"Medications are like barnacles; they’re easy to start, but they can be hard to stop." This stark analogy captures the pervasive challenge of "medical inertia," where evidence-based shifts in prescribing practices for older adults lag significantly behind evolving scientific understanding, leaving many vulnerable to unnecessary drug risks.
The journey from scientific discovery to widespread clinical adoption of new medication guidelines is often a protracted and imperfect one, particularly for the aging population. While researchers and medical bodies continuously refine our understanding of drug efficacy and safety in older adults, the practical implementation of these findings in everyday healthcare encounters faces considerable hurdles. This phenomenon, termed "medical inertia," leads to the continued use of medications that have been shown to be less effective, more harmful, or simply unnecessary for elderly patients. This article delves into the persistent issue of medical inertia by examining the complex patterns surrounding the use of three classes of drugs – benzodiazepines, antibiotics for diverticulitis, and aspirin for primary prevention – highlighting the gap between evidence-based recommendations and actual prescribing practices among older Americans.
The lifecycle of a frequently prescribed medication often follows a predictable, yet frustratingly slow, trajectory concerning its appropriateness for older adults. Initially, a drug may be widely adopted based on general efficacy data. However, as medical research progresses, studies begin to emerge specifically investigating its use in older populations. These studies frequently reveal that the drug’s effectiveness diminishes with age, or that the inherent risks, such as increased susceptibility to side effects or drug interactions, begin to outweigh its benefits. This growing body of evidence typically prompts revisions in clinical guidelines by influential medical associations. These revisions might include warnings against the drug’s use or recommendations for more selective prescribing, often leading to its inclusion in established lists like the Beers Criteria, a vital resource for identifying potentially inappropriate medications for older adults, curated by the American Geriatrics Society.
Further reinforcing these concerns, independent expert panels like the U.S. Preventive Services Task Force may issue cautionary statements regarding the drug’s role in preventive care. Regulatory bodies such as the Food and Drug Administration (FDA) may also step in, issuing "black box" warnings to highlight particularly serious or life-threatening side effects. Yet, despite these layered warnings and updated recommendations, a subsequent review of national prescribing data often reveals that the intended decline in the drug’s utilization among older adults is either insufficient or, in some troubling instances, has not occurred at all, or has even reversed.
Dr. Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the U.S. Deprescribing Research Network, eloquently likens medications to barnacles, emphasizing their ease of initiation and the inherent difficulty in their discontinuation. This "medical inertia" is a multifaceted problem. A significant contributor is the inherent time lag in disseminating new research findings to the vast and diverse network of clinicians. As Dr. Steinman notes, "Clinicians have a million things they need to know and attend to, and information may take a while to get to them." However, the inertia is not solely a matter of information delay. It also stems from deeply ingrained habits and established treatment paradigms that both clinicians and patients have become accustomed to. Shifting these established practices requires significant effort and the identification of viable alternative approaches, making it "easy to go with what you know."
The persistent challenges of medical inertia are vividly illustrated by recent studies examining three drug classes extensively used by older Americans: benzodiazepines, antibiotics for diverticulitis, and aspirin for primary prevention.
The Enduring Shadow of Benzodiazepines
Concerns regarding the safety and efficacy of benzodiazepines in older adults have been voiced by scientists for over two decades. These medications, commonly prescribed for insomnia and anxiety, offer rapid relief, a characteristic that contributes to their widespread use. However, their problematic nature for the elderly population is well-documented. As explained by Mark Olfson, a psychiatrist and epidemiologist at Columbia University, benzodiazepines, including well-known brands like Valium, Xanax, and Ativan, along with related "Z-drugs" such as Ambien and Lunesta, can significantly impair balance, coordination, and cognitive function. These impairments directly translate into an increased risk of falls, fractures, and motor vehicle accidents, which are particularly devastating for older individuals. Furthermore, when co-prescribed with opioids for pain management, benzodiazepines can dangerously elevate the risk of overdose.
A critical issue with benzodiazepines is the development of dependence. Olfson points out that prolonged use leads to a physical dependence, and abrupt cessation can trigger severe withdrawal symptoms. Despite these known risks, studies examining prescribing trends for benzodiazepines among older adults, who are inherently more susceptible to their adverse effects, reveal a complex picture. While one recent examination of prescribing patterns published in the Annals of Internal Medicine showed a modest decline in the rate of patients aged 65 and older filling prescriptions for benzodiazepines, dropping from approximately 14% in 2015 to 11.5% in 2024, this progress has unfortunately stalled since 2020. Compounding this concern, prescribed use actually increased among those over 75, rising from 12% in 2020 to about 13% four years later. A particularly alarming trend is the more than doubling of benzodiazepine dispensing through pharmacies in long-term care facilities, coupled with the finding that about a third of users were taking the drug for longer than six months, significantly increasing the likelihood of dependence. Olfson expresses concern over these trends, emphasizing that patients should never discontinue benzodiazepines abruptly or without medical supervision, as this can provoke dangerous withdrawal. He stresses the necessity of a carefully managed, supervised tapering process that can extend over many weeks.
