For elders, too few drugs are as much a risk as too many

By Steve Tokar

Doctors are as likely to underprescribe medications for elders as they are to overprescribe, according to a study led by researchers at the San Francisco VA Medical Center.

More than 40 percent of patients studied were taking at least one inappropriate medication and simultaneously not taking one or more other medications that could have helped them, according to lead author Michael Steinman, MD, a staff physician at SFVAMC.

“It’s not just a question of, ‘are you taking too much or too little’,” says Steinman, who is also an assistant professor of medicine at the University of California, San Francisco (UCSF). “Physicians need to look at both sides of the equation, and be attentive to different kinds of prescribing problems that potentially coexist within the same patient.”

The study appears in the October 2006 issue of the Journal of the American Geriatrics Society.
The researchers observed 196 outpatients - 194 of them male - aged 65 or older who were taking five or more prescribed medications and receiving care at a Veterans Affairs Medical Center. A pharmacist analyzed each patient’s medical record and medication list for potential problems.

Sixty-five percent of patients were taking a drug that was ineffective, not indicated, duplicative of another medication, or considered generally inappropriate for older persons. Sixty-four percent were not taking a drug that would have been appropriate for a medical condition they had. Together, 42 percent were simultaneously taking an inappropriate drug and not taking an appropriate drug. Only 13 percent were taking all drugs appropriate for their conditions and not taking inappropriate drugs, according to the pharmacist’s analysis.

Overall, note the study authors, “inappropriate medication use rose rapidly as the total number of drugs taken by a patient increased,” while under-use of medications was “common and constant at all levels of medication use,” with an average of one under-used medication per patient. 

“Perhaps in patients taking relatively few medications, we should focus more on what other drugs might be beneficial.  In patients taking many medications, we need to be vigilant about drugs that are underused as well as drug that are overused,” concludes Steinman.

Co-authors of the study were C. Seth Landefeld, MD, of SFVAMC and UCSF; Gary E. Rosenthal, MD, of the Iowa City VA Medical Center and the University of Iowa; Daniel Berthenthal, MPH, of SFVAMC; Saunak Sen, PhD, of SFVAMC and UCSF; and Peter J. Kaboli, MD, MS, of ICVAMC and UI.

The study was funded through support from the Department of Veterans Affairs, and by grants from the National Institute on Aging and the John A. Hartford Foundation, Inc. that were administered by the Northern California Institute for Research and Education.

NCIRE is the largest research institute associated with a VA medical center. Its mission is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care.