A nationally representative survey of health care use has shown that about one in every five elderly Americans received at least one potentially inappropriate medication, according to an article in the Dec. 12, 2001 issue of the Journal of the American Medical Association.

Chunliu Zhan, M.D., Ph.D., of the Agency for Healthcare Research and Quality, and colleagues analyzed data from the 1996 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of health care use -— including medications, expenditures, sources of payment, and insurance coverage —- for the noninstitutionalized U.S. civilian population. The survey included 2,455 community-dwelling Americans 65 years and older.

According to background information cited in the article, researchers have documented widespread potentially inappropriate medication use by elderly people in hospitals, nursing homes, board and care facilities, physicians' offices, hospital outpatient departments, and among the homebound elderly.

The researchers estimated that between 12% and 40% of all the elderly persons in the study were given or used inappropriate drugs. Prior studies had put that figure between approximately 17% and 23%.

"In 1996, 21.3% of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications," the authors stated. That translates to 6.9 million individuals.

"Using the expert panel's classifications, about 2.6% of elderly patients used at least 1 of the 11 medications (such as barbiturates, chlorpropamide, dicyclomine, hyoscyamine, and belladonna preparations) that should always be avoided by elderly patients; 9.1% used at least 1 of the 8 medications (such as propoxyphene, diazepam, cyclobenzaprine, and cariosoprodol) that would rarely be appropriate; and 13.3% used at least 1 of the 14 medications (such as amitriptyline, dipyridamole, promethazine, hydroxyzine, and diphenhydramine) that have some indications but are often misused," the authors wrote.

The use of some inappropriate medications declined over time.

"Of the 15 drugs with prior estimates of use, use of 9 drugs declined from 1987 to 1996, including 5 of the 6 drugs that our expert panel classified as those that should always be avoided by elderly patients," the authors reported.

"Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use," they said. Elderly women were also more likely to receive potentially inappropriate medications.

"At a time when the United States is considering the addition of a prescription drug benefit to Medicare, we should recognize the potential for increased inappropriate prescriptions and develop measures to protect Medicare beneficiaries from the harms of inappropriate prescriptions," the authors concluded.

In an accompanying editorial, Jerry Avorn, M.D, of Harvard Medical School and Brigham and Women's Hospital, Boston, noted that the disconcerting findings of this study describe only a small piece of the puzzle in geriatric medication use.

"Elderly patients are falling and sustaining hip fractures because of the overuse and misuse of a wide variety of more modern agents, even those short half-life tranquilizers and hypnotics that would never make it onto any most wanted list of inappropriate drugs," he wrote. "Some patients are being labeled with diagnoses of new illnesses, or are simply viewed as 'just getting old' when they manifest adverse effects of antipsychotic drugs used to excess."

"With the demographic tidal wave of increased numbers of elderly patients continuing its sweep through the industrialized world, the current view of problematic drug use in elderly patients will have to be broadened beyond an every-few-years snapshot of how many elderly patients were prescribed outmoded drugs identified from a 'gotcha' list that is itself becoming elderly," he suggested.

"Assessing prescribing quality should be woven into the very fiber of the delivery system, performed on an ongoing basis, and tightly linked to appropriate educational strategies to improve care," he concluded. "Given the organizational and fiscal difficulties inherent in caring for elderly patients, these challenges will make the pharmacologic issues involved in this question seem easy in comparison."

SOURCES: "Potentially Inappropriate Medication Use in the Community-Dwelling Elderly Findings From the 1996 Medical Expenditure Panel Survey," by Chunliu Zhan, M.D., Ph.D., et. al.; Journal of the American Medical Association, December 12, 2001.

"Improving Drug Use in Elderly Patients Getting to the Next Level," by Jerry Avorn, M.D.; Journal of the American Medical Association, December 12, 2001.