Working Together on Seniors Medication Use:  A Federal/Provincial/Territorial Strategy for Action

Prepared on behalf of the Federal/Provincial/Territorial Committee of Officials (Seniors) for the Ministers Responsible for Seniors.

June 1996

Table of Contents

• The Issue
• The Players
• The Problem
• The Changing Demographics
• The Costs
• What Can Be Done?
• A Federal/Provincial/Territorial Approach
• References
• Goal 1
• Goal 2
• Goal 3
• Goal 4
• Goal 5
• Conclusion
• Endnotes

The Issue

The Players

A large number of players are involved in fully addressing the many complex issues of promoting appropriate medication use in general. Seniors of course are major players. They take the medications and are involved in discussions with physicians and pharmacists concerning their health. Prescription medications are only available on the recommendation of physicians. The choice of which medications to prescribe and for what conditions is a decision made by physicians. Governments develop and approve policies influencing the safety and regulation of drugs and the provision of drug benefits. These policies may influence the availability, choice and accessibility of medications for seniors. Industry develops, tests, and markets drugs that are used by seniors. Decisions made by industry may influence the availability of drugs and the information provided to professionals and consumers. Other health professionals, nurses and pharmacists in particular, may be involved in dispensing medications and in providing drug-related information to seniors. Family members and caregivers may be involved in monitoring medication use by seniors.

National action to ensure appropriate use of all medication will require the active participation of all these players. All are involved in some way, and all will need to stay involved and informed in order to reduce the risks associated with inappropriate medication use by all Canadians, in particular risks within the seniors' population. Ministers Responsible for Seniors have a role to play in addressing this issue both directly and indirectly by influencing action taken in other jurisdictions and sectors, most notably in the health sector. They also have a role in ensuring that seniors are provided with information and education on how to reduce risks associated with inappropriate medication use.

The Problem

Medication use among seniors is a multifaceted issue. It involves actions and decisions made by all the players noted above. Inappropriate use of medication poses a serious threat to the health and quality of life of Canadian seniors. Advancing years may increase the possibility of chronic or acute illness, with the accompanying increase in the number of prescribed medications. At the same time, the complex physiological processes that occur as part of the aging process can affect the action of the medications for many seniors. These factors among others put seniors at particular risk of inappropriate medication use that often leads to increased admissions to hospitals and long-term care facilities, as well as additional costs for the public and private sectors.

Unintended medication interactions, undesirable side effects and adverse drug reactions can result when:

• medications that may be inappropriate for a senior's health needs are taken or prescribed;
• medication is not taken exactly as prescribed (non-compliance);
• prescription medication is combined with over-the-counter drugs, alcohol or other drugs;
• prescription medications are taken without a prescription; and/or
  multiple medication interaction results from inappropriate prescribing.

• seniors consume between 20% and 40% of all prescription medicine¹;
• 18% to 50% of all medication used by seniors is used inappropriately²;
• between 19% and 28% of hospital admissions for patients over 50 years of age occur as a result of medication problems ³, ⁴; and
• 60% of these admissions are attributed to adverse reactions to medications and 40% to non-compliance⁵.

The Changing Demographics

It has been well documented that Canada's population is aging. By 2016, Canadians aged 65 will make up 16% of the population, compared to the current 12%, and by 2041, they will account for between 22% and 25%. The most rapidly growing age group will be the 85-and-over segment, which is expected to more than double in size between 1993 and 2016, jumping from 300,000 to 800,000 and increasing five-fold to 1.6 million by 20416. This is of particular concern when one considers that the use of medications, particularly multiple medications, is greatest amongst the very old.

Working to solve the medication concerns with today's population of seniors can only benefit tomorrow's seniors. Many seniors are concerned about this issue and want to be informed and involved in strategies to address it.

The Costs

Research studies have estimated the economic costs of non-compliance for all medications to be in the order of several $billion annually, and may be equivalent to the total cost of coronary heart disease. Factors that contribute to this cost include the total number of medications taken by seniors, non-compliance by seniors, and inappropriate prescribing.

