New data on medication use by the elderly should increase the pressure for deprescribing
High numbers of elderly Australians are being given inappropriate and potentially dangerous drugs and drug combinations, according to research presented at the first national meeting on the Choosing Wisely initiative.
An “extraordinary” 44% of residents in aged-care facilities were taking proton pump inhibitors, Dr Chris Alderman, director of clinical excellence at Ward Medication Management, told The Medical Republic.
And one in 10 patients taking PPIs were also taking clopidogrel, potentially neutralising the effect of the antiplatelet, Dr Alderman said.
His cross-sectional analysis of de-identified data from almost 25,000 Residential Medication Management Reviews also revealed substantial statin use in the very old, often for primary prevention.
Researchers analysed the diagnostic and prescribing data from 11% of federally funded aged-care homes in Australia which, they said, gave a more accurate picture of prescribing patterns than previous studies which relied on data from sources such as the PBS.
The level of potentially inappropriate prescribing in aged care might not have been appreciated prior to this, Dr Alderman said.
“We know that if you are treated with a proton pump inhibitor you are more likely to get pneumonia, and possibly more likely to get osteoporosis and chronic diarrhoea,” he said. “So the fact that nearly one in two people in nursing homes is taking them is, for me, quite striking.”
Similarly, inappropriate statin use appeared rife. In total, 28.5% of the residents were taking a statin at the time of the review, and of these, one in three was aged 90 or older.
Dr Alderman was shocked to find that 79 people who were older than 100 had been prescribed a statin.
Of all residents taking statins, only about 20% appeared to be taking them for secondary prevention, they found. This was true even in the older age range, meaning that about 80% of residents were taking statins for primary prevention in direct conflict with Choosing Wisely recommendations which advise against statins for primary prevention in individuals with a limited life expectancy.
“I’m looking at these 2167 people age 90 to 99 [and] it is difficult to say we are doing something to add to their quality of life, ” he said.
It was even worth questioning the benefits of statins for secondary prevention in these older patients. “Whether or not you choose to lower cholesterol using medications depends on a composite risk of cardiovascular disease,” Dr Alderman said.
Total cardiovascular risk needed to be assessed, including the contribution of lower cholesterol to that risk.
Clinicians working with elderly patients and in aged-care facilities had huge pressure placed upon them, and limited time to give these patients, he said.
However this research showed that there was a wonderful opportunity to engage in deprescribing, Dr Alderman said.
In this cohort, the average number of medications residents were taking on any day was 8.4.
Yet the likelihood of a drug-drug interaction increased exponentially the greater the number of medications being taken, he said.
Other potential targets for deprescribing included antipsychotics and bisphosphonates.
Around one in four patients were found to be taking antipsychotics, despite evidence suggesting the incidence of psychotic illness in aged care facilities was similar to that in the broader community at around 2%, he said.
The vast majority, almost 80%, of these patients did not even have a record of dementia in their medical files.
“We all understand there are some really difficult challenges in keeping those people safe, and no one is criticising clinicians,” he said.
“[The antipsychotics] just probably don’t help very much.”
There was also a high prevalence of bisphosphonate use in older patients which was often associated with a prescribing cascade, Dr Alderman said.
“They get put on a bisphosphonate which makes them nauseous, which means they have to take an anti-nausea drug. This causes symptoms like Parkinson’s, then they are given drugs for Parkinson’s … and so on and so forth.”
