Worse Than the Disease : Seniors at Risk for Medication Misuse, Overload

NORTH HILLS — The moment John Han stepped into the old man’s apartment, he knew he’d entered another prescription-drug warehouse.

Vials of drugs were strewn in the bathroom, kitchen and living room. There were medications for heart trouble and high blood pressure. There were inhalers, antidepressants, diuretics and cough syrups.

The labels indicated some prescriptions had expired, and some of the drugs could have caused dangerous interactions if mixed with others.

The man, in his early 80s, “had 15 to 20 medications in the medicine cabinet,” said Han. “He was still taking drugs he was not supposed to take.

“He was in danger because he didn’t know what the drugs were, and he didn’t know what he was supposed to take. . . . It could be potentially fatal.”

Han, a pharmacist, visits elderly Valley veterans in their homes to check the drugs they’re using as part of a home health care program run by the Sepulveda VA Medical Center.

And what he finds is an alarming level of prescription drug misuse by veterans who are homebound as a result of age or disability.

“It’s kind of a sad thing,” said Han, who is also an assistant professor at UC San Francisco. “Patients get admitted to the emergency room because they’re taking inappropriate drugs, or taking them in amounts they’re not supposed to take.”

Han’s experience is consistent with research that shows many older Americans routinely ingest drugs in doses that are too strong, that duplicate each other’s therapeutic effects or can cause life-threatening interactions.

Since the elderly often have multiple health problems, they often use a number of drugs at the same time.

“If you take the average 85-year-old, they’re on an average of six to eight drugs,” said Dr. Rick L. Smith, medical director of the Jewish Home for the Aging in Reseda. “Many are on 10 to 15.”

Such a heavy intake, experts say, can produce mental confusion or dizziness that often leads to bone-breaking falls or other serious accidents. Misuse of prescription drugs also can cause gastrointestinal bleeding, kidney damage, impaired blood circulation and heart failure.

One study estimated that each year, 32,000 senior citizens suffer hip fractures in falls caused by adverse drug reactions. Another study concluded that 16,000 car accidents annually that result in injuries can be attributed to such reactions. Hospitalizations stemming from drug misuse among older people cost $20 billion annually, according to the U.S. Food and Drug Administration.

Those who specialize in caring for the elderly blame the situation on doctors, pharmacists and the patients themselves.

Physicians often prescribe drugs in incorrect doses or without determining if a patient is taking other drugs that might interact in a harmful way.

“They prescribe a drug and say goodbye,” said Nancy Wexler, director of Gerontology Associates, a Tarzana firm that counsels families on caring for elderly members.

Wexler said doctors often fail to check if elderly patients hear well enough to understand drug-taking instructions, see well enough to read a bottle label or even have enough hand strength to get the cap off.

A study last year by the U.S. General Accounting Office, the watchdog arm of Congress, concluded that about 17.5% of 30 million noninstitutionalized Medicare recipients 65 and older used at least one drug that was unsuitable for them since safer alternatives exist.

Although that percentage had declined from 25% in an earlier study, prescription drug misuse remains a “significant health problem” among the elderly, the GAO said.

Physicians also receive little training in geriatrics and may pay scant attention to older patients, partly because they can’t heal them, specialists say.

“Old people are often patients who are not going to get better,” said Dorie Gradwohl, a social worker at Valley Storefront Jewish Family Service in North Hollywood.

“They sometimes come in exhibiting and talking about a lot of complaints. Historically, old people do not get the attention they should be getting.”

Moreover, doctors often prescribe drugs to the elderly that trigger side effects nearly as bad as the original problem, experts say.

A GAO official testifying before Congress in March told of a woman in her 80s with severe arthritis who was prescribed a medication that caused stomach problems.

To ease the stomach discomfort, the woman was put on a second drug, which caused a urinary-tract infection. To cope with that, she was given a third drug, which gave her terrifying hallucinations.

Finally, she was taken off all the pharmaceuticals and treated by nondrug means, the official said.

But physicians aren’t the only culprits, experts say. Pharmacists often fail to determine if the elderly are on multiple medications that might lead to dangerous interactions.

And the elderly themselves sometimes don’t tell one physician that they are seeing others who are prescribing different drugs.

“They may be embarrassed,” said Dr. Laurence Rubinstein, director of the Geriatric Research, Education and Clinical Center at the Sepulveda VA. “They may think it’ll harm their relationship with their doctor.”

As part of the Sepulveda VA’s program, Han makes one or two visits a week to homebound veterans. He goes with a doctor and a nurse who examine veterans for other health problems.

Most of the people Han visits are men, ranging in age from early 60s to the 90s. At their homes, he asks veterans to show him all the medications they are taking.

Han weeds out expired prescriptions along with drugs that the patient shouldn’t be taking anymore. Then he explains which drugs the veteran still needs and what side effects may occur.

He also draws up a “drug calendar” to guide the vet in taking medications at proper intervals. The program, he said, has had some success in reducing inappropriate drug use among Valley veterans.

Experts say one reason the problem is so widespread is the lack of accepted guidelines for what drugs are appropriate for the elderly and in what doses.

In 1989, the U.S. Food and Drug Administration issued voluntary guidelines for clinical testing of new drugs intended for elderly people. Most drug manufacturers complied with them. But some experts criticize those guidelines, arguing that not enough people over 75 had been included in the trials and that the guidelines were not representative of all seniors.

The GAO report suggested that doctors should rethink the use of drugs for some of their older patients and in many instances recommend changes in diet and lifestyle instead.

Experts also say medical schools should put more emphasis on geriatric training. And they say physicians, pharmacists and patients should communicate better about what drugs are prescribed and why.

But social worker Gradwohl said seniors are often too timid to question or disagree with their doctor.

“Most older people are kind of afraid to speak up for themselves,” she said. “They don’t want to cross swords with their physician. They’re apt to take the physician’s word as gospel.”