Drug-related harm in older adults: underdiagnosed – InSight+

A MAJOR challenge in addressing the substantial burden of drug-related harm in Australia is recognizing the complexity of this underdiagnosed problem.

That burden results in approx 250 000 hospital admissions (2-4% of all hospital admissions) per year, costing the Australian healthcare system $1.4 billion per year† About one third of older Australians aged 70 or over are taking five or more regular medicines at the same time† Increasingly, evidence of drug-related harm is related to taking multiple medications that interact or are unsafe and less tolerated by older adults. Therefore, much of the drug-related harm and associated costs are: possible to prevent

Medication-related harm can extend beyond the nature of the medication itself. Worryingly, many drug-related problems can go undetected. For example, the clinical manifestations of drug-related damage cannot be distinguished from the signs and symptoms of disease states or attributed to underlying aging processes. In addition, disease-specific prescribing protocols established by single-specialty teams often recognize the broader picture for elderly patients with multimorbidities. This failure makes the identification of drug-related damage very challenging.

Harm from unsafe drug prescribing can be attributed to inaccurate clinical judgment, or under-recognition of risk in balancing the benefits versus risks of drug prescribing, especially when compared to appropriate alternative therapies.

Two recent publications (here and here) help to raise awareness of potential drug-related harm from unsafe prescribing practices for the elderly, and to highlight the need to reduce a wide range of burdens associated with drug-related harm.

U.S systematic review and meta-analysis published in the British Journal of Clinical Pharmacology used the results of 63 studies to examine associations between potentially inappropriate prescribing (ie, prescribing drugs with no benefit relative to harm and not prescribing recommended drugs) and a range of outcomes in older adults. Potential inappropriate prescribing was significantly associated with functional decline, falls, and hospitalizations due to drug-related harm. We found that inappropriate prescribing was associated with a 91% increased risk of drug-related hospitalizations (adjusted odds ratio, 1.91; 95% CI, 1.21-3.01; p = .005).

Our recent Australian prospective cohort study included research into outcomes associated with potentially inappropriate prescribing, adding further evidence to support the review’s findings. The prospective study identified that about two-thirds of older adults were taking at least one drug that was not needed, or believed to have an unclear indication, upon hospital discharge from the general medicine department of a tertiary health service. Potentially inappropriate medication was associated with more readmissions and greater dependence on activities of daily living 3 months after discharge.

Potentially inappropriate drugs that most frequently contributed to these adverse health outcomes were from the classes of benzodiazepines, opioids, and antipsychotics.

Compelling evidence shows that benzodiazepine use in older adults impairs cognitive and physical functioning and is associated with a 25% increased risk of fracture (herehere and here† Prescribing tools such as the Prescription Screening Tool for Older People (STOPP) identify both short- and long-acting benzodiazepines as potentially inappropriate drugs and recommend their use for only a maximum of 4 weeks

Observations in our prospective cohort study showed that elderly people often take benzodiazepines for months to years, which probably leads to this one of the most abused classes of prescription drugs in Australia† Likewise, opioid use leads to increased abuse; about one in three older Australians are prescribed opioids if needed† This issue is more concerning given the trend towards under-treatment of pain in older adults and increasing opioid-related mortality associated with a marked increase in opioid prescribing (here and here† Multimodal analgesic use – a pharmacological method of pain relief that combines different groups of drugs for pain relief – can offer a possible solution for both problems.

Another important consideration is prescribing medications with anticholinergic properties, including antipsychotics. Patients may take multiple medications with anticholinergic effects for comorbid diseases, such as drugs for Parkinson’s disease, depression, and genitourinary diseases. The cumulative use of this anticholinergic medication, or anticholinergic load, can have serious long-term effects, increasing the risk of falls, poor cognitive and physical functioning, and even death (hereherehere and here† This issue needs the attention of clinicians as some older Australians (9%) regularly two or more drugs with anticholinergic properties

Furthermore, the risk associated with the use of the above classes of drugs increases in patients with cognitive impairment or dementia. Hospital admissions caused by drug-related harm are reported to be: three times higher in elderly people with dementia (14%), compared to people without dementia (4.2%)† These three drug classes combined – benzodiazepine, opioid, and antipsychotics – represent the drugs with the most adverse health effects in people with dementia

The urgency to find solutions to address the inappropriate use of antipsychotics to control the behavior of people with disabilities and the elderly is supported by the Aged Care Quality and Safety Commission (ACQSC), the National Disability Insurance Scheme Quality and Safeguards Commission (NDIS Commission), and the Australian Commission on Safety and Quality in Health Care (ACSQHC)Different tools are available to help prescribers make prescribing decisions, but are not yet integrated into drug management systems.

Missed opportunities in patient care are also attributed to lack of teamwork, gaps in interprofessional communication and poor coordination of care, especially when patients move from one healthcare facility to another† Active involvement of patients and their families in the prescribing decision-making process is an important strategy to enable patients to enhance their self-care (herehere and here† Building appropriate tools to support drug assessment and alignment practices can provide effective interventions to ensure drug adequacy, alone or in conjunction with other quality improvement programs, such as care transition programs.

dr. Alemayehu Mekonnen is an Alfred Deakin postdoctoral researcher at the Center for Quality and Patient Safety Research, School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

A/Professor Bernice Redley is an associate professor at the Center for Research on quality and patient safety – Monash Health Partnership, School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

Professor Elizabeth Manias is a Professor and Associate Head of School (Research), School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MYA or InSight+ unless so stated.

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