The scenario often unfolds like this: Medical researchers investigate a frequently used drug and report that it\u2019s not as effective for older patients as previously thought, or that in older adults, its risks outweigh its benefits. More studies follow, confirming those findings.<\/p>\n
After a few years, medical associations revise their guidelines, warning that the drug in question should be avoided or at least prescribed more selectively. It might be added to the Beers Criteria, an influential list of potentially inappropriate medications for older patients, published by the American Geriatrics Society.<\/p>\n
If the drug\u2019s role is preventive, the U.S. Preventive Services Task Force, an independent expert panel, may weigh in with cautions. The Food and Drug Administration may issue black box warnings about concerning side effects.<\/p>\n
After a few\u00a0more\u00a0years, researchers look at broad national data to see whether use of this drug declined. Often, the answer is: Yes, but not enough. Sometimes, though, use didn\u2019t decline much at all or actually increased.<\/p>\n
\u201cMedications are like barnacles,\u201d said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of the U.S. Deprescribing Research Network. \u201cThey\u2019re easy to start, but they can be hard to stop.\u201d<\/p>\n
This medical inertia partly reflects the time lags involved in disseminating findings. \u201cClinicians have a million things they need to know and attend to, and information may take a while to get to them,\u201d Steinman said.<\/p>\n
But it also reflects the way \u201cclinicians and patients get used to treating conditions in certain ways,\u201d he said. \u201cThey become ingrained habits.\u201d Finding alternative approaches is challenging, so \u201cit\u2019s easy to go with what you know.\u201d<\/p>\n
Recent studies of three medications or classes of drugs widely used among older Americans illustrate the problem.<\/p>\n
The Drawbacks of Benzodiazepines<\/b><\/p>\n
Scientists began raising alarms about benzodiazepines more than 20 years ago. Prescribed for insomnia and anxiety, \u201cthey offer prompt relief,\u201d said Dr. Mark Olfson, a psychiatrist and public health researcher at Columbia University.<\/p>\n
The problem? Benzodiazepines (including Valium, Xanax and Ativan) and the related \u201cZ\u201d drugs (Ambien, Lunesta) \u201cmay impair balance, coordination and cognition that can translate into falls and fractures and motor vehicle accidents,\u201d Olfson said. In patients also taking opioids for pain, benzodiazepines can cause overdoses.<\/p>\n
Moreover, \u201conce you\u2019ve taken them for a period of time, you develop a dependence,\u201d Olfson added. \u201cWhen you come off them, you may develop withdrawal symptoms.\u201d<\/p>\n
So what\u2019s happened to benzo use among older adults, who are more sensitive to these effects? In a recent examination of prescribing trends, published in Annals of Internal Medicine, Olfson and his team reported progress. Among people over 65, overall benzo use from 2015 to 2024 dropped to 11.5% from 14%.<\/p>\n
But that decline has stalled since 2020, perhaps related to the COVID-19 pandemic. Moreover, use actually rose among those over 75, from 12% in 2020 to about 13% four years later. Dispensing through pharmacies in long-term care facilities more than doubled. And about a third of users were taking the drug for longer than six months, increasing the likelihood of dependence. \u201cIt\u2019s worrisome,\u201d Olfson said.<\/p>\n
But he cautioned that patients shouldn\u2019t stop benzodiazepines suddenly or on their own, which can provoke withdrawal. \u201cIt requires supervised tapering\u201d with a medical professional, he said. \u201cIt takes many weeks.\u201d<\/p>\n
Overprescribing Antibiotics<\/b><\/p>\n
For years, the standard treatment for diverticulitis, the inflammation of small pouches that form in the colon, was antibiotics, primarily fluoroquinolones (like Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin).<\/p>\n
\u201cIt was unquestioned,\u201d said Jesse Sutton, a pharmacist and researcher at VA Minneapolis Health Care. \u201cAntibiotics are safe and effective, great, lifesaving drugs, so the mindset was, when in doubt, use them.\u201d<\/p>\n
