Americans increasingly come into contact with powerful medicines that possess great potential both to heal and to harm. Used correctly, prescribed medications and those purchased by consumers directly can be the single best means of staying healthy, getting better, and controlling chronic health problems. The right medication, in the right amount, administered in the right way to the right patient can produce a "medical miracle." As a cost-effective alternative to many surgeries or to loss of health and independence, pharmacologic agents are a genuine social good and are particularly useful given the challenge of delivering health care to an increasingly older population in the United States. For older patients with multiple diseases, properly managed pharmacotherapy can help them live longer and live better.
However, medications also have the potential to cause serious harm on a wide scale. Several recent studies point to the severity of the problem. Although these studies examined medication use in Americans of all ages, given the special vulnerabilities of older people to medication-related problems, it is reasonable to expect that older people carry a disproportionate burden of adverse outcomes due to medication therapy.
An April 1998 report in the Journal of the American Medical Association (JAMA) showed that even when medications are taken as intended, some adverse reactions occur severe enough to cause disability and even death. Although the JAMA study did not focus specifically on older people, it estimated that 106,000 fatal adverse drug reactions occur annually. If adverse reactions to medications were classified as a distinct disease, it would rank as the fifth leading cause of death in the U.S.
The cost of medication-related problems in all age groups approaches $85 billion annually. The vast majority of these costs ($76.6 billion) occur in people living in the community, while direct costs of medication-related problems amount to $4 billion in hospitalized patients and another $4 billion in nursing facility residents.
Two major studies cited in this report show that older Americans are especially vulnerable to dangerous medication interactions and medications or doses that are inappropriate because of age or disease burden. A 1996 General Accounting Office report and another in November 1997 by the Department of Health and Human Services Office of Inspector General found approximately one-fifth of older patients are given medications considered by medical experts to be unsuitable for older people because of the high risk of unintended harm.
Even short of fatal side effects and toxicities, medications can cause disabilities, impair function, cause confusion, and reduce independence in older persons. Each year medications are implicated in tens of thousands of auto accidents, home injuries, falls, and fractures. Nonetheless, medication-related problems continue to be under-studied and poorly understood. They constitute a "silent epidemic" in America.
Relatively little research has been done to assess the full extent of the costs, both human and economic, of medication-related problems in the older population. There is an urgent need for further studies of medication effects in the over-65 and even more urgently in the over-85 population. Without more information — especially on medications intended to treat conditions commonly seen in older people — medication-related problems in the older population in the U.S. will only increase.
People over age 65 are especially vulnerable to medication-related problems, due to the number of medications they take and the biologic changes of aging and disease. They are the greatest consumers of prescriptions and over-the-counter medications. They are more likely to be taking multiple medications at the same time for various health problems. Changes in physiology places older people at greater risk of adverse reactions when taking some medications. Older people are more likely to suffer hospitalization or psychiatric problems as a result of adverse medication reactions, and are at greater risk of memory loss, hip fracture, or automobile-related injuries as a result of adverse medication effects. Among older persons, visual or cognitive impairment can combine with psychological, social, and care-giving needs to interfere with the proper use of medications.
More education of health care professionals about medication effects in older persons could reduce the risks of adverse effects. In addition, there is evidence that problems in the organization of care in some health systems result in medication use patterns that are especially dangerous to older patients. Still, there are serious gaps in the knowledge base that need to be filled by further study. Among these gaps are:
While the impact of medication-related problems in the elderly population is serious, a large body of research has shown that these problems are largely preventable. Medication-related problems can be prevented and avoided through better knowledge about appropriate medication use in the older population; through increased provider, patient, and care-giver education; through improvements in systems tracking medication use and outcomes in older people; and through new strategies to identify those older persons most at risk for medication-related problems.
The Alliance for Aging Research has prepared this report to stimulate debate and action on the issues surrounding medication-related problems in older people. The Alliance convened an expert panel from the fields of geriatrics, nursing, health care economics, and pharmacy. The expert panel developed recommendations for researchers, health care organizations, and public policy makers. These recommendations are intended to encourage steps that will reduce health care costs, needless hospitalizations, additional disabilities, and lives lost due to medication-related problems in older people. A summary of the recommendations follows:
Compile and disseminate a list of medications considered potentially inappropriate for use in older persons and mandate that the list be used as a screening tool.
Provide geriatrics-relevant labeling information for over-the-counter medications.
Fund and encourage research on medication-related problems in older persons to determine which medications are most troublesome and which patients are most at risk.
Provide incentives to pharmaceutical manufacturers to better study medication effects in the frail elderly and oldest old in pre- and post-marketing clinical trials.
Establish mechanisms for data collection, monitoring, and analysis of medication-related problems by age group.
Encourage health care professionals’ competency in geriatric pharmacotherapy.
Direct Medicare Graduate Medical Education dollars to training in geriatric pharmacotherapy.
Fund and provide education and resources for care-givers providing medication assistance to older people.