"Medications are like barnacles; they’re easy to start, but they can be hard to stop." This insightful analogy from Dr. Michael Steinman encapsulates a pervasive issue in geriatric medicine: the enduring use of drugs that have been shown to be less effective or more harmful for older individuals, even after evidence and guidelines suggest otherwise.
The journey from scientific discovery to widespread clinical practice change is often a protracted and complex one. Medical research frequently identifies medications that, while beneficial for some, pose increased risks or diminished efficacy for the elderly population. These findings, often confirmed by subsequent studies, lead to revised clinical guidelines from medical associations, inclusion in authoritative lists like the Beers Criteria, and sometimes urgent warnings from regulatory bodies like the FDA. Yet, despite these efforts, a comprehensive analysis of national data reveals a persistent trend: the use of these problematic medications often declines, but not sufficiently, and in some cases, it remains unchanged or even increases. This phenomenon, termed "medical inertia," stems from a combination of factors, including the time lag in information dissemination to clinicians, the ingrained habits of both healthcare providers and patients, and the challenges in identifying and implementing alternative treatment strategies. This article delves into the complexities of this issue, examining three prominent examples of medications whose continued use among older adults highlights the critical need for more effective deprescribing strategies.
The enduring challenge of optimizing medication use in older adults is a multifaceted problem that underscores the gap between emerging medical evidence and its consistent integration into routine clinical practice. While the scientific community diligently works to identify drugs that may be less suitable or even detrimental for aging populations, translating these findings into tangible shifts in prescribing habits proves to be an arduous undertaking. This inertia is not necessarily a reflection of negligence but rather a confluence of systemic and behavioral factors. Clinicians, faced with demanding workloads and an ever-expanding body of medical knowledge, may not always have immediate access to or the capacity to fully process the latest recommendations. Furthermore, established treatment protocols and patient-doctor relationships built around specific therapeutic approaches can create a psychological barrier to change. The concept of "deprescribing" – the planned and supervised process of withdrawing or reducing medication – is gaining traction as a vital countermeasure, but its implementation requires a concerted effort from all stakeholders.
A significant area of concern involves benzodiazepines, a class of drugs commonly prescribed for insomnia and anxiety. For over two decades, researchers have voiced concerns regarding their suitability for older adults. Dr. Mark Olfson, a psychiatrist and epidemiologist at Columbia University, notes that while benzodiazepines offer prompt relief, their adverse effects can be particularly pronounced in the elderly. These medications, which include widely recognized names like Valium, Xanax, and Ativan, as well as related "Z-drugs" such as Ambien and Lunesta, can significantly impair balance, coordination, and cognitive function. These impairments can tragically translate into an increased risk of falls, fractures, and motor vehicle accidents. The dangers are further amplified when benzodiazepines are co-prescribed with opioids, elevating the risk of potentially fatal overdoses. Moreover, the development of physical dependence is a common consequence of prolonged benzodiazepine use, leading to challenging withdrawal symptoms when attempts are made to discontinue them.
Despite these well-documented risks, recent analyses of prescribing trends reveal a concerning picture regarding benzodiazepine use among older adults, a demographic particularly vulnerable to their adverse effects. While a study examining prescribing patterns in the Annals of Internal Medicine indicated a modest decline in the rate of patients aged 65 and older filling benzodiazepine prescriptions between 2015 and 2024, the progress has notably stalled since 2020. This stagnation may be partly attributed to the disruptions and increased stress associated with the COVID-19 pandemic. Alarmingly, prescribed use actually saw an increase among individuals over the age of 75 during this period, rising from 12% in 2020 to approximately 13% four years later. The rise in dispensing through pharmacies in long-term care facilities, more than doubling during the same timeframe, is particularly troubling. Furthermore, a substantial proportion of users, around one-third, were taking these medications for longer than six months, significantly increasing the likelihood of dependence. Dr. Olfson emphasizes that abrupt cessation of benzodiazepines is dangerous and can trigger severe withdrawal symptoms, underscoring the critical need for a carefully supervised tapering process, which can extend over many weeks.
