AGING: Is your patient taking too many pills?

A medication may be inappropriate if it duplicates, cancels out the action of, or otherwise interacts with another drug the patient is taking; is contraindicated in older patients; or is ineffective for the condition for which it was prescribed. In one key study of nearly 200 patients 65 years and older who took 5 or more medications, more than half had been prescribed at least one drug that was ineffective for the patient’s condition or that duplicated the action of another medication.⁸

In addition to finding drugs that the patient should not be taking, medication reconciliation may also reveal that the patient is not receiving optimal therapy and that one or more drugs should be added to his or her treatment regimen.

Check meds after transitions. A move from home to hospital, from emergency department to home, or any other transition relating to patient care should prompt a medication reconciliation. Medications are often added or inadvertently discontinued at such times,^9,10 and instructions relating to medication are often misunderstood.¹¹ In one study of 384 frail elderly patients being discharged from a hospital, for example, 44% were found to have been given at least one unnecessary prescription—most commonly for a medication that was neither indicated nor effective for any of the patient’s medical problems.¹² It was also common for patients to be given drugs that duplicated the action of others they were already taking.

Even in the absence of such transitions, medication reconciliation should occur at regular intervals. Many physicians do a medication reconciliation at every visit to ensure that the medical record is accurate and the patient’s medication regimen is optimal.

Managing polypharmacy: These resources can help

Numerous tools are available to help you evaluate and monitor patients’ medication regimens, including some that were developed specifically for older patients.

START (Screening Tool to Alert doctors to Right Treatment) identifies drugs and drug classes that are underused with older patients.¹³ START criteria (TABLE 1)^13-17 focus on medications that should be used yet are often omitted in older patients who have the appropriate indications.

TABLE 1
START criteria: Drug therapy that should be given to older patients^13-17

In using START or any other drug-related tool, it is important to keep in mind that therapy should be individualized. Not all the medications in the START criteria are appropriate for every patient, and a medication that is indicated for a given medical condition may or may not provide real benefit for a particular patient. That would depend on the individual’s overall health and life expectancy, the goals of treatment, and how long it would take for the patient to realize any benefit from the drug in question.¹⁸ A vigorous 79-year-old might benefit from statin therapy for prevention of cardiovascular events, for instance, while a patient like Mrs. R, who is also 79 but has dementia and multiple other medical problems, would be unlikely to live long enough to realize such a benefit.

”Age” assessment tool. One criterion in deciding whether medication(s) are appropriate for an older patient is his or her “physiologic age”—calculated on the basis of the individual’s chronological age and self-reported health status (TABLE 2).¹⁹

TABLE 2
Calculating your patient’s “real” age¹⁹

Flagging drugs that may be inappropriate
Several tools have been developed to aid clinicians in identifying medications that are potentially inappropriate for older adults, although here, too, decisions about their use must be individualized. Two of the most widely used tools are the Beers criteria and STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions).