are often less than optimal. Epidemiologic studies are often flawed by nonrandom subject selection, dependence on patient recall, the inability to define the suitability of drug therapy, the absence of dosage information, and lack of outcome analysis. To determine polypharmacy, studies must be able to demonstrate that the increased use of drugs is not warranted. This demonstration requires careful prospective studies that are expensive and seldom performed. Otherwise, polypharmacy may be implied rather than strictly established. Similarly, the potential for drug-drug and drug-disease interactions has been noted in epidemiologic reviews, but the clinical outcomes are seldom evaluated. Thus, the clinician can surmise from such studies that prescribing is suboptimal but not clinically deleterious. Despite these problems, the undoubted evidence of increased drug use42 and adverse drug reactions4' with aging, taken together with documentation of undesirable prescribing practices for older patients,", a 47 indicates problems with geriatric therapeutics and the need for improvement. '
Polypharmacy and Adverse Drug Reactions
Despite the difficulty in assessing the appropriateness of drug usage, considerable data suggest that the number of medications prescribed to the elderly may be detrimental to their health. Polypharmacy may contribute significantly to the incidence of both adverse drug events and medical nonccmpliance. Furthermore, drugs that are commonly implicated in drug-drug interactions are prescribed more often in the elderly." Multiple drug therapy is a risk factor for adverse drug reactions (ADRs).~~ About 10% of geriatric admissions to a medical service are associated with A D R s . ~In ~ addition, ,~~ one fifth of admissions attributed to drug-induced illness are due to nonprescription OTC medications.14 Up to 44% of inpatients and 30% of outpatients suffer from ADRs, but there is controversy whether or not age per se is associated with the incidence of ADRs41Undoubtedly, the most consistent risk factor for ADRs is the number of drugs taken by a patient,41and the elderly are prescribed more medications than the young,42especially when h ~ s p i t a l i z e dThe . ~ ~ incidence of ADRs rises exponentially with the number of drugs taken by the patient,41as shown in Figure 1. Possible reasons for this exponential rise include an increase in severity of disease with disease-drug interactions, an increased incidence of drug interactions, and the use of drugs to treat ADRs.
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no. drugs Figure 1. Relationship between the number of drugs taken concurrently and the incidence of adverse reactions. Note the logarithmic scale on the y-axis. (From Nolan L, O'Malley K: Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. J Am Geriatr Soc 36:145, 1988, with permission, Elsevier Science Publishing.)
The potential of polypharmacy for causing ADRs toxicity was well described in a study of anticholinergic Tennessee Medicaid patients." About 7% of ambulatory patients and 10% of nursing home patients in this study took three or more anticholinergic medications. The authors felt that the physicians did not choose selectively among antipsychotic and tricyclic antidepressant drugs to minimize the risk of anticholinergic toxicity when prescribing them concurrently to nursing home patients. Drugs also may be used to treat symptoms caused by ADRs. The elderly are especially prone to acquire a growing list of drugs due to the treatment of ailments that are actually caused by current therapy. The most prevalent example is the use of psychoactive drugs to treat symptoms of insomnia, anxiety, depression, or psychotic symptoms that may well be due to medications already in use. Possible iatrogenic causes for common geriatric syndromes should be considered so that unnecessary evaluation and treatment can be avoided. The use of psychoactive agents in old age can lead to falls, fractures,47 and confusion.33Larson and colleagues found that almost 12% of outpatients undergoing diagnostic evaluation of suspected dementia were found to have . ~ ~ the offending agents were disconADRs causing cognitive i m ~ a i r m e n tWhen tinued, cognition improved in all of these patients. Sedative hypnotics were most commonly associated with cognitive impairment in this study, especially long-acting benzodiazepines. The drugs most commonly associated with ADRs in the elderly include
psychotropic drugs (especially benzodiazepines), antihypertensive medications (including diuretics), digoxin, nonsteroidal anti-inflammatory agents, systemic steroids, theophylline, and ~ a r f a r i n . ' ~It, is ~~ of , interest ~~ to note that most of these drugs have a narrow therapeutic index (small difference between therapeutic and toxic doses) and readily cause dose-related toxicity. Because the elimination of many of these medications is altered with age, older patients are more likely to suffer from drug-induced illness.14 Furthermore, increased sensitivity to the pharmacologic effects (e.g., sedation from benzodiazepines) is also an important contributor to age-related toxicity. Polypharmacy and Noncompliance
A patient's noncompliance or nonadherence to a medical regimen can prevent the physician and patient from reaching the goals of therapy. Nonadherence results in a lack of therapeutic effect and is associated with 5% to 10% of geriatric medical admissions.1627 Several studies suggest that an increased number of medications is associated with higher rates of nonadherence to prescribed medication^.^^,^^, 52 It is unclear whether age is a risk factor itself," because about one third to one half of patients at any age are likely to be nonadherent.ls Nonetheless, polypharmacy seems to play a role in poor medical compliance in older patients. DRUG THERAPY IN AMBULATORY CARE Polypharmacy
