Optimizing Medication Use in Older Adults

Abstract

Older adults often take multiple medications, with almost 20% of adults aged >65 years taking ≥10 medicines,1Slone Epidemiololgy Center at Boston UniversityPatterns of medication use in the United States.https://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdfDate: 2006Date accessed: June 5, 2018Google Scholar,2Steinman M.A. Hanlon J.T. Managing medications in clinically complex elders: there's got to be a happy medium.JAMA. 2010; 304: 1592-1601Crossref PubMed Scopus (237) Google Scholar primarily because chronic diseases and multimorbid conditions are more common in older adults. Multiple medication use in older adults introduces challenges for medication management because it is associated with lower adherence and the increased potential for drug–drug interactions.3Field T.S. Gurwitz J.H. Harrold L.R. et al.Risk factors for adverse drug events among older adults in the ambulatory setting.J Am Geriatr Soc. 2004; 52: 1349-1354Crossref PubMed Scopus (222) Google Scholar Compounded with these issues, older adults are also more susceptible to adverse drug reactions due to changes in body physiology and renal and hepatic clearance and reserves,4Mather G.G. Levy R.H. Pharmacokinetics of polypharmacy: prediction of drug interactions.Epilepsy Res Suppl. 1996; 11: 113-121PubMed Google Scholar particularly when multiple medicines are involved.5Gurwitz J.H. Field T.S. Harrold L.R. et al.Incidence and preventability of adverse drug events among older persons in the ambulatory setting.JAMA. 2003; 289: 1107-1116Crossref PubMed Scopus (1318) Google Scholar,6Steinman M.A. Landefeld C.S. Rosenthal G.E. Berthenthal D. Sen S. Kaboli P.J. Polypharmacy and prescribing quality in older people.J Am Geriatr Soc. 2006; 54: 1516-1523Crossref PubMed Scopus (379) Google Scholar Age-related changes include variations in absorption (eg, gastric changes in clearance, acidity, motility), distribution (eg, adipose tissue distribution, vascular changes that affect blood flow to liver and kidneys), metabolism (eg, changes in half-lives, active metabolites, clearance), and excretion (eg, changes in kidney function, tubular secretion, resorption).7Rowe J.W. Andres R. Tobin J.D. Norris A.H. Shock N.W. The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study.J Gerontol. 1976; 31: 155-163Crossref PubMed Scopus (878) Google Scholar,8Tan J.L. Eastment J.G. Poudel A. Hubbard R.E. Age-related changes in hepatic function: an update on implications for drug therapy.Drugs Aging. 2015; 32: 999-1008Crossref PubMed Scopus (44) Google Scholar These changes potentiate adverse drug reactions, requiring adjustments in medication use and dosing to optimize safety and use.9Wallace E. McDowell R. Bennett K. Fahey T. Smith S.M. Impact of potentially inappropriate prescribing on adverse drug events, health related quality of life and emergency hospital attendance in older people attending general practice: a prospective cohort study.J Gerontol A Biol Sci Med Sci. 2017; 72: 271-277Crossref PubMed Scopus (70) Google Scholar,10Wimmer B.C. Cross A.J. Jokanovic N. et al.Clinical outcomes associated with medication regimen complexity in older people: a systematic review.J Am Geriatr Soc. 2017; 65: 747-753Crossref PubMed Scopus (79) Google Scholar Previous studies have found that adverse drug events in older adults may lead to emergency department visits, hospitalizations, and other undesirable events. Recognizing the potential adverse effects of medication use in older adults, researchers and clinicians have developed a number of evidence-based guidelines to improve prescribing in older adults such as the START/STOPP criteria (Screening Tool to Alert to Right Treatment/Screening Tool of Older Persons' Prescriptions)11Blanco-Reina E. Garcia-Merino M.R. Ocana-Riola R. et al.Assessing potentially inappropriate prescribing in community-dwelling older patients using the updated version of sTOPP-START criteria: a comparison of profiles and prevalences with respect to the original version.PLoS One. 2016; 11e0167586Crossref PubMed Scopus (24) Google Scholar and the Beers criteria.12American Geriatrics SocietyUpdated Beers criteria for potentially inappropriate medication use in older adults.J Am Geriatr Soc. 2015; 63: 2227-2246Crossref PubMed Scopus (1735) Google Scholar These criteria identified potentially inappropriate medications more likely to have adverse effects in older adults, in which the risks may outweigh their benefits, thereby cautioning clinicians to avoid their use. Examples include the use of antipsychotic medications for behavioral symptoms in dementia and medications with strong anticholinergic activities and limited clinical benefit. In this Specialty Update, two articles used these criteria to characterize medications in the inpatient setting and the emergency department setting to identify potential adverse effects associated with their use13Anderson B.J. Liu M. Cui X. et al.Adverse outcomes associated with inpatients administration of Beers list medication following total knee replacement.Clin Ther. 2020; 42: 592-604Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and suggest tools to help clinicians select alternatives.14Burningham Z. Jackson G.L. Kelleher J. et al.The enhancing quality of prescribing practices for older veterans discharged from the emergency department (EQUIPPED) potentially inappropriate medication dashboard: a suitable alternative to the in-person academic detailing and standardized feedback reports of traditional EQUIPPED?.Clin Ther. 2020; 42: 573-582Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Another challenge for medication use in older adults is that clinical trials that examine effectiveness and efficacy of medications often lack representation of older adults, particularly those with multiple, complex chronic diseases in whom medication use is more likely.15Herrera A.P. Snipes S.A. King D.W. et al.Disparate inclusion of older adults in clinical trials: priorities and opportunities for policy and practice change.Am J Public Health. 