It is one of the worst scandals in medicine and yet it has been ignored for decades. Millions of older people are prescribed medications that are totally inappropriate. Many of these drugs are likely to do more harm than good.
More than two decades ago a physician who specialized in treating older people, Mark Beers, MD, was shocked to discover that more than half of nursing home residents were receiving drugs that might cause them confusion, sedation and disorientation, not to mention constipation, dizziness or dry mouth. Dr. Beers was so incensed that he worked with other experts to develop a list of medications generally considered inappropriate for older people. You will find the Beers list of inappropriate drugs in our Guide to Drugs and Older People.
We’re not talking about really old folks. This list applies to anyone over the age of 65. Some people who are younger may also be vulnerable to these medications. Geriatricians who specialize in treating older people have been warning their colleagues to be extremely cautious with these medicines. Despite this effort, a new study (PLOS ONE, August, 2012) reveals abysmal results.
Researchers reviewed 19 studies that looked at prescribing patterns for those over 65 who were living in the community and not in nursing homes. What they found was that overall, roughly 20 percent of the prescriptions doctors wrote for older people were inappropriate. Examples of such drugs include:
- The pain reliever propoxyphene (Darvon, Darvocet).
- The antidepressant amitriptyline (Elavil, Endep) which is commonly prescribed for insomnia or nerve pain.
- The blood pressure pill doxazosin (Cardura) which is frequently prescribed for enlarged prostate symptoms.
- The antihistamine diphenhydramine (Benadryl) which is used for allergy symptoms and insomnia
Categories of drugs that require extra vigilance when prescribed to senior citizens include NSAIDs (nonsteroidal anti-inflammatory drugs), drugs to regulate irregular heart rhythms, anticholinergics and anticoagulants. This is especially true when someone is on multiple medications. For example, the NSAID ibuprofen that might be taken for arthritis or bursitis can interact with aspirin or the anticoagulant warfarin to increase the risk of a bleeding ulcer. Anticholinergic drugs like diphenhydramine (found in Advil PM or Tylenol PM) could increase the risk for confusion, especially when taken together with another anticholinergic drug for bladder control such as Detrol (tolterodine) or Ditropan (oxybutynin).
What does all this mean for real people? Here are some stories to illustrate what happens when someone gets an inappropriate medication:
Amitriptyline:
“I have been on this medication for more than 20 years for fibromyalgia and sleep problems. I am trying to get off of it now. As I have aged, I have noticed that it has made me more tired, my vision is worse, and many other problems. I know this is not due to just aging.
“I know this medication is addictive even though doctors say it is not because of withdrawal symptoms. I wish I had the Internet when I started it. I would have never touched it.”
G.I.
“I’ve been on amitriptyline for 15 years for fibromyalgia. It was a miraculous cure. I slept through night and my pain was gone. Now for the bad news. The long term effects plus age (now 75) are really bad. I now have heart problems, high blood pressure, can’t wake up in the morning and memory loss (not just old age). My sex life was wiped out (rather quickly after starting amitriptyline). Libido went in a week, ED and anorgasmia came quickly. I tried to compensate with Viagra but that gradually failed.
“I’ve been reading about anticholinergics like amitriptyline. Over time they have really bad effects. Most of the postings about ami refer to constipation and dry mouth, but there are all sorts of other complications. I quit cold turkey a week ago and am experiencing dizziness, digestive upset, headaches and insomnia.”
Allen
Flurazepam:
One of the medications that should almost never be prescribed to an older person is flurazepam (Dalmane). It shows up on every list of potentially dangerous drugs for those over 65. Here is a poignant story that reveals the consequences of careless prescribing:
“I hope you will continue to educate people about the dangers of these drugs for elderly patients.
“About a year ago, my Mother seemed to be going downhill fast. She was showing signs of memory loss, confusion, and depression. She was exhausted all the time and would often sleep through the day. Her balance was poor and she had had a number of bad falls. In addition, she seemed to have become mean and bad-tempered. She was always looking on the dark side of any situation and seemed to remember only the bad things that had happened in her life.
“At the time, she was taking Flurazepam every night as a sleeping pill. I suspected that it might be causing her problems, so I talked to her doctor. He just smiled as if to say “She’s 87 years old. What do you expect?” I also talked to two pharmacists, neither of whom thought that such a low dose could make any difference.
“Then I read in your column that this class of drugs (benzodiazepines, which also include Xanax and Valium) is inappropriate for elderly people, and the list of side effects sounded just like Mother’s. I took her to another doctor.
“After she stopped taking Flurazepam, almost overnight she was a new person. Her balance improved, along with her memory. She wasn’t exhausted all the time. She wasn’t depressed anymore and was once again able to look on the bright side. She even started doing some simple exercises, for the first time in her life.
“My family thanks you for passing along this very important information.”
Older people may have more health problems than younger folks, but that does not mean that their medicine should be making them worse. The results from this new study are discouraging since it shows no improvement in prescribing patterns over the last few decades despite efforts to educate doctors. The conclusion by these researchers is:
“Despite intensified efforts to scrutinize and improve the quality of medication prescription among elderly persons in the primary care setting, inappropriate medication prescriptions are still common. Approximately one in five prescriptions to elderly persons is inappropropriate. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events.”
What this means is that patients and their family members need to watch out for themselves. Here is some sage advice from one of our readers.
“Please read and study “Top Screw Ups Doctors Make.” You need to protect yourself and your family members from mistakes doctors make. I can’t imagine anyone taking all the meds your father is taking. All meds have side effects, good and bad, and mixed so many together the bad side effects are going to increase.
“I don’t know why seniors are so keen on taking medicine. I am 72 years old and the doctors keep trying to push expensive meds off on me that I know from research I don’t need. I have a good internist who tells me also I don’t need these dangerous drugs. I take a blood pressure med and Synthroid for hypothyroidism and that is all I am going to take. Just because you have the sniffles or a little depression (start thinking of something you like, not dwelling on things you don’t like) stretch several times a day and get up and move! Don’t let the doctors and their pills and the rocking chair get you!”
Barbara in Houston
In our book, Top Screwups Doctors Make and How to Avoid Them, there is a chapter about protecting older people from overprescribing, dangerous drug interactions and medications that are inappropriate. You will also find a list of the “Top 10 Tips to Surviving Old Age.” We only have a few autographed hard-back copies left. If someone you know is over 65 and taking any medications, this might be a life-saving gift.
The new study suggests that prescribing mistakes are shockingly common. Please do not let someone you love take the wrong medicine in the wrong dose or in the wrong combination!
