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Protecting Patients From Dangerous Prescriptions

By Jamie Santa Cruz

Physicians must take steps to combat the significant numbers of older patients who are prescribed high-risk medications.

Despite efforts in recent decades to define and discourage the use of medications known to pose a high risk to the elderly, a recent study by Brown University public health researchers demonstrates that a large percentage of older adults are taking one or more high-risk medications.

According to the study, published in the April Journal of General Internal Medicine, 21% of elderly enrollees in Medicare Advantage plans in 2009 received at least one high-risk medication, with nearly 5% receiving two or more. For the purposes of the study, high risk was defined using the list of medications labeled as such by the Healthcare Effectiveness Data and Information Set (HEDIS), the quality indicator to which all Medicare Advantage plans must report.

Study authors Danya Qato, PharmD, MPH, PhDc, and Amal Trivedi, MD, MPH, found that the use of high-risk medications was notably higher among women, in poorer areas, and in the southeast United States, where the percentage of enrollees receiving a high-risk medication jumped to as high as 38%.

According to Trivedi, an assistant professor of health services, policy, and practice at Brown University and a hospitalist at the Providence VA Medical Center in Rhode Island, the greater prevalence among female patients is fairly easy to explain, since many of the medications defined as high risk are used to treat conditions that are either specific to women (eg, hormone replacement therapies) or are at least more common in women.

Surprising, however, is the geographic variation in usage and the fact that residents of the southeast United States were substantially more likely to be receiving a high-risk medicine. “The question is why,” Trivedi says. “We don’t know the answer.”

An Ongoing Problem
Although Qato and Trivedi’s discoveries about geography as a predictor of usage are new, the basic finding that one in five patients nationwide is receiving high-risk medications falls in line with other research.

“That’s pretty consistent, unfortunately,” says Paul Y. Takahashi, MD, a consultant in the division of primary care internal medicine at the Mayo Clinic and a member of the clinic’s geriatric consultative group. “We hope that that number continues to lower over time, but it really hasn’t and it’s been routinely fairly high.”

The issue of high-risk medicine usage continues despite substantial efforts to identify medications that are dangerous for older adults and raise physician awareness about the risks. The most well-known and widely used list of high-risk medicines is the Beers criteria, developed in 1991. The list has been updated several times, with the most recent update published by the American Geriatrics Society in 2012. (The HEDIS list of high-risk medications that served as the basis for Qato and Trivedi’s study is derived from the Beers criteria.)

But such lists have been only partially successful in reducing the prevalence of risky medicine usage. According to Todd Semla, PharmD, a clinical pharmacy specialist with the VA and an associate professor in the Feinberg School of Medicine at Northwestern University in Chicago, there has been improvement with some classes of medications, such as certain problematic skeletal muscle relaxants. Some drugs of particular concern have been removed from the market altogether, such as propoxyphene (Darvon), a pain medication. But certain categories of drugs remain much more prevalent than they should be, especially benzodiazepines, such as Valium or Xanax-like drugs used to treat anxiety or sleep problems.

Contributing Factors
One reason for the continuing prevalence of high-risk drug use among older adults is a lack of alternative medications. “Sometimes you’re really in a corner,” Takahashi says.

If the only alternatives to high-risk drugs are nonpharmacologic treatments, these can be a hard sell for both physicians and patients. “It’s quicker to write a prescription than to get somebody into therapy or something like that,” says Semla, who cochaired the panel that revised the Beers criteria last year. “The patient may not accept that either; they may be looking for a pill, too.”

The reasons high-risk medications are significantly more common in the southern United States remains unclear, but Trivedi suggests that it could result from patients in this area requesting high-risk drugs. Different prescribing norms and different training practices for clinicians in the South could also play a role.

Semla and Trivedi agree that lack of awareness among clinicians is likely a significant factor in the ongoing prevalence of high-risk drugs. “It may be that a lot of providers are not aware of the risks that are associated with these medications,” Semla says. “They’re trying to do something that they believe will benefit the patient but without realizing that it may also put them at risk for adverse effects.”

Responsible Prescribing
The implications for clinicians are fairly simple, and much of the solution lies in clinician awareness and adherence to straightforward prescribing principles. A review of basic best practices includes the following:

Review the lists of medications that are deemed high risk. The full Beers criteria document can be viewed here through the American Geriatrics Society website. For on-the-go reference, the society provides a pocket card version of the Beers criteria on its website. Laminated versions are available for purchase, but a free download of the card also is available. In addition, a Beers criteria smartphone app is available for both Apple and Android users.

Monitor patients carefully. According to Semla, this applies even if patients aren’t taking a known high-risk medication because some medications that can be appropriate for many elders still have a high-risk profile. For example, if a patient is taking warfarin (Coumadin), his or her physician should ensure there are no dietary changes, the international normalize ratio remains at a safe level, and a new medication that may interact with the warfarin isn’t prescribed.

Use caution when prescribing newly released medications. Semla encourages waiting until further information becomes available about the drug’s adverse effect profile before prescribing it to older, frail patients.

Recommend nonpharmacologic solutions as alternatives to high-risk medications. For issues such as pain management or sleep problems, Takahashi favors therapy, exercises, or sleep hygiene. “It takes more time and resources on the part of the patient to not just have a simple pill,” he says, noting that many patients are open to alternative solutions when they are presented correctly. “People just want an option. They want to be told, well, if it’s not this, then what can I do?”

In cases where a high-risk medicine is justified, start with a low dosage. If necessary, titrate the drug to find the minimum effective dose, Semla says.

Communicate with pharmacist colleagues in cases where there are uncertainties about the advisability of a particular prescription. “We’re not alone,” Takahashi says. “If there are complications or issues or you’re not sure, utilize the extra help. It’s a simple thing.”

Communicating With Patients
Because patients play an important role in their own health care, Trivedi and Semla suggest several messages clinicians should convey to their patients, including the following:

Encourage patients to communicate with all their providers and pharmacists about every medication they are taking, including dietary supplements, vitamins, and over-the-counter drugs. Patients may not consider all of these items to be drugs and may not know to volunteer the information.

If a patient asks for a particular medication, explain the risks. Trivedi notes that since requests for specific medications may be a factor in the prevalence of high-risk drug usage, patient education is an essential strategy for reducing reliance on inappropriate medicines.

Make sure patients understand how each medication should be taken. Particularly in cases where there is a specific device for medication administration, such as an inhaler or insulin syringe, ensure that the patient knows how to use it.

Explain to patients the purpose of each medication (eg, blood pressure, diabetes). Semla encourages providers to write the information in the directions of the medication, as it’s helpful not just for patients but also for pharmacists who need to talk to patients about their medications. “Some medications are used for more than one condition,” Semla says, “but if the physician doesn’t specify, you’re never sure which one.”

Make sure patients know which side effects are normal and which ones warrant follow-up. For example, Semla says, a medication may cause diarrhea or loose stools, but when do these effects become cause for concern?

Reducing the prevalence of high-risk prescriptions has proven to be a formidable challenge, but Takahashi is optimistic about eventual success: “Most providers are really starting to get on board and saying, ‘OK, let’s really be aware of this.’ Our next job is to continue to educate.”

— Jamie Santa Cruz is a freelance writer based in New York City.