Some Psychotropics May Be Inappropriate for the Elderly
by Kenneth J. Bender, Pharm.D., M.A.
| Geriatric Times |
 |
March/April 2001 |
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Vol. II |
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Issue 2 |
Despite their accounting for only 14% of the population, the elderly receive
more than one-third of all prescribed medications (Shelton et al., 2000). This
high prescription rate, coupled with their decreased capacity to clear
medications, already deems the elderly susceptible to adverse drug reactions.
In addition to this, a new study found that 27.2% of psychotropic prescribing
for elderly outpatients may be inappropriate (Mort and Aparasu, 2000).
The study investigators applied the Beers consensus-developed criteria for
identifying potentially inappropriate medication use in patients over 65 years
of age in their screening of almost 30,000 patient record forms collected in
the 1996 National Ambulatory Medical Care Survey (NAMCS) and National Hospital
Ambulatory Medical Care Survey (NHAMCS) by the National Center for Health
Statistics (NCHS).
Jane Mort, Pharm.D., and Rajender Aparasu, Ph.D., characterized the
potentially inappropriate prescribing they identified as a "major issue in the
effort to optimize care for the elderly while avoiding excessive costs
associated with adverse outcomes."
What the Survey Found
Extrapolation of the survey data, based on the patient sampling weight
provided by the NCHS, yielded an estimated 16.55 million visits to physician
offices and outpatient departments in the United States in 1996 in which
psychotropics were prescribed. This was approximately 8.7% of all clinic visits
made by the elderly, or 51.97 visits for every 100 people aged 65 years or
older.
Psychotropic medications were deemed potentially inappropriate based upon
susceptibility of the elderly to particular adverse drug effects or because of
a patient's particular disease state at the time of prescription. The available
survey data from the NCHS precluded considering prescribed dosage.
From the two surveys, 1,373 patient records were found to involve
psychotropic prescriptions, and 309 of these appeared potentially inappropriate
from the applied criteria. Mort and Aparasu projected that approximately 4.5
million visits nationwide (27.2% of those involving psychotropic prescriptions)
involved at least one potentially inappropriate psychotropic prescription.
Most (94.14%) of the psychotropic prescriptions screened as potentially
inappropriate for elderly patients were independent of disease state, while
12.13% appeared inappropriate, because of existing illness. Prescriptions for
antidepressants and anxiolytics were most often deemed potentially
inappropriate independent of disease state, while antidepressants and
sedative/hypnotic agents were most often identified based on patients'
illness.
The tricyclic antidepressant (TCA) amitriptyline (Elavil) was the
psychotropic most frequently identified as potentially inappropriate, having
more anticholinergic and sedative effects than newer classes of
antidepressants. Long-acting benzodiazepines were the most frequently
identified anxiolytics because of their accumulation from repeated dosing and
sedative effect. Both psychotropics and anxiolytics are associated with falls
and resultant fractures in the elderly.
Mort and Aparasu indicated, "[Amitriptyline use] is rarely justified for the
elderly because safer antidepressants are available." They argue, further, "By
focusing on amitriptyline and long-acting benzodiazepines, physicians can
significantly change inappropriate prescribing for and quality of life of the
elderly."
Striving for Safe Prescribing in Elderly
Although this caution against the use of amitriptyline in the elderly is
based partially on the TCAs causing more orthostasis and interference with
psychomotor function than the selective serotonin reuptake inhibitor
antidepressants, an earlier study suggested that falls and fractures in the
elderly using antidepressants are not averted by selecting the newer agents
(Bender, 1999). A pharmacoepidemiology study by Purushottam Thapa, M.S.,
M.P.H., and colleagues at Vanderbilt University found TCAs and SSRIs comparable
in increasing elderly patients' risk for falling (1998).
These investigators conducted a retrospective analysis of records from 180
days of treatment of 2,428 nursing home residents who either were
antidepressant nonusers or had newly prescribed antidepressants. Six hundred
sixty-five patients received TCAs or other heterocyclic antidepressants, 612
received SSRIs, and 304 received trazodone (Desyrel). There were 3,524 falls
occurring in the 1,460 person-years studied. The elderly patients receiving
SSRIs had 80% more falls than matched patients not receiving antidepressants,
and those receiving TCAs had twice the number of falls than their matches. This
similarly heightened risk of falling with TCAs and SSRIs was also found in
another study, which assessed rates of hip fractures subsequent to falls (Liu
et al., 1998).
This evidence of comparable risk of falling with TCA and SSRI use does not
negate the finding of Mort and Aparasu that the use of amitriptyline is
potentially inappropriate in the elderly, since their finding is also based on
the greater risk for cardiovascular complications with TCAs than with newer
antidepressants. It does reflect, however, the heightened susceptibility of the
elderly to react adversely even to medications that meet criteria as
appropriate for having relatively safer side-effect profiles. It also points to
the difficulties in establishing and applying criteria for inappropriate
prescribing.
Prescribing found outside the criteria by Mort and Aparasu was qualified as
"potentially" inappropriate because the investigators lacked data on how the
drugs were dosed and monitored or the potential drug benefits outweighed the
apparent risks. In addition, in a separate review of the Beers criteria,
Aparasu and Mort (2000) noted that the medications included as potentially
inappropriate reflected opinion differences as well as the consensus of the
experts on the criteria development panel.
Some of the cardiovascular medications listed in the Beers criteria as
potentially inappropriate, such as methyldopa (Aldomet), reserpine and
propranolol (Inderal), "were considered appropriate by some researchers because
they have been shown to decrease morbidity and mortality, and a therapy change
may not be in the best interest of adequately managed patients."
Consensus-developed criteria remain valuable in assessing whether
prescribing is appropriate despite these limitations, argued Aparasu and Mort,
as long as the criteria are frequently evaluated and refined, and the findings
are reasonably interpreted. Prescribing falling outside these criteria can only
be considered as potentially inappropriate until further evaluation. "Criteria
can only suggest the likelihood and potential ramifications in terms of adverse
outcomes, and are used until studies are done that actually measure outcomes,"
Aparasu and Mort concluded.
References
Aparasu RR, Mort JR (2000), Inappropriate prescribing for the elderly: Beers
criteria-based review. Ann Pharmacother 34(3):338-346.
Bender KJ (1999), Assessing antidepressant safety in the elderly.
Psychiatric Times 16(1):51-52.
Liu B, Anderson G, Mittmann N et al. (1998), Use of selective serotonin
reuptake inhibitors or tricyclic antidepressants and risk of hip fractures in
elderly people. Lancet 351(9112):1303-1307 [see comments].
Mort JR, Aparasu RR (2000), Prescribing potentially inappropriate
psychotropic medications to the ambulatory elderly. Arch Intern Med
160(18):2825-2831.
Shelton PS, Fritsch MA, Scott MA (2000), Assessing medication
appropriateness in the elderly: a review of available measures. Drugs and Aging
16(6):437-450.
Thapa PB, Gideon P, Cost TW et al. (1998), Antidepressants and the risk of
falls among nursing home residents. N Engl J Med 339(13):875-882 [see
comments].