Drug expenditures are increasing at a faster rate than any other health care cost at a time of severe fiscal restraint. Each province and territory provides some level of assistance to some or all of its senior citizens to help them cover the cost of prescription medications. Provincial coverage varies across Canada with estimated annual public expenditures by provinces of $2.0 billion (1994) for medication benefit programs and services for seniors (Health Canada estimate, February 1996). These drug benefit programs have been and will continue to be very important in sustaining the health and quality of life for seniors.

Sharp increases in the cost of drugs over the past few years have led all governments to re-examine these programs and to seek ways of reducing costs without jeopardizing the health of seniors. Provinces have responded to higher costs and smaller budgets in a number of ways, including delisting some drugs, restricting new formulary listings, modifying eligibility criteria, introducing reference-based pricing and introducing additional user payments. These changes to drug benefits will need to be monitored to ensure that seniors are not facing economic barriers to needed drug therapy. Finding ways of promoting optimal drug therapy will be a way of addressing these significant cost pressures.

What Can Be Done?

There is evidence that a variety of strategies involving seniors, family members, health professionals, governments and industry can and need to be used in addressing this serious issue. Strategies will be strengthened by the participation of all the players involved. Benefits to individual seniors, their families and the Canadian health care system should result from a concerted effort by all partners towards:

• increasing the appropriate use of medications by seniors;
• developing appropriate medications for seniors;
• improving appropriate prescribing of medications for seniors;
• training and involving health professionals in these strategies; and
• improving information provided to health professionals and consumers concerning medication.

A Federal/Provincial/Territorial Approach

Some work has already been done by the public and private sectors to promote the appropriate use of medications by seniors. More is needed. The development of a Federal/Provincial/Territorial Strategy for Action is a logical next step to the work that has already been undertaken by most Provincial Health Ministries and Health Canada. Ministers Responsible for Seniors can influence some of the key players including their Health counterparts, and can certainly bring to their attention the particular concerns of seniors. This Strategy also complements initiatives under way in the professional, non-governmental and private sectors. A collective FPT approach to the issue and agreement on shared goals and priorities for improving medication use by seniors will have many short-term and long-term benefits. Such a strategy has the potential to:

• expand and share the growing body of knowledge about effective policies, programs and projects related to medication use by seniors;
  
  
• assist governments and organizations to adopt and expand interventions found to be effective and to establish "best practice" standards, thus avoiding resource allocation to ineffective strategies, and minimizing duplication of effort;
  
  
• build upon existing and develop new federal/provincial/territorial partnerships in establishing priorities for research and evaluation to improve safer utilization and prescribing of medication for seniors (e.g., Advisory Committee on Health Services, Canadian Council on Health Technology Assessment, Sub-Committee on Pharmaceutical Policy Issues);
  
  
• enhance opportunities to collaborate on education programs that will
  increase seniors' knowledge to enable them to become informed consumers of medications; and
  
  
• increase the knowledge and understanding of the diversity of seniors and their health needs and the importance of adequate assessment and appropriate prescribing by all health care providers;
  
  
• enhance the knowledge of seniors, caregivers and health care providers in utilizing alternative therapies in conjunction with appropriate medication utilization;
  
  
• improve the health status of seniors and reduce the health risks associated with the inappropriate use of medications, as well as reduce hospital and physician visits caused by non-compliance and adverse reactions.

This Strategy for Action is based on three principles representing the fundamental beliefs which guide the goals and objectives contained in this document.

Goal 1:

Enhance the health and well-being of seniors through the promotion of lifestyle changes, where appropriate, as an alternative to medication.

Rationale:

Medical and pharmaceutical research advancements and marketing information have encouraged the belief that there is a "pill for every ill". In some cases, treatments which are as effective and less intrusive than medication could provide appropriate alternatives. Sleeping and anti-anxiety medication, stomach remedies and laxatives are prime examples of drugs that may be used inappropriately. Consider the following:

• a 1994 study found that 30.8% of seniors in Quebec received a benzodiazepine* for more than 30 consecutive days⁷ (the criterion for questionable prescribing for this drug). The effectiveness of this drug decreases and dependency becomes an issue when used over a long term;
• according to this Quebec study⁸, high risk prescribing was most prevalent for psychotropic drugs, and questionable prescribing was more frequent than rational prescribing in this drug group;
• benzodiazepines may produce side effects such as drowsiness and impaired coordination and increased risk of falls and other accidents;
• stomach remedies or laxatives were the third most common drugs prescribed to seniors in 1989.
  

