Pharmacotherapy in the Elderly: Ethical Implications
Gonzalo Herranz, department Bioethics, University of Navarra
Symposium on Aging and the Family
Blue Life + University Extension Center
São Paulo, June 18, 1999
The unique biology of the aging body
The unique relationship between prescribing physicians and geriatric patients
Pharmacotherapy for the elderly is a complex issue. It is particularly appropriate to discuss it in the context of this meeting, since it not only requires the intelligent cooperation of its two main parties—the elderly patient and the physician—but often cannot be fully implemented without the essential contribution of the patient’s family.
The complexity stems from the fact that the pharmacotherapy of the elderly involves a convergence of biological, medical, economic, and partner factors, which must be harmonized in order to address both the challenges faced by physicians in treating each individual elderly patient and the major dilemmas encountered by healthcare planners. I need not point out that I will approach this issue from the perspective of professional ethics. It is obvious that I will only be able to make a few brief and incomplete references to topic.
The unique biology of the aging body
In my view, respect lies at the heart of medical ethics. Ethical respect begins with respect for the biological reality of human beings. Indeed, we all know that older men and women exhibit certain unique biological characteristics that give them a special profile 1.
First of all, many older adults are ill. Poor health is an almost constant reality for them, which means they are prescribed many medications. As a result, older adults are heavy users of medications2.
Second, many older adults suffer not from a single illness, but from several at the same time: comorbidity is very common among them. More than a third of them are forced to take multiple medications simultaneously. There is a form of polypharmacy specific to older adults—frequent, severe, and chronic—that forces them to take many medications for months and even years3. But, as we well know: while polypharmacy constitutes a status for everyone, it poses a particularly serious threat to the elderly.
Third, significant changes occur in the bodies of older adults that have a major impact on how medications are absorbed, distributed, metabolized, and eliminated. We do not know whether this unique way in which the elderly body processes medications is due to the anatomical and functional changes caused by aging itself, or whether it is the result of a history of previous illnesses. However, we do know that the abnormal pharmacokinetics of the aging body can lead to reduced drug elimination or an extension of the average , which can cause elevated drug levels in the blood and tissues, resulting in toxic effects or undesirable interactions. In the elderly, the frequency of drug-induced iatrogenic harm is often higher4.
Fourth, pharmacodynamic disturbances frequently occur in the elderly. Medications may cause increased or decreased effects due to quantitative or qualitative changes in the response of specific receptors.
The unique biological characteristics of the elderly body require physicians to understand these particularities, recognize them, and take them fully into account when developing a treatment plan. This is an excellent way to demonstrate ethical respect.
The unique relationship between prescribing physicians and geriatric patients
It is against this unique biological backdrop that the doctor’s therapeutic approach takes shape. The elderly person is also special as a patient, and not merely as a biological being. They often become, or tend to become—sooner or later—chronically ill, never fully recovering. On the contrary, it is common for them to develop new health issues on top of existing ones. As the years go by, their frailty increases. They are continually prescribed new medications to treat their new ailments. And this is felt most acutely by the frailest among them: the very elderly, those over 85 years of age.
This backdrop of vulnerability and irreversible frailty can leave a mark on a physician’s professional ethics: it can undermine their commitment to quality care. It is curious: physicians do to the elderly what they would never allow themselves to do to their other patients—they prescribe medication without having established a diagnosis. They sometimes prescribe with an empirical, rather than etiological, mindset, as they treat symptoms rather than causes. They do not always do this out of laziness, but out of necessity, since illnesses can present themselves in the elderly in a deceptive and atypical manner, influence one another, or manifest in a distorted way due to the effect of the medication they are already receiving for other illnesses.
