Medication-related harm in older adults: underdiagnosed

A KEY challenge in tackling the substantial burden of medication-related harm in Australia is recognising the complexities of this underdiagnosed problem.

That burden results in approximately 250 000 hospital admissions (2–4% of all hospital admissions) every year, and costs the Australian health care system $1.4 billion annually. Over one-third of older Australians, aged 70 years or older, consume five or more regular medications concurrently. Increasingly, evidence of medication-related harm relates to taking multiple medications that interact or are unsafe and less tolerated by older adults. Hence, a high proportion of medication-related harm and associated costs are potentially preventable.

Medication-related harm may extend beyond the nature of the medication itself. Of concern, many medication-related problems can go unnoticed. For example, the clinical manifestations of medication-related harm may not be differentiated from the signs and symptoms of disease conditions or are attributed to underlying aging processes. In addition, disease-specific prescribing protocols written by mono-specialty teams often fail to recognise the broader picture for older patients with multimorbidities. This failure makes the identification of medication-related harm very challenging.

Harms from unsafe prescribing of medications can be attributed to erroneous clinical judgement, or under-recognition of risk when weighing the balance of benefit versus risk when prescribing medications, especially compared with suitable alternative therapies.

Two recent papers (here and here) help to highlight potential for medication-related harms due to unsafe prescribing practice for older people, and draw attention to the need to reduce a broad range of burdens related to medication-related harm.

Our systematic review and meta-analysis published in the British Journal of Clinical Pharmacology used the results of 63 studies to investigate associations between potentially inappropriate prescribing (ie, prescribing medications that may not produce benefits relative to harm and not prescribing medications that are recommended), and a range of outcomes in older adults. Potentially inappropriate prescribing was significantly associated with functional decline, falls, and hospital admissions due to medication-related harm. We found that inappropriate prescribing was linked to a 91% increased odds of medication-related hospital admissions (adjusted odds ratio, 1.91; 95% CI, 1.21–3.01; P = .005).

Our recent Australian prospective cohort study involved investigation about outcomes associated with potentially inappropriate prescribing, adding further evidence to support the findings of the review. The prospective study identified approximately two-thirds of older adults were taking at least one medication that was unnecessary, or deemed to have unclear indication, at hospital discharge from general medicine wards of a tertiary care health service. Potentially inappropriate medications were associated with increased re-hospitalisations and increased dependence in activities of daily living at 3 months after discharge.

Potentially inappropriate medications that most often contributed to these adverse health outcomes were from the benzodiazepine, opioid and antipsychotic classes.

Compelling evidence shows that benzodiazepine use in older adults reduces cognitive and physical function, and is associated with a 25% increased risk of fracture (here, here and here). Prescribing tools, such as the screening tool of older people’s prescriptions (STOPP) identify both short- and long-acting benzodiazepines as potentially inappropriate medications, recommending their use for only up to 4 weeks.

Observations in our prospective cohort study showed that older people often take benzodiazepines when needed for months to years, likely leading to this being one of the most commonly misused classes of prescription medications in Australia. Likewise, opioid use similarly leads to increased misuse; approximately one in three older Australians are prescribed opioids on an as-needed basis. This problem is more worrisome given the trend towards undertreatment of pain in older adults, and an increasing opioid-related mortality associated with a marked increase in opioid prescribing (here and here). Multimodal analgesic use – a pharmacologic method of pain management which combines various groups of medications for pain relief – can provide a potential solution to both these problems.

Another important consideration is the prescription of medications with anticholinergic properties, including antipsychotics. Patients may take multiple medications with anticholinergic effects for comorbid diseases, such as medications for Parkinson’s disease, depression, and genitourinary diseases. The cumulative use of these anticholinergic medications, or anticholinergic burden, can have serious long term effects, increasing the risk of falls, poor cognitive and physical function, and even death (here, here, here and here). This issue needs the attention of clinicians, as some older Australians (9%) are regularly taking two or more medications with anticholinergic properties.

Further, risk related to the use of the above classes of medications increases in patients with cognitive impairment or dementia. Hospital admissions caused by medication-related harm are reported to be three times higher in older people living with dementia (14%), compared with people without dementia (4.2%). These three medication classes combined ─ benzodiazepine, opioid and antipsychotic medications ─ represent the medications with the most adverse health consequences in people with dementia.

The urgency of finding solutions to address the use of inappropriate use of antipsychotics to manage the behaviour of people with disability and older people is supported by the Aged Care Quality and Safety Commission (ACQSC), the National Disability Insurance Scheme Quality and Safeguards Commission (NDIS Commission) and the Australian Commission on Safety and Quality in Health Care (ACSQHC). Several tools are available to assist prescribers in making prescribing decisions but are not yet integrated into medication management systems.

There are also missed opportunities in the care of the patient attributed to lack of teamwork, gaps in interprofessional communication, and poor coordination of care, especially when patients move from one health care setting into another. Active involvement of patients and their families in the prescribing decision-making process is an important strategy to empower patients in their self-care (here, here and here). Building suitable tools to support medication review and reconciliation practices can provide effective interventions to ensure appropriateness of medications, alone or in combination with other quality improvement programs, such as care transition programs.

Dr Alemayehu Mekonnen is an Alfred Deakin Postdoctoral Research Fellow at the Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

A/Professor Bernice Redley is an Associate Professor at the Centre for Quality and Patient Safety Research–Monash Health Partnership, School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

Professor Elizabeth Manias is a Professor and Associate Head of School (Research), School of Nursing and Midwifery, Institute for Health Transformation, Deakin University

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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