Eliminating inappropriate medications in the elderly

When thinking of quality improvement in the long-term care setting, not many areas are more important than the threat of medication errors and their aftermath in patients. Long-Term Living Editor Maureen Hrehocik spoke with Jay A. Gold, MD, JD, MPH, senior vice president and chief medical officer of MetaStar, Madison, Wisconsin, a recognized expert in this area. His company, MetaStar, is a quality improvement (QI) organization “dedicated to ensuring the healthiest lives possible.” MetaStar works with healthcare providers to continually improve quality of care.

Hrehocik: How prevalent of a problem is inappropriate medications in the elderly? Why is it a problem?

Dr. Gold: I would direct your readers to the article found in the Archives of Internal Medicine at https://archinte.ama-assn.org/cgi/reprint/163/22/2716. Toxic effects of medications and drug-related problems can have profound medical and safety consequences for older adults and economically affect the healthcare system. Thirty percent of hospital admissions in elderly patients may be linked to drug-related problems or drug toxic effects. Adverse drug events (ADEs) have been linked to preventable problems in elderly patients such as depression, constipation, falls, immobility, confusion, and hip fractures.

A 1997 study of ADEs found that 35% of ambulatory older adults experienced an ADE and 29% required healthcare services (physician, emergency department, or hospitalization) for the ADE. Some two thirds of nursing facility residents have ADEs over a four-year period. Of these ADEs, one in seven results in hospitalization. Recent estimates of the overall human and economic consequences of medication-related problems vastly exceed the findings of the Institute of Medicine (IOM) on deaths from medical errors, estimated to cost the nation $8 billion annually. In 2000, it is estimated that medication-related problems caused 106,000 deaths annually at a cost of $85 billion. Others have calculated the cost of medication-related problems to be $76.6 billion to ambulatory care, $20 billion to hospitals, and $4 billion to nursing home facilities. If medication-related problems were ranked as a disease by cause of death, it would be the fifth leading cause of death in the United States.

Hrehocik: What medications are the biggest offenders and why?

Dr. Gold: National guidelines have been published (foremost being the Beer’s List developed by the late Dr. Mark Beers, who died in February) that deal with avoidance of specific “potentially inappropriate medications” in the elderly. The above-cited article identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions (See tables 1 and 2 at https://archinte.ama-assn.org/cgi/reprint/163/22/2716.) Of these potentially inappropriate drugs, 36 were considered by the panel to have adverse outcomes of high severity.

Hrehocik: Why are the elderly specifically at risk for these medications?

Dr. Gold: First, the elderly are more likely to have comorbidities-that is, the simultaneous presence of multiple chronic diseases, than younger patients, and hence are more likely to require multiple medications. Second, physiologic changes due to aging lead to changes in the rate at which the body processes medications, and therefore it is easier to reach toxic levels inadvertently. Third, variations in the way the body handles medications are wider among the elderly than among younger patients, making it more difficult to calibrate the proper dosage for older patients.

Jay Gold, MD, JD, MPH

Hrehocik: How can a medical director or a director of nursing in a long-term care (LTC) facility ensure that inappropriate medicines are not used with their residents?

Dr. Gold: A 2001 article by Novielli et al offers the following prescribing principles for the elderly:

Hrehocik: Explain MetaStar’s involvement in the research that was published in the Wisconsin Medical Journal.

Dr. Gold: The Medicare Modernization Act of 2003 directs Medicare Quality Improvement Organizations like MetaStar to offer QI assistance pertaining to prescription drug therapy to providers, practitioners, Medicare managed care organizations, and prescription drug plans. Working with the Centers for Medicare & Medicaid Services (CMS), MetaStar developed a project designed to decrease the use of medications known to pose unnecessary risk in the elderly. Working with a panel of experts, MetaStar chose four potentially inappropriate medications: amitriptyline, cyclobenzaprine, glyburide, and propoxyphene. MetaStar partnered with a Wisconsin prescription drug plan to find physicians who were prescribing and pharmacists who were dispensing these medications to Medicare beneficiaries. MetaStar sent beneficiary-specific profiles and intervention materials to these prescribers and pharmacists, which included information about the risks of these medications. The prescribers and pharmacists also were asked to respond to a set of questions about their use of the medications.

Comparing data from before and after the mailings showed that the use of these medications by elderly Medicare beneficiaries, and the prescription of these medications to such beneficiaries, decreased from the baseline to the follow-up period. While it cannot be proved that this decrease was the result of the mailings, MetaStar is reasonably certain that the mailings played a strong role in the decrease.

Hrehocik: That study says “it appears to be more difficult to induce physicians to change existing prescriptions for elderly patients than it is to change prescribing patterns for future products.” Please explain this.

Dr. Gold: MetaStar’s data indicate that while the rate of beneficiaries being prescribed these medications decreased, if a patient already was receiving one of these medications, that patient was likely to continue receiving it. Physicians are apt to be more reluctant to change the medication a patient already is taking, even if it is potentially inappropriate, than to prescribe a different medication to new patients.

Hrehocik: How important are proper medication regimens as a quality indicator in an LTC facility?

Dr. Gold: Given the statistics cited in the answer to the first two questions, there may be no more important quality indicator in LTC facilities to decrease resident morbidity and mortality.

Disclaimer: The opinions and advice of Dr. Jay A. Gold do not necessarily represent CMS policy.

To send your comments to the editors, please e-mail hrehocik0509@iadvanceseniorcare.com.


At a glance…

Adverse drug events caused by medication errors in the elderly are common and costly. Dr. Jay A. Gold of MetaStar explains what medications are the culprits and how LTC staff can ensure compliance with prescribing principles.


  1. At each encounter, assess your patient’s current drug regimen (including prescription, OTC, and alternative medications) before prescribing a new medication.

  2. Determine if any current medications are on the Beers List and could be gradually switched to an alternative, safer therapy.

  3. For medications that have no alternative, monitor your patient closely for adverse effects.

  4. Prescribe as few drugs as possible. Consider if one drug could be prescribed to treat two conditions.

  5. Avoid adding new drugs to treat side effects of current medications.

  6. “Start low and go slow” with new medications, and increase only as needed.

  7. Discuss potential side effects and treatment adherence with patients and caregivers.

  8. Decide if drug therapy is needed or if a nondrug alternative exists.

  9. Determine how often medications on the Beers List, such as diazepam or propoxyphene, are used in your elderly patients through chart review or an electronic medical record. Develop systems or reminders to decrease the use of these medications.

  10. Understand the side effect profile and pharmacokinetic properties of medications you’re prescribing to elderly patients.

  11. Discontinue medications without a known benefit or clinical indication.

  12. If a patient develops a new or unexplained medical problem, consider an ADE as a potential cause.

  13. Work as an interdisciplinary team of physician, pharmacist, and nurse to optimize patient outcomes and safety.

  14. Provide patients with written information about their medications, and ensure every patient carries a list of his or her medications at all times.

Long-Term Living 2009 May;58(5):28-30

Topics: Articles , Clinical , Facility management