Objective:

To reduce use and reliance on sedatives, hypnotics, laxatives and other commonly used medications by seniors for which there may be non-drug alternatives.

• A significant reduction in the use of sedatives/hypnotics such as benzodiazepines, and in stomach remedies and laxatives.
• Overall reduction of medications taken by seniors.
• Development of national evidence-based guidelines on medications commonly used by seniors.

Goal 2:

Rationale:

Seniors learn about medication from a variety of sources including physicians, pharmacists, friends and consumer advertising and reports. Similarly, health professionals receive information about medications from sources such as continuing education programs and from the pharmaceutical industry in its detailing and marketing practices. These sources need to be up-to-date, objective and sensitive to seniors' needs.

It is important to recognize factors such as multiple health problems, lack of social support networks, low literacy skills, and low income that place seniors at greater risk of inappropriate medication use and to implement programs that will increase their ability to make informed choices.

Objective:

To increase knowledge among seniors at risk, caregivers and health professionals regarding the most effective way for seniors at risk to reduce inappropriate medication use.

An increase in the availability of information and proven educational strategies on appropriate medication use designed specifically for seniors at risk.

**Seniors at risk may include seniors taking multiple medications, low-income seniors, cognitively impaired seniors, isolated seniors, seniors with low literacy, non-French or non-English speaking seniors, and the frail elderly.

Goal 3:

Rationale:

With increasing age, people absorb, metabolize, and excrete medication more slowly. Medication effects also differ depending on individual weight, age and gender. Seniors continue to be under-represented in drug evaluation studies and monitoring activities despite the reality that many drugs are targeted at conditions found primarily in seniors. Therefore, it remains very important to continue monitoring all unintended side effects and adverse drug reactions in seniors to ensure that all drugs are as safe as possible for the senior population, taking into consideration gender differences. Evaluation of drugs and dosages for the senior population is needed on a regular basis.

Objective:

To increase knowledge about the effects and effectiveness of medications for seniors.

Expected Outcomes:

Increased monitoring of drug interactions for the senior population.
More evidence-based (e.g., dosage, duration, etc.) guidelines regarding medications prescribed for and/or selected by seniors.

Goal 4:

Rationale:

A substantial proportion of seniors take several prescription and non-prescription medications at one time. In persons aged 55 and over, the average number of prescription drugs per person is 2.1 per year¹⁰. Surveys of individuals over the age 65 have reported averages of 3.1 to 4.5 prescription drugs per person per year¹¹. As the number of different drugs and number of daily doses increase, the less likely the patient can or will comply with the medication regime, thus increasing their susceptibility to adverse drug reactions¹². In addition, taking several medications has been found to reduce the correct knowledge of the drugs being taken¹³.

Objective:

To reduce unintended effects such as nausea, dizziness and falls, as well as adverse drug reactions associated with inappropriate multiple medication use.

Expected Outcomes:

• An increase in available information and educational opportunities for health professionals, paraprofessionals and seniors regarding appropriate medication use for seniors.
• A decrease in adverse drug reactions and unintended side effects associated with multiple medication use.
• A reduction in hospital and physician visits resulting from adverse drug reactions.
• A system of communicating effective practices across jurisdictions to promote appropriate medication prescribing and use for seniors.

Goal 5:

Rationale:

A great number of initiatives designed to address the many issues surrounding seniors and appropriate medication use exist throughout Canada. Too frequently the results of these efforts are not widely known by groups and individuals who could benefit from this knowledge. The workshop "Partners for Action: A Canadian Workshop on Seniors Medication, Alcohol and Other Drugs" (January 1995) recommended developing mechanisms to increase the availability and dissemination of information on medication, alcohol and other drugs to seniors, and people working with seniors. Suggested action included the development of national and regional resource networks/centres which could provide information on research, programs, training, and linkages to people working on the issue.

Objective:

To increase access to current seniors-specific information on medication, alcohol and other drugs through recognized and accessible sources.

