Drugs overlooked, underused for elderly

Routine therapies not part of treatment plans

If a recent study of elderly patients living in long-term care facilities is any indication, too little attention is being focused on how to treat the very old and frail — a rapidly growing segment of the country’s population.

The study used the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database to study the cases of 86,094 patients with congestive heart failure admitted to any of 1,492 long-term care facilities in five states from 1992 to 1999.

The study indicated that although drugs now used in treating the elderly may play a role in reducing deaths, other medications are vastly underutilized. These drugs not only could reduce hospitalizations and enhance their quality of life, but otherwise would be a routine component of drug therapy in treating heart failure.

"Because it is a disease process that arises almost naturally with the aging process, heart failure is at epidemic proportions among older people. This becomes even more apparent in a nursing-home environment, where people are the right age to be vulnerable," says Daniel E. Forman, MD, a member of the research panel and assistant professor at Boston University and director of cardiovascular services for Boston Health Net.

The patients’ average age was 84.9 years. Eighty-nine percent were 75 and older, and 55% were older than 85. An overwhelming majority (80%) of patients was women. More than two-thirds underwent frequent hospitalizations related to CHF in the year preceding admission to the long-term facility. The most common causes were coronary heart disease and hypertension.

Half of all patients received digoxin and 45% a diuretic, regardless of background or cardiovascular comorbidities. Only 25% had a prescription for ACE inhibitors.

The intent of the study was threefold:

1. to describe patients’ clinical and functional characteristics;

2. to characterize specific pharmacologic regimens and the extent to which they vary depending on comorbid conditions;

3. to evaluate predictors of appropriate pharmacologic care, including specific facility characteristics.

Most troubling to researchers was the disparity among treatments. There was a "dramatic underuse" of drugs such as ACE inhibitors, a virtual staple in recent years that according to Forman "[has] proved to be so effective" in treating heart failure.

Jane Geraci, MD, MPH, an assistant professor at the Baylor College of Medicine in Houston, agrees with Forman’s view.

"There is every reason to believe that older, and even much older patients, especially if they have normal or minimal physical or cognitive impairment could benefit from ace inhibitor treatment, and an attempt should be made to treat them." Geraci is treating a 90 year-old man with coronary artery disease, diabetes, and severe osteoarthritis of the knees with an ACE inhibitor.

A lot more data needed

"I am slowly trying to titrate his dose to as high as he can tolerate. I would expect this to be an easier task in a long-term setting than in the outpatient area, because patients could be watched more closely and with greater ease in a nursing home," she explains.

Geraci also expressed a concern regarding the amount of aspirin used in long-term care facilities. "I was concerned that, even though one-third of the patients were diagnosed with coronary heart disease, only 19% are getting aspirin," she says.

As a whole, Forman says, it became apparent from the study that "in addition to the fact that treatment modalities lag, there are not a lot of data available, and what are available are ambiguous."

A large part of the problem may be the fact that clinicians only now are really beginning to establish a true definition of heart failure.

"In the past 10 years, the idea of what heart failure really is has undergone dramatic changes. At one time, it was thought that the most important thing was to treat inappropriate fluid accumulation. As a result, everyone was given lasix. The other thrust of treatment focused on systolic dysfunction, and people were given digoxin in an effort to make their hearts squeeze properly," he adds.

Why is ACE inhibitor use lower?

"Our understanding of heart failure has become much more sophisticated, and we are now recognizing that medications like ACE inhibitors are very important. Yet, their [use] lags significantly behind that of digoxin and lasix," says Forman, who speculates that the fact that patients in long-term care facilities are not seen on a regular basis may partly explain clincians’ reluctance to try new treatments.

The study only pointed up what researchers already had recognized. Heart failure trials, almost invariably, have excluded elderly patients, especially the oldest ones. In addition, they have all but ignored women — which is ironic, as women account for the vast majority of the older population, he adds.

"The literature that’s so predominant focuses on younger people, and men specifically — yet, women tend to live longer. We don’t have a clear treatment on older people — and we certainly don’t have a clear treatment on women," Forman says.

Minireum Data Set (MDS) data were linked to a drug utilization file listing all drugs consumed by each resident during the seven days preceding the assessment. Up to 18 different drugs were coded according to the National Drug Codes. Information included brand and generic name, dose, route and frequency of administration, and whether the prescription was standing or administered as needed.

Drug codes were matched to the Master Drug Data Base (MediSpan Inc., Indianapolis), which contains complete records for prescription drug products in the retail pharmacy environment.

The MDS and pharmacologic data were linked to Medicare enrollment files. Residents then were cross-linked with MDS data to the Medicare inpatient claims database that contains information for all health services for which a claim had been filed between 1991 and 1997.

From 478,508 residents, all patients who had a diagnosis of CHF as their initial MDS assessment were identified. Staff physicians coded a diagnosis of heart failure using information obtained from the medical record, including the physical examination of the resident, medication and other treatment orders, and hospital discharge documentation (available for 78% of patients). Of 89,174 patients with CHF, those younger than 65 or in a vegetative state were excluded, leaving a sample population of 86,094 patients.