"Medications are like barnacles; they’re easy to start, but they can be hard to stop. Despite mounting evidence of risks and diminished benefits for older populations, the use of certain drugs persists, revealing a complex interplay of medical inertia, ingrained habits, and challenges in disseminating new information."
The journey of a drug from widespread prescription to cautious recommendation for older adults is often a protracted and incomplete one. Despite a growing body of research highlighting potential risks and diminishing efficacy in geriatric populations, many medications continue to be widely used, underscoring a phenomenon medical experts call "medical inertia." This inertia is fueled by several factors, including the time lag in disseminating new research findings, the ingrained habits of both clinicians and patients, and the difficulty in finding suitable alternative treatments. The implications for patient safety and healthcare costs are significant, as older adults, who are more vulnerable to adverse drug reactions, continue to be exposed to medications that may offer little benefit and considerable harm.
This challenge is vividly illustrated by the trends in the use of three prominent drug classes: benzodiazepines, antibiotics for diverticulitis, and aspirin for primary prevention. Each case study reveals a familiar pattern: scientific scrutiny, updated guidelines, and yet, a stubborn persistence in prescribing and using these medications, particularly among the elderly.
The Lingering Shadow of Benzodiazepines
For over two decades, the medical community has been raising alarms about the use of benzodiazepines, a class of drugs commonly prescribed for insomnia and anxiety, including well-known names like Valium, Xanax, and Ativan, as well as related "Z-drugs" such as Ambien and Lunesta. While these medications offer prompt relief for acute symptoms, their long-term use in older adults is fraught with significant risks. As Mark Olfson, a psychiatrist and epidemiologist at Columbia University, explains, benzodiazepines can impair balance, coordination, and cognition, directly increasing the risk of falls, fractures, and motor vehicle accidents – common and often devastating events in the elderly. When combined with opioids, the danger escalates, significantly raising the likelihood of fatal overdoses. Furthermore, these drugs are highly habit-forming, leading to physical dependence. Discontinuation can trigger uncomfortable and sometimes severe withdrawal symptoms, making it difficult for patients to stop, even when aware of the risks.
Despite these well-documented concerns, research indicates that the decline in benzodiazepine use among older adults has been insufficient. A recent examination of prescribing trends revealed a modest drop in the rate of patients aged 65 and older filling prescriptions for these drugs, from approximately 14% in 2015 to 11.5% in 2024. However, this progress has stalled since 2020, with prescribed use actually increasing among those over 75, rising from 12% to about 13% in four years. The dispensing of these medications through pharmacies in long-term care facilities has more than doubled, a particularly concerning trend given the vulnerability of residents in these settings. Compounding the issue, about one-third of older adults taking benzodiazepines do so for longer than six months, significantly increasing their risk of developing dependence. Olfson emphasizes that abruptly stopping these medications can be dangerous and necessitates a supervised tapering process under medical guidance, a regimen that can extend over many weeks.
The Overuse of Antibiotics for Diverticulitis
For years, the standard treatment for diverticulitis, an inflammatory condition of the colon, primarily involved antibiotics, such as fluoroquinolones (Cipro, Levaquin) or amoxicillin-clavulanate (Augmentin). This approach was largely unquestioned, driven by the perception of antibiotics as universally safe and life-saving. Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system, notes the prevailing mindset: "When in doubt, use them." However, by 2015, major medical organizations, including the American Gastroenterological Association, began recommending against the routine prescription of antibiotics for "uncomplicated" diverticulitis, which accounts for the vast majority of cases.
Extensive clinical trials demonstrated that, for uncomplicated diverticulitis, antibiotics offered little to no discernible benefit in terms of mortality, the need for surgery, complications, or recurrence rates. "They hadn’t improved anything," Sutton states. Yet, like all medications, antibiotics carry potential downsides. Side effects such as nausea, vomiting, and diarrhea are common and lead to a substantial number of emergency room visits. More seriously, antibiotic use heightens the risk of developing the virulent Clostridioides difficile infection. Furthermore, the widespread and often unnecessary use of antibiotics contributes to the growing crisis of antimicrobial resistance, a major global health threat identified by the World Health Organization.
Despite these evolving guidelines and established risks, a recent study by Sutton and his colleagues analyzing treatment patterns across 70,000 visits to 120 VA facilities over a decade revealed a startling lack of change. Antibiotic prescriptions for uncomplicated diverticulitis remained nearly universal, at 97% of visits, underscoring the deep-seated nature of the "when in doubt, prescribe" mentality. For many of these patients, a few days of pain relievers and a clear liquid diet would have been equally effective, with far fewer risks. The problem of antibiotic overuse extends beyond diverticulitis, remaining common for other conditions prevalent in later life, including asymptomatic urinary tract infections and viral upper respiratory infections. Sutton encourages patients to proactively question their healthcare providers about the rationale for antibiotic prescriptions and to feel empowered to "press pause" if the justification is unclear.
The Misguided Use of Aspirin for Primary Prevention
Aspirin, a readily available and inexpensive medication, presents a unique challenge because it can be self-initiated by individuals without medical consultation. Millions of older Americans take daily low-dose aspirin, believing it offers protection against cardiac events. For individuals who have already experienced a heart attack, stroke, or undergone cardiac interventions, daily low-dose aspirin for "secondary prevention" has been proven to reduce the risk of subsequent events.
However, the landscape of "primary prevention"—preventing a first-time cardiac event in individuals without a history of cardiovascular disease—has shifted significantly. In 2019, major cardiology organizations, including the American College of Cardiology and the American Heart Association, revised their guidelines, recommending against aspirin for primary prevention in individuals aged 70 and older. The U.S. Preventive Services Task Force took an even more cautious stance, advising against its use for primary prevention starting at age 60. These updated recommendations were based on large clinical trials that found scant benefit from aspirin in preventing initial cardiovascular events, while simultaneously identifying significant harms, most notably gastrointestinal bleeding. Timothy Anderson, an internist at the University of Pittsburgh and co-director of its Prescribing Wisely Lab, highlights that "as we age, the risks of bleeding go up." Aspirin can also cause less common but more severe bleeding in the brain.
A study published in JAMA last year indicated that the message regarding aspirin for primary prevention is slowly reaching the public, with its use dropping substantially from 2011 to 2023 among those surveyed. However, more than a third of individuals aged 70 and older were still taking it for primary prevention. While there are specific subgroups of older adults with high cardiovascular risk factors who may still benefit from aspirin for primary prevention, and some evidence suggests that discontinuing aspirin can increase cardiovascular risk in those already taking it, the general trend points towards overutilization. Anderson stresses the importance of a direct conversation with a primary care physician to determine if continuing aspirin is appropriate as individuals age. He notes that older adults taking aspirin, often without medical guidance, are motivated by a desire to be proactive about their health. However, he points out that for conditions like high blood pressure and high cholesterol, "we have better strategies than aspirin" through medications like blood pressure regulators and statins.
The enduring use of these medications in older adults, despite evolving scientific understanding and updated clinical guidelines, reflects a complex system grappling with information dissemination, ingrained practices, and the inherent challenges of changing established medical habits. Addressing this "medical inertia" requires a concerted effort from researchers, clinicians, professional organizations, and patients to ensure that medication use in older adults is not only evidence-based but also tailored to their individual needs and evolving risk profiles, prioritizing safety and well-being above outdated routines.
