How many elderly adults are taking medications that may be inappropriate for the elderly?

In 2002, 18 percent of community-dwelling elderly adults were taking one or more of 33 medications that are potentially inappropriate for the elderly, down from 21 percent in 1996. About 3 percent were taking one or more of 11 medications that should always be avoided in the elderly.

Why is this important?

Inappropriate medication use is a particular safety concern for elderly adults. The elderly are often more physiologically vulnerable and tend to use a greater number of medications (Kaufman et al. 2002), which puts them at risk for potentially harmful drug-drug and drug-disease interactions (Zhan et al. 2005).

To address this problem, experts have developed lists of medications that are potentially inappropriate to use in older adults because they may cause harm or have limited effectiveness (Beers 1997; Fick et al. 2003; Zhan et al. 2001). The use of these drugs by elderly adults in the community has been associated with adverse health outcomes and increased use of health care resources (Chin et al. 1999; Fick et al. 2001; Fillenbaum et al. 2004; Fu et al. 2004; Zuckerman et al. 2006).

Findings

The percentage of community-dwelling elderly adults (ages 65 and older) who reported using one or more of 33 medications that are potentially inappropriate for the elderly decreased by 2.9 percentage points overall from 1996 (21.3%) to 2002 (18.4%). The rate fluctuated during this time period; specifically, the rate:

• decreased by 7.8 percentage point from 1996 to 2000;
• increased by 4.9 percentage points from 2000 to 2002.

The percentage of elderly who reported using one or more of 11 medications that experts say should always be avoided in the elderly ranged from 2.4 percent to 3.3 percent from 1996 to 2002 (AHRQ 2005).

Implications

About 6.7 million community-dwelling elderly individuals received at least one potentially inappropriate medication in 2002, and about 1.1 million received at least one drug that should always be avoided by elderly patients. The overall downward trend in the rate of potentially inappropriate medication use suggests that physicians are heeding concerns for more careful drug prescribing among the elderly.

Patients in poorer health and taking more medications tend to be at higher risk for inappropriate prescribing (Aparasu and Mort 2000; Zhan et al. 2001). Other factors may include poor coordination among multiple health care providers, lack of complete and accurate information on patients' current medication use, and disagreement about legitimate uses for certain drugs (Garcia 2006; Zhan et al. 2001).

As important as minimizing medication overuse is for the elderly, failing to prescribe recommended medications and provide adequate patient education and medication monitoring may be even more problematic quality issues (Higashi et al. 2004).

Improvement Ideas and Resources

A systematic review of research suggests several strategies that may help reduce inappropriate prescribing in elderly patients (Garcia 2006), such as:

• including a pharmacist in the care team and/or in specific interventions aimed improving medication use for elderly patients (Hanlon et al. 2004);
• using drug- and age-specific computerized alerts as part of electronic prescribing systems (Simon et al. 2006; Smith et al. 2006); and
• regularly reviewing the appropriateness of elderly patients' medications and the accuracy of current medication lists (Fillit et al. 1999).

Additional research is needed to test these interventions more thoroughly, especially with regard to their effects on adverse events and other patient outcomes.

The new Medicare prescription drug benefit offers an important opportunity to advance quality measurement and promote appropriate and effective prescription drug use among the nation's seniors (AMCP and NCQA 2006).

Measure:

The denominator includes community-dwelling adults ages 65 and older. The numerator is the subset of the denominator population who reported using at least one of 33 prescription drugs identified in Beers (1997) criteria that are potentially inappropriate for the elderly regardless of dosage, frequency, or duration of treatment. The subset of 11 drugs that should always be avoided in the elderly were based on a list derived by the Zhan expert panel (Zhan et al. 2001). Rates of 33 drugs were significantly different between 1996 and 2000, 1996 and 2002, 1998 and 2000, and 2000 and 2002. Rates of 11 drugs were not significantly different.

The numbers of individuals affected in 2002, described in the Implications, were calculated by the chartbook authors based on a population estimate of 36,256,000 civilian, noninstitutionalized individuals ages 65 and older in 2002.

Limitations:

There is a lack of definitive evidence that decreasing the use of potentially inappropriate medications actually leads to a reduction in the occurrence of adverse events in routine ambulatory care (evidence for the association comes from retrospective studies). Larger prospective studies are needed to confirm this relationship.

