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In Depth

Seniors and Drugs

Seniors and Drugs: Prescribed to death

Dec. 8, 2005

Drugs, not just age and disease, are killing Canadian seniors.

As many as 3,300 seniors die every year due to adverse drug reactions, according to a CBC estimate done by analyzing Health Canada's adverse drug reaction database (obtained under Access to Information).

SENIORS AND DRUGS:
CBC FINDINGS

Prescriptions

In 2004, nearly 1.5 million seniors (38 per cent) received drugs on the Beers list - drugs considered to be ineffective in the elderly, or thought to put seniors at an unnecessarily high risk, when safer alternatives are available. (Prescription data provided by Brogan Inc., a health-care data and research company based in Ottawa).

Adverse drug reactions

The following findings are based on CBC's analysis of Health Canada's adverse drug reaction database.

  • Seniors account for 44 per cent of all reported adverse drug reactions suspected of causing death.
  • Seniors account for more the one-third of all adverse drug reaction reports made to Health Canada.
  • More than 16,000 Canadian seniors died from adverse drug reactions during the five years between 1999 and 2003. (Based on a five per cent reporting rate of suspected adverse reactions to Health Canada)
  • One-third of the seniors who died from reported adverse drug reactions were taking a Beers list drug.
  • One in 14: The proportion of reported seniors' deaths where a drug on the Beers list was a suspected cause.
  • One in 20: The proportion of reported seniors' deaths where a drug on the Beers list that had no usage conditions was a suspected cause.

It's an estimate that has been judged credible by a number of researchers who study pharmacology and adverse drug reactions.

"The 3,300 deaths number and the way it's been calculated by CBC I think is quite cautious and is realistic. It's likely to be higher than that, but nobody at the present time has a way of really getting a good measure of the seriousness of this matter," says Dr. Jim Wright, a clinical pharmacologist and the managing director of the Therapeutics Initiative at the University of British Columbia.

And seniors as a demographic group are over-represented in the database when it comes to reported deaths from an adverse drug reaction.

CBC found that seniors account for 44.4 per cent of all deaths reported to the adverse drug reaction database between 1999 and 2003, even though they make up just 13 per cent of the population.

But deaths are the extreme end of the scale when it comes to seniors and bad outcomes from drugs. They're also being hurt.

Canadian seniors make up a large proportion of those who have reported being injured by drugs.

Looking at all adverse drug reactions, not just deaths, seniors account for more than one-third of all suspected side effects reported to Health Canada, according to CBC's analysis of the Canadian Adverse Drug Reaction Information System (CADRIS), the database used to tracked reported adverse reactions.

This is partly due to the fact that seniors take more prescription drugs than the regular population. They account for the consumption of up to 40 per cent of all medications, according to Health Canada.

Keep in mind that all the people behind these reports have required medical intervention, and that means there has been a human cost, as well as a medical cost.

"The burden on the health-care system is enormous," says pharmacist and doctoral candidate Linda Levesque.

"If you think that each one of these adverse reaction reports, which again represents the tip of the iceberg, if they require an intervention with a health-care professional, that's a cost to the system.

"If there is residual harm, a chronic situation, then there's an ongoing cost. And that's not even touching the effect on the quality of life of the individual affected."

Levesque calls reported adverse reactions the "tip of the iceberg" because a vast majority go unreported.

At best, Health Canada receives reports for 10 per cent of all adverse events, but some put that figure at one per cent. And according to Dr. Wright, the reporting rate for seniors is thought to be lower than for other age groups.

THE ACCIDENTAL ADDICT

Wilma Johannesma needed assistance after her sister and stepmother died of cancer, and her marriage of 36 years fell apart.

To help Johannesma cope, her doctor prescribed Ativan, a benzodiazepine that should be used with caution by seniors. (See Beers List: Drugs) She took it for years. David McKie tells the story of Johannesma's hard road to overcome her addiction, with the help of her daughter.

The documentary is set up by Bob Carty in conversation with host Anna Maria Tremonti.

AUDIO: The Accidental Addict, from The Current (April 11, 2005) Runs 22:40

ON THE ROAD TO RECOVERY

Six months along, Wilma Johannesma is much better, but she's a long way from being completely healed.

David McKie spent two days with Wilma, her daughter Diana and David, Diana's husband who also has become a major player in his mother-in-law's long and painful recovery.

David Mckie takes you inside their home to give you an idea of what a good day is like for Johannesma as she tries to overcome her addiction to Ativan.

AUDIO: On the Road to Recovery, from The Current (Dec. 8, 2005) Runs 8:56

"You're going to expect more deaths in the older people, but you would also expect that the reporting of adverse events would be less and that there would be more acceptance of serious adverse events in the older population," says Wright.

There's "more acceptance" because people expect seniors' health to fail. A drug reaction is often mistaken for another sign of ageing.

"[Adverse drug reactions] are not obvious all the time," says Dr. Paula Rochon, a geriatrician and senior scientist at the Baycrest Centre for Geriatric Care. "They are often very subtle or things people may not associate with the drugs. So they may be things like a person becomes more confused, sedated, may not be eating or drinking as well, may fall.

"A lot of people think that when people are older, they're likely to have a lot of medical issues, so they dismiss it," says Rochon.

This highlights a complex set of factors at work, from cultural attitudes toward drugs and toward seniors, to a medical system where hospital stays are shrinking, and seniors are often in the care of numerous physicians.

Underlying all this is the fact that seniors are more vulnerable to the effects of drugs. As we age, our bodies change and manage drugs differently.