Both prescription and nonprescription drug use increase with age in the ambulatory population.* From 76% to 92% of the elderly use at least one prescription or nonprescription and three out of four office visits to primary care physicians are associated with the continuation or initiation of a prescribed m e d i c a t i ~ n Studies .~~ evaluating outpatient medication use in the United States include two national surveys of prescription drug use based on pharmaceutical marketing data4* and two surveys of distinct elderly popula36 The surveys published by Baum and colleagues were generated t i o n ~ . 30, ~% from data recorded from 1971 through 1982.4, After age 40, the number of drug mentions per year increased substantially with age. (Drug mentions are defined as drugs recorded during a physician-patient contact that reach the patient through formal prescription, hospital ordering, dispensing, sampling, recommendation, or administration. It is therefore a relative value for drug usage, not directly signifying the number of prescriptions given.) In 1981, the elderly averaged approximately 11 drug mentions per person per year. Patients aged 65 or older accounted for 38% of drug mentions for all age groups in 1982 compared with 28% in 1979. Therefore, relative drug consumption in older persons has increased in the recent past. Two surveys have evaluated medication use in populations of ambulatory elderly people. The Dunedin Program in Florida was set up in 1975 to screen a population of retirees for hypertension and other undetected health probl e m ~ . The ~ % average ~~ number of medications was 3.2 in 1978 to 1980 and 3.7 in 1983 to 1985. About one half of the drugs were OTC agents. The upper limit
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of the medication number was 24, and the number increased with age within this population over age 65. The most common indications for drug use were hypertension (38%), analgesia (23%), rheumatism (19%), and vitamin use (18%). Cardiovascular drugs, diuretics, and sedative-hypnotics accounted for over 75% of prescription drugs. Analgesics, nutritional supplements, and laxatives were the most commonly used nonprescription items. The Iowa 65 + Rural Health Study was a project intended to define health and health-related problems of a rural, elderly p o p ~ l a t i o nThe . ~ ~ overall mean number of drugs taken per respondent was 2.8 with means of 1.7 and 1.1 for prescription and nonprescription drugs, respectively. The number of prescription drugs ranged from 0 to 9 for women and 0 to 13 for men, whereas the number of nonprescription medications ranged from 0 to 17 for women and 0 to 9 for men. The most commonly used drugs were very similar to those found in the Dunedin Program, and the most frequently stated indications were cardiovascular disease for prescription medications and musculoskeletal disorders for nonprescription drugs. Both surveys found that approximately 75% of the prescribed medications had directions to be taken daily as scheduled, but the schedule for most of the remaining medications was left to the discretion of the patient. A national survey of physician prescribing habits published in 1973 led investigators to conclude that most prescriptions of psychotherapeutic drugs were warranted.43 This conclusion is predominantly based on patient-derived responses without access to medical records. In the United Kingdom, several studies have been performed that suggest that prescribing rates by family practitioners increase with the age of the patients.42A linear relationship between age and polypharmacy also has been documented in ambulatory patients in A ~ s t r a l i aIn . ~this ~ study, patients taking 10 or more medications were found to be significantly older than a random sample of patients taking
Several studies have attempted to characterize drug misuse in elderly ambulatory pop~lations.~, 15, 50 Bernstein and colleagues surveyed residents for 6 months in the San Francisco area for drug misuse classified by three categories: drug use, drug interactions, and redundancy of compounds from a pharmacologic class.9 Drug use was measured by the appropriateness of the dosage prescribed, indication, and actual patient use. The participants were relatively healthy and well educated. All information was obtained from the patients with no input from their physicians; therefore, the indication for a given medication depended on the patient's knowledge of his or her disease. It should be noted that between 8% and 45% of the elderly do not know the correct purpose of their medication^.^^ In 141 study participants, there were 771 drugs being taken (including alcohol), resulting in an average of 5.5 drugs per person. Misuse events occurred in 62 persons (44%) of which two thirds were due to errors in patient drug use (most often underuse). Fifteen patients (11% of the participants) had an error in drug indication; either they reported the wrong indication for a drug or took a drug that was inappropriately prescribed. An aggregate score for all three major categories of drug misuse correlated with the number of drugs taken by the participants. Patients using psychotherapeutic agents were at greater risk for drug misuse.
