Medications and Older People

People age 65 and older consume more prescription and over-the-counter (OTC) medicines than any other age group, according to the National Institute on Aging. Older people tend to have more long-term, chronic illnesses--such as arthritis, diabetes, high blood pressure and heart disease--than do younger people. Because they may have a number of diseases or disabilities at the same time, it is common for older people to take many different drugs.

The Food and Drug Administration is working to make drugs safer for older people, who consume a large share of the nation's medications. People over age 65 buy 30 percent of all prescription drugs and 40 percent of all over-the-counter drugs.

"Almost every drug that comes through FDA [for approval] has been examined for effects in the elderly," meaning people over 65, says Robert Temple, M.D., director of one of the FDA's offices of drug evaluation. "If the manufacturer hasn't done a study that includes the elderly, we would usually ask for it."

More than 15 years ago, the agency established guidelines encouraging drug manufacturers to include more elderly patients in their studies of new drugs. The FDA suggested that upper age limits be eliminated in drug studies, and that even patients who had other health problems be allowed to participate if they are able. Including older people in these studies gives information about whether they will respond to the drug differently because of their age or health conditions common in this age group.

In several surveys in the 1980s, the FDA discovered that drug manufacturers had been including older people in their drug studies, but they weren't examining the study results to see if the older participants responded differently to the drugs.. Now, they do. Today, new prescription drugs are generally required to have a section in the labeling about their use in the elderly.

Says Temple, "The FDA has done quite a bit and worked fully with academia and industry to change drug testing so that it does analyze the data from elderly patients. We're very serious about wanting these analyses." In fact, The analyses have been a regulatory requirement since 1999.

When More Isn't Necessarily Better

When prescribed and taken appropriately, drugs have many benefits: They treat diseases and infections, help manage symptoms of chronic conditions, and can contribute to an improved quality of life. But medicines can also cause problems, and the medical and physical needs of older people can sometimes make being aware of potential problems especially important. Of all the problems older people face in taking medication, drug interactions are possibly the most dangerous. When two or more drugs are mixed in the body, they may interact with each other and produce uncomfortable or even dangerous side effects. This is especially a problem for older people because they are much more likely to take more than one drug. The average older person is taking more than four prescription medications at once plus two over-the-counter medications.

It's often necessary to take drugs in combination; it just requires care. High blood pressure, for example, is often treated with several different drugs. Many older people have multiple cardiovascular risk factors--high blood pressure, diabetes, abnormal cholesterol--and will often need multiple drugs to treat them. Unless supervised by a doctor, however, taking a mixture of drugs can be dangerous.

For example, a person who takes a blood-thinning medication should not combine that with aspirin, which will thin the blood even more. And antacids can interfere with absorption of certain drugs for Parkinson's disease, high blood pressure, and heart disease. Before prescribing any new drug to an older patient, a doctor should be aware of all the other drugs the patient may be taking.

"Too often, older people get more drugs without a reassessment of their previous medications," says Madeline Feinberg, Pharm.D., a pharmacist and former director of the Elder Health program of the University of Maryland School of Pharmacy. "That can be disastrous."

Older people tend to be more sensitive to drugs than younger adults are, due to changes in organ function and, in some cases, loss of muscle tissue that can cause the drug to be more concentrated in the blood. They also may be more susceptible to certain side effects, such as a drop in blood pressure. The adage "Start low and go slow" is good advice for the elderly.

Older people who experience dizziness, constipation, upset stomach, sleep changes, diarrhea, incontinence, blurred vision, mood changes, a rash or other symptoms after taking a drug should call their doctors. The following suggestions may also help:

• Make sure you tell your doctor and pharmacist about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. You may sometimes have more than one doctor, each prescribing different medicines. Make sure they all know what the others are prescribing, and ask one doctor (such as an internist or general practitioner) to coordinate your drugs.
  "You are a partner in your health care," says Feinberg. "This is a partnership between you, your doctor, and your pharmacist. You need to be assertive and knowledgeable about the medications you take."
• Get all your prescriptions filled at one pharmacy. Your pharmacist can serve as a central point to maintain a list of all your medicines, and can screen for drug interactions to avoid harmful situations.
• Tell your doctor if you are allergic to any medicines.
• Keep track of side effects. New symptoms may not be from old age but from the drug you're taking.
• Learn about your drugs. Find out as much as you can by asking questions and reading the package inserts. Both your doctor and pharmacist should alert you to possible interactions between drugs, how to take any drug properly, and whether there's a less expensive generic drug available.
• Have your doctor review your drugs. If you take a number of drugs, take them all with you on a doctor's visit.
• Ask the doctor, "When can I stop taking this drug?" and, "How do we know this drug is still working?"
• Follow directions. Read the label every time you take the medication to prevent mistakes, and be sure you understand the timing, dose prescribed, and how long to take it. Ask a pharmacist what foods to take with each drug. Some drugs are better absorbed with certain foods, and some drugs shouldn't be taken with certain foods.
• Don't forget to take your medicines. Use a memory aid to help you--a calendar, pill box, or your own system. Whatever works for you is best.

