"Medications are like barnacles; they’re easy to start, but they can be hard to stop." Despite years of research and revised guidelines, potentially harmful drugs continue to be widely used by older adults, revealing a significant inertia in medical practice.
The medical landscape for older adults is frequently marked by a predictable pattern: a drug once considered a standard of care is scrutinized, found to be less effective or more risky for this demographic, and subsequently flagged by professional organizations and regulatory bodies. Yet, even as evidence mounts and recommendations evolve, the use of these medications often persists at concerning levels, highlighting a complex interplay of ingrained habits, information dissemination challenges, and patient-doctor dynamics. This phenomenon, often termed "medical inertia," means that drugs that should be discontinued or used with extreme caution remain prevalent, posing unnecessary risks to a vulnerable population.
This inertia isn’t a sudden development but rather a gradual, often multi-year process. It begins with researchers identifying a problem: a commonly prescribed medication demonstrates diminished efficacy or an elevated risk profile in older patients compared to younger ones. These initial findings, often published in peer-reviewed journals, are the first domino to fall. Following these foundational studies, a cascade of further research typically emerges, aiming to corroborate, refine, or expand upon the initial observations. The consensus that builds over time is crucial, solidifying the evidence base for potential intervention.
As the scientific understanding matures, medical associations and professional bodies step in. They review the accumulating evidence and, if warranted, revise their clinical guidelines. This often involves issuing strong warnings against the continued use of certain drugs for older adults, or at least advocating for their highly selective prescription. A significant milestone in this process is the inclusion of a medication on influential lists such as the Beers Criteria. Developed and maintained by the American Geriatrics Society, the Beers Criteria serves as a vital resource, identifying potentially inappropriate medications (PIMs) for older adults, thereby guiding clinicians toward safer prescribing practices.
Beyond professional guidelines, other authoritative bodies may lend their weight to these concerns. The U.S. Preventive Services Task Force (USPSTF), an independent panel of national experts in prevention and primary care, may issue recommendations or statements cautioning against the use of specific drugs for preventive purposes in older individuals. Concurrently, regulatory agencies like the Food and Drug Administration (FDA) can take action by issuing "black box" warnings. These are the strongest type of warnings issued by the FDA, alerting healthcare professionals and patients to serious or life-threatening risks associated with a drug, demanding careful consideration before prescription.
However, the journey from evidence-based recommendation to widespread practice change is often protracted. Years may pass after these authoritative warnings are issued before researchers can adequately assess the impact on actual prescribing patterns. Studies analyzing broad national data sets are typically employed to determine whether the use of the flagged medications has declined. The findings are frequently mixed: while some drugs see a reduction in use, the decline is often less substantial than anticipated. In some instances, the usage may remain stubbornly high or, alarmingly, even increase, defying the established evidence.
Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the U.S. Deprescribing Research Network, aptly describes this phenomenon: "Medications are like barnacles; they’re easy to start, but they can be hard to stop." This metaphor encapsulates the challenge of medication discontinuation, which is often more complex than initiation.
This "medical inertia" is attributed to several interconnected factors. One primary driver is the significant time lag involved in the dissemination of new research findings and updated guidelines to the frontline clinicians who make prescribing decisions. "Clinicians have a million things they need to know and attend to, and information may take a while to get to them," Steinman explains. The sheer volume of medical knowledge and the demanding pace of clinical practice mean that even crucial updates can take time to permeate the system.
Furthermore, ingrained habits and established treatment paradigms play a substantial role. As Steinman notes, "clinicians and patients get used to treating conditions in certain ways. They become ingrained habits." Over time, specific medications become the default approach for certain conditions, and breaking these established patterns requires conscious effort and often the identification of viable alternatives. When effective and easily implementable alternatives are not readily available or well-understood, "it’s easy to go with what you know." This reliance on familiar approaches can perpetuate the use of drugs that have fallen out of favor based on evolving evidence.
The persistent challenge of medical inertia is vividly illustrated by recent studies examining the prescribing trends of three classes of drugs widely used among older Americans: benzodiazepines, antibiotics, and aspirin. These examples highlight how established practices can endure despite clear evidence of potential harm.
The Enduring Drawbacks of Benzodiazepines
Concerns surrounding the use of benzodiazepines, a class of drugs prescribed for insomnia and anxiety, have been voiced by scientists for over two decades. Mark Olfson, a psychiatrist and epidemiologist at Columbia University, acknowledges their appeal: "they offer prompt relief." However, the significant downsides for older adults have become increasingly apparent.
Benzodiazepines, which include well-known medications like Valium, Xanax, and Ativan, along with related "Z-drugs" such as Ambien and Lunesta, carry substantial risks for older individuals. Olfson points out that these drugs "may impair balance, coordination, and cognition that can translate into falls and fractures and motor vehicle accidents." These physical and cognitive impairments can lead to severe injuries and a decline in functional independence. Compounding these risks, when benzodiazepines are co-prescribed with opioids for pain management, they can dangerously increase the likelihood of overdose.
Another critical issue is the development of dependence. Olfson explains, "once you’ve taken them for a period of time, you develop a dependence. When you come off them, you may develop withdrawal symptoms." This physical dependence can make discontinuing the medication difficult, even when it is no longer medically indicated, as withdrawal can be uncomfortable and even dangerous if not managed properly.
Given that older adults are often more sensitive to the adverse effects of these medications, one would expect a significant decline in their use. Indeed, a recent examination of prescribing trends published in the Annals of Internal Medicine by Olfson and his team did show some progress. Among individuals aged 65 and older, the rate of patients filling prescriptions for benzodiazepines decreased from approximately 14% in 2015 to 11.5% in 2024.