But in 2015, the American Gastroenterological Association recommended against routinely prescribing antibiotics for \u201cuncomplicated\u201d diverticulitis, which represents a great majority of cases. Other medical groups followed suit.<\/p>\n
Clinical trials had shown that for this condition, antibiotics had little or no effect on mortality, the need for surgery, complications or recurrences. \u201cThey hadn\u2019t improved anything,\u201d Sutton said.<\/p>\n
And as with any drug, \u201cthere are downsides, unintended consequences,\u201d he said. \u201cSide effects from antibiotics account for a substantial amount of emergency room visits\u201d for symptoms like nausea, vomiting and diarrhea. Antibiotics heighten the risk of the virulent C. difficile infection, too.<\/p>\n
Plus, \u201cthe more you use antibiotics, the less they work in the future,\u201d Sutton said. The World Health Organization has deemed antimicrobial resistance \u201ca major global health threat.\u201d<\/p>\n
So Sutton and his colleagues, studying treatment in 70,000 visits to 120 Veterans Affairs facilities, expected to see antibiotic use for uncomplicated diverticulitis decline over 10 years.<\/p>\n
Instead, they reported recently in Annals of Internal Medicine, antibiotic prescriptions remained nearly universal at 97% of visits, guidelines or no guidelines. The patients (average age: 63) would most likely have done as well with a few days of Tylenol and a clear liquid diet.<\/p>\n
Antibiotic overuse remains common for other conditions of later life, too, including urinary tract infections that cause no troublesome symptoms and upper respiratory infections that are typically viral, not bacterial.<\/p>\n
In such cases, when a doctor prescribes an antibiotic, \u201cI\u2019d encourage patients to say, \u2018Please explain the rationale for doing this,\u2019\u201d Sutton said. \u201cIf they don\u2019t, it\u2019s OK to press pause.\u201d<\/p>\n
When Aspirin Isn\u2019t the Answer<\/b><\/p>\n
Aspirin is different. Because it\u2019s cheap and over the counter, anybody can start taking it on their own \u2014 and millions of older Americans do, thinking it will help prevent cardiac problems.<\/p>\n
For people who\u2019ve already had a heart attack, stroke or cardiac intervention like a stent or bypass surgery, daily low-dose aspirin for \u201csecondary prevention\u201d does lower the odds of another event, studies have demonstrated.<\/p>\n
But for \u201cprimary prevention\u201d in people who haven\u2019t had one, the guidelines changed in 2019, when the American College of Cardiology and the American Heart Association recommended against aspirin for this purpose in those 70 and older. The U.S. Preventive Services Task Force went further, warning against aspirin for primary prevention starting at age 60.<\/p>\n
Large clinical trials had shown scant benefit for aspirin as a primary prevention measure, but there were harms, notably gastrointestinal bleeding. \u201cAs we age, the risks of bleeding go up,\u201d said Dr. Timothy Anderson, an internist at the University of Pittsburgh who directs its Prescribing Wisely Lab. More rarely, but more seriously, aspirin can cause bleeding in the brain.<\/p>\n
In a JAMA study last year, Anderson and his co-author found the message was getting through: Aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had dropped substantially from 2011 to 2023. But more than a third of those 70 or older were still taking it.<\/p>\n
Some caveats: A subgroup of older adults with high risk factors for cardiovascular disease may benefit from aspirin for primary prevention. And, confusingly, some evidence suggests that older patients already taking aspirin face a higher risk of cardiovascular disease if they discontinue it.<\/p>\n
\u201cStep 1 is a conversation with your primary care physician\u201d about aspirin, Anderson said. \u201c\u2018Is this still right for me as I get older?\u2019\u201d<\/p>\n
Older patients taking aspirin, many without any medical guidance, \u201care interested in reducing their risk of heart attack and stroke,\u201d he said. \u201cThey\u2019re trying to be proactive and healthy.\u201d But with blood pressure medications and statins for cholesterol, \u201cwe have better strategies than aspirin for that.\u201d<\/p>\n