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Sunday, January 7, 2018

America’s Other Drug Crisis

Older adults and prescription pills

Older adults are popping a lot of pills, but the medications can be doing more harm than good. What are the risks and how can you avoid them?

As we get older, we are likely to take more medication. Adults aged 65 to 69 fill an average of 15 prescriptions per year, and it goes up to 18 for those aged 80 to 84, according to the American Association of Consultant Pharmacists. The practice starts earlier. The average 45-year-old takes four different prescription drugs daily.

It’s a problem that tends to build on itself. One medication is prescribed, then side effects appear and another medication is added to counter them. While the current mantra for prescribing to seniors is “go low, go slow”, the medications can still add up.

Why Older Adults Are at Greater Risk

This practice, called polypharmacy, has increased risks for older adults. Seniors are more likely to be living with multiple chronic conditions such as diabetes and high blood pressure, and they have greater rates of anxiety, pain, and sleep disorders. Treating these diverse conditions can involve complex drug therapy by multiple doctors.

Older adults may have a hard time remembering to take their medications at the right time and in the correct dose. Hearing and vision loss can interfere with reading or understanding medication instructions. Using a variety of specialists or different pharmacies increases the chance for unintended drug interactions.

It gets worse. Older adults, especially those experiencing serious health issues, are more likely to have emotional, physical, cognitive, social and functional changes that may encourage them to seek out more medications to cope. In addition, it’s estimated that 14% of adults aged 50 and up have a mental illness such as depression or anxiety. Left untreated, depression can lead to drug abuse. The number of older adults taking three or more psychiatric or pain medications has more than doubled in the last decade, according to a CDC study of data collected from primary care physician visits.

Additionally, changes in metabolism, weight, and body fat that often happen as part of the aging process can affect how a medication works in the body. Older adults cannot detoxify and eliminate medications as quickly as their younger counterparts, leading to adverse reactions to drugs that used to work.

Drug Company Pushes Pill to Seniors for Off-Label Use

A CNN investigation found one drug company making hundreds of millions of dollars a year by targeting frail and elderly care facility residents for whom the drug appears unnecessary or unsafe.

A little red pill called Nuedexta is being prescribed to seniors at an astonishing rate. Its use in long-term care facilities, where more than half of the pills are prescribed, jumped nearly 400% from 2012 to 2016.These aggressive prescribing efforts are pushed by doctors receiving payments from the drug’s developer, Avanir, for seniors suffering from dementia and Alzheimer’s disease.

The drug is approved to treat a rare condition known as PBA that causes sudden and uncontrollable laughing or crying. PBA afflicts less than 1% of all Americans, and is most commonly associated with multiple sclerosis (MS) or ALS, Lou Gehrig’s disease. Avanir acknowledges that the drug has not undergone extensive studies in older adults. The sole research study done by Avanir on patients with Alzheimer’s revealed that those taking Nuedexta fell at double the rate of those taking a placebo.

It is not illegal for prescribers to write scripts for off-label use of medication, although insurance companies may require authorization from the prescriber, justifying the use of the medication, before they’ll agree to pay for the therapy.

The company website avows that about 40% of dementia patients may suffer from PBA. However, medical experts, including some paid by Avanir, repeated disputed that figure. Geriatric physicians and dementia researchers said the condition is “extremely rare in dementia patients”. State regulators found doctors inappropriately making a diagnosis of PBA to justify the use of Nuedexta on nursing home residents that displayed confusion, agitation, and difficult behavior to make them easier to manage.

Between 2013 and 2016, thousands of doctors received nearly $14 million for consulting, speaking, and other services related to the promotion of Nuedexta. An additional $4.6 million was spent by Avanir and its parent company, Otsuka, for travel and dining expenses for speakers and doctors being targeted as potential prescribers of the drug. The practice is legal but controversial.

Almost half of Nuedexta claims filed with Medicare in 2015 were from doctors who had gotten money or other perks from the company. In one Los Angeles nursing home last year, regulators discovered that more than a fourth of the patients were prescribed Nuedexta after a psychiatrist who was a paid speaker for Avanir gave a presentation about the drug to employees.