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Cartwright surveyed patients of general practitioners in the United Kingdom and found that over one third of the patients were taking medications of which their physicians were unaware.15In addition, these patients were more likely to be using medications with inappropriate indications-31% versus 13% for those patients taking only medications of which their physicians were aware. Shaw and Opit also evaluated the supervision of drug therapy in elderly outpatients and found that 19 of 64 patients (30%) taking long-term prescribed medication had no recorded contact with their family doctors for over 6 months.50 Three of these patients were thought to be suffering from drug toxicity. Other studies have found evidence of increased long-term use of benzodiazepines in older patient^.^' The majority of users over age 65 take hypnotics for over 1year.39This level of use is excessive in view of the increased risk of benzodiazepine toxicity with age3*and recommendations to limit use in elderly patient^.^, l7 These studies underscore the need for close supervision of drug therapy in elderly outpatients. DRUG THERAPY IN HOSPITALIZED PATIENTS
Few studies characterize the effect of hospitalization on the number of drugs taken by elderly patients, but those performed in the United States suggest that the average number is unchanged from admission to discharge.', Beers and colleagues found that 40% of all admission medications were discontinued and 45% of all discharge medications were commenced during the ho~pitalization.~ These major changes in the drug regimen of elderly patients while in the hospital may increase the risk of drug misuse after discharge. Discharge from the hospital may be an important time for clinicians to counsel patients to prevent such drug misuse. Gosney and Tallis surveyed 573 elderly patients admitted to a medical service screening for the prescription of contraindicated or interacting Medications both at admission and during hospitalization were analyzed. Contraindicated or adversely interacting drugs were found in 3.2% of all prescriptions. Twenty-four per cent of the patients were affected by this misprescribing, but only 1.2% suffered adverse consequences. The authors believed that two thirds of the undesirable prescriptions were avoidable and another one fifth were probably avoidable. The study might have shown higher rates of misprescribing if the appropriateness of prescriptions was addressed, but this element is much more difficult to assess. For example, a diagnosis or symptom for which drug therapy is administered may not be recorded. Secondly, when a diagnosis is known, it is not always clear whether one drug is more appropriate than another on the basis of efficacy alone. DRUG THERAPY IN LONG-TERM CARE FACILITIES
Although elderly patients requiring chronic care suffer from the same maladies as their counterparts in the community, some diagnoses are more likely to be encountered in the nursing home population. These include dementia, stroke, depression, and urinary incontinence, all of which are conditions that either alter central nervous system function or require medications resulting in this effect. Symptoms of depression, anxiety, insomnia, and agitation are commonly encountered in the nursing home, and more often than not, drugs are prescribed indiscriminately to treat them.
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The drug use of residents or patients in nursing homes or intermediatecare facilities is easily monitored. Several well-performed studies suggest the misuse of medications in this population usually in the form of indiscriminate use or excessive dosing. Psychotherapeutic agents are the major offenders. Borda and colleagues studied drug use in five Boston hospitals, two of which were dedicated to long-term care.13 Age was again found to be associated with the number of drugs administered, but length of stay also correlated with drug intake. A study based on a large sample of nursing home patients covered by Medicaid and Medicare was published by the Office of Long-Term Care of the Department of Health, Education, and Welfare in 1972.44An average of 6.1 drugs were taken per patient. Nearly one half of all residents were prescribed tranquilizers, which included antipsychotic medications and minor tranquilizers. About one third of the patients were prescribed sedative-hypnotic agents, and 12% received two or more psychoactive drugs. Amitriptyline, the tricyclic with the greatest anticholinergic potency, was prescribed to 38% of those patients receiving antidepressants. A more recent survey does not suggest that this pattern of misuse and overuse has improved over the past 20 years.6Twelve intermediate-care facilities in Massachusetts were monitored for medication use over a 1-month p e r i ~ d . ~ Institutions with a significant percentage of admissions from psychiatric hospitals were excluded to target a typical geriatric nursing home environment. Homes with active nurse practitioner prescribing also were excluded to specifically analyze physician prescribing habits. Patients were found to receive an average of 5.5 drugs given at least once during the monthlong surveillance. Nearly 50% of medication orders were for use as needed (pm). Of the one third of patients with orders written for antipsychotic agents, 58% were for regularly scheduled regimens. The remainder were written as asneeded medications, but only 11% were activated during the month of study. Haloperidol and thioridazine were the most commonly prescribed antipsychotic agents, and the median daily dose from various homes was the equivalent of 65 mg chlorpromazine per patient per day. Forty per cent of patients were prescribed a sedative-hypnotic. Of those actually receiving a sedative-hypnotic, the majority (82%) were by regularly scheduled administration. Diphenhydramine hydrochloride constituted one fourth of the administered sleeping agents. Twenty per cent of all patients received benzodiazepines, and one third of them were taking long-acting drugs, such as flurazepam, diazepam, and chlordiazepoxide, usually as a standing order. Fourteen per cent of the patients used antidepressant medications, with amitriptyline the most commonly received. A study by Ray and colleagues reviewed Medicaid prescription records in Tennessee nursing homes over a 1-year period and found similar prescribing practices by physician^.