Overprescribing in the elderly: We have a problem
Walton-Shirley M (2018)
Medscape 17 September. Available at: www.medscape.com/viewarticle/901207
This commentary is based on a session at the European Society for Cardiology 2018 Congress entitled “Drug Prescription in the Elderly”. Key highlights were the importance of considering glomerular filtration rate, sarcopenia, frailty and the tendency to fall in people aged ≥65 years when considering medicine use. These parameters must always be considered because they are important predictors of whether a person will break a hip, become confused or even die.
The discussion also highlighted the increased rates of heart failure and impaired heart function in older people, as well as the increasing number of older people with five or more comorbidities. Consequently, polypharmacy also increases as people age and increases the risk of drug interactions and adverse drug-related events. It also represents a significant self-care burden for older people and often family carers.
In the session it was claimed that 20% of older people receive inappropriate prescriptions. These often result from a prescription cascade in which one medicine is prescribed to treat a side effect of another. Underprescribing some medicines was also raised as an issue; for example, not using cardioselective beta-blockers for older people with heart failure and chronic obstructive pulmonary disease.
Importantly, the frequent use of complementary and alternative medicine (CAM) was raised: 40% of older people use CAM but often do not disclose its use to conventional healthcare providers – usually because they are not asked about it. People may inappropriately stop their conventional medicines when they commence CAM, which could compromise disease management. However, stopping conventional medicines could also prevent serious drug–CAM interactions.
While the concepts discussed in the session are well described in the literature, they highlight a significant issue: the need to undertake a medicines assessment before prescribing a new drug, especially in older people; to ask about CAM use; and to use non-medicine options when safe and indicated.
Higher protein intake preserves physical function in older people
Mustafa J et al (2018)
Am J Epidemiol 187: 1411–9
These researchers examined the relationship between dietary protein intake and longitudinal changes in physical function among participants in the Framingham Offspring Study aged ≥50 years. Protein intake was calculated from 3-day self-report records and functional status was determined over 12 years using two self-report scales. High protein intake was defined as ≥1.2 g/kg/day and low intake as <0.8 g/kg/day.
In the multivariate analysis, high protein intake was associated with greater physical function. Participants with high protein intake were 41% less likely (95% confidence interval, 0.43–0.82) to become dependent in one or more of the functional tasks over follow-up compared with low protein intake. Lower BMI and higher physical activity also reduced the likelihood of becoming dependent. The authors suggest that older people may require higher dietary protein intake than the current US recommended daily allowance to slow functional decline.
This information is not particularly new or surprising but it is a reminder to ask people about their usual activities and any changes they may have noted.
Factors associated with frequent attendance to outpatient care by older people
Hajek A, Konig HH (2018) BMC Health Serv Res 18: 673
Older people attend health services for a range of reasons. Although frequent attenders may represent a small percentage of overall attenders, they place a significant burden on healthcare systems. These authors undertook a longitudinal study to explore the factors that lead to frequent attendance among middle-aged and older people in Germany. They collected data from examinations in 2002, 2008 and 2011 in the German Ageing Survey.
Participants were community-dwelling people aged ≥40 years who visited their GP or specialist (n=1049). They were classified as frequent attenders if they had attended their GP or specialist on average every other month in the preceding 12 months.
The onset of frequent GP/specialist visits was associated with becoming unemployed, reduced function, increases in physical illnesses and declining self-rated health. Perhaps surprisingly, there was a negative association with age. These relationships were not affected by gender or education level. The authors conclude that individuals only start to use health services more frequently when their needs increase.
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