Progress in Chronic Disease Prevention Surgeon General's Workshop on Health Promotion and Aging: Summary Recommendations of the Medication Working Group

The "Surgeon General's Workshop on Health Promotion and Aging" met in Washington, D.C., on March 20-23, 1988. This workshop provided health professionals with recommendations and proposals for health promotion that address the needs of the elderly. The recommendations of the Alcohol Working Group have been summarized (1). Following is a summary of recommendations from the Medication Working Group. SUMMARY RECOMMENDATIONS OF THE MEDICATION WORKING GROUP Education and Training

More training and continuing medical education courses should be provided that emphasize the resources available to the prescriber, understanding of age-related physiologic metabolic changes, nonjudgmental patient-counseling skills, and interdisciplinary communication skills.

Social service providers, home caregivers, family members of older adults, and older adults should be trained in medication management and educated about the potential for adverse medication reactions.

The role of pharmacists in management of and education about geriatric medications should be expanded, and sites for prescribing information in all practice settings should be identified. Service

Reimbursement for pharmacy services for the elderly should be independent of dispensation or cost of the product.

Reimbursement patterns should encourage better access to medical care for persons needing complex medication regimens and for isolated patients.

Access to medicines and pharmaceutical services should be included as a basic part of health-care programs for the elderly and should include access to medicines for the geographically isolated and mobility-impaired.

Community-based programs should strengthen efforts to ensure that older Americans have the information necessary to participate with their health-care providers in medication management. Research

Cross-sectional and longitudinal studies and other pharmacoepidemiologic research should emphasize nonlethal side effects, efficacy, risks, compliance, and cost-effectiveness of medications.

National data sets should be studied further to assess medication-use patterns among older adults. oStudies should focus on cost-effective means of educating the consumer and the home caregiver on proper use of medications and monitoring of side effects and on the standardization of medication profile and drug interaction information. Policy oThe federal government should implement quickly the recently passed medication provisions of the Medicare Catastrophic Coverage Act of 1988 (100 PL 360; 1988 H.R. 2470). oRegulatory agencies should explore fraud and quackery by reviewing the marketing of certain drugs, vitamins, food stuffs, and nutritional supplements used as medications. oThe Food and Drug Administration (FDA) should complete development and implementation of proposed guidelines for drugs for use in the elderly, especially elderly subgroups at risk, and should emphasize not excluding persons from participating in clinical trials on the basis of age alone. oDrug labeling should be enforced and should emphasize patient education by including specific instructions for the elderly. Reported by: Office of the Surgeon General, Public Health Svc. Cardiovascular Health Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Most (60%) adverse reactions from drugs are pharmacologic (2,3), and many of these may be preventable with more careful prescribing, monitoring, and patient education. Elderly patients have a higher risk for developing adverse drug reactions than do persons in the general population (4,5); use of multiple drugs may be the strongest of several factors that predispose older persons to this excess risk. Thus, one important strategy for preventing adverse drug reactions among elderly persons is to limit the number of drugs used. This approach can reduce side effects, the possibility of drug interactions, and noncompliance (6). Furthermore, noncompliance appears to be associated more with the number of prescribed drugs taken than with increasing patient age (7).

Understanding of drug reactions in the elderly is based on multicenter collaborative drug surveillance programs, voluntary reporting to the FDA, cohort studies, control phase of intervention demonstrations, institutional or population-specific prevalence surveys, and computerized record linkage of secondary data sets. FDA data now indicate an overall rate of 8.5 adverse drug reaction reports per 100,000 population; the rate among persons aged greater than or equal to 65 years is 16.0, nearly double this rate (5).

Antihypertensive diuretics provide an important illustration of the current problems and the potential solutions in the area of geriatric medications. When FDA data from 1968 through 1982 were tabulated to identify medications associated with untoward effects in older patients (4), antihypertensive diuretics ranked fifth among the generic drug classes with the highest reported number of adverse drug reactions. Studies on hypertension in the elderly have demonstrated the importance of attentive monitoring during treatment (8,9). Such monitoring is important because these medications are so frequently implicated in adverse drug reactions among the elderly (7).

A major recurring theme in the recommendations of the Surgeon General's Workshop is education of health professionals, home caregivers and family members, and the elderly patients themselves. Implementing the recommendations of the Medication Working Group should help reduce the number of adverse drug reactions and increase medication compliance among the elderly.

References

1. CDC. Surgeon General's Workshop on Health Promotion and Aging: summary recommendations of the Alcohol Working Group. MMWR 1989;38:385-8.

2. Burnum JF. Preventability of adverse drug reactions (Letter). Ann Intern Med 1976;85:80-1.

3. Melmon KL. Preventable drug reactions: causes and cures. N Engl J Med 1971;284:1361-8.

4. Moore SR, Jones JK. Adverse drug reaction surveillance in the geriatric population: a pre liminary view. In: Moore SR, Teal TW, eds. Geriatric drug use: clinical and social perspec tives. New York: Pergamon Press, 1985:70-7.

5. Tanner LA, Baum C, Prela MC, et al. Spontaneous adverse reaction reporting in the elderly for 1986. J Geriatr Drug Therapy 1989;3:31-54.

6. Montamat SC, Cusack BJ, Vestal RE. Management of drug therapy in the elderly. N Engl J Med 1989;321:303-9.

7. German PS, Klein LE. Drug side effects and doctor/patient  relationship among elderly pa tients. J Soc Admin Pharm 1984;2:67-73.

8. Hypertension Detection and Follow-Up Program Cooperative Group. Five year findings of the Hypertension Detection and Follow-up Program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA 1979;242:2562-71.

9. Amery A, Birkenhager W, Brixbo P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet 1985;1:1349-54.

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