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Preventing adverse drug events in Older
Adults
Newswise — Adverse drug
events are more common in older adults
because they are prescribed more drugs and
are effected differently by these drugs than
their younger counterparts.
A review article
written by Tufts University School of
Medicine clinicians, published in
American Family Physician, summarizes
steps that physicians and other healthcare
providers can take to avoid overuse, misuse,
and underuse of medication in older adults.
“About one in three
older persons taking at least five
medications will experience an adverse drug
event each year, and about two-thirds of
these patients will require medical
attention.
Approximately 95
percent of these reactions are predictable,
and about 28 percent are preventable,” cite
the authors, Cung Pham, MD, fellow in the
Tufts University Family Medicine Residency
at Cambridge Health Alliance’s Malden Family
Medicine Center, and Robert Dickman, MD,
Jaharis Family Chair of Family Medicine at
Tufts University School of Medicine.
Pham and Dickman
summarize interventions for reducing
inappropriate prescriptions as follows,
while noting that there is limited research
to support clear interventions.
--Avoiding misuse of
medications
If a drug is listed on the Beers Criteria, a
widely-adopted list of drugs that labels
medications as “potentially inappropriate”
for older persons or for older persons with
specific medical conditions, the authors
report that physicians can avoid those drugs
apt to cause a severe adverse drug event
simply by selecting alternatives.
If there is no
alternative, the best choice for a necessary
drug is to start at the lowest effective
dose and, when possible, discontinue the
drug.
--Avoiding overuse of
medications: polypharmacy and overdosing
Polymedicine describes the use of an
increasing number of drugs related to an
increasing number of medical problems, while
polypharmacy is defined as inappropriate use
of multiple drugs.
While there is no
standard marker for when a patient’s
polymedicine list becomes polypharmacy,
“increasing the number of medications
increases the risk of drug-drug interactions
and adverse drug events,” says Pham, “and
reviews of medications should be routine.”
The “brown-bag” method,
where patients bring all of their
medications in a brown bag to the
physician’s office, can lead to dropping at
least one medicine in 20 percent of patients
and a change in medication in 29 percent of
patients.
Pham and Dickman
highlight other methods, from systematic
reviews, found to be effective in reducing
inappropriate prescriptions.
These include using a
team approach involving pharmacists and
nurses to evaluate drug regimens and suggest
changes; exploring nonpharmacologic
treatment options, such as exercise or
cognitive therapy; and using advances in
technology, including personal digital
assistants and computerized alerts with
health records, to reduce adverse events.
--Avoiding underuse of
medication: underprescribing and
nonadherence
“Despite concerns about overprescribing,
many conditions remain underdiagnosed or
undertreated,” write the authors.
“Ascribing all symptoms
to degenerative disease or old age will
potentially miss treatable conditions,”
including heart disease, depression,
osteoporosis and pain.
“Nonadherence (or
noncompliance) is a complex phenomenon
determined by a variety of issues, including
physician-patient communication, cognitive
decline, and the cost of medication,” write
the authors.
Most interventions
focus on education or on cognitive aids, but
the combination is more promising. In some
cases, cost is a factor that will not be
mentioned unless the physician inquires.
“Simply asking
whether a patient plans to use his or her
prescription may open a dialogue about the
costs of a patient’s prescriptions,” say
Dickman, senior author.
“Sometimes there are
alternatives, including prescriptions for
generic substitutes or identifying a
combination drug that may be less expensive
than two individual drugs.”
“Much drug therapy in
older adults is to prevent illnesses by
decreasing risks that will never affect
them,” writes Allen Shaughnessy, PharmD,
associate director of the Tufts University
Family Medicine Residency, in an
accompanying editorial.
Physicians will benefit
by finding “the balance between the
potentially lifesaving benefits of
medication and the life-threatening
complications of these drugs.”
The Tufts University
Family Medicine Residency at Tufts
University School of Medicine is based at
Cambridge Health Alliance’s Malden Family
Medicine Center.
Pham CB and Dickman RL.
American Family Physician. 2007
(December);76 (12):1837- 1844. “Minimizing
Adverse Drug Events in Older Patients.”
Shaughnessy AF.
American Family Physician. 2007
(December);76 (12):1768.“Prescribing for
Older Adults: Finding the Balance.”
About Tufts University
School of Medicine
Tufts University School of Medicine and the
Sackler School of Graduate Biomedical
Sciences at Tufts University are
international leaders in innovative medical
education and advanced research.
The School of Medicine
and the Sackler School are renowned for
excellence in education in general medicine,
special combined degree programs in
business, health management, public health,
bioengineering and international relations,
as well as basic and clinical research at
the cellular and molecular level.
Ranked among the top in
the nation, the School of Medicine is
affiliated with six major teaching hospitals
and more than 30 health care facilities. The
Sackler School undertakes research that is
consistently rated among the highest in the
nation for its impact on the advancement of
medical science.
