OLDER PEOPLE constitute almost 12 per cent of the population of the Republic but receive nearly half of all the medicines dispensed under the medical card scheme. Is this level of prescribing either necessary or appropriate?
Questions have been raised by the results of a recent study by the Centre for Ageing Research and Development in Ireland (Cardi), which found that seven out of 10 older people in nursing homes were getting at least one inappropriately prescribed medicine. The cross-Border research found that 630 older people in long-term care in Northern Ireland and the Cork area were receiving, on average, 11 medicines. Overall, almost one-fifth of those studied were receiving three or more potentially inappropriate medicines.
People aged over 65 now live longer with a greater number of chronic diseases, many of which require active treatment. Balancing safety and quality of prescribing for older people can be challenging.
Polypharmacy – the simultaneous prescribing of multiple drugs – is common in the older population. Multiple drug–taking poses a risk of precipitating a drug interaction; a person taking six or more types of drugs a day is estimated to have an 80 per cent risk of such an interaction. This can result in either toxicity or reduced effectiveness, both of which increase the possibility of an adverse outcome for the patient.
Inappropriate prescribing, as identified in the Cardi study, is the use of medicines that pose more risk than benefit to patients. It includes the use of drugs known to cause interactions as well as the under-use of medicines with a potential benefit. And it is not confined to those in long-term care, with about a quarter of older people who live in the community also experiencing inappropriate prescribing.
There is clearly a need for careful prescribing practices on the part of doctors looking after older people. Prescribing aids such as Stopp (Screening Tool of Older Peoples’ Prescriptions) have been shown to be effective in hospital practice. In the community, formal medication reviews by pharmacists are useful and must be incorporated into payment systems. And there is a need to develop medicines specifically for older people, who are generally excluded from drug trials.
When combined with recent evidence of non-compliance with medication, inappropriate prescribing represents a significant drain on increasingly scarce health resources and must be addressed.