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Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS ASCP Director of Policy & Advocacy. “Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population”.

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Principles of Drug Use:

Prescribing for the Elderly

Thomas R. Clark, RPh, MHS

ASCP Director of Policy & Advocacy


“Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population”

Avorn, J. Medication use and the elderly: current status and opportunities. Health Affairs. 1995(Spring):278-86.

importance of geriatric drug therapy
Aging of population

High use of drugs in elderly

Prevalence of medication therapy problems

Shift from nursing facility to home and community-based services

Importance of geriatric drug therapy
the proportion of older americans is growing

Source: Health, United States, 2005. Figure 2.

aging trends
Those over 85 will grow by 106%, from 3.4 million in 2000 to close to 7 million by 2020

By 2050, nearly 20 million Americans will be age 85 or over

Aging Trends
aging trends1
About half those age 85 and over need assistance with daily living

About half those age 85 and over have some degree of cognitive impairment

About one out of five live in NF

Aging Trends
rx use in the us
Rx Use in the US

Source: Center on an Aging Society, Georgetown University, 2000

rx use and seniors
1998 - 34.4% of 2.733 billion Rxs

933 million Rxs for seniors

Rx Use and Seniors

US Population

Rxs for seniors


Rxs for non-seniors

Source: IMS 1998

rx use and seniors1
In 2005, seniors comprised 12.5% of the population and consumed 37% of prescriptions

By 2020, seniors will comprise 16% of the population and will consume 49% of prescriptions

Source: US Census, IMS National Prescription Audit, July 2005

Rx Use and Seniors
rx use and seniors2
Typical NF Resident

75-85+ years of age

Average number of routine prescription medications: 8.1

Average number of PRN prescription medications: 3.2

Percent of residents receiving 9+ routine medications per day: 41.1

Rx Use and Seniors
rx use and seniors3
Assisted Living

13 medications/resident

Rx Use and Seniors
medication therapy problems
Polypharmacy: drug use without indication

Undertreatment: indication without drug use

Dose too low

Dose too high

Adverse drug reaction

Medication Therapy Problems
medication therapy problems1
Drug interaction

Inappropriate drug

Lack of adherence or compliance

Medication error

Medication Therapy Problems
“As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral”

Jerry Avorn, quoted in Arch Intern Med 164:1957–59

“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”

Sir William Osler, in H. Cushing, Life of Sir William Osler (1925)

“One of the first duties of the physician is to educate the masses not to take medicine.”

Sir William Osler, Aphorisms from his Bedside Teachings (1961) p. 105.

“I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”

Oliver Wendell Holmes, 1860

“Over the past few years, the pendulum has swung from concern about the risks of excessive prescribing of inappropriate or unnecessary drug therapy to concerns about the consequences of underprescribing of potentially beneficial therapies to seniors (65 years and older).”

Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA, 1999;282:113-5

examples of undertreatment
Pain management

Pneumococcal and flu vaccine


Secondary heart attack prevention

Examples of Undertreatment
quality of health care for older adults
Vulnerable elders receive about half of recommended care

Preventive care suffers the most

Physicians often fail to prescribe recommended medications

Care for geriatric conditions (e.g. falls, incontinence) is poorer than care for medical conditions such as hypertension

Source: Rand Research

Quality of Health Care for Older Adults
adverse effects
“Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”

Gurwitz J, Monane M, Monane S, Avorn J. Polypharmacy. In: Morris JN, Lipsitz LA, Murphy K, et al. Quality Care in the Nursing Home. St. Louis, MO: Mosby Year Book;1997:13-25.

Adverse Effects
adverse drug events ade
Rate of ADEs requiring an ER visit for persons 65 and over is more than twice the rate for persons under age 65

Rate of ADEs requiring hospitalization is nearly seven times greater for persons age 65 or over versus persons under age 65.

Source: JAMA 2006;296(15):1858–66

Adverse Drug Events (ADE)
inappropriate drugs
Antibacterial to treat a viral infection

“Beers medications” - medications considered potentially inappropriate for older adults based on risk versus benefit (expert consensus)

Ref: Arch Intern Med 2003;163:2716–24

Inappropriate Drugs
inappropriate drugs1
21% of older adults take one or more medications categorized by Beers as generally inappropriate

Source: Arch Intern Med 2004;164:1621–25.

Inappropriate Drugs
medication adherence
Social and economic factors

Health care system-related factors

Condition-related factors

Therapy-related factors

Patient-related factors

Medication Adherence
medication adherence1
More than 10% of hospital admissions for older adults may be due to nonadherence

Nonadherence costs the U.S. health care system $100 billion per year

Source: Vermiere E. et al. Patient adherence to treatment: three decades of research, a comprehensive review. J Clin Pharm Ther 2001;26:331–42.

Medication Adherence
principles of drug use
Ask: Is treatment warranted?

Are nonpharmacologic alternatives available?

Consider risk vs. benefit of drug therapy

Establish goals of therapy

Quality of care

Quality of life

Functional status

Principles of Drug Use
goals of therapy
“Is it quality of life or quantity of life? Truthfully, if my destiny is to feel great now and maybe shorten my future, I’d rather feel well now.”

Source:Nancy Richardson, 60, of Wayland, Mass., referring to risk versus benefit of estrogen therapy. Quoted in New York Times, December 18, 2006 article by Gina Kolata, “Breast Cancer News Brings a Range of Reactions”

Goals of Therapy
principles of drug use1
Consider the whole person, not just one disease or one drug

Be aware of assumptions behind clinical practice guidelines

Disease management may not be adequate or appropriate if multiple chronic diseases are present

Principles of Drug Use