Another area where evidence-based guidelines have struggled to curb the use of potentially inappropriate medications is in the treatment of diverticulitis. For years, antibiotics, primarily fluoroquinolones (such as Cipro and Levaquin) and amoxicillin-clavulanate (Augmentin), were considered the standard of care for this condition, characterized by inflammation or infection of small pouches in the colon. Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system, describes the prevailing mindset as one where antibiotics were seen as unequivocally safe and effective, leading to a default approach of "when in doubt, use them." However, in 2015, the American Gastroenterological Association issued a recommendation against the routine prescription of antibiotics for "uncomplicated" diverticulitis, which accounts for the vast majority of cases. This guidance was subsequently adopted by other leading medical organizations.
Clinical trials had demonstrated that, for uncomplicated diverticulitis, antibiotics offered little to no discernible benefit in terms of mortality, the need for surgery, complication rates, or recurrence. In essence, they "hadn’t improved anything," as Mr. Sutton stated. Yet, as with all medications, there are inherent risks and unintended consequences. Side effects from antibiotics contribute to a significant number of emergency room visits, manifesting as symptoms like nausea, vomiting, and diarrhea. Moreover, antibiotic use heightens the risk of developing the highly virulent Clostridioides difficile infection. Perhaps most critically, the widespread and often unnecessary use of antibiotics fuels the growing global threat of antimicrobial resistance, a phenomenon acknowledged by the World Health Organization as a major public health crisis.
Given this evidence, Mr. Sutton and his colleagues anticipated a significant decline in antibiotic prescriptions for uncomplicated diverticulitis over a decade of study involving 70,000 visits across 120 VA facilities. Their recent findings, published in the Annals of Internal Medicine, revealed a starkly different reality. Despite the existence of updated guidelines, antibiotic prescriptions remained nearly universal, being administered in 97% of visits. This suggests that patients could have likely achieved comparable outcomes with simpler interventions, such as a few days of 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 that are often mistakenly treated with antibiotics. In such scenarios, Mr. Sutton advocates for patients to actively engage with their physicians, asking for a clear rationale for antibiotic prescriptions and feeling empowered to "press pause" if the justification is unclear.
A distinct, yet equally concerning, aspect of medication inertia involves aspirin. Unlike prescription drugs, aspirin’s low cost and over-the-counter availability mean that millions of older Americans self-medicate with it, often with the intention of preventing cardiovascular events. For individuals who have already experienced a heart attack, stroke, or undergone cardiac procedures, 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 history of cardiovascular disease – has shifted significantly. In 2019, major cardiovascular organizations, including 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 further broadened this caution, advising against aspirin for primary prevention starting at age 60.
These updated recommendations are rooted in large-scale clinical trials that demonstrated minimal benefits from aspirin as a primary prevention measure, while simultaneously highlighting significant harms. The most notable adverse effect is gastrointestinal bleeding, a risk that demonstrably increases with age. Dr. Timothy Anderson, an internist at the University of Pittsburgh and co-director of its Prescribing Wisely Lab, notes that the risks of bleeding escalate as individuals age. More rarely, but with potentially devastating consequences, aspirin can lead to intracranial hemorrhage. A study published in JAMA last year, conducted by Dr. Anderson and his co-author, found some encouraging signs of the message reaching the public, with aspirin use for primary prevention showing a substantial decline between 2011 and 2023, as reported in the National Health and Nutrition Examination Survey. Nevertheless, more than one-third of individuals aged 70 and older were still taking aspirin for this purpose.
It is important to acknowledge certain nuances. A subset of older adults with high cardiovascular risk factors may indeed benefit from aspirin for primary prevention. Additionally, paradoxically, some evidence suggests that older patients who are already taking aspirin may face an increased risk of cardiovascular events if they discontinue it. Therefore, the initial step for any older adult considering their aspirin regimen is a thorough "conversation with their primary care physician," as Dr. Anderson emphasizes, to determine if it remains appropriate given their evolving health status and age. Many older patients who take 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, Dr. Anderson points out that for cardiovascular risk reduction, more effective and safer strategies exist, such as blood pressure medications and statins for cholesterol management. The continued prevalence of potentially inappropriate medication use in older adults underscores the critical need for ongoing research, enhanced educational outreach, and robust deprescribing initiatives to ensure that the benefits of medical advancements are realized safely and effectively for this vulnerable population.