The Overuse of Antibiotics for Diverticulitis
For many years, the standard treatment for diverticulitis, an inflammatory condition affecting small pouches in the colon, predominantly involved the prescription of antibiotics, most commonly fluoroquinolones (such as Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin). Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system, describes this approach as "unquestioned," reflecting a prevailing mindset that antibiotics, being safe, effective, and lifesaving drugs, should be employed liberally.
However, in 2015, the American Gastroenterological Association issued a pivotal recommendation advising against the routine prescription of antibiotics for "uncomplicated" diverticulitis, a category encompassing the vast majority of cases. This guidance was subsequently adopted by other prominent medical organizations. Clinical trials had conclusively demonstrated that, for this specific condition, antibiotics offered little to no discernible benefit in terms of reducing mortality, the need for surgery, the incidence of complications, or the recurrence of the condition. In Sutton’s words, "They hadn’t improved anything."
Beyond their lack of efficacy in uncomplicated diverticulitis, antibiotics, like all medications, carry inherent risks and unintended consequences. Sutton highlights that side effects from antibiotic use are a substantial cause of emergency room visits, presenting with symptoms such as nausea, vomiting, and diarrhea. Furthermore, antibiotic use heightens the risk of developing the dangerous and often antibiotic-resistant Clostridioides difficile infection. Crucially, the more antibiotics are used, the less effective they become in the future, contributing to the global health crisis of antimicrobial resistance, recognized by the World Health Organization as a major threat.
Given these well-established concerns, Sutton and his colleagues anticipated a decline in antibiotic prescriptions for uncomplicated diverticulitis over a 10-year period, based on their study of treatment patterns across 70,000 visits to 120 VA facilities. Instead, their recent findings, published in the Annals of Internal Medicine, revealed a stark reality: antibiotic prescriptions remained nearly universal, present in 97% of visits, irrespective of updated guidelines. Patients with uncomplicated diverticulitis, the study suggests, would likely have achieved similar outcomes with conservative measures like a few days of pain relievers such as Tylenol and a clear liquid diet. The problem of antibiotic overuse extends beyond diverticulitis, remaining prevalent for other conditions common in later life, including asymptomatic urinary tract infections and viral upper respiratory infections where antibiotics are ineffective. Sutton encourages patients to proactively question the rationale behind antibiotic prescriptions, suggesting it is appropriate to "press pause" if a clear explanation is not provided.
When Aspirin Isn’t the Answer: The Case of Primary Prevention
Aspirin presents a unique challenge due to its accessibility and low cost. It is readily available over-the-counter, leading millions of older Americans to initiate aspirin use independently, often with the belief that it offers protection against cardiac events. For individuals who have already experienced a heart attack, stroke, or undergone cardiac interventions like stent placement or bypass surgery, daily low-dose aspirin for "secondary prevention" is indeed proven to reduce the risk of subsequent events.
However, the landscape for "primary prevention" – use 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, recommended against aspirin for primary prevention in individuals aged 70 and older. The U.S. Preventive Services Task Force further strengthened these recommendations, advising against aspirin for primary prevention in those aged 60 and older. These updated guidelines are grounded in large clinical trials that demonstrated minimal benefit from aspirin as a primary preventive measure, while simultaneously highlighting significant harms, most notably gastrointestinal bleeding. Timothy Anderson, an internist at the University of Pittsburgh and co-director of its Prescribing Wisely Lab, notes that "As we age, the risks of bleeding go up." Aspirin can also cause more serious, albeit rarer, complications such as bleeding in the brain.
A JAMA study published last year, analyzing data from the National Health and Nutrition Examination Survey, found that aspirin use for primary prevention had substantially decreased between 2011 and 2023, indicating that the message is gradually reaching the public. Nevertheless, more than a third of individuals aged 70 and older were still taking aspirin for primary prevention. It is important to acknowledge nuances: a select subgroup of older adults with high cardiovascular risk factors might still benefit from aspirin for primary prevention. Furthermore, counterintuitively, some evidence suggests that older patients already on aspirin may face an increased risk of cardiovascular events if they discontinue its use.
Dr. Anderson emphasizes that the crucial first step for any older adult considering or continuing aspirin use is a direct conversation with their primary care physician to ascertain if it remains appropriate as they age. He observes that many 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, he concludes that for cardiovascular risk reduction, "we have better strategies than aspirin," pointing to the efficacy of blood pressure medications and statins for cholesterol management.