^^ Interestingly, just 14% of the physicians were responsible for 81% of the antipsychotic medications prescribed. Indices of physician prescription of antipsychotics increased as the size of the nursing home practice increased; many times the majority of antipsychotic prescriptions in a nursing home was directed by a single physician. The number of beds in a nursing home also correlated with antipsychotic drug use. At least one study has characterized drug use in a nursing home. Bergman reviewed drug regimens of residents in a community nursing home and evaluated individual medications for appropriate FDA-approved use and their efficacy or need for the designated use.* Only 4% of drugs were prescribed for an unapproved indication. Although the evaluation of efficacy and need was quite subjective, the investigators concluded that about one fourth of the
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prescribed medications were without efficacy or need. As in the study by Ray ,~~ who prescribed the majority of drugs were more and c o l l e a g ~ e sphysicians likely to prescribe inefficacious or unnecessary drugs. Antipsychotic drug use is also widespread in rest homes, with little supervision by physicians or understanding by staff members of the possible side effects from these medication~.~ Extended institutional care appears to be the setting where drug misuse and polypharmacy are most likely to occur in geriatric patients. This increased risk for multiple drug use is associated with patient load, either of the home itself or the physician. Also, in comparison to ambulatory and hospital care, long-term care facilities show the most evidence of inappropriate prescribing, especially with regard to psychotropic medications. Research with more objective measures of appropriate drug prescribing and use is undoubtedly needed in each of these areas of geriatric practice. Factors Leading to Polypharmacy and Drug Misuse
Generally, causes of polypharmacy or drug misuse can be attributed to both the patient and the prescribing physician (Table 1). One of the major influences on drug prescription is the expectation of the patient or physician that medication is required as the definitive solution to an illness. Up to 50% of patients do expect the visit with a physician to result in the prescription of a drug.'= Many times, however, physicians believe that patients expect a prescription even when the patient does not expect one. Usually, the elderly suffer from multiple pathologic conditions, and many of these are amenable to treatment by medical therapy. Unfortunately, these conditions often are chronic in nature, requiring the indefinite use of drugs. Table 1. POTENTIAL CAUSES OF POLYPHARMACY OR DRUG MISUSE
~atiezrelatedfactors 1. Expectation of physician to prescribe medication 2. lnadequate reporting of current medications 3. Failure to complain about symptoms, especially if related to medication 4. Use of multiple, automatic refills without visiting physician 5. Hoarding prior medications 6. Use of multiple pharmacies or multiple physicians 7. Borrowing medications from family members or friends 8. Self-medication with over-the-counter drugs 9. Impaired cognition or vision 10. Economic factors such as high drug costs Physician-related factors 1. Presuming that patients expect prescription of medication 2. Drug treatment of symptoms without sufficient clinical evaluation 3. Treating conditions without setting goals of therapy 4. Communicating instructions in unclear, complex, or incomplete manner 5. Failure to review medications and their possible adverse effects at regular intervals 6. Use of automatic refills without adequate follow-up 7. Lack of knowledge of geriatric clinical pharmacology, leading to inappropriate prescribing practices 8. lnadequate supervision of medications in long-term care 9. Failure to simplify drug regimens as often as possible
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This in itself leads to the accumulation of drug therapy in the elderly. Multiple illnesses also may underlie the association of hospitalization and nursing home placement with polypharmacy. In addition, the severity of illness correlates with the degree of polypharmacy. Upon questioning the patient about exact medication use, physicians may receive an incomplete drug list. Without knowing about pun or OTC medications, the physician may prescribe a drug that the patient is already taking. Aggressive and persistent inquiry into the patient's drug regimen can reduce the risk of duplication. Because of cost, time constraints, or limited mobility, patients may refill a medication many times without visiting the physician for a follow-up. The indication for the medication may resolve, or adverse effects of the medication may occur, leading to the inappropriate use of a once properly prescribed medication. Medicine cabinets may fill with drugs that were discontinued but are kept for possible future need. This provides another opportunity for polypharmacy to occur, with the patient selecting medication for a given problem. With