2010; 100: S105-S112Crossref PubMed Scopus (140) Google Scholar This creates challenges for the management of older adults with complex chronic illness in whom the uncertainty of whether medications achieve the level of effectiveness and health benefits in outcomes seen in trials could be inferred.16Mody L. Miller D.K. McGloin J.M. et al.Recruitment and retention of older adults in aging research.J Am Geriatr Soc. 2008; 56: 2340-2348Crossref PubMed Scopus (199) Google Scholar Large trials for treatment of common chronic disease such as hypertension17Beckett N.S. Peters R. Fletcher A.E. et al.Treatment of hypertension in patients 80 years of age or older.N Engl J Med. 2008; 358: 1887-1898Crossref PubMed Scopus (2310) Google Scholar,18Wright Jr., J.T. Williamson J.D. Whelton P.K. et al.A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373: 2103-2116Crossref PubMed Scopus (3209) Google Scholar have been conducted particularly to address these research gaps, but this represents the exception rather than the rule. The frail older adult population such as those in nursing homes or residential care is still underrepresented. As noted by Boockvar et al,19Boockvar K.S. Song W. Lee S. Intrator O. Comparative outcomes between thiazide diuretics and other first-line antihypertensive drugs in long-term nursing home residents.Clin Ther. 2020; 42: 583-591Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar a randomized trial for a common chronic disease such as hypertension in the nursing home population will likely not be conducted; clinicians therefore need to rely on existing clinical trial evidence as well as observational studies to guide their treatment decisions. Another important issue in the use of medications in older adults is that there is a significant amount of heterogeneity in the older adult population20Lowsky D.J. Olshansky S.J. Bhattacharya J. Goldman D.P. Heterogeneity in healthy aging.J Gerontol A Biol Sci Med Sci. 2014; 69: 640-649Crossref PubMed Scopus (170) Google Scholar in how well they are able to manage activities of daily living, including medication use, and maintain independence at home. Changes associated with aging both physically and cognitively may further complicate medication management for older adults, considering the often long list of multiple medicines coupled with complex instructions on their use. Placido et al21Plácido A.I. Herdeiro M.T. Morgado M. et al.Drug-related problems in home-dwelling older adults: a systematic review.Clin Ther. 2020; 42: 559-572Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar highlight the challenges of home medication management in older adults. It is important for clinicians and prescribers to consider these issues. Also, because older adults are more likely to experience transitions of care in which they receive care at different settings such as in the community, in inpatient care, and residential care settings, medication errors such as omission or duplication may occur.22Moore C. Wisnivesky J. Williams S. McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting.J Gen Intern Med. 2003; 18: 646-651Crossref PubMed Scopus (508) Google Scholar The 4 articles13Anderson B.J. Liu M. Cui X. et al.Adverse outcomes associated with inpatients administration of Beers list medication following total knee replacement.Clin Ther. 2020; 42: 592-604Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,14Burningham Z. Jackson G.L. Kelleher J. et al.The enhancing quality of prescribing practices for older veterans discharged from the emergency department (EQUIPPED) potentially inappropriate medication dashboard: a suitable alternative to the in-person academic detailing and standardized feedback reports of traditional EQUIPPED?.Clin Ther. 2020; 42: 573-582Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,19Boockvar K.S. Song W. Lee S. Intrator O. Comparative outcomes between thiazide diuretics and other first-line antihypertensive drugs in long-term nursing home residents.Clin Ther. 2020; 42: 583-591Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,21Plácido A.I. Herdeiro M.T. Morgado M. et al.Drug-related problems in home-dwelling older adults: a systematic review.Clin Ther. 2020; 42: 559-572Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar in this Topic Update represent use of medications and unique issues across settings; thus, management strategies may need to be tailored and refined in each. Patient-centered and personalized approaches through applying best available evidence and consideration of individual factors such as complex chronic diseases, prognostic factors in terms of risk and benefits, avoidance of medications where harms may outweigh benefits using the clinical tools available, and understanding patient preferences and patient-directed goals are all important aspects to optimize pharmacotherapy in older adults. One approach that deserves further consideration is deprescribing,23Frank C. Weir E. Deprescribing for older patients.CMAJ. 2014; 186: 1369-1376Crossref PubMed Scopus (49) Google Scholar which is the purposeful discontinuation of medications that are inappropriate, unnecessary, and limited in clinical benefit, often in consideration of a patient's goals and values. Deprescribing may help to reduce polypharmacy, potential drug interactions, and adverse effects. Trials have shown that in certain populations, deprescribing reduces the number of medications with no significant adverse effects on clinical outcomes.24Potter K. Flicker L. Page A. Etherton-Beer C. Deprescribing in frail older people: a randomised controlled trial.PLoS One. 2016; 11e0149984Crossref PubMed Scopus (114) Google Scholar Further evidence on deprescribing and its effects may guide clinicians on how best to optimize medication use.