Source:

National rates were compiled by the Agency for Healthcare Research and Quality (AHRQ 2005) based on data in the Medical Expenditure Panel Survey Prescribed Medicines Database, which combines data from a nationally representative household survey of the civilian, noninstitutionalized population and a follow-back survey of pharmacy providers to confirm medications dispensed to survey participants.

References:

* Indicates source of data used in the chart(s).

* AHRQ (Agency for Healthcare Research and Quality). 2005. National Healthcare Quality Report, 2005. Rockville, Md.: Agency for Healthcare Research and Quality.

AMCP, and NCQA. 2006. Developing a Robust Quality Measurement Approach for Medicare Part D. Washington, D.C.: Academy of Managed Care Pharmacy and the National Committee for Quality Assurance.

Aparasu, R. R., and J. R. Mort. 2000. Inappropriate Prescribing for the Elderly: Beers Criteria-Based Review. The Annals of Pharmacotherapy 34 (3): 338–46.

Beers, M. H. 1997. Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly. An Update. Archives of Internal Medicine 157 (14): 1531–6.

Chin, M. H., L. C. Wang, L. Jin et al. 1999. Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department. Academic Emergency Medicine 6 (12): 1232–42.

Fick, D. M., J. W. Cooper, W. E. Wade et al. 2003. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts. Archives of Internal Medicine 163 (22): 2716–24.

Fick, D. M., J. L. Waller, J. R. Maclean et al. 2001. Potentially Inappropriate Medication Use in a Medicare Managed Care Population: Association with Higher Costs and Utilization. Journal of Managed Care Pharmacy 7 (5): 407–13.

Fillenbaum, G. G., J. T. Hanlon, L. R. Landerman et al. 2004. Impact of Inappropriate Drug Use on Health Services Utilization Among Representative Older Community-Dwelling Residents. The American Journal of Geriatric Pharmacotherapy 2 (2): 92–101.

Fillit, H. M., R. Futterman, B. I. Orland et al. 1999. Polypharmacy Management in Medicare Managed Care: Changes in Prescribing by Primary Care Physicians Resulting from a Program Promoting Medication Reviews. The American Journal of Managed Care 5 (5): 587–94.

Fu, A. Z., G. G. Liu, and D. B. Christensen. 2004. Inappropriate Medication Use and Health Outcomes in the Elderly. Journal of the American Geriatrics Society 52 (11): 1934–9.

Garcia, R. M. 2006. Five Ways You Can Reduce Inappropriate Prescribing in the Elderly: A Systematic Review. The Journal of Family Practice 55 (4): 305–12.

Hanlon, J. T., C. I. Lindblad, and S. L. Gray. 2004. Can Clinical Pharmacy Services Have a Positive Impact on Drug-Related Problems and Health Outcomes in Community-Based Older Adults? The American Journal of Geriatric Pharmacotherapy 2 (1): 3–13.

Higashi, T., P. G. Shekelle, D. H. Solomon et al. 2004. The Quality of Pharmacologic Care for Vulnerable Older Patients. Annals of Internal Medicine 140 (9): 714–20.

Kaufman, D. W., J. P. Kelly, L. Rosenberg et al. 2002. Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States: The Slone Survey. Journal of the American Medical Association 287 (3): 337–44.

Simon, S. R., D. H. Smith, A. C. Feldstein et al. 2006. Computerized Prescribing Alerts and Group Academic Detailing to Reduce the Use of Potentially Inappropriate Medications in Older People. Journal of the American Geriatrics Society 54 (6): 963–8.

Smith, D. H., N. Perrin, A. Feldstein et al. 2006. The Impact of Prescribing Safety Alerts for Elderly Persons in an Electronic Medical Record: An Interrupted Time Series Evaluation. Archives of Internal Medicine 166 (10): 1098–104.

Zhan, C., R. Correa-de-Araujo, A. S. Bierman et al. 2005. Suboptimal Prescribing in Elderly Outpatients: Potentially Harmful Drug-Drug and Drug-Disease Combinations. Journal of the American Geriatrics Society 53 (2): 262–7.

Zhan, C., J. Sangl, A. S. Bierman et al. 2001. Potentially Inappropriate Medication Use in the Community-Dwelling Elderly: Findings from the 1996 Medical Expenditure Panel Survey. Journal of the American Medical Association 286 (22): 2823–9.

Zuckerman, I. H., P. Langenberg, M. Baumgarten et al. 2006. Inappropriate Drug Use and Risk of Transition to Nursing Homes among Community-Dwelling Older Adults. Medical Care 44 (8): 722–30.