impaired vision or cognition, another drug can be mistaken for the prescribed medication. It is not uncommon for patients to borrow medications from friends or family members for convenience or economic reasons. Finally, patients may obtain their drugs from separate physicians or pharmacies, which reduces the chance of recognizing inappropriate drug regimens. It is easy to understand how such behavior may lead to serious drug interactions or unsuitable treatment. Physicians must realize that these habits occur quite often in patients in their practices. Without an accurate clinical assessment, practitioners may make prescribing errors, including treating the wrong diagnosis, undertreating the correct diagnosis (due to not recognizing its severity), or exposing the patient to unnecessary drug therapy. If it is not recognized that symptoms are due to a current medication, another drug may be added inappropriately to treat the symptom, rather than removing the offending medication. Even if the physician correctly prescribes a medication for a given condition, therapy may be misdirected if goals are not set. Therapeutic end points may be reached without recognition by the physician or patient, resulting in continued therapy that may be unnecessary. This can occur, for example, with anticoagulants treating thrombosis, H,-receptor antagonists treating peptic ulcer disease, or antidepressants treating a major depressive episode. Another common error is to add medications to treat a given condition without an adequate trial of the initial drug. If the physician fails to review medications on a regular basis, he or she may unwittingly allow the accumulation of medications to occur, with the danger of misuse. This problem may be compounded by the use of automatic refills over the telephone without a follow-up of the patient's initial problem. Certain drugs are more commonly implicated in patients with multiple drug therapy, with psychotherapeutic agents, cardiovascular drugs, and diuretics Finally, a lack of knowledge about the principles of geriatric leading the list.28,36 clinical pharmacology can lead to inappropriate prescribing practices, such as excessive dosage, toxic drug combinations, and inappropriate drug selection. PHYSICIAN APPROACHES TO PREVENT POLYPHARMACY AND DRUG MISUSE
To avoid the perils of polypharmacy and drug misuse, the physician and patient must communicate effectively. The achievement of efficient and appropriate medical management is difficult, of course, and requires patience and
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diligence on the part of both the physician and the patient. Table 2 includes 10 recommendations to limit polypharmacy. The benefits of reducing drug use have been illustrated in a study from Israel that compared drug use and ADRs in hospitalized patients from two separate 3-year periods of time.34An 11% reduction in the average number of drugs prescribed per patient from 1969 to 1972, to 1973 to 1976 correlated with a 60% decrease in the incidence of adverse effects. No other studies are available to document the effects of lowering drug use in outpatients or the elderly, in particular. The best defense against polypharmacy is to consistently prescribe the least number of drugs possible in a given patient. No prescription or nonprescription medication should be used without scrutinizing the absolute need and possible adverse effects of the medication. Prescribing drugs for symptoms without a diagnosis should be discouraged, although obtaining an exact diagnosis is not always possible. Frank discussion with the patient about the need to limit medications can be helpful, and this conversation may establish a rationale for sometimes trying nonpharmacologic means that are understood by the patient. Ample time should be included in office visits so that detailed verbal and written instructions may be given." Increased clarity of instructions given to patients and discussion of possible adverse effects may help patients understand symptoms targeted for treatment and symptoms due to drug therapy. This alone may diminish the number of drugs used by a patient. Physicians should ensure that their patients are able to distinguish different medication vials, suggesting the use of such identification markings as color codes, if necessary. Patients should be given containers they can easily open and close. ~edicationsprescribed for as-needed use should also be restricted, with regular monitoring of the frequency of their actual use. Problems may arise with increased frequency of use. For example, occasional use of a nonsteroidal anti-inflammatory agent in a hypertensive patient may be harmless, but daily use of this medication may offset control of the patient's blood pressure. The goals of treatment of symptoms using as-needed medication should be mutually agreed upon. This may limit pm use and inappropriate self-treatment by the patient. A useful practice to improve compliance in the elderly is to simplify the drug regimen. Not only should the physician prescribe few drugs, but the
Table 2. GUIDELINES FOR EFFECTIVE PRESCRIBING TO LIMIT POLYPHARMACY AND DRUG MISUSE IN OLDER PERSONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Ask patients to bring in all medicines to office. Restrict prn prescribing for minor symptoms. Select a drug that may treat more than one condition. Check for contraindications and potential drug interactions before prescribing a drug. Start with low doses and titrate the dose according to effect. Monitor for adverse reactions. Educate the patient about the drug therapy. Routinely check and encourage compliance. Periodically simplify the therapeutic regimen and stop drugs if possible. Place realistic limits on the duration of drug prescribing.
