The winter edition of the American Society on Aging’s publication “Generations” focuses on medications and older adults. The writers and guest editor did a great job of synthesizing information on medications and their usage for a non-clinician. I was most struck, however, with the overarching message that we actually know very little about medications’ true effects on elders. A particular article highlighting this point was titled “Medicating Elders in the Evidence-Free Zone” by John P. Sloan.
In Sloan’s work he asks us to take a step back from the escalating debate around the growing health care and drug costs in America, and to consider the drugs themselves. “The newest shift in prescribing,” he writes, “is the shift from drugs that treat conditions to drugs that prevent them – particularly in elders.” Drugs are being prescribed for older adults to treat chronic illnesses and help them feel and function better, but many drugs are also taken with the goal to prevent illness and prolong life. Sloan provides an example: A 90-year-old woman is told she has low bone density and is prescribed a drug to help. Before leaving the office, she asks her doctor how long it will take for the medicine to have a beneficial effect. The doctor tells her it will take 2 to 3 years before they’ll see any noticeable improvement. Knowing her life expectancy to be not much longer than 3 years, she wonders about the benefits of preventative medicine for someone her age.
This example raises number of questions for the reader: Do the frailest, oldest-old want to prolong their life and prevent future illness? If so, at what cost and with what negative side-effects? Are we confident preventative medicines will help this population?
Sloan addresses the last question in his article and I was startled by the answer. Older, frail adults are members of what has been called an “Evidence-Free Zone.” Drug trials, which are the only support for prescribing preventative medications, do not include older adults, frail individuals, people with more than one chronic illness, or people taking multiple medications. Consider this for a moment. Drug trails, so they are safe for participants and accurately testing a drug’s effects, cannot include complicated people. Older adults, however, are the most heterogeneous and complicated group when it comes to their medical care and conditions.
The author states point blank, “When an older person takes a medication, no one has any idea what is going to happen.” This is because of the four “Absurdities of Prevention in Frailty”:
- You can’t predict the outcomes of a drug in people whose biology is unpredictable.
- Clinical trials never include frail elders because frailty by definition includes multiple pathologies.
- Older people are less likely to benefit from preventative medicines.
- Preventative medicines, even if safe in everyone else, are just riskier in frail elders.
Drug trials also do not test for outcomes that may matter most to older people like functional status, cognition, mood, quality of life, and caregiver burden. Geriatric patients, who use our medical system most, may be surprised to find little is known about them and their health. I know I was. The good news is geriatricians and medical researchers are aware of the problem. They continue to investigate the best ways to help older adults age well and provide helpful information for the rest of us so we can stay informed about caring for ourselves and our loved ones as they age.