Adverse Drug Events in the Elderly: An Ongoing Problem

formal continuing medical education (CME) programs, pocket cards listing high-risk medications, messaging in the electronic medical record suggesting therapeutic alternatives to high-risk medications, focused therapeutic interchange initiatives, and dissemination of “frequently asked questions” documents. These tools are designed to explain, teach, and reinforce the message that many drugs adversely affect older patients by leading to falls, fractures, and functional and cognitive decline, and sometimes to unnecessary and costly hospitalizations and nursing home placements. For example, recent attention at KP has focused on suggesting safer alternatives to skeletal muscle relaxants and long-acting benzodiazepines. Educational presentations to practitioners include suggestions for safer medications, as well as nonpharmacologic interventions, in treating musculoskeletal pain. Another initiative provided education about alternatives to antihistamines such as diphenhydramine, hydroxyzine, and promethazine. Specific recommendations were made regarding alternatives (based on the indication, such as sleep or cough) including nonpharmacologic treatment strategies as appropriate. KP regions have programs devoted to caring for patients who are older, frail, or have multiple chronic conditions. Many such programs include the opportunity for a clinical pharmacy specialist to participate in evaluating and reconciling those patients’ medications, especially during transitions in care settings such as from hospital to home. In KP of Georgia, one such program includes an interdisciplinary team consisting of a geriatrician, nurse care manager, nurse, and clinical pharmacy specialist. The team evaluates and treats older patients identified as high risk through predictive modeling based upon chronic medical conditions and other factors. Much of the work is conducted telephonically, using the electronic health record to document and communicate recommendations to the patients and their treating physicians. In many cases, the clinical pharmacist works closely with the patient’s primary care physician (PCP) to implement changes under the PCP’s supervision. The team thoroughly evaluates overall functional and health status, including review of all prescribed and over-the-counter medications and supplements, and makes recommendations for changes to optimize regimens and patient safety. Annual program evaluation includes measurement of number of program enrollees identified as having been prescribed medications on the Healthcare Effectiveness Data and Information Set (HEDIS) high risk list, and whether the team recommended/made changes to the regimen. New tools are being developed to enhance the team’s effectiveness in addressing this issue. By the year 2030, nearly 1 in 5 U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double in number from 38.7 million in 2008 to more than 88.5 million in 2050.1,2 Likewise, the population aged 85 years or older is expected to increase almost 4-fold, from 5.4 million to 19 million between 2008 and 2050.1 As the elderly population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed continues to increase, resulting in polypharmacy. In a manuscript that we reviewed recently for possible publication in JMCP, the authors examined the prevalence of concomitant drug-drug interactions (DDIs) and potentially inappropriate medications (PIMs) in 6 health plans and concluded that 2 factors, polypharmacy and polyprescribers, appear to be strongly associated with the increased exposure of elderly patients to DDIs and PIMs. Polypharmacy can be appropriate when multiple drug regimens are necessary for the treatment of conditions and are carefully monitored by clinicians for achieving a therapeutic goal and for drug-related problems. Illnesses such as cardiovascular disease, arthritis, gastrointestinal disorders, and bladder dysfunction are common in the elderly. A patient who has congestive heart failure requires multiple agents such as digoxin, a diuretic, and angiotensin-converting enzyme (ACE) inhibitor for management. Even with specialized attention, balancing the multiple medications and their potential related side effects can be challenging for clinicians and patients. The key question is how to address the overall care needs of these patients, while ensuring appropriate medication use. In this commentary, we review “best practices” used at Kaiser Permanente (KP) to address these challenges, and address specific concerns about the implications of research into potentially inappropriate drug use in the elderly for routine care.