Medication misuse

Dr. Susan Zieman Johns Hopkins University School Of Medicine

Ask The Expert

November 17, 2008|By Helby Selby

As people live longer and suffer from more chronic diseases, the risk of inappropriately using drugs or overmedicating increases among the elderly, says Susan Zieman, geriatric cardiologist and assistant professor of medicine at the Johns Hopkins University School of Medicine.

Most elderly people are on multiple medications and frequently metabolize drugs differently from younger people, she says. The drugs may build up in their systems and interact with other drugs in unexpected ways.

How serious is the problem of misusing drugs or overmedicating among the elderly?

About 25 percent of hospital admissions in older adults are due to some form of medication side effect or complication.

Typically, an elderly person living in the community [living on their own] is taking three to eight prescription drugs, and that doesn't include over-the-counter drugs or herbal remedies. What makes things even more worrisome is that, as we get older, we metabolize drugs a little differently.

This is a stoic population: The elderly often don't mention side effects because they think it is part of aging. They may not realize that some of their aches are side effects from the medicine.

You mentioned that as we age, we may metabolize medications differently. Why does an elderly person's body react differently to drugs?

As we age, our bodies change in ways that can affect the way drugs are processed and eliminated. On top of this, older adults may be taking multiple drugs for different conditions or several for the same condition and the drugs may build up in their system or interact with each other. Some may have multiple conditions, including heart and lung disease; a medication given for one disease may make the other disease worse.

Add to that, about half of the elderly take herbal supplements that are not subjected to the same FDA regulations and rigorous testing, so they aren't tested for interactions.

Why is it difficult to regulate drugs taken by the elderly?

Most drugs are tested on homogenous, healthy, younger people who don't have other conditions, don't take other drugs and who have normally functioning kidneys. In contrast, aging is completely heterogeneous: No two people age the same way and may have illnesses and age-related changes in kidney function, which exclude them from drug-testing trials. People say, "Why don't we just test medication on the elderly?" But it is really difficult to test drugs in this population, as what might be harmless to one older adult may be harmful to another given the differences in aging changes and other conditions. That is why the problems that occur in the elderly often don't show up until after the drugs are released.

What are the most common effects of overmedication?

The most common are falling, bleeding, gastrointestinal side effects and kidney problems.

Are there medications about which you should be particularly cautious?

The drug most commonly related to hospital admissions for management problems is a blood thinner called Warfarin (or Coumadin). Anyone who takes this needs to be very aware and educated on its interaction with other medications. Those who take this drug need to be followed by health professionals regularly with blood tests at least once a month. Both the patient and their doctor and specialists need to know the patient is taking the blood thinner as many other drugs may increase or decrease its potency.

These drugs usually are prescribed with a heart rhythm problem - they tend to reduce the risk of stroke, so they are a very good drug when taken cautiously.

Are there over-the-counter drugs with which particular caution should be taken?

Non-steroidal anti-inflammatory drugs (NSAIDs like ibuprofen, Advil or Aleve). They cause stomach irritation and bleeding, kidney problems and increased swelling, and all those problems are magnified in the elderly. An elderly person's kidneys don't work as well as a younger person's, so when the kidneys are challenged [by a medication] they have less reserve.

Do you have any advice for practitioners?

We always say, "start low, go slow" when it comes to prescribing medications to the elderly. Many people see many specialists and [each of the specialists] may prescribe drugs without knowing what the patient is taking.

Do you have advice for the elderly or those who care for them?

There needs to be a "quarterback" who knows what is being taken. Usually that would be the primary care giver or internist or geriatrician.

What is your advice to the patient?

I ask my patients to tell me not just what prescription drugs they are taking but all the over-the-counter drugs. When they come to see me, I tell them that I expect them to have everything they are taking written down on a list. And I always ask them to tell me what other kinds of things they take, whether it's ginkgo, garlic, Vitamin E. ...

I also tell them to let me know if the costs are too high. Most doctors have no idea what the patient pays. Usually a generic will do just fine. But there are a few occasions where I think it is too dangerous to prescribe a generic drug, and those are the drugs that we have to keep tightly controlled because they have dangerous side effects one way or another.

With generics, the patient may get one lot from one manufacturer and one from the other, even if they are getting them from the same store, and that is a complication that we don't need.

Holly Selby is a former reporter for The Baltimore Sun.

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