The Physics of Geriatric Pharmacotherapy: Overcoming Therapeutic Inertia and Momentum
In this issue of The American Journal of Medicine [June 2012], Scott et al(1) provide a framework to reduce medication use in older patients to the minimum number of necessary therapies. As the authors write, “this framework draws attention to the dangers of therapeutic inertia—whereby drugs continue to be prescribed in the absence of periodic review of net benefit—and therapeutic momentum—where more drugs are added in response to new but questionable indications, including unrecognized side effects arising from pre-existing medications.” The proposed framework is designed to lead to more rational drug regimens for older patients, thereby reducing the risk of adverse drug events and the costs associated with preventable drug-related injuries.
Ongoing reappraisal of an older patient’s medications, with identification of all opportunities to simplify complex drug regimens, is an essential component of providing high-quality care to geriatric patients. It is encouraging that recently published minimum geriatric competency standards(2, 3) developed for medical school graduates and for internal medicine and family medicine residents include multiple items relevant to medication management that align closely with the framework proposed by Scott et al.(1)
Applying the framework may seem relatively straightforward, but the reality is not so clear-cut. For example, defining care goals in relation to life expectancy, level of function, quality of life, and patient priorities can present a range of challenges. As Gill(4) has written, “Because of competing chronic conditions and diminished life expectancy, careful consideration of prognosis is particularly important for clinical decision making in older patients.” However, there exists insufficient evidence at this time to recommend the widespread use of prognostic indices in clinical practice.(5) Furthermore, older persons’ willingness to take medications, especially those prescribed for prevention, is more strongly influenced by the perceived risk of adverse effects than benefits.(6) Despite these challenges, pragmatic approaches to incorporating life expectancy and patient preferences into clinical decision making have been described.(7)
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— Jerry H. Gurwitz, MD
This article originally appeared in the June 2012 issue of the The American Journal of Medicine.
Related article: Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework.
