How can we assess medication underutilisation or underprescribing in older patients?
Dear Shamsher,
The usual problem is too much medication for elderly in Sweden. A student of mine studied the relationship between the staff's level of knowledge and the amout of medication. The less the staff knew the more medications in assisted living for elderly. Yearly pharmaceutical reviews could reveal underutilisation as well as overuse. In Finland many old persons who were thought to suffer from dementia "recovered" when they got adequate antidepressant medication some years ago.
In Sweden medication use in the elderly has increased continuously over the
past 20 years.This is most apparent for older people in particular housing, but also for multi-disordered elderly in regular housing, which today are prescribed an average of 8-10 different medications (was it between 75 to 85 years, i do not remember). At such a high use of drugs the risk increased tenfold for
side effects, confusion, falls, low blood pressure and reduced alertness and impaired intellectual functions. Often misinterpreted
side effects means that the patients get new drugs to suppress
adverse symptoms. Tranquilizers and sleeping medications,
anticholinergic drugs drugs used to reduce severe psychiatric symptoms and medications that can trigger delirium were of special concern.
How would you define older adults? This is a rather broad subgroup of the human population. Age and comorbidities will influence whether there is a (perceived)sufficiently large net benefit to initiate or prolong certain drug therapies.
START, ACOVE are but some of many (published) criteria.
There is a relatively new doctoral theses on this subject that may be of use for you. It concerns inequalities in drug treatment among older adults. A link to the thesis:
https://openarchive.ki.se/xmlui/handle/10616/42168
You can use also European START criteria version 2, published last year published by denis O´Mahony
Dear Béatrice Marianne Ewalds-Kvist.
Thank you for your comment. I guess the situation is quite similar all across the globe. The number of prescribed medications increase with the age. There is an established relationship between increasing age and polypharmacy. However, recently a relationship between polypharmacy and medication underutilisation has also been established in older patients. This means that with increasing number of medications, the odds of missing on potentially important medications also increase. This indeed increases complexity in medication prescribing to older adults.
Shamsher
Dear Lena Dahlberg
Thank you for sharing the doctoral thesis. I found it very helpful in broadening my sphere of understanding for this topic.
Kind regards
Shamsher
Dear Lorenz Roger Van der Linden
That is a really important question - how we define older adults. I am glad that you raised this issue here in this small discussion of ours. Often chronological age is used to define 'old' age. However, the amount of heterogeneity that exists in this population is tremendous. Using an age based cut off to define 'old' fails to highlight the heterogeneity in their health status, functional and cognitive status, and socioeconomic status.
Well, I seek your views on this, how can we define 'older'?
Regards
Shamsher
Dear Eva Topinková
Thank you for suggesting START version 2. To be honest, I did not know anything about the second version of START.
Kind regards
Shamsher
Essential to your research concern is variation in elders metabolizing medications. A study done in the early 1970's at Vancouver BC, Canada (perhaps at Vancouver General Hospital) revealed a 400% variation in serum levels of certain meds prescribed to women over 65. This changes a question of 'underutilization' significantly. Paul
Dear Paul O Mcgaffey
Thanks for your answer. I completely agree with you that because of age-associated pharmacokinetic and pharmacodynamic changes, there is a high risk of adverse drug reactions in older adults. But what if medication underutilisation is because of patient age rather than person's health status? There are many studies that found that both pharmacokinetics and pharmacodynamics of a medication remain preserved despite the old age of the participants. This highlights the heterogeneity in physiological status of older adults.
Looking forward to hear your views on this.
Regards
Shamsher Singh
There is also just the basic difference between public and private healthcare and availability of medications based on cost. Application of cost versus perceived quality of life issues can have an effect on what types of medications are provided for older persons, and this obviously affects what can be utilised. Discrimination on the basis of age and not merely health status plays a significant role.
Yes it is true, because you get poorer when you grow older and cannot visit the doctor so often.