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Improved medications have a downside for seniors
"We've known about this problem for a while, but we're only just beginning to identify effective intervention methods," says Dr. Jerry Gurwitz, a professor of medicine at the University of Massachusetts in Worcester who has studied medication problems in the elderly. "And adverse events continue to be common." Nearly 25% of all hospital and nursing home admissions result from older adults not taking their medications properly. Part of the problem stems from the fact that the ability to process and tolerate medications weakens with age. Liver and kidney function diminish, and muscle and fluid levels decline, meaning drugs stay in the body longer. Because people over 65 are more sensitive to drugs, their medication dosages must be closely monitored. Warfarin, for example, which prevents blood clots, can reduce risks of stroke and heart attacks. But dosages must be carefully calibrated in the elderly. If they're too high, the drug can trigger cerebral bleeding and strokes. What's more, the typical senior takes four to six medications, plus over-the-counter drugs. The nation's 1.5 million nursing home residents typically consume 11 or more prescription medications. As the number of prescription and over-the-counter drugs increase, so do the chances for adverse reactions. The antibiotic erythromycin, for instance, when used in combination with some cholesterol-lowering drugs, can cause a toxic reaction and even kidney failure. And combining certain antidepressants with hypertension medication can cause a sudden drop in blood pressure. Often, too, the frailties we associate with old age--confusion, memory loss, lethargy, depression, incontinence, slurred speech, loss of balance--are actually side effects of medication. While there are no hard numbers on how often this is the case, experts say it is common. "Typically, an older person will be out of it, and we just assume it's because they're old," says Dr. Jerry Avorn, an associate professor of medicine at Harvard Medical School in Cambridge, Mass. "But then we find it's the sleeping pill or antidepressant or tranquilizer that's causing the trouble." To prevent these adverse reactions, some HMOs for the elderly, such as Secure Horizons and Wellpoint's Senior Secure, as well as Kaiser Permanente, have installed computerized systems to flag potential problems with prescription drugs, such as possible interactions. Wellpoint's computers even send electronic alerts to doctors if patients are taking medications that are considered high risk in the elderly, or if they have conditions that need to be closely monitored, like diabetes, angina, hypertension or depression. Kaiser Permanente also has programs for the elderly to increase adherence to therapeutic regimens for chronic ills such as heart disease, diabetes, asthma and kidney disease. Still, only 1.5 million of California's 3.5 million seniors are in HMOs. The other 2 million may see several doctors--their primary care physician and a series of specialists, depending on whether they have chronic conditions--who might not know what other drugs they are taking. And they may get their prescriptions filled at different pharmacies. Here again, this boosts chances of adverse reactions. And even the sophisticated computer systems used by HMOs can't always improve compliance. Conditions such as congestive heart failure and high blood pressure, for instance, are well controlled by medication and reduce unnecessary hospitalizations. Yet some people experience unpleasant side effects from cholesterol-lowering drugs, and may stop taking them without telling their doctors. Seniors also may have trouble reading labels and get confused about the proper dosages. Or they may forget to take their pills or double up on doses because they don't remember they already took them. "Noncompliance with prescribed medicines is often as high as 50%," says Harvard's Avorn. "And it's especially hard for seniors to comply with multi-drug regimens that are excessively complex." The solution, according to experts, is to simplify medications: More is not necessarily better. Some drugs could be eliminated, while others can do double duty and be used to ease symptoms of more than one illness. "People need to gather up all their prescription drugs, and show their doctors and pharmacists what they're on," says Harold J. Washington Jr., a Los Angeles pharmacist and president of the California Pharmacists Assn. "These professionals can work up a suitable drug regimen for the patient." Robert Smith's drug regimen offers a case in point. The 73-year-old Los Angeles resident must take an arsenal of prescription drugs each day to control his emphysema and congestive heart failure: four inhaled medications, two blood pressure drugs, one water-retention pill and a potassium supplement. His pharmacist has provided the help he needs in sticking to his complicated regimen. Smith follows a schedule, taking certain medications in the morning when he wakes up, others with lunch, and still others just before bedtime. "If it wasn't for these drugs," says Smith, who still drives and lives independently, "I wouldn't be here." |