Adapted from Cusack B: Polypharmacy and clinical pharmacology. In Beck JC (ed): Geriatrics Review Syllabus. New York, American Geriatrics Society, 1989, p 127, with permission.
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drugs prescribed should require as few daily doses as possible. For example, antihypertensive agents that can be used once or twice daily should be favored over agents requiring three or four daily doses, given equal efficacy and risk of adverse effects. This practice is becoming increasingly possible as more longer-acting agents become available. Cost savings also should accrue from enhanced compliance that may occur with fewer drug doses. Simplification of medication regimens (including OTC medications) should be a part of each patient visit. When possible, physicians should choose the least expensive medications to avoid overburdening the elderly, fixed-income patient with high drug costs, a factor known to reduce ~ o m p l i a n c e . ~ ~ Communication with the patient concerning drug indications, doses and the need for compliance can be greatly enhanced if the patient routinely brings all medications on every office visit. Instead of reviewing the patient's problem list separately, complaints can be elicited at the time of drug review, using the patient's medications to facilitate comprehensive assessment in a concise fashion. Care should be taken to efficiently match drug therapy with diseases. Redundant medications treating the same problem should be discontinued. Treatment of more than one disorder with a single medication, such as coronary artery disease and hypertension with a calcium channel blocker, can increase the efficiency of drug therapy. Once drug therapy has been started, efforts should be directed towards limiting the duration of its use. If a targeted goal of therapy has been reached, the responsible agent should be discontinued. When treating chronic ailments in the elderly, it is tempting to continue therapy even when specific signs or symptoms of disease activity are no longer evident. Where the indication is in doubt due to the absence of signs or symptoms, an attempt should be made to reduce the dose or stop the medicine while monitoring for the return of disease activity. For example, digoxin often can be discontinued in sinus rhythm in ambulatory elderly individuals with a history of congestive heart failure. In one study it was found that all 30 patients taking digoxin in this manner were able to discontinue it without clinical evidence of worsening heart failure.z2Just as it is important to define therapeutic end points for beginning a medication, it is equally important in a trial of drug therapy to define signs or symptoms whose return suggests that the drug is necessary. There are many other factors to consider to prevent polypharmacy and drug misuse. Repeat prescriptions should be limited, especially for pun medications. Indications such as insomnia, musculoskeletal pain, or constipation should be reviewed before a vicious cycle of chronic and inappropriate pharmacologic therapy is begun. The physician should recommend use of only one pharmacy. Patients under the care of other physicians are more likely to receive redundant medications; therefore, the primary care physician should be notified of any additional medications at the time they are prescribed. Consultants should be encouraged to allow the primary care physician to actually prescribe the medication. Multiple refills over short periods of time should signal drug misuse, such as hoarding, lending, or illicit selling, and they should be addressed by the physician. Other Practical Methods to Reduce Polypharmacy and Drug Misuse
Other recommendations have been made for reducing drug misuse in the elderly beyond the patient-physician interaction. The increased use of clinical
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pharmacists has been shown to reduce drug consumption with cost savings in a nursing home.54Pharmacists can enhance compliance by providing more comprehensive instructions to patients as well as reducing adverse effects by increased surveillance of drug regimen^.'^ Home health aides and visiting nurses also can assist in this capacity. There have been novel methods for increased monitoring such as the use of prescription booklets12and the use of computerized medication records that signal possible drug interaction^.