Drug Use in the Elderly--the Two Edged Sword

Barry Goldlist, MD, FRCPC, FACP

The issue of drug use in the elderly is extraordinarily important. All physicians know that medications in older patients are a two edged sword: the elderly have many more diseases that potentially benefit from medications, but they are also prone to more adverse effects from those same medications. The increased burden of disease in the elderly is the major reason for the high drug utilization in the elderly, but in the clinical practice of geriatric medicine, it is almost as common to see potentially beneficial medications withheld, as it is to see unnecessary polypharmacy. Of the many reasons for this, I would like to discuss two physician-related factors, excessive fear of side effects, and a flawed understanding of cost effectiveness.

There is no doubt that the elderly are prone to drug side effects. However, withholding effective treatment because of a fear of side effects is often an example of flawed reasoning. All treatments, regardless of the age of the patient, require that the risks and benefits are evaluated and a judgement regarding the balance is then made. To withhold anticoagulants from an elderly patient with atrial fibrillation because age increases the risk of bleeding is assessing only one side of the equation. The number of strokes prevented by anticoagulation is greater in older patients, and if anything the risk/benefit ratio is more favorable for seniors. Similarly, withholding anticoagulants because a patient has fallen once or twice, means a definite benefit is lost to prevent a theoretical complication of traumatic bleeding. Current evidence does not warrant the common perception that recurrent falls are an absolute contraindication to anticoagulation.

Many new pharmaceuticals are quite expensive, and there is a feeling among some physicians that they are too expensive for the elderly. While pharmacoeconomics is a crucial new discipline, none of the experts in the field would eliminate the elderly from potentially beneficial treatments. Decisions not to use expensive medications when cheaper efficacious therapies are available are an appropriate approach regardless of age. Once again, because of the higher event rates for the elderly, treatments are generally more cost effective in the elderly. The best example of this is the use of thrombolytic therapy in those over 70. The cost per life year saved is much less in the elderly than in younger patients with myocardial infarction.

In summary, we do want to avoid polypharmacy in the elderly, and the prescribing cascade that can result, as more drugs are prescribed to relieve side effects of prior medications. However, it is just as important to ensure that therapies of proven value are not withheld from older patients.