Medicine and Special Needs

Arthritis, poor eyesight, and memory lapses can make it difficult for some older people to take their medications correctly. Studies have shown that between 40 percent and 75 percent of older people don't take their medications at the right time or in the right amount.

A number of strategies can make taking medication easier. Patients with arthritis can ask the pharmacist for an oversized, easy-to-open bottle. For easier reading, ask for large-type labels. If those are not available, use a magnifying glass and read the label under bright light.

Invent a system to remember medication. Even younger adults have trouble remembering several medications two or three times a day, with and without food. Devise a plan that fits your daily schedule. Some people use meals or bedtime as cues for remembering drugs. Others use charts, calendars, and special weekly pill boxes.

Mary Sloane, 78, keeps track of five medications a day by sorting her pills each evening into separate dishes. One is for morning pills, the other for the next evening. Then she turns each medicine bottle upside down after taking the pill so she can tell at a glance if she has taken it that day.

"You have to have a system," Sloane says. "Because just as soon as I get started taking my pills, the phone rings, and when I come back to it, I think, 'Now have I taken that?'"

Drug-taking routines should take into account whether the pill works best on an empty or full stomach and whether the doses are spaced properly. To simplify drug-taking, always ask for the easiest dosing schedule that's available for the drug you've been prescribed--just once or twice a day, for example.

Older people with serious memory impairments require assistance from family members or professionals. Adult day care, supervised living facilities, and home health nurses can provide assistance with drugs.

Active Lives

Not all older people are in danger of drug interactions and adverse effects. In fact, as more and more people live active lives well into their 80s or beyond, many take few medications at all. Among healthy older people, medications may have the same physical effects as they do in younger adults. It is primarily when disease interferes that the problems begin.

To guard against potential problems with drugs, however, older people must be knowledgeable about what they take and how it makes them feel. And they should not hesitate to talk to their doctors or pharmacists about questions and problems they have with a medication.

"We need to have educated patients to tell us how the drugs are working," says Feinberg.

Cutting Costs

The cost of medications is a serious concern for older people, most of whom must pay for drugs out of pocket. Even those who have insurance to supplement Medicare must often pay a percentage of the cost of their medicines.

For a new prescription, don't buy a whole bottle but ask for just a few pills. You may have side effects from the medication and have to switch. If you buy just a few, you won't be stuck with a costly bottle of medicine you can't take.

For ongoing conditions, buy medications in the largest quantities you can. Do this only if you know your body tolerates them well, since it's not usually possible to return medications.

Call around for the lowest price. Pharmacy prices can vary greatly. If you find a drug cheaper elsewhere, ask your regular pharmacist if he or she can match the price.

Other ways to make your prescription dollars go further include:

• Ask for a senior citizen discount.
• Ask for a generic equivalent. These non-brand substitutes are tested to be sure they are chemically identical to the original, and they deliver the same amount of the drug to the body in the same amount of time.
• Get drug samples free. Pharmaceutical companies often give samples of drugs to physicians. Tell your doctor you'd be happy to have them. This is especially convenient for trying out a new prescription.
• Buy store-brand or discount brand over-the-counter products. Ask the pharmacist for recommendations.
• Find out about drug discount or assistance programs. Check out the list on the AARP Web site or ask your local chapter of national disease-related organizations (American Diabetes Association, Arthritis Foundation, etc.). Financial assistance may also be provided through the Center for Medicare and Medicaid Services if you qualify.
• Try mail order from a reputable pharmacy. Mail-order pharmacies can provide bulk medications at discount prices. Use this service only for long-term drug therapy because it takes a few weeks to be delivered. Compare prices before ordering anything. Buying drugs online is another option that can save money. If the site is certified by the Verified Internet Pharmacy Practice Sites (VIPPS) program, it meets standards set by the National Association of Boards of Pharmacy. Go to the VIPPS Web site for more information.

What to Ask the Doctor

Before you leave your doctor's office with a new prescription, make sure you fully understand how to take the drug correctly. Your pharmacist can also provide valuable information about how to take your medicines and how to cope with side effects. Ask the following questions:

• What is the name of this drug, and what is it designed to do? Is this a generic or a name-brand product?
• What is the dosing schedule and how do I take it?
• What should I do if I forget a dose?
• What side effects should I expect? What should I do if I experience these side effects?
• How long will I be on this drug?
• How should I store this drug?
• Should I take this on an empty stomach or with food? Is it safe to drink alcohol with this drug?

For More Information

Food and Drug Administration
Drug information for consumers
www.fda.gov/cder/consumerinfo/DPAdefault.htm

"Buying Prescription Medicines Online: A Consumer Safety Guide" www.pueblo.gsa.gov/cic_text/health/buyperscript-online/guide.htm

This article originally appeared in the September-October 1997 FDA Consumer and contains revisions made in January 1999, August 2000, November 2002, and September 2003.