^', 53 In the authors' Veterans Affairs Medical Center where the patient's medications are dispensed by a central pharmacy, the patient's record is supplemented by a drug profile that is updated at each visit. This profile includes the list of medications with dosage, number, date of last refill, and the option of discontinuing or refilling the prescription. Pertinent laboratory information also is included. Data on the effectiveness of this method to reduce drug use and prevent misuse are not available, but clinical experience suggests that it is helpful. Educational Methods. The need for knowledge of geriatric clinical pharmacology is obvious for all practitioners who evaluate and treat older patients. This area has been ignored in the past but is now slowly gaining attention and corrective action at the level of medical school education. It has been shown that office-based physician education programs can be employed to reduce drug usage by implementing academically based "detailix~g."~Another controlled outpatient trial including patients (mean age 61.2) taking 10 or more drugs resulted in a significant reduction of prescriptions at 4 months by means of a combination of written reminders and educational instructions to physic i a n ~By . ~ 12 ~ months, however, there was no difference between the control and intervention groups. Also, drug manufacturers will be required by the Food and Drug Administration to include information concerning use by the elderly in the package insert of any new product. It is hoped that an increase in the availability of information and attention to proper drug use in the elderly will help improve physician prescribing habits, particularly in the nursing home setting. LEGISLATIVE REGULATION OF DRUG USE
As part of the Omnibus Budget Reconciliation Act (OBRA) in 1987, federal legislation has established regulations for the use of antidepressants, anxiolytic and hypnotic agents, and neuroleptics in Medicare- and Medicaid-certified nursing homes.29Table 3 lists irregularities in the use of these agents that should be reported to the attending physician or director of nursing by a licensed pharmacist. Implementation of these guidelines for psychotherapeutic drug monitoring began in October 1990. A recent study of neuroleptic drug use in 60 nursing homes was conducted by reviewing extant data from 1976 to 1985.23One half of neuroleptic use was found to be "ineligible" according to Health Care Financing Administration guidelines. In those cases, antipsychotic drugs were used without specific psychiatric diagnoses or documentation of psychotic or agitated features of dementing illness. Therefore, it appears that enforcement of the guidelines will lead to greater scrutiny of psychoactive drug use in Medicare and Medicaid nursing home residents. As a part of the OBRA legislation in 1990, a national drug utilization review (DUR) program is to be implemented for the review of drug use in all Medicaid patients by October 1992." Each state will be required to form a DUR board that includes physicians and pharmacists. DUR will be conducted both retro-
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Table 3. IRREGULARITIES IN DRUG USE IN NURSING HOME RESIDENTS DEFINED BY THE HEALTH CARE FINANCING ADMINISTRATION Drug Class
Irregularities
Antidepressants
Use of antidepressants for less than 3 days More than two changes of an antidepressant within a 7-day period Use of antidepressants in excess of listed daily maximal doses
Anxiolytics/hypnotics
Continuous use of hypnotic drugs for more than 30 days Use of two or more hypnotic drugs at the same time Hypnotic or anxiolytic drugs administered in excess of the listed maximum doses
Neuroleptics
Use of antipsychotics for less than 3 days, with the exception of intermittent use to control acute episodes of agitation Use of two or more antipsychotic drugs at the same time Use of anticholinergic therapy with antipsychotic drugs in the absence of extrapyramidal side effects Neuroleptic agents administered in excess of the listed maximum doses
Adapted from Health Care Financing Administration: Medicare and Medicaid: Requirements for long-term care facilities. Federal Register 54:5316, 1989.
spectively and prospectively. Retrospective DUR will be performed by the review of prescriptions with special emphasis on costly and high-risk drugs. Prospective DUR will be initiated by pharmacist screening of current prescriptions in order to inform physicians of therapeutic duplication or drug interactions. Although DUR will become law, there is no rigorous scientific evidence that DUR actually improves health care and lowers expenditures; however, it does appear a reasonable starting point in the attempt to formally ensure improved prescribing practices.