The status sometimes become very complex. The phenomenon in which an adverse drug reaction is misinterpreted as a new disease has been described as a “prescription cascade.” Hyperuricemia induced by a thiazide diuretic is diagnosed as gout and treated accordingly; or the extrapyramidal manifestations of metoclopramide treatment are mistaken for Parkinson’s disease and treated with levodopa. These pharmacological side effects lead to the prescription of a new medication, which can trigger a new cycle of iatrogenic disease5. In some patients, the clinical picture can become so confusing that the physician no longer strives for the necessary diagnostic precision. However, although there is no shortage of criteria for determining when drugs, alone or in combination, are potentially dangerous or inappropriate in the elderly6, in fact, many physicians prefer to take risks and continue to overprescribe.
Furthermore, many illnesses affecting the elderly are incurable. This can lead to two opposing attitudes, both of which conflict with ethical principles. The doctor may succumb to passivity or indifference and under-treat the patient. Or the doctor may yield to the irrational demands of the patient or the family to pursue aggressive treatment when, in reality, no further aggressive measures are appropriate. This can lead to the prescription of a treatment that is obstinate and deliberately futile.
In short, in geriatrics, physicians discussion when prescribing: they discussion between austerity and indulgence. This is not a new dilemma—it has long been whether to promote a stoic culture of pharmaceutical restraint or to foster a hyper-medicated society that sees in Chemistry substitute for effort and virtue7.
The doctor-elderly patient relationship is also threatened by the temptation to be disloyal. A dissatisfied patient will always try to find a remedy for his ailments. He will knock on the doors of various doctors, experiment with alternative medicines, and follow the advice given by the pharmacist or other patients, his fellow sufferers. This behavior is impossible to prevent, but it carries risks. Deviating from the ideal 1:1 doctor-to-patient ratio can lead to unfavorable pharmacological consequences. An old Spanish proverb puts it bluntly: “One doctor cures; two, they hesitate; three, certain death.” Indeed, enquiry increase the issue prescribed medications, which is to say, the number of medications consumed. The elderly are not inclined to discard medications: they keep them all, alternate them, and recombine them. Sometimes they skip doses because they forget to take them or misplace them, which, ironically, can be an excellent way to prevent interactions or adverse reactions8.
All these circumstances lead to chaotic polypharmacy—sometimes on an alarming scale—in which problems related to incompatibilities and interactions, as well as synergistic or antagonistic effects (all equally undesirable), increase in proportion to issue medications taken. Faced with status a confusing status , some patients decide fail . Others, however, press on: they are the typical candidates for taking diuretics in triple doses, or for dangerously combining antiarrhythmics with hypoglycemic agents or tranquilizers, with results that not even computer simulation programs are capable of calculating.
And this usually happens without the doctor or pharmacist knowing9. And without the patients themselves remembering: it is sometimes impossible to determine during the clinical interview which medications an elderly patient is taking. To find out, you have to ask them to bring all of them to the office, preferably with the financial aid a family member to ensure they follow through: then it becomes clear that they are taking, without their doctor’s knowledge, many—up to 10, 15, or more—medications10. At other times, a visit home visit to the patient’s residence can be very effective in uncovering veritable therapeutic arsenals11. It will then be necessary to lay out the medications, sorted by class, on the table, identify the risks of interaction, and, based on clinical priorities, separate those that should be kept from those that need to be discarded.
The doctor-elderly patient relationship is not straightforward. As we can see, it requires the doctor to ask themselves from time to time: Are the diagnoses correct? Do they need, or continue to need, drug therapy? Is this patient taking more medications than they can tolerate? God rewards that effort: sometimes, a proper dose adjustment and the discontinuation of certain drugs lead to a dramatic improvement in the clinical picture.
Reducing excessive medication must be done gently. A patient’s emotional attachment to their beloved medications is sometimes much stronger than the relationship they may have with their doctor. financial aid a family financial aid can therefore be very effective. And we must not forget that just as important as discontinuing medications is avoiding the addition of new ones to treat minor symptoms that can be managed with a little patience or self-restraint.
