Medications and Elders: Quality of Care or Quality of Life? (2011)

An interdisciplinary approach to decision making-factoring in diseases and values-can improve medication regimens. Advancing age is accompanied by an increased prevalence of disease and a concomitant increase in the use of medications (Klotz, 2009). Medication therapy is among the most widely used and highly valued interventions for acute and chronic diseases of older adults, yet the use of drug therapy in this patient population is one of the most difficult aspects of patient care (Murray and Callahan, 2003; Hutchison and O'Brien, 2007). Clinicians are obligated to prescribe appropriate medications for older adult patients, but they must often decide which medications are most effective in disease management of older adults, which combinations of medications to use or avoid in this population, and how many medications are enough or too many-all while anticipating unexpected responses. Factors That Complicate Medication Decision-Making Decisions about appropriate medication use in older adults are sometimes complicated by the potential conflict between the clinician's traditional disease-focused orientation (especially specialists) and the patient's desire to maintain independence and functional abilities- an enhanced quality of life. Achieving qualityof- care goals (e.g., blood pressure control in a patient with diabetes) can result in reducing the patient's quality of life (e.g., medication side effects, increased risk of falls). Some patients may prefer to tolerate medication risks to achieve the benefits, while others may prefer foregoing potential medication benefits to avoid the risks (Tinetti et al., 2008). Medications are often prescribed for older people based on studies with younger people who do not have the combinations of disease present in elders, and who have a life expectancy of several decades. Applying results from these drug studies or disease treatment algorithms derived from the drug studies to older patients is often inappropriate because of higher medication risk-to-benefit ratios that accompany increased age-the presence of multiple diseases, the presence of disability, and the number of medications prescribed (Garfinkel and Mangin, 2010). Review of Regimens Medications are also prescribed at various points in patients' lives by numerous specialists addressing specific problems in their field of expertise, not always taking into account the presence of other diseases, conditions, or medications (Garfinkel and Mangin, 2010). In the absence of a periodic thorough review of an older patient's medication regimen, unnecessary medications can accumulate and place the patient at risk for medication-related problems. It's often much easier to prescribe medications than to discontinue them. It's also easy to overlook adverse effects of medications in the presence of complex multiple diseases. Physicians may be reluctant to review decisions or discontinue or change drug regimens that have been determined by specialists or by treatment guidelines developed for younger populations. A scheduled, formal drug re-evaluation may never be performed for an older adult. There is good rationale to support a thorough review of medication regimens for elders and for a periodic re-evaluation of medication therapies that includes discontinuing unnecessary or ineffective medications and back-titration of drug dosages. A patient who has received antihypertensive medications or antianginal medications when still independent and active may not need the same regimen years later when they are disabled or frail, making minimal physical efforts, and have possibly reduced body mass (Garfinkel and Mangin, 2010). Clinical Practice Guidelines In an effort to improve the quality of healthcare, the Institute of Medicine (IOM) recommends the use of clinical practice guidelines (CPG), which synthesize the best evidence and expert opinion to support decision making about treating specific diseases (IOM, 2000; Boyd et al. …