SUMMARY
Polypharmacy, the inappropriate use of multiple drug regimens, has a significant impact on the health of elderly individuals. Drug use increases with age, but suitability of therapy is sometimes difficult to define. In ambulatory and hospital care, there is some documentation of poor prescribing practices by physicians and drug misuse by patients. Sound data suggest that polypharmacy and drug misuse are highly prevalent in long-term care facilities. Psychotherapeutic agents are the most commonly misused drugs by physicians in this setting. Polypharmacy is associated with factors such as the number and severity of illnesses, hospitalization, number of physicians seen, number of pharmacies used, and possibly increased patient age. Methods to prevent polypharmacy and drug misuse have not been well studied. There is a need for intensive research to define effective methods to strengthen prescribing practice of physicians for elderly patients, to promote cooperation among health care personnel in ensuring optimal drug use by patients, and to enhance the role of patients as responsible partners in drug therapy. The authors are confident, however, that drug misuse and polypharmacy can be reduced in
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older persons by the use of current knowledge of risk factors associated with polypharmacy and by improved communication between the physician and patient. References 1. Alexander N, Goodwin JS, Currie C: Comparison of admission and discharge medications in two geriatric populations. J Am Geriatr Soc 332327, 1985 2. Avorn J, Dreyer, P, Connelly K, et al: Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study. N Engl J Med 320:227, 1989 3. Avorn J, Soumerai SB: Improving drug-therapy decisions through educational outreach-a randomized controlled trial of academically based "detailing". N Engl J Med 3081457, 1983 4. Baum C, Kennedy DL, Forbes MB, et al: Drug use and expenditures in 1982. JAMA 253:382, 1985 5. Baum C, Kennedy DL, Forbes MB, et al: Drug- use in the United States in 1981. JAMA 251:1293, 1984 6. Beers MH, Avorn J, Soumerai SB, et al: Psychoactive medication use in intermediatecare facility residents. JAMA 260:3016, 1988 7. Beers MH, Dang J, Hasegawa J, et al: Influence of hospitalization on drug therapy in the elderlv. 1 Am Geriatr Soc 37679, 1989 8. Bergman HD: Prescribing of drugs i n a nursing home. Drug Intel1 Clin Pharmacy 9:365, 1975 9. Bernstein LR, Folkman S, Lazarus RS: Characterization of the use and misuse of medications by an elderly, ambulatory population. Med Care 27654, 1989 10. Blazer DG: Alcohol and drug problems in the elderly. In Busse EW, Blazer DG (eds): Geriatric Psychiatry. Washington, American Psychiatric Press, 1989, p 489 11. Blazer DG, Federspiel CF, Ray WA, et al: The risk of anticholinergic toxicity in the elderly: A study of prescribing practices in two populations. J Gerontol38:31, 1983 12. Bliss MR: Prescribing for the elderly. BMJ 283:203, 1981 13. Borda I, Tick H, Slone D, et al: Studies of drug usage in five Boston hospitals. JAMA 202:506, i967 14. Caranassos G. Stewart RB. Cluff LE: Drutl " induced illness leading " to hosvitalization. JAMA 228:713, 1974 15. Cartwright A: Medicine taking by people aged 65 or more. Br Med Bull 46:63, 1990 16. Col N, Fanale JF, Kronholm P: The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 150:841, 1990 17. Consensus Conference. Drugs and insomnia. JAMA 251:2410, 1984 18. Cooper JK, Love DW, Raffoul PR: Intentional prescription nonadherence (noncompliance) by the elderly. J Am Geriatr Soc 30:329, 1982 19. Cusack B: Polypharmacy and clinical pharmacology. In Beck JC (ed): Geriatrics Review Syllabus. New York, American Geriatrics Society, 1989, p 127 20. Cypress BW: Drug utilization in office visits to primary care physicians: National Ambulatory Medical Care Survey, 1980. Department of Health and Human Services Publication (PHs) 82-3320. Washington, Public Health Service, 1982 21. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med 100:258, 1984 22. Filner B, Williams TF: Health promotion for the elderly: Reducing functional dependency. In Hamburg DS, Nightingale EO, Kalmar V, et a1 (eds): Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, Background Papers. DHEW Publication No 79-55071A. Washington, US Government Printing Office, 1979, p 365 23. Fleg JL, Gottlieb SH, Lakatta EG: Is digoxin really important in treatment of compensated heart failure? A placebo-controlled crossover study in patients with sinus rhythm. Am J Med 73:244, 1982 24. Garrard J, Makris L, Dunham T, et al: Evaluation of neuroleptic drug use by nursing
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54. Stewart RB, Cluff LE: A review of medication errors and compliance in ambulant patients. Clin Pharmacol Ther 13:463-468, 1972 55. Tallis RC, Edmond ED, O'Halloran A: A computer system to prevent prescriptions of contraindicated drugs. Br J Pharmaceut Pract 6:223, 56. Thompson JF, McGhan WF, Ruffalo RL: Clinical pharmacists prescribing drug therapy in a geriatric setting: Outcome of a trial. J Am Geriatr Soc 32:154, 1984 57. Vestal RE, Jue SG, Cusack BJ: Increased risk of adverse drug reactions in the elderly: Fact or myth? In O'Malley K, Waddington JL (eds): Therapeutics in the Elderly. Amsterdam, Elsevier Science Publishers, 1985, p 97 58. Whitcup SM, Miller F: Unrecognized drug dependence in psychiatrically hospitalized elderly patients. J Am Geriatr Soc 35:297, 1987 59. Williamson J, Chopin JM: Adverse reactions to prescribed drugs in the elderly: A multicentre investigation. Age Ageing 9:73, 1980
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