Introduction
Ensuring Appropriate, Effective, and Safe Medication Use for Older People

By Janice L. Feinberg, guest editor

Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population," as Jerry Avorn (1995) has written. However, it is also true that "any symptom in an elderly patient should be considered a drug side effect until proved otherwise" (Gurwitz et al., 1997).

This issue of Generations on medications and aging presents a series of articles concerning medication use in the older population that should be of interest and importance to older people, family caregivers, healthcare professionals, and people working in the aging network.

The older population is at greatest risk for medication-related problems because of age-related physiological changes, the higher incidence of multiple chronic disease and conditions among older people, and the greater number of prescription and over-the-counter medications they consume. In his article, Mark Beers provides an overview of age-related changes as a risk factor for medication-related problems. He reviews the pharmacokinetic and pharmacodynamic changes that occur with age and the ways that these changes may affect drug disposition and the ways that individuals respond to medication effects. He also presents information on medications potentially inappropriate for use in the older population.

In people over the age of 65, the economic impact of medication-related problems may be as high as $60 billion annually (Bootman, 1999), which rivals the cost of Alzheimer's disease, cancer, cardiovascular disease, and diabetes. Medication-related problems may be the third or fourth leading cause of death in the over-65 age group. And, just as important, medication-related problems can cause unnecessary disability, resulting in loss of independence from confusion, depression, gait disturbances and falls, or inability to manage medication regimens.

The economic and human costs of medication-related problems in the older population will escalate exponentially into the foreseeable future as the baby boom generation ages unless healthcare professionals, policy makers, and, especially, healthcare payers begin to recognize and respond to the impact of medication-related problems on the total cost of drug therapy. In this issue, Dan Perry and Tim Webster present data on the economic and human toll of medication-related problems in the older population. They describe medication-related problems as a "serious public health concern" requiring expert attention and note that there is substantial evidence that most medication-related problems are predictable and therefore preventable. The article also provides professional and public policy recommendations to reduce medication-related problems in the older population and describes a new paradigm for determining the total cost of medication therapy.

The prospect for an outpatient Medicare prescription drug benefit will substantially increase access to needed and appropriate medications for many elders. Bruce Stuart presents an overview of prescription drug coverage currently available, recent data showing which plans elders tend to select, and the options for a Medicare prescription drug benefit.

During the twenty-first century, growth in the number of people aged 65 and older will produce an unprecedented increase in the number at risk for costly age-associated chronic diseases and other health conditions and injuries. Increased life expectancy will result in more elders suffering from multiple chronic diseases and conditions requiring complex medication regimens. Although managed care organizations are placing a great deal of emphasis on disease management, disease management alone is not enough for the older population.

While it is extremely important to ensure that a patient's medications are appropriately and adequately managing the disease or condition for which they were prescribed, Courtney Lyder and colleagues discuss why it is equally important to ensure that the patient's medication regimen is not at the same time contributing to common geriatric problems that lead to excess disability, loss of independence, decreased quality of life, and, frequently, nursing home placement. Adverse medication effects in the older population have been associated with 32,000 hip fractures, 163,000 cases of mental impairment, and 61,000 cases of drug-induced Parkinson's disease annually. The authors describe "polypharmacy" and the reasons for it in the older population and discuss why traditional disease management programs, which focus on the primary disease and the medications used to treat it, are inadequate in a population that suffers from multiple chronic diseases or conditions.

More medicines than ever are in development for the diseases and conditions commonly affecting older adults. According to the Pharmaceutical Research and Manufacturers of America, drug companies are currently researching nearly 700 new medicines for diseases of aging. Nicole Brandt highlights medicines recently approved or in development for Alzheimer's disease, Parkinson's disease, osteoporosis, and urinary incontinence.

In addition to the billions spent on research to develop new medicines, pharmaceutical companies spent more than $2 billion on direct-to-consumer advertising in 2000, appealing to consumers to influence physician prescribing. Lisa Foley presents findings from a recent aarp Public Policy Institute study of the impact of this type of printed advertising as a source of information for consumers, highlighting the perceptions of older consumers (age 60 and older) in particular. The national survey of consumers suggests that printed direct-to-consumer advertising is less informative about medications for older consumers than about most medications for younger consumers, and that older consumers are less likely to talk about medications with their physicians. The article also discusses public policy options for addressing the "medication information gap."

It is estimated that consumers spend $3.87 billion annually on herbal products, botanicals (plant parts or extract used in products for skin and hair), "nutraceuticals," and dietary supplements. The notion that these "natural" products are inherently safe is disabused by Brian Sanderoff in his article on herbal medicines. Sanderoff reviews herbal medicines that are commonly used by elders and cautions users about the possible powerful effects of herbal medicines on the body and the potential for side effects and drug interactions. The bottom line is, herbal products must be thought of as drugs, with the attendant potential for adverse drug effects and drug-drug and drug-food interactions.

In the lead article, Kathy Cameron and Anne Werner Richardson provide a comprehensive guide to medications and aging for consumers and caregivers. The reader is introduced to the seven types of medication-related problems and what can be done to reduce their incidence, to information on the proper use and administration of medications, and to ways of simplifying medication regimens. The authors also provide suggestions for communicating with healthcare providers to empower consumers and caregivers to play a more active role in decisions regarding medication use.

Terry Fulmer and colleagues review the literature on medication compliance, which highlights the complexity of the problem, especially in older adults. Studies evaluating strategies to enhance compliance are also reviewed. The authors conclude that medication compliance is an extremely complex phenomenon and that the well-being of older adults will continue to rest with a well-informed partnership between the consumer and the healthcare team.

At no other time in history has it been more important to ensure access to healthcare professionals with specialized knowledge and skills for treating the growing older population. If medication-related problems are a serious public health concern that requires expert attention, then the medication-related needs of the older patient demand that pharmacists possess special skills and increased knowledge to provide optimal drug therapy to this population. William Simonson describes "senior care pharmacists" and their specialized knowledge in geriatrics, geriatric pharmacotherapy, and the unique medication-related needs of the older patient. He describes the Commission for Certification in Geriatric Pharmacy, which offers a national voluntary certification program for pharmacists.

For those Web-savvy consumers interested in healthcare electronic commerce, Tejal V. Gandhi and Bao-Anh Nguyen-Khoa review the advantages and disadvantages of using Internet pharmacies and stress the important distinction between online prescribing and online dispensing. They describe acceptable Internet pharmacy practices and review current regulatory and voluntary certification efforts.

In summary, the U.S. population is aging. People are living longer in large part because of modern medicines. In the future, we can expect an unprecedented increase in the number of elders suffering from multiple chronic diseases and conditions, and the pharmaceutical industry is responding with more drugs in development for conditions affecting elders. Prescription drug benefits will expand access to pharmaceuticals. However, we must ensure that each patient's medication regimen is appropriate, that it is the most affective available, and that it is the safest possible. And we must ensure that it is used correctly. These goals can be accomplished by identifying, resolving, and preventing medication-related problems that may cause or contribute to common geriatric problems that lead to excess disability, loss of independence, and decreased quality of life or interfere with the goals of therapy. This issue of Generations will serve as an excellent resource for all concerned with medication and aging.

References

Avorn, J. 1995. "Medication Use and the Elderly: Current Status and Opportunities." Health Affairs. (Spring): 278­86.

Bootman, L. 1999. Personal communication with the author.

Gurwitz, J., et al. 1997. "Polypharmacy." In J. N. Morris et al., eds. Quality Care in the Nursing Home. St. Louis, Mo.: Mosby-Year Book.

Generations Table of Contents

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