The Journal of the American Medical Association features two pieces that address medication use among older adults. One is a commentary by Dr. Jerry Avorn, a proponent of academic detailing, which is the practice of disseminating pharmaceutical information according to evidence based on clinical research rather than via advertising. The other is a case study of a medication review by two research practitioners that also includes an analysis of the current research literature. Each article stresses the need for improvement in drug prescription for older adults.
While adults 65 and older are the biggest consumers of pharmaceuticals, they are arguably poorly served by current pharmaceutical practice. Older adults are grossly underrepresented in clinical pharmaceutical trials and are most prone to negative side effects and drug interactions. Avorn also argues that medical education poorly serves older adults, as geriatric training is overlooked or underemphasized, particularly in the area of applied therapeutics.
Avorn identifies these and other structural problems and suggests a few remedies. He argues that recent federal changes to health care and Medicare funding are inadequate and have left intact the “fragmented, overspecialized system of care” that currently exists. According to Avorn, such reform has neglected to address the problem of insufficient geriatric training in medical schools. Additionally, the current system fails to reimburse doctors’ time spent on drug regimen reviews and does not encourage best, evidence-based practices in pharmaceutical decision-making. Avorn presents the case that academic detailing and electronic medical records are underutilized resources due to insufficient funding and weak federal and state standards in the U.S. Thus, current pharmaceutical practices among older adults are wildly financially inefficient and often iatrogenic.
The review presented by Steinman and Hallon is based on research evidence and the kind of careful, patient-centered time that Avorn argues is structurally discouraged by the current health care system. The authors suggest reviews that include an accounting of all the medications taken by the patient, an assessment of the patient’s medication adherence, and an evaluation of what the patient, the patient’s family and the patient’s doctor hope to achieve through medication use. Based in part on a review of the literature, the authors address medication changes that might be made in this and similar cases, including discontinuation of some medications and the underuse of other potentially useful drugs. In terms of maintaining changes, behavioral and social interventions as well as follow-up tests and reviews are suggested.
While differing in their scope and focus, the two articles suggest the real possibility of improved pharmacological practice for older adults and the utility of (and need for) both social and practice-level changes that allow for more evidence-based, patient-centered decision-making.
Sources: Avorn, Jerry (2010). “Medication Use in Older Patients: Better Policy Could Encourage Better Practice.” JAMA 304(14):1606-1607
Steinman, Michael A. and Hanlon, Joseph T. (2010). “Managing Medications in Clinically Complex Elders: ‘There’s Got to be a Happy Medium’.” JAMA 304(14)-1592-1601.