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Many Elderly Receive Unsuitable Psychotropics

Kate Traynor

A new study estimates that clinicians who prescribe psychotropic drugs to elderly patients during office or outpatient-department visits select agents whose potential risks may outweigh treatment benefits in one out of every four cases.

Using data from 1996, researchers estimated that about 16.6 million office or  hospital outpatient-department visits by elderly patients resulted in prescriptions for psychotropic medications. During 4.5 million of these visits, clinicians prescribed psychotropic drugs considered potentially dangerous to adults age 65 and older.

The study (PDF), which appeared in the Oct. 9 Archives of Internal Medicine, reported that prescriptions for amitriptyline and long-acting benzodiazepines—drugs generally contraindicated for elderly patients—constituted the bulk of the potentially dangerous medication orders. The researchers estimated that clinicians prescribed these drugs to seniors during nearly three million visits in 1996.

The study also examined patients' and health care providers' characteristics that might influence prescribing. Patients who had previously visited the prescribing physician were more than twice as likely as new patients to receive a prescription for a potentially inappropriate psychotropic drug.

Potentially unsuitable prescriptions were about 40 percent less commonly prescribed to Medicaid beneficiaries than patients with other types of medical insurance. The researchers speculated that Medicaid's mandatory drug-use reviews, which aim to protect the program's clients from inappropriate therapies, may account for this difference.

A drug was considered appropriate or inappropriate on the basis of the updated "Beers criteria" for medication use in the elderly. The original Beers criteria were released in 1991 as drug-use guidelines for patients in nursing homes. The 1997 revisions offered recommendations for drug use by all adults 65 years or older.

Along with amitriptyline and long-acting benzodiazepines, the 1997 Beers criteria identified several other drugs best avoided by all elderly patients: flurazepam and barbiturate sedatives, the antidepressant doxepin, and the antianxiety medications meprobamate and chlordiazepoxide. Other psychotropic drugs were classified as potentially unsuitable for use by elderly patients with specific diseases.

The present study applied the Beers criteria to psychotropic drug prescriptions in ambulatory care settings. Study data came from the 1996 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). These studies were conducted by the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention.

The NAMCS data described ambulatory care services provided in physicians’ offices. Over 2,000 physicians responded to the survey, which collected 29,805 patient record forms during randomly selected office visits. NHAMCS data was collected from 235 hospital outpatient departments; 29,806 patient record forms were obtained in 1996.

After combining data from these studies, the researchers identified 1,373 records of prescriptions for psychotropic medications written for people 65 years or older. Among these records, 309 listed prescriptions for drugs considered potentially problematic for the elderly.

The researchers used sampling weights provided by NCHS to estimate the problem at the national level.

Even if physician reminders about inappropriate drug choices focused on only amitriptyline and long-acting benzodiazepines, said the researchers, a large number of elderly patients could benefit.