"It's a general rule. Most drugs are actually less well handled by the elderly, and that's because the organs that remove them from the body, the kidneys and the liver and the circulation in general, function a little less efficiently as time goes by," says Dr. Warren Bell, a B.C. physician.

We also have more fat in our bodies.

"Many of the drugs that older persons take, and especially drugs that may act on the brain and cause confusion or falls, many of those drugs are what we call 'fat-loving drugs.' And so they're stored up in the fat and they quickly reach toxic levels in an older person, compared to a younger person," says Donna Fick, a gerontological clinical nurse specialist and professor in the School of Nursing at Penn State.

Despite this difference in the workings of our bodies, few drugs are tested specifically on older people in clinical trials.

So, once a drug gets to market, adverse events often show up first in the older population, says Dr. Bell.

Another part of the problem is our "prescribing culture," says Dr. PK Rangachari, a University of Calgary professor who has a medical degree and a doctorate in pharmacology.

"Most patients who end up at a physician's office want something and usually it is in the form of a pill or a tablet, or something that they can take away with them."

However, that pill isn't always the right thing.

It's not getting at the reason someone can't sleep. It's not dealing with the underlying reasons for someone's anxiety or depression. That takes time, so "it's easier to write the script," says Dr. Eric Wooltorton, who faces the moral dilemma in his practice just outside of Ottawa.

OVERDOSED: THE DRUGGING OF CANADIAN SENIORS

When John Lisowy was 76 he began showing signs of dementia, so his daughter, Stephanie Baziuk, put him in a nursing home.

He was immediately put on Haloperidol. Baziuk was told it was for anxiety.

It's an anti-psychotic, and it changed her father. The life "had been taken out of him," she said.

After four weeks, Baziuk complained, asking that her father be taken off the drug.

Instead, the residence "actually wanted me to write a blank cheque so that they could administer as much Haloperidol as they deemed fit. When I refused I got a call the next day saying, 'Pick up your dad's luggage. It's standing at the door. He's evicted.'"

In Overdosed: The Drugging of Canadian Seniors, Bob Carty explores the use of psychotropic drugs as chemical restraints for Canada's seniors.

AUDIO: Overdosed: The Drugging of Canadian Seniors, from The Sunday Edition (April 10, 2005) Runs 28:14.

VIDEO: In this 30-second clip, John Lisowy is suffering the troubling and lingering adverse effects of two anti-psychotics. Lisoway shows signs of Tardive dyskinesia, which are involuntary movements sometimes caused by using neuroleptics. In Lisoway's case, it lasted for months as he was weaned from Loxapine.

"The system really doesn't reimburse physicians very well for spending that kind of time [with patients]," he says. "And if you do it, you really are doing it at a loss financially. That's unfortunate to admit."

Partly as a result of this prescribing pas de deux, "there is a problem with too many older adults being on too many medications and being on medications that are inappropriate," says Penn State's Donna Fick.

She's also the lead author of a study that tackles problematic drug use in seniors called "Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults."

The widely cited, peer-reviewed study lists drugs that are either ineffective in the elderly or put seniors at an unnecessarily high risk when safer alternatives are available.

But many health professionals aren't even aware the Beers list exists.

"Not prescribing the right drug for the right condition is an enormous problem," says Dr. PK Rangachari. "In fact it contributes significantly to the so-called adverse events that are seen in the hospital population in Canada," he says, citing a study published in the May 2004 Canadian Medical Association Journal.

During CBC's research, physicians and pharmacists who were contacted did not know of the Beers criteria.

Using data provided by Brogan Inc., a health-care data and research company based in Ottawa, CBC found that 1.5 million seniors were given a drug on the Beers list in 2004. That's more than a third of all Canadian seniors.

In this light, CBC asked the question: "Are seniors getting hurt or killed by their drugs, when safer alternatives exist?"

To do this, CBC prepared a list of Beers drugs available in Canada, and then compared it with Health Canada's adverse drug reaction database (obtained through Access to Information laws and containing reports to the end of November 2004).

The findings suggest that seniors are suffering some bad outcomes while taking Beers drugs.

  • One-third of all reported seniors deaths were for people who were taking at least one of the Beers list drugs when they died.
  • One in 20 reported seniors deaths were suspected to have been caused by Beers drugs that had no conditions, meaning they generally should not be prescribed to seniors.

Some drugs are on the Beers list conditionally, meaning they can be used in certain ways, such as below a certain dosage. When CBC included these in its queries, it found:

  • One in 14 reported seniors deaths were suspected to have been caused by a Beers drug.
Fick says CBC's findings answer some of the criticisms the Beers list has faced, namely that "there has not in the past been enough evidence that links the Beer's criteria to poor outcomes.

"The [CBC's] Canadian data certainly shows what seems to be some very direct links with the Beer's criteria in poorer outcomes - increased risk of death, increased risk of death in those that are on these drugs versus other drugs," says Fick. "It certainly is a very strong argument to look more closely at these drugs in terms of getting people off of them and getting increasing awareness about the Beer's criteria."

As for Wright, he calls CBC's findings "an important red flag of what is almost certainly happening and hopefully some things will be done as a result of it."

Levesque echoes Wright. "It definitely should raise some red flags," she says.

"It's either indicating that we are not familiar enough with the Beers list, or that it's, in principle, not well accepted or disseminated. It adds justification for the need for such a list. How to do something about it is a more difficult situation.

"Changing prescribing patterns is not an easy thing."

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