Report tackles the risk of medication overload among older adults

Liz Seegert

About Liz Seegert

Liz Seegert (@lseegert), is AHCJ’s topic editor on aging. Her work has appeared in NextAvenue.com, Journal of Active Aging, Cancer Today, Kaiser Health News, the Connecticut Health I-Team and other outlets. She is a senior fellow at the Center for Health Policy and Media Engagement at George Washington University and co-produces the HealthCetera podcast.

Photo: tr0tt3r via Flickr

Experts on aging are sounding the alarm about another U.S. drug crisis: Too many older adults taking too many medications.

This trend is leading to a surge in adverse drug events (ADE) over the past two decades. The rate of emergency department visits by older adults for ADEs doubled between 2006 and 2014 — a problem as serious as the opioid crisis but whose scope appears to remain virtually invisible to families, patients, policymakers and many clinicians, according to a recent report by the Lown Institute, a nonprofit think tank in Brookline, Mass.

Medication overload is an unseen epidemic that could result in 74 million outpatient visits, 4.6 million hospitalizations, and 150,000 premature deaths among older Americans, costing our health system $62 billion, according to report author Shannon Brownlee, a Lown senior vice president.

The problem is systemic, said Brownlee, during an April 2 telebriefing. “No health care professional group, public organization or government agency to date has formally assumed responsibility for addressing this national problem.”

Over the past decade, older adults sought treatment for a serious drug event 35 million times and were admitted to the hospital about 2 million times, said Brownlee. The rate of emergency department visits for ADEs jumped from 5 to 10 per 1,000 older adults (194,000 to 450,000 ED visits over 10 years). It has to do with the corresponding rise in polypharmacy, a situation that has reached “epic proportions,” she added.

More than four in 10 older adults take five or more prescription medications daily — a 300 percent increase in the past 20 years. Data shows that 20 percent of older adults take 10 or more prescriptions in a year, as Austin Frakt wrote in this New York Times article. The risk of an adverse drug event increases by 7% to 10% with each medication.

Three classes of drugs contribute to 60% of emergency room visits for adverse drug events among older adults, according to the report:

  • Blood thinners such as warfarin, which may lead to severe bleeding; diabetes medications such as insulin or gliclazide, which can cause low sugar, increasing risk of falls or confusion; and opioids, which can cause sedation, falls or cognitive impairment.
  • Sedative hypnotics such as benzodiazepines and sleep medications, blood pressure medications.
  • Antipsychotic drugs have also shown potential to increase the risk of adverse side effects.

The report looks at how the culture of medicine and a fragmented system of care can drive overprescribing. Medication overload isn’t new, but seems to be getting worse, said James McCormack, Pharm.D., a professor in the pharmaceutical sciences department of the University of British Columbia.

“It is often far easier to prescribe medications than it is to reduce dosages or deprescribe,” McCormack said. We strive to give the right medication in the right dose, at the right time, but the U.S. health care system isn’t structured properly to achieve that goal.”

Patients often become confused or overwhelmed when trying to track numerous medications, including where, when, and how to take them and what they’re for, the Lown report said. Managing this “pill burden” can make compliance difficult, despite the best efforts of pharmacists, family caregivers or providers.

Patients often see multiple specialists who prescribe multiple medications, leading to an ADE jigsaw puzzle, said James Rudolph, M.D., professor of medicine and health policy at Brown University and the director of the Center for Innovation in Geriatric Services at the Veterans Administration’s Providence, R.I., facility.

“So what happens is that there’s this prescription cascade,” Rudolph said. A patient then returns to the primary provider with symptoms like dizziness, leading perhaps to yet another medication to address that. Despite a hierarchy in medicine which makes primary practitioners reluctant to question medications prescribed by specialists, “we should perhaps step back and ask if symptoms are related to another medication,” he said.

The primary provider and specialist should work together to address polypharmacy and ADEs, Rudolph told me during the Q&A period. “It’s also a good time to involve the pharmacist since a lot of medications need time to taper off.” He suggests that patients or family caregivers bring all the information or pill bottles to the primary provider and ask for a medication checkup. A key goal is to determine whether all the medications are really needed.

Make the provider aware there’s a concern about all of these medications and start that conversation, McCormick said. It can sometimes it can take months to unravel which prescription is causing the problem.

The cost burden is another issue for many patients who take multiple medications, the report noted. In a 2015 survey, more than 40% of adults over age 50 expressed concerned about affording medications due to high out-of-pocket costs. This can lead to non-adherence or pill rationing that can bring additional problems.

“These are critical issues, and we have to ask ourselves what’s taking so long,” said Terry Fulmer, Ph.D., R.N., president of the John A. Hartford Foundation. “This report makes it clear we need to get on this; we need to be thinking about the high-risk medications that we already know are so deleterious to older people.”

