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Quality Indicators for Appropriate Medication Use in Vulnerable Elders
- Eric L. Knight, MD, MPH; and
- Jerry Avorn, MD
- From Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Medications are a centrally important aspect of the care of elderly patients, especially vulnerable elders, and are the final common pathway for most therapeutic decisions. While they make up only 14% of the U.S. population, persons 65 years of age and older consume more than 30% of all prescription drugs (1). Because they more often experience acute and chronic illnesses, elders are particularly likely to benefit from the therapeutic and preventive effects of pharmaceutical therapy. However, aspects of the aging process that occur in healthy elders and that are considerably magnified in vulnerable elderly patients increase their risk for drug side effects (2). These include impaired renal function in clearing drugs that are primarily excreted by the kidney; reduction in hepatic blood flow, liver size, and phase I degradative metabolic processes; increased body fat at the expense of lean body mass, which increases the volume of distribution for lipid-soluble drugs and extends their half-life; and aging-induced changes in receptor sensitivity, which can further complicate the prediction and assessment of drug effects.
Another important aspect of medication use in vulnerable elders is that the patient, caregivers, or even physician often mistake side effects for the onset of new illness, or worse, for aging itself. Such side effects include confusion, forgetfulness, gait instability, parkinsonian signs, incontinence, and fatigue. Because complex, frail elderly patients with multiple comorbid conditions are generally underrepresented in clinical trials of drugs, the effect of particular doses on such patients is more difficult to predict from the available clinical literature. This factor, in turn, contributes to therapeutic nihilism: Potentially life-saving medications, such as those that reduce serum cholesterol levels, may be underused because too few older adults were enrolled in key efficacy studies to allow conclusions on their use in this population—a kind of pharmacologic paradox. However, …
