Mismedicating the elderly - says who? - Editorial

Journal of Family Practice, Oct, 1995 by August E. Miller, Jr.

It hardly seems possible that three, relatively obscure, Ivy League academicians could trash the collective reputations of nearly every practicing physician in this country and get away with it. Not long ago, that's exactly what happened.

Sharon Willcox, David Himmelstein, MD, and Steffie Woolhandler, MD, writing in The Journal of the American Medical Association (JAMA),[1] accused American doctors of wrongly medicating nearly one fourth of the country's entire senior-citizen population. This estimate was a conservative one, said the authors of this Harvard-based study; the true incidence of "inappropriate prescribing for the elderly" was probably closer to 32%. In an accompanying JAMA editorial, Harvard's Jerry Gurwitz, MD, added that "this was only the tip of the iceberg."[2]

Having appeared in a respectable journal, these numbers promptly sprang to life. The reaction in the popular press was swift and predictable:

* "Wrong Drugs Given to 1 in 4 of Elderly," hollered the same-day headlines in The New York Times.[3]

* "Frightening . . . horrifying . . . " gasped Time magazine,[4] . . . medications that are notorious."

* "More than 6.6 million elderly Americans not in nursing homes are prescribed a dangerous or inappropriate medication every year," blared the Associated Press.[5]

* "The nation's biggest drug problem," claimed USA Today, "is the poor prescribing practices of doctors.[6]

Having touched off a firestorm, Himmelstein and Woolhandler showed no inclination to douse the flames. In Time magazine,[4] Himmelstein said, "It's a sad commentary on the prescribing practices of many doctors in this country." In the same vein, Woolhandler remarked to The New York Times,[3] "Based on my own clinical practice, I knew it was a problem." Though Woolhandler was not surprised by the study's findings, she found them deeply disturbing, said the Times. What disturbed Himmelstein, confided USA Today,[6] was the number of elderly patients taking drugs that were likely to do more harm than good. "The quickest and easiest route to get the patient out of the doctor's office is to write a prescription. And in the day of the 7-minute office visit, that's what doctors resort to. "

No mugging of the medical profession would be complete without a few extra licks from Sidney M. Wolfe, MD, of Public Citizen Health Research Group. "Young and old are being given the wrong drugs, the wrong doses and the wrong combinations," said Wolfe to USA Today.6 . . . This new study ... reflects an abysmal ignorance on the part of doctors." The Harvard researchers had merely confirmed what Wolfe knew all along: medicine is a game best played by a few smart guys sitting behind big piles of journals. The rest of us abysmally ignorant numskulls should be tarred, feathered, and sent packing. This was merely one more example of our incompetence, documented in JAMA for all to see.

Surely, such "landmark research" deserves a much, much closer look. Nearly 7 months after publishing the Harvard study, JAMA printed a series of highly critical responses.[7] This time around, however, there was no burst of outrage in the national press, and unfortunately, none of these rebuttals unearthed the basic methodological flaws of the Harvard study.

At first glance, the study seems simple and straightforward. Take one list of medications "contraindicated for the elderly," crossmatch it against a database of pills actually ingested by the elderly, extrapolate the results to the general population, and Bingo! You have instant sound bites on the evening news. Perhaps the slickest part of the Harvard study, however, was in utilizing both a drug list and a database that others had already created. With the laborious parts of their study completed in advance, all that remained for the authors was number crunching and the banking of a $22,631 grant from the Robert Wood Johnson Foundation (documentation on file at the Robert Wood Johnson Foundation, Princeton, NJ, 1993; grant No. 022608). Little did it matter that the adopted drug list was not what they claimed it to be or that their 7-year-old database bore no resemblance to present-day prescribing practices.

The purpose of the Harvard study, we are told, was "to examine the amount of inappropriate drug prescribing for Americans aged 65 or older living in the community [italics added]."[1] Having said that, the authors promptly produced a list of "hazardous" drugs co-opted directly from a 1991 paper by Beers et al[8]: "Explicit Criteria for Determining Inappropriate Medication Use in Nursing Home Residents [italics added]." The Beers criteria had been "specifically" devised for "a population older than 65 years, and frail enough to reside in a nursing home."

Very plainly, Beers and coauthors were not talking about ordinary old people living in their own homes. Ordinary, everyday physicians know the difference, without being told, between robust, 65-year-old gadflies, and the "frail, elderly patients confined to nursing homes." My repeated MEDLINE searches produced no evidence that the human body's ability to detoxify drugs ceases abruptly on the 65th birthday. Whether giving a Darvon pill to a healthy 65-year-old constitutes a mortal sin is left for the reader to decide.