"Medications are like barnacles; they’re easy to start, but they can be hard to stop." This observation captures a critical challenge in geriatric care: the slow, often incomplete, dislodgement of medications found to be less effective or more risky for older patients. Despite evolving medical knowledge and updated guidelines, ingrained habits and systemic inertia mean that many older adults continue to take drugs that offer diminishing benefits and increasing harms.
The journey from identifying a medication’s potential harm in older adults to its widespread discontinuation is often a protracted and imperfect one. It typically begins with rigorous scientific inquiry, where researchers scrutinize the efficacy and safety of frequently prescribed drugs, particularly for the aging population. These studies frequently reveal that certain medications, once considered beneficial, may prove less effective or carry a disproportionately higher risk of adverse events in older individuals, who often have altered physiology and multiple co-existing conditions. This initial wave of research is frequently followed by corroborating studies, solidifying the evidence base for concern.
As scientific consensus builds, medical associations and expert bodies begin to revise their recommendations. Prestigious organizations like the American Geriatrics Society, through its influential Beers Criteria, identify and flag medications deemed potentially inappropriate for older patients. The U.S. Preventive Services Task Force, an independent panel of experts, may issue cautionary statements regarding drugs used for preventive purposes, while regulatory bodies like the Food and Drug Administration might mandate "black box" warnings to highlight severe side effects. These advisures represent crucial turning points, signaling a shift in clinical understanding and practice.
However, the impact of these updated guidelines on actual prescribing patterns is often delayed and incomplete. Years after these warnings are issued, researchers examining broad national data frequently find that while the use of these problematic medications may have declined, it often falls short of the recommended levels. In some instances, usage may even remain stagnant or, alarmingly, increase. This phenomenon, termed "medical inertia," stems from a complex interplay of factors.
Dr. Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the U.S. Deprescribing Research Network, aptly describes medications as "barnacles," emphasizing the ease of initiation versus the difficulty of cessation. This inertia is partly attributed to the time lag in disseminating new research and guidelines to a vast and busy clinical community. "Clinicians have a million things they need to know and attend to, and information may take a while to get to them," Steinman explains. Beyond the practicalities of information dissemination, deeply ingrained clinical habits and patient-doctor routines also contribute. "Clinicians and patients get used to treating conditions in certain ways," he notes. "They become ingrained habits." The absence of readily available or well-established alternative treatment pathways can further entrench the status quo, making it "easy to go with what you know."
Recent analyses of prescribing trends for several classes of medications commonly used by older Americans vividly illustrate this persistent challenge.
The Lingering Shadow of Benzodiazepines
Concerns regarding the use of benzodiazepines, prescribed for conditions such as insomnia and anxiety, have been circulating for over two decades. These drugs, including well-known agents like Valium, Xanax, and Ativan, along with related "Z-drugs" such as Ambien and Lunesta, offer prompt relief. However, as Dr. Mark Olfson, a psychiatrist and epidemiologist at Columbia University, points out, their benefits come with significant drawbacks for older adults.
"They may impair balance, coordination, and cognition that can translate into falls and fractures and motor vehicle accidents," Olfson explains. The risks are further amplified when benzodiazepines are co-prescribed with opioids, increasing the potential for dangerous overdoses. Moreover, prolonged use leads to physical dependence, with abrupt cessation often triggering challenging withdrawal symptoms.
Despite these well-documented risks, particularly for older individuals who are more susceptible to their adverse effects, benzodiazepine use among this demographic has seen only modest declines and, in some segments, even an increase. A recent examination of prescribing trends, published in the Annals of Internal Medicine, revealed that while the overall rate of patients aged 65 and older filling prescriptions for benzodiazepines dropped from approximately 14% in 2015 to 11.5% in 2024, this decline has plateaued since 2020. Worryingly, prescribed use actually rose among those over 75, from 12% in 2020 to about 13% four years later. The dispensing of these medications through pharmacies in long-term care facilities more than doubled during the same period. Furthermore, a significant proportion of users, about one-third, were taking the drugs for longer than six months, escalating the risk of dependence. "It’s worrisome," Olfson states. He strongly cautions that patients should never discontinue benzodiazepines abruptly or without medical supervision, as this can provoke severe withdrawal. "It requires supervised tapering" with a healthcare professional, a process that "takes many weeks."
