Australia, like many other countries, has an ageing population. Old age is associated with chronic diseases and disabilities, which in turn require multiple medications. In 1996, 178 million prescriptions were written in Australia. Approximately 40% of these prescriptions were for people over the age of 65, who constitute only 12% of the population. General practitioners write 64% of these prescriptions.1
Our own survey found that in a major teaching hospital, 30% of older people were on 6-10 types of medications and 13% were taking more than 10 types of medications each day. Up to 22% of emergency admissions for elderly people are drug-related.2
Why are adverse drug reactions so frequent in older people? With old age there are changes in both pharmacokinetics and pharmacodynamics. Cognitive dysfunction, poor vision, poor hearing and arthritis of the hands make for difficulties in taking medicines as prescribed. Frailty is also associated with more adverse drug reactions. With rapid growth in the population of very old people (above 80 years old), adverse drug reactions are likely to increase, unless we are vigilant! Vigilance is important because up to 69% of adverse effects are predictable and preventable.3
What about the benefits of treatment? Are older people getting the evidence-based medication they deserve? The answer is no. We know now that systolic hypertension is a common disorder in older people and is a good predictor of cardiovascular and cerebrovascular morbidity and mortality. There are many randomised controlled trials to prove the efficacy and effectiveness of treatment of systolic hypertension. This knowledge has not been translated into clinical practice and improved outcomes for patients. Again, from randomised controlled trials, we know older people with atrial fibrillation may benefit from long-term anticoagulation. How many of our patients with atrial fibrillation are offered this treatment and make an informed choice?
Much has been written about drug prescribing and adverse effects, but what about evidence-based drug cessation? We have few data on this important topic. For example, should we stop antihypertensives in a 90-year-old patient? This issue will be debated when we have new treatments for Alzheimer's disease on the Pharmaceutical Benefits Scheme. When will it no longer be cost-effective to continue treating someone with dementia-modifying drugs? Similar dilemmas occur with lipid-lowering drugs and gout treatment.
Meanwhile, public interest in drug safety is increasing and `pharmacovigilance' is the only answer. This can be achieved by spontaneous reporting of adverse drug reactions, or reviewing computerised prescriptions.4 To make pharmacovigilance work, we need better communication between patients and health professionals.
We should make the whole health care system work better for older people. Patients, community, nurses, general practitioners, hospital staff and pharmacists should work together. Communication between all these professionals is vital to improve our prescriptions and thereby patient outcomes. One good example is the initiative by the Royal Australian College of General Practitioners and the Pharmaceutical Society of Australia, to improve communication between general practitioners and pharmacists. Simple things like writing the purpose of the medication on the label are appropriate and effective provided privacy issues are considered. Initiatives like this are cost-effective too! In some studies, net savings of $110 per patient per year have been achieved.1 Another good example is psychotropic drug prescribing in nursing homes. In 1993, over 50% of the residents in Sydney nursing homes were taking antipsychotic drugs or benzodiazepines.5 A repeat survey in 1998, after educational interventions, found a significant and appropriate reduction in these prescriptions. Prescription of psychotropic drugs fell from 59% to 48.5% while benzodiazepine prescriptions fell from 32% to 23%.
The Australian Pharmaceutical Advisory Council and the Pharmaceutical Health and Rational Use of Medicines Committee are government initiatives to encourage judicious, appropriate, safe and evidence-based drug prescribing. An independent body, the National Prescribing Service, is also beginning to work in this area6 along with existing resources such as Australian Prescriber. The Department of Veterans' Affairs funds health reviews for veterans where the doctor or a consultant pharmacist carries out an annual medication review. The accreditation process for nursing homes under the new Aged Care Reform will also require review of medication use. All these initiatives are to be applauded and supported.
This year is the International Year of the Older Person. Now is the time to review what we have been doing in the past and aim for the best available care for our seniors. Their future is in our hands. Quality use of medicines will increase quality without reducing quantity of life!
