More vigilance needed in prescribing for the elderly
More vigilance needed in prescribing for the elderly
Fewer-the-better’ approach has fallen by the wayside
Conventional wisdom has swung toward concerns about underuse of beneficial drug therapies for older Americans, says a physician who specializes in geriatric medicine and the use of drug therapy in the elderly.
Health professionals who think this way should take caution before adding any new drug to an elderly person’s drug regimen, says Jerry H. Gurwitz, MD. Gurwitz is executive director of the Meyers Primary Care Institute, a joint initiative of the Fallon Foundation and the University of Massachusetts Medical School in Worcester. He also holds the Dr. John Meyers Endowed Chair in Primary Care Medicine at the University of Massachusetts Medical School, where he is chief of the division of geriatric medicine and professor of medicine and family medicine/community health.
In an Oct. 11, 2004, article published in the Archives of Internal Medicine, he says the issue of undertreatment of elderly patients should be addressed by looking at three problem areas: 1) the scarcity of quality data from clinical trials regarding older patients who have multiple chronic medicalconditions; 2) the need for systems of care that improve drug safety and enhance adherence in elderly persons on complex medication regimens; and 3) the continuing financial barriers that block access to medications for elderly patients.
Research has shown that a third of studies published in major medical journals excluded elderly people without justification, Gurwitz says in his article. "Without adequate clinical trial data, clinicians are forced to prescribe without a strong evidence base or may elect to withhold medications from older patients, for fear of doing more harm than good."
He calls for new approaches to alter these patterns of exclusion of elderly patients from clinical trials. He would also like to see the use of interdisciplinary teams to care for older patients receiving complex medication regimens. These teams may include the involvement of clinical pharmacists, nurse specialists, and other health professionals. Setting up such teams in the current health care environment is difficult, however, Gurwitz says.
"The way health care is structured in the United States isn’t conducive to that," he says in an interview. "There are not organized ways of using interdisciplinary teams except in rare situations."
Some progressive hospitals and program such as PACE (Program of All-Inclusive Care for the Elderly) have shown great promise by emphasizing an interdisciplinary approach to care, he says. "[These] are situations where those things do happen." This is the exception, Gurwitz adds. "[Generally], there is inadequate communication and coordination and teamwork among the health care professions, including doctors, nurses, pharmacists, etc."
The elderly also struggle with paying for their medications. Research links the lack of prescription drug coverage and underuse of essential medications to cost issues, Gurwitz says. Since they can’t afford their medications, elderly patients may reduce their use of the drugs, increasing the incidence of serious adverse effects and the number of visits to the emergency department.
Gurwitz doesn’t expect this trend to abate when more elderly Americans begin using the Medicare drug benefit. "The reality is that physicians generally are not aware of the costs of the medication. If there is an expectation that the new Medicare drug benefit will alleviate all the financial issues related to drug costs for the elderly; that is obviously not true. Everyone realizes that," he says. "Physicians have to understand the costs of the drugs they are prescribing and realize that the costs of the drugs will still have an impact on the patient."
Gurwitz would like to see pharmacists more engaged in educating patients about their medications and cost issues as well.
The large number of medicines will always be an important part of the medical care of many elderly Americans, he concludes. The tension will be between knowing how to avoid the excessive use of medications and providing access to therapies that might have a "beneficial effect on morbidity, mortality, function, and quality of life."
"While the fewer-the-better’approach to drug therapy in the elderly may have fallen by the wayside," he says, "more, not less vigilance against excessive and inappropriate prescribing is required."
Conventional wisdom has swung toward concerns about underuse of beneficial drug therapies for older Americans, says a physician who specializes in geriatric medicine and the use of drug therapy in the elderly.Subscribe Now for Access
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