Researchers want to see physicians reevaluate the drugs their elderly patients take to determine if they are appropriate

Jan 6 2005

Just as our bodies physically slow down as we age, changes occur in the way that older bodies handle pharmaceuticals, and prescribing physicians need to be aware of those medications inappropriate for the elderly.

"With age, drugs tend to build up in the body, and the distribution and elimination of drugs from the body changes as well," says Dr. Donna M. Fick, R.N., associate professor of nursing at Penn State. "Many drugs, like diazepam (Valium) and other anti-anxiety drugs build up fast."

Also, doctors may not know all the prescriptions, let alone over the counter, drugs that elderly patients are taking. "Sometimes someone is started on a drug in their 50s, but 20 years later, it has not been reevaluated," says Fick. "Some drugs are fine at 55 but not OK at 75. However, sometimes doctors have tried everything else and this drug with negative implications for the elderly is the only one that works. It is a complicated issue that requires all health professionals to communicate better and work together."

The researchers want to see physicians reevaluate the drugs their elderly patients take to determine if they are appropriate, if alternative drugs would be better or if dosages should be adjusted. They reported their findings in a recent issue of the American Journal of Managed Care.

Fick, working with Nancy A. Rodriguez, Louise Short and Richard Vanden Heuvel, Blue Cross and Blue Shield of Georgia; Jennifer L. Waller; and J. Ross Maclean, Medical College of Georgia; and Rebecca L. Rodgers, Augusta State University, tested a method to alert physicians to possibly inappropriate prescriptions. Fick was at the Medical College of Georgia when this work was done.

The researchers divided primary care physicians in Blue Cross Blue Shield of Georgia's senior plans between a treatment and control group and sent all of doctors a packet of information on prescribing for the elderly. The packet included an educational letter, the brochure, "The Challenges of Prescribing to Seniors," and the Beers criteria list. The 1997 Beers criteria lists established drugs that have either high or low severity adverse effects in the elderly.

Three months later, the treatment group received additional information including a detailed educational brochure, a list of suggested alternative medications for potentially inappropriate medications and a personal letter that contained a list of all the physician's patients who were taking one or more potentially inappropriate medications. The information came from the prescriptions filled during the previous three months.

They also gave the physicians a fax back form on which they could reply that they discontinued medication, assessed patient with no change indicated, decreased dosage, prescribed an alternative or did not prescribe the medication in question.

Approximately 70 percent of the doctors in the intervention group had actually prescribed a potentially inappropriate medication and of those, 71 percent responded with the fax back form. Of those, 78.4 percent reassessed the patient but did not change the medications, 12.5 discontinued the medication, 1.7 percent decreased the dosage and 1.2 percent prescribed an alternative. The drug category most likely to be discontinued was antihistamines, followed by analgesics and muscle relaxants.

Because of changes in the Blue Cross and Blue Shield of Georgia's physician base and an ever-changing patient population, continuation of the study was not possible.

The fax back method was an inexpensive method of alerting the prescribing physicians to the problem, but it had some problems of its own.

"We could have set the study up to call when the physician originally prescribed a drug rather than waiting for the reimbursements for the drugs to signal drug prescribing, but that would have been a more expensive approach," says Fick. "With the fax backs however, we do not really know who is receiving them or if the physician ever actually sees them."

The researchers concluded that while most physicians did not change their prescriptions, the added awareness of the problem was beneficial. They believe that "thoughtful application using the Beers criteria and other tools for identifying potentially inappropriate medication use can enable providers and insurers to plan interventions . . . " that would decrease the ill effects of these drugs on the elderly and improve their care.