The Enduring Overprescribing of Antibiotics
For years, the standard approach to treating diverticulitis, an inflammation or infection of small pouches in the colon, involved a course of antibiotics, primarily fluoroquinolones like Cipro and Levaquin, or amoxicillin-clavulanate (Augmentin). "It was unquestioned," says Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system. "Antibiotics are safe and effective, great, lifesaving drugs, so the mindset was: When in doubt, use them."
This established practice began to shift in 2015 when the American Gastroenterological Association recommended against the routine prescription of antibiotics for "uncomplicated" diverticulitis, which accounts for the vast majority of cases. Other medical organizations subsequently adopted similar stances. Clinical trials had demonstrated that for this specific condition, antibiotics had little to no impact on mortality, the need for surgery, complications, or recurrence rates. "They hadn’t improved anything," Sutton asserts.
However, as with any medication, antibiotics carry inherent risks and unintended consequences. "Side effects from antibiotics account for a substantial amount of emergency room visits" for symptoms like nausea, vomiting, and diarrhea. They also increase the risk of contracting the highly virulent Clostridioides difficile infection. Furthermore, the overuse of antibiotics contributes to the growing global threat of antimicrobial resistance. "The more you use antibiotics, the less they work in the future," Sutton warns, a concern echoed by the World Health Organization, which has declared antimicrobial resistance "a major global health threat."
Given these accumulating concerns, Sutton and his colleagues anticipated a decline in antibiotic use for uncomplicated diverticulitis over a 10-year period, based on their study of treatment patterns in 70,000 visits across 120 VA facilities. Instead, their recent findings, published in the Annals of Internal Medicine, indicated that antibiotic prescriptions remained nearly universal, occurring in 97% of visits, irrespective of the updated guidelines. This is particularly concerning as patients with uncomplicated diverticulitis would likely fare just as well with conservative management, such as pain relief with acetaminophen and a clear liquid diet. 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. In such scenarios, Sutton encourages patients to proactively ask their doctor for a clear rationale for antibiotic prescription. "If they don’t, it’s OK to press pause," he advises.
When Aspirin Isn’t Necessarily the Answer
Aspirin presents a unique challenge due to its widespread availability and low cost, making it easily accessible for self-initiation by millions of older Americans who believe it offers cardiovascular protection. For individuals with a history of heart attack, stroke, or prior cardiac interventions like stent placement or bypass surgery, daily low-dose aspirin for "secondary prevention" has been proven to reduce the risk of future cardiovascular events.
However, the landscape for "primary prevention"—in individuals who have never experienced a cardiovascular event—has shifted significantly. In 2019, 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 extended this caution, advising against aspirin for primary prevention starting at age 60. These updated recommendations are based on large clinical trials that demonstrated minimal benefit from aspirin in primary prevention, while highlighting significant harms, most notably gastrointestinal bleeding. "As we age, the risks of bleeding go up," notes Dr. Timothy Anderson, an internist at the University of Pittsburgh and co-director of its Prescribing Wisely Lab. More severe, though rarer, complications can include bleeding in the brain.
A JAMA study published last year by Anderson and his co-author indicated that the message regarding aspirin for primary prevention is beginning to penetrate. Aspirin use for this purpose, as reported in the National Health and Nutrition Examination Survey, declined substantially between 2011 and 2023. Nevertheless, more than a third of individuals aged 70 and older were still taking it. It is important to note that a subgroup of older adults with high cardiovascular risk factors may still benefit from aspirin for primary prevention. Furthermore, some evidence suggests that older patients already on aspirin may face an increased risk of cardiovascular events if they discontinue it, adding a layer of complexity to treatment decisions.
"Step 1 is a conversation with your primary care physician" about aspirin, Anderson emphasizes. "Is this still right for me as I get older?" Older patients taking aspirin, often without medical guidance, are motivated by a desire to reduce their risk of heart attack and stroke, seeking to be proactive about their health. However, as Anderson points out, "we have better strategies than aspirin" for achieving these goals, citing the efficacy of blood pressure medications and statins for cholesterol management.