On the one hand, the primacy of the bioethical principle of autonomy, and on the other, the physician’s lack of time to provide information, do not contribute to the development of a well-considered ethics of prescribing, one of the most complex areas of medical ethics. So much emphasis has been placed on the patient’s freedom of choice and the decision-making power of their self-determination that there has been no in-depth reflection on the ethics of the patient’s obligations. No distinct doctrine has emerged regarding the complementary dyad of prescription and treatment follow-up, in which the patient’s freedom to decide and consent harmoniously combines with the duty to adhere to the therapeutic plan; and, on the part of the physician, the obligation to offer only validated and effective treatments alongside the determination of the scope of therapeutic prudence and discretion.
In this age of almost miraculously effective medications, prescribing has become the physician’s fundamental, defining professional act. Doctors are now less “doctors” than they once were; that is to say, they no longer educate patients about health. Today, few patients are satisfied with an explanation about the self-limiting nature of their illness—that it heals spontaneously and requires no medication. Explanation, persuasion, and psychotherapy have become very costly, as they demand many hours of the doctor’s time. And the doctor works with time running out. The quickest solution is to fill out a prescription. The enquiry reduced to a few minutes, but this comes at the cost of overusing the placebo effect. Yet medications prescribed as placebos contribute, like any others, to polypharmacy. And, curiously, patients cling tenaciously to placebos, in whose efficacy they have been led to trust.
Doctors’ lack of time—and sometimes their lack of energy as well—have contributed to the social norm of expecting medication: patients go to enquiry doctor convinced that they will have failed if they return home without a prescription. Curiously, on the threshold of the third millennium, the act of receiving a prescription remains, across all cultures, imbued with magical significance.
In the pharmacotherapy of the elderly, there are several economic extremes, ranging from extreme abundance to extreme scarcity, both of which are equally dangerous. expense associated with the elderly vary greatly from one country to another.
In development countries development among the poor in wealthy nations, older adults constitute a group , if not marginalized, group , which in turn leads to serious problems. The difficulty in accessing regular medical care in many development countries development the elderly to resort to a very precarious form of self-prescription and self-medication. It is surprising to learn that, in Latin America, in contrast to what happens in Europe, the elderly consume less than 8% of medications12, many of which may be of highly questionable quality13. In the United States, the Economics elderly move from the third world to the first whenever they become seriously ill. Under a strange cost-saving policy, financial aid receive financial aid for medications only when they are hospitalized, but not when they are at home. Such practices often have deplorable consequences, for by failing to invest a few dollars in outpatient care for these patients, enormous amounts of money are spent when they are treated in the hospital14.
In the developed world—that is, industrialized countries—people aged 65 and older are the group responsible for the largest share of invoice : In Europe, people aged 65 and older, who make up 18% of the population, consume nearly half of all prescription drugs2; in North America, those over 65, who make up 12% of the population, account for 35% of prescriptions15.
But when it comes to the elderly, the financial impact isn’t limited to what they spend on medications. Just as important—if not more so—is what is spent on treating the side effects of those medications. The issue of the cost—in lives, health, and money—of medication-related side effects in the elderly has been the subject of tremendous exaggeration, both in academic circles and in the tabloid press16. But there is no denying that it is a matter of concern, among other reasons because of its astronomical economic cost.
We have data on the cost of adverse drug reactions experienced by hospitalized patients, calculated based on the length of hospital stay and the medical care required to manage these reactions. There are no data on the elderly, but they are the primary group affected by iatrogenic conditions. For example, in the study by Bates et al.17, conducted at two Boston hospitals, the cost of adverse drug events amounted to $5,250 per bed per year. One in three of these events could have been prevented.
data medication-related harm in the outpatient setting are purely speculative. In a calculation based on the model , Johnson and Bootman18 estimated that morbidity and mortality due to medications result in an annual cost in the United States of the astronomical figure of $76.6 billion, exceeding the nation’s total initial expense . Although there are other, more moderate estimates, there is ample reason to believe that, in many cases, the cure may be worse than the disease.