However, this positive trend has shown signs of stagnation since 2020, potentially exacerbated by the disruptions of the COVID-19 pandemic. More concerningly, prescribed use actually increased among those over 75, rising from 12% in 2020 to about 13% four years later. Dispensing through pharmacies in long-term care facilities, where a significant portion of the elderly population resides, more than doubled during this period. Furthermore, approximately one-third of patients were taking these medications for longer than six months, a duration that significantly increases the likelihood of dependence. "It’s worrisome," Olfson stated, highlighting the continued prevalence of these risky drugs.
Crucially, Olfson emphasizes that patients should never stop benzodiazepines abruptly or without medical supervision. Such actions can precipitate severe withdrawal symptoms. "It requires supervised tapering with a medical professional," he advises, noting that this process "takes many weeks," underscoring the complexity of safely discontinuing these medications.
The Persistent Overprescribing of Antibiotics
For years, antibiotics were the unquestioned standard treatment for diverticulitis, an inflammation or infection of the small pouches that form in the colon. Medications like fluoroquinolones (e.g., Cipro, Levaquin) and amoxicillin-clavulanate (Augmentin) were routinely prescribed. Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system, recalls the prevailing mindset: "Antibiotics are safe and effective, great, lifesaving drugs, so the mindset was: When in doubt, use them."
This dogma began to shift in 2015 when the American Gastroenterological Association recommended against the routine prescription of antibiotics for "uncomplicated" diverticulitis, a category that encompasses the vast majority of cases. Other leading medical groups subsequently echoed this guidance. The rationale stemmed from clinical trials that demonstrated antibiotics had little to no impact on mortality, the need for surgery, the occurrence of complications, or the recurrence rate of the condition. "They hadn’t improved anything," Sutton stated, emphasizing the lack of demonstrable benefit.
Despite the absence of clear advantages, antibiotics carry inherent risks and potential "downsides, unintended consequences," as Sutton puts it. Side effects from antibiotic use are a significant cause of emergency room visits, manifesting as symptoms like nausea, vomiting, and diarrhea. Moreover, antibiotics increase the risk of developing the highly virulent Clostridioides difficile (C. diff) infection, a serious gastrointestinal illness.
Beyond immediate side effects, the broader implication of antibiotic overuse is the escalating threat of antimicrobial resistance. "The more you use antibiotics, the less they work in the future," Sutton warned. The World Health Organization has declared antimicrobial resistance "a major global health threat," underscoring the long-term consequences of indiscriminate antibiotic use.
Given this evidence, Sutton and his colleagues embarked on a study analyzing treatment patterns in 70,000 visits across 120 VA facilities, expecting to observe a decline in antibiotic prescriptions for uncomplicated diverticulitis over a ten-year period. Their findings, recently published in the Annals of Internal Medicine, were disheartening. They reported that antibiotic prescriptions remained nearly universal, present in 97% of visits, regardless of the updated guidelines. The study suggested that most patients with uncomplicated diverticulitis would have fared just as well with conservative management, such as a few days of pain relievers like acetaminophen and a clear liquid diet.
The overuse of antibiotics extends beyond diverticulitis, remaining common for other conditions prevalent in later life. This includes asymptomatic urinary tract infections and upper respiratory infections, which are often viral and do not require antibiotic treatment. Sutton encourages patients in such situations to actively engage with their physicians. "I’d encourage patients to say, ‘Please explain the rationale for doing this,’" he advised. "If they don’t, it’s OK to press pause."
When Aspirin Isn’t the Answer
Aspirin presents a unique challenge due to its accessibility and perceived benign nature. Being inexpensive and available over the counter, millions of older Americans take it independently, believing it offers protection against cardiovascular events.
For individuals who have already experienced a heart attack, stroke, or undergone cardiac procedures like stent placement or bypass surgery, daily low-dose aspirin for "secondary prevention" has been proven to reduce the risk of subsequent events. However, the landscape for "primary prevention"—in individuals without a prior cardiovascular history—has seen significant shifts in guidance.
In 2019, the American College of Cardiology and the American Heart Association recommended against aspirin for primary prevention in individuals aged 70 and older. The U.S. Preventive Services Task Force (USPSTF) further broadened this caution, advising against aspirin for primary prevention starting at age 60. These updated guidelines were based on large clinical trials that revealed minimal benefit from aspirin as a primary preventive measure, while highlighting significant harms, particularly gastrointestinal bleeding. "As we age, the risks of bleeding go up," explained Timothy Anderson, an internist at the University of Pittsburgh and co-director of its Prescribing Wisely Lab. More serious, though rarer, complications include bleeding in the brain.
A JAMA study published last year, conducted by Anderson and his co-author, provided some encouraging news: aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had substantially decreased from 2011 to 2023. Nevertheless, more than a third of individuals aged 70 and older were still taking aspirin for this purpose.
It is important to note some nuances. A subgroup of older adults with high cardiovascular risk factors might still benefit from aspirin for primary prevention. Furthermore, confusingly, some evidence suggests that older patients already taking aspirin may face an increased risk of cardiovascular events if they discontinue the medication.
"Step 1 is a conversation with your primary care physician about aspirin," Anderson stressed. He advises patients to ask, "’Is this still right for me as I get older?’" Older patients who self-medicate with aspirin are often motivated by a desire to reduce their risk of heart attack and stroke, seeking to "be proactive and healthy." However, Anderson points out that for these goals, "we have better strategies than aspirin," citing the efficacy of blood pressure medications and statins for cholesterol management. These more targeted and often safer interventions represent superior alternatives for cardiovascular risk reduction in the aging population.
