The challenge of drug prescribing for older people

It is with pleasure that I write this introduction to the reprint of the first article in the ‘Geriatric Therapeutics’ series, published in this Journal in 1991 (then known as the Australian Journal of Hospital Pharmacy).¹ The Geriatric Therapeutics initiative arose from the Pharmacy Department at the Heidelberg Repatriation Hospital in Melbourne, with support from the Aged and Extended Care Department.² Initially published as an internal bulletin from 1986 to 1990, its aim was to provide awareness to the physicians at the hospital to the special needs of the older veteran population. Geriatric medicine as a specialty was very much in its infancy at that time, and patients were generally treated under similar guidelines as the general younger adult population. I had the opportunity to write the first article for the bulletin in 1986, entitled ‘Problems associated with drug use in the elderly’. That early version was re-written for the Journal in 1991.¹

As I look back now to 1983, when I became the first geriatrician to be appointed to an acute care hospital in Victoria, the number of geriatricians overall was exceptionally low. Today, geriatric medicine is the largest training specialty within the Royal Australasian College of Physicians (RACP), with 392 trainees, ahead of other specialties such as oncology (268), cardiology (245) and respiratory medicine (242). This remarkable evolution of geriatric medicine as a specialty in Australia is a recognition of the significant ageing of the population and the special needs it brings to their care. The life expectancy at birth in 1983 was 71.4 years for males and 78.0 years for females. In 2021, it was 81.3 years and 85.4 years respectively.³ This marked increase in life expectancy has resulted in older people now making up a very large proportion of patients in acute care hospitals and large numbers of older people requiring rehabilitation, care at home and residential aged care services. Hence, issues related to drug prescribing are even more important today and need to be understood by all involved.

The first Geriatric Therapeutics article highlighted the reasons for increased vulnerability of older people to adverse drug outcomes, which included altered pharmacokinetics, polypharmacy, multiple comorbidities, atypical disease presentation, inappropriate prescribing, use of non-prescribed over-the-counter medications, drug hoarding and issues with poor drug compliance.¹ These issues remain equally relevant today, but with some added caveats.

Since 1986 a plethora of new drugs have been developed, along with guidelines for various conditions that add more drugs to a patient's list, leading to much higher rates of polypharmacy.⁴ For example, ischaemic heart disease, heart failure, diabetes and stroke result in the prescription of a suite of drugs, with resultant unknown drug interactions and the greater risk of potential side effects and non-compliance.

Most drug trials do not target the older population. The strict exclusion criteria for drug trials makes extrapolating results to older people, especially those with comorbidities and polypharmacy, very difficult.

Non-pharmacological strategies are generally preferred over drug therapy in older people, particularly for conditions affecting mental health. But this is often not available, accessible or practical to many of the vulnerable older patients where drugs are used to manage behaviour. The Royal Commission into Aged Care Quality and Safety (2018–2021) identified this conflict where so many patients today are on potentially inappropriate antipsychotic, antidepressant or anti-anxiolytic drugs.⁵

When prescribing care to older people, more than ever the challenge faced by treating doctors and pharmacists is trying first to determine whether any current drugs could be contributing to patients’ presenting problem(s) by virtue of side effects that sometimes manifest in subtle or atypical ways, for example as fatigue, confusion, falls or cognitive decline. Drugs causing adverse effects or that are unnecessary should be deprescribed. If a new drug is felt necessary, it is important to start an appropriate drug at the lowest possible dose and build up the dose slowly while re-evaluating its effectiveness and tolerability. The old adage of ‘start low, go slow’, and if no benefit noted then to wean or stop, remains important. Finally, when prescribing or dispensing drugs for older people, it is important to provide clearly written instructions, as all too often the important information given at the time of an appointment, or on discharge from hospital, is not well heard, understood or remembered.

The challenges in prescribing for older people have only increased over time, with numerous new drugs coming to market and older drugs under multiple trade names. The drug interactions of all of these, especially when there is coexistent comorbidity, exacerbates these challenges even more. Over the last 37 years, the Geriatric Therapeutics series has played an important role in educating clinicians about these evolving challenges.

The author declares no conflicts of interest.

No funding was received for this article.