I am unaware of the impact that these data may have on individual physicians’ behavior. However, it would be desirable for the relationship between Economics the ethics of prescribing medications to exert a stronger influence on the behavior of prescribing physicians. In a recent statement by the Central Ethics Committee of the Spanish Medical Association19, it is stated that: “Freedom of prescription also implies taking into account the economic aspects of medical decisions. There is an ethical duty to prescribe responsibly and with moderation [...]. The physician must not forget that the resources used to pay for their prescriptions do not belong to them, but to the patient or to the institutions, public or private, that bear position. The physician is, therefore, particularly obligated to prescribe rationally and with sound economic judgment. It is unethical to prescribe—sometimes incentivized—products of leave no therapeutic value or higher-priced medications when their efficacy is identical to that of lower-cost alternatives.”
There is no doubt that a physician’s prescribing behavior can be compromised by financial pressures that create conflicts of interest between serving the patient and accepting incentives that are not always ethically sound20.
Fortunately, this symposium provides an in-depth examination of the partner relationship in geriatric care. I will limit myself to highlighting the ethical aspects of the challenges older adults may face in adhering to their treatment plan. It is therefore worthwhile to discuss the role that families can play in overcoming these challenges. This topic important, as aging and dependence partner go hand in hand.
Although, fortunately, many older adults are capable of taking care of themselves and managing their own medication, there comes a time when almost all the very elderly—and many who are not yet in that category—cannot survive without the help of others. To live with dignity, we need and help one another. Solidarity between generations is the primary bond that holds humanity together. When that bond fails—and it can do so due to the selfishness of loved ones or the extreme individualism of the elderly—the consequences can be tragic. Today, in the United States, the most frequently cited reason for apply for medically assisted apply for is the rejection of dependence: not being able to fend for oneself and relying precariously on others is considered by some to be an undignified degradation, a life devoid of value and dignity.
Medication is one of the key components of the financial aid diary financial aid elderly individuals with disabilities21. And this is the case, as is well known, for various reasons. Sometimes the difficulty is cognitive: the elderly person cannot distinguish one medication from another, or cannot remember how and when to take the medication (whether daily, once or twice a day, with or between meals). Other times, the difficulty is guide: the elderly person is unable to open medication containers, apply eye drops, or administer insulin injections. Active work is underway on mechanical and dosing systems to promote medication adherence22. Some of these systems require the diligent participation of a caregiver who must pick up the medications at the pharmacy and fill the numerous compartments of the trays or monitored dosing systems on a daily or weekly basis. Some pharmacists view with some concern the possibility that a layperson might make a mistake when loading and labeling the compartments, which raises questions of responsibility from rules and regulations and legal rules and regulations of pharmacy23. However, this does not preclude recommending the use of procedures that facilitate monitoring. It is always necessary to simplify dosing regimens by prescribing medications that require fewer doses or controlled-release formulations. However, there has been some criticism of the idea that a single daily dose is better24. A family member can also be a keen observer of side effects and the most skilled negotiator of treatment changes.
It is advisable for the training of the caregiver responsible for administering the medication (the care partner) to begin while the patient is still in the hospital, following a special program25.
There may come a time in the life of an elderly person and their caregivers when the question inevitably arises as to what is best: living and receiving care at home, or residing and receiving care in a nursing home. Obviously, home is preferable as long as it is possible to live there—even from a pharmacological standpoint. Moving an elderly person to a residency program is residency program always an indisputable advantage: quantitative and qualitative disparities have been observed in the pharmacological treatment received by both types of elderly individuals. Those cared for in long-term care facilities are medicated more intensively—and not always to their advantage—with excessive use of psychotropic medications, a status has given rise to both radical criticism26, as well as legislation aimed at correcting such abuses27.
Pharmacotherapy for the elderly is, at its core, not only a fascinating chapter in clinical pharmacology—enriched by biological and clinical challenges—but also a deeply complex human issue, intertwined with economic and social factors, awaiting solutions. These solutions will come one day, if we do not forget that pharmacotherapy for the elderly is, at its core, from start to finish, an intense lesson in medical ethics that we must study with care and dedication.
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