Jason Kellogg, a geriatric psychiatrist with patients in California nursing homes, calls the drug “such a blessing in psychiatry”. Kellogg says he never hears, “hey doc, we put a patient on this and had really bad side effects.” The doctor has received payments, meals, and travel from Avanir and its parent company in the amount of $612,000 from 2013 to 2016, according to government data.

Soon after its 2011 market launch, reports started coming in about potential harm caused by the drug. Complaints ranged from rashes, dizziness, and falls to comas and death. Nuedexta was listed as a “suspect” medication in almost 1,000 adverse event reports filed with the FDA.

Director of the University of Southern California’s California Alzheimer’s Disease Center Lon Schneider reviewed information from about 500 of those cases. Schneider had concerns about how Nuedexta might interact with elderly patients who often take other powerful medications to treat difficult behaviors. Adding just one more pill, he noted, especially one that hasn’t been broadly tested, could be dangerous.

Finally, care facilities may dole out powerful antipsychotics to elderly residents to keep them manageable by staff, according to the Health and Human Services inspector general. And a ProPublica investigation revealed that some drug companies promote off-label use of their medications to doctors and nursing homes (see sidebar on Nuedexta).

Adverse Consequences of Overprescribing

Every year, hospitals admit 32,000 older adults with hip fractures from falls induced by overmedication. Reactions to medications are one of the five biggest threats to seniors, according to the U.S. Government Task Force on Aging.

“Studies have shown that as many as one-third of hospitalizations in the elderly may be due to multiple-drug interactions,” says Neela Patel, M.D., MPH, a board-certified geriatrician. “Broken hips and other injuries are very common in the elderly due to dizziness brought on by multiple medications.”

Dr. Patel will ask new patients to bring all of their medications on the first visit. “They will bring them in a grocery bag and pour them out on the counter,” Dr. Patel said. “You can instantly see that they are overwhelmed. And we usually find one or two medications that are no longer necessary, or are doing more harm than good.”

What else can you do to manage your medications?

Tips for Effective Medication Management

1. Ask your provider if the dosage is right for your age.
You may need to start with a lower dose and taper up.

2. Some medications are unsafe for older adults.
Consult the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. It’s used by Medicare to evaluate skilled nursing facilities to ensure they make proper attempts to reduce medication doses or try “drug holidays” with their patients.

3. Bring a list of your medications to the doctor.
Include vitamins, herbs, and any other over-the-counter medications you take.

4. Check out your prescriber.
Use the ProPublica Prescriber Checkup tool to find and compare prescribers.

5. Help cognitively impaired adults to monitor medications.
Avoid potentially harmful or fatal consequences by assisting cognitively impaired seniors with medications.

6. Create and maintain a current medication list.
Write a list of all medications with generic and brand names, dosage amount and frequency, and what it treats.

7. If in doubt, get a second opinion.
When you don’t feel confident about a medication that has been prescribed, don’t hesitate to check with another professional.

8. Know the side effects of your medications.
Use the internet to check on side effects so you can be prepared if one arises.

9. Check if the pharmacy label states what the medication is for.
This will help keep track of medications if one for a specific problem needs to be changed or adjusted.

10. Use the same provider and pharmacist whenever possible.
This provides another layer of review to avoid drug interactions, over-prescribing or prescribing more than one drug to treat the same problem.

11. Ask your pharmacist questions.
Your pharmacist can tell you what to watch for, how to store the drug, and if the dose looks appropriate.

12. Update your provider about any drug reactions.
Make sure your provider is aware of any drugs you should avoid.


Prescription Drug Abuse Among Older Adults,” AARP.

The Elderly Are Taking Too Many Pills,” Huffington Post.

Are you (or your parents) taking too many pills?,” The University of Texas Health Science Center at San Antonio.

Are You Taking Too Many Mind Medicines?,” The People's Pharmacy.

Trends in Central Nervous System–Active Polypharmacy Among Older Adults Seen in Outpatient Care in the United States,” JAMA: The Journal of the American Medical Association.

12 Medication Management Tips That May Save Your Life,” A Place For Mom.

The little red pill being pushed on the elderly,” CNN.

Blog posting provided by Society of Certified Senior Advisors