In your reporting on this issue:

  • Look at whether hospitals or health systems on your beat are conducting any patient or provider awareness and educational efforts about overprescribing, overmedication, or annual medicine checkups.
  • Find out how many ED visits or admissions were made in the last year for ADEs.
  • What is being done to address this at the patient, practitioner and system levels?

4 thoughts on “Report tackles the risk of medication overload among older adults

  1. Paul Burke

    Too many drugs are definitely a problem, but having checked a couple of numbers, the Lown report is not reliable. I wanted to quote their numbers on deaths, and on 5 or more drugs, so I checked those. Lown says:
    * “medication overload will lead to the premature deaths of at least 150,000 older people in the U.S. over the next decade”
    Their source counts all deaths during hospital admissions if an adverse drug event was present on admission. They don’t actually know how many of these patients had drug overload, let alone how many deaths it caused. Some deaths were caused by a single drug, or by illnesses being treated by the drug(s). https://hcup-us.ahrq.gov/reports/statbriefs/sb234-Adverse-Drug-Events.jsp

    Lown also says
    * “From 1994 to 2014, the proportion of older adults [defined as 65+] taking five or more drugs tripled, from 13.8 percent to 42.4 percent.[4]”
    * “an increase of 300 percent over the past two decades.[4]”
    “Tripling” (200% increase) is bad enough; they don’t need to erroneously call it a 300% increase. In fact their source says 40.7% used 5+ drugs per month in 2011-14, which not exactly the same number, and covers 5 years. https://www.cdc.gov/nchs/hus/contents2017.htm#079

    Lown’s serious flaw in the death number and silly flaw in the percent make me mistrust all their other numbers I didn’t check. Their references don’t have links, which is pretty unhelpful to readers.

    For solutions, they recommend asking doctors to coordinate more. Doctors are too over-scheduled. Most patients can look up effectiveness, side effects and interactions, which will reduce harm, and lead to better practice even for patients who cannot.

    Paul Burke
    http://drugs.globe1234.com

  2. Liz SeegertLiz Seegert Post author

    Hi Paul,
    thanks for your comments. I appreciate you catching the discrepancy in numbers. I’ve reached back out to Lown to see whether they can address some of your concerns and/or explain how they got to their numbers.
    One point I disagree with is that “most patients can look up effectiveness, side effects and interactions…” Remember, we’re talking about older adults here — and many just won’t do that because they’re hesitant to question what the doctor or NP prescribes. And if they do, health literacy is a huge problem among this demographic. So many may not understand the effects that come with drug-drug interactions. If they do, that’s great. But often they’ll either just stop taking the medication or think side effect X is supposed to happen.

    And unfortunately, there’s still a lot of ageism in medicine; complaints of issues like balance problems or insomnia or lightheadedness, which may be legitimate side effects of medications, are often dismissed as “oh that’s normal at your age,” It’s still a pervasive attitude among many non-geriatricians (including PCPs). In an ideal world your scenario would be great; however, according to numerous geriatric medicine experts I’ve interviewed, it’s more the exception than the standard.
    .

  3. Ruth Taber

    And – what about the “unethical” (according to me) practice of testing drugs up to age 65 – but prescribing same up to 100+!!!!
    I see this as a dreadful problem with the ongoing shortage of geriatricians, and so much “knowledge” imparted by pharma detail reps.
    As a 90 year-old I’m a great believer in the “less is more” concept – along with wait 24-48 hours before you start ingesting “remedies”.
    Ruth Taber, MPH 1954
    taber.ruth@gmail.com

  4. Liz SeegertLiz Seegert Post author

    Following is a response to Paul Burke’s comments from report co-author Judith Garber, MPP, Lown Institute Health Care Policy and Communications Fellow:

    Thanks for your comment on the Lown Medication Overload report. We are confident that the estimates used in the report are accurate estimates of potential harm from adverse drug events in the 65+ population. For the estimates of ER visits and hospitalizations attributable to adverse drug events, we used this source (Shehab N, Lovegrove MC, Geller A. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014) which used measurements of ADE that seek to capture harm caused by medications that were prescribed to patients, not simply hospital or outpatient visits with any ADE code present on admission.

     To estimate potential deaths from ADE in the 65+ population, we then used the rate of mortality from ADE from the Hcup study (Weiss et al, 2018). Weiss et al. found that the rate of mortality for adverse drug events present on admission was 3.2 percent in 2014 (for all ages). We applied this mortality rate to estimate the number of deaths from ADE-related hospitalizations (this is for all ages, so may underestimate mortality from ADE for older Americans). We acknowledge that the definition of ADE in Weiss et al. is different from that in the sources previously used; however, this was the only source we found that provided mortality estimates from adverse drug event hospitalizations.

     For much more detail about how we calculated these estimates, please see the Appendix A of the report. Regarding the second comment about the rate of 5+ medication use tripling, you are correct that it is a 200% increase. Our source for the 42% use of prescription drugs is from this CDC report (https://www.cdc.gov/nchs/data/hus/hus16.pdf; see page 25).

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.