Expected Outcomes:

Development, dissemination and use of appropriate resources on the Internet and in other widely available and accessible sources by various stakeholders, including governments, researchers, seniors organizations and individuals. Greater coordination of efforts, less duplication, quicker and broader dissemination of new information.

Conclusion

There is little doubt that seniors represent a high risk group in terms of inappropriate medication use and that this poses a threat to the health and quality of life of Canadian seniors. Inappropriate use of medication can also be costly, both due to the direct expense of drugs prescribed unnecessarily and the indirect health care expenditures related to the adverse effects of medications used improperly.

Federal/Provincial/Territorial Ministers Responsible for Seniors have expressed support for a collaborative approach to reducing the risks related to inappropriate medication use by seniors. This Federal/Provincial/Territorial Strategy framework is based on an agreement that a concerted effort by all partners is the best way to encourage safe medication and prescribing practices for seniors, increase appropriate use of medication by seniors, and foster partnerships that will encourage shared knowledge and approaches to this important issue. In practical terms, this document has drawn on the considerable amount of work already accomplished by the public, non-governmental and private sectors in this area to establish the key principles and goals for a Federal/Provincial/Territorial Strategy. It also proposes some practical objectives which could support these goals and principles.

This Federal/Provincial/Territorial Strategy framework is another step in a comprehensive action plan. It is meant to provide a common reference point to which federal, provincial and territorial officials responsible for both seniors and health initiatives can refer to as they develop their own and shared strategies for appropriate medication use by seniors. It is also designed to provide a shared direction for all concerned with this issue: seniors, health practitioners, organizations, governments, industry, caregivers, and family members. Working together, we can all contribute to ensuring the most appropriate use of all medications by all seniors.

Endnotes

1.  Quinn, K., Baker, M. and Evans, B. Clinical and Community studies. A Population Wide Profile of Prescription Drug Use in Saskatchewan 1989. Canadian Medical Association Journal, 1992, 146(12), 32.

2.  Tamblyn, R. M. et al. Questionable Prescribing for Elderly Patients in Quebec. Canadian Medical Association Journal, 1994, 150(11), 1802.

3. Grymonpre, R.E., Mitenko, P.A., Sitar, D.S., Aoki, F.Y. and Montgomery, P.R. Drug Associated Hospital Admissions in Older Medical Patients. Journal of the American Geriatrics Society, 1988, 36, 1092.

4. Col, N., Fanale, J.E. and Kronholm, P. The role of medication Non-compliance and Adverse Drug Reactions in Hospitalizations of the Elderly. Archives of Internal Medicine, 1990, 150, 841-845.

5. Col, N., Fanale, J.E. and Kronholm, P. Ibid.

6. George, M. V. et al. Population Projections for Canada, Provinces and Territories 1993-2016. Statistics Canada, Ottawa, 1994, Catalogue 91-520, vi.

7. Tamblyn, R. M. et al. Questionable Prescribing for Elderly Patients in Quebec. Canadian Medical Association Journal, 1994, 150 (11), 1805.

8. Tamblyn, R. M. et al. Ibid.

9. Bergob, M. Drug use Among Senior Canadians. Canadian Social Trends, Statistics Canada, Ottawa, No. 33, Summer 1994, 26, Catalogue 11-008E.

10. Angus Reid Group Inc. Medication use in Canadians aged 55 and older: Opinions and Attitudes, prepared for the Canadian Coalition on Medication Use and the Elderly, 1991.

11. Ostrom, J., Hammarlund, E., Christensen, D., Plein, J. and Kethey, A. Medication Usage in an Elderly Population. Medical Care, 1985, 23, 157-164.

12. McEwan, K. and Dawers, D. Seniors Medication Framework for B. C. Pharmacare: Final report, 1993. Unpublished report.

13. German, P.S., Klein L.E. and McPhee, S.J. Knowledge of and Compliance with Drug Regimes in the Elderly. Journal of American Geriatric Society, 1982, 30, 568-571.

References

Angus Reid Group Inc. Medication use in Canadians aged 55 and older: Opinions and attitudes. Prepared for the Canadian Coalition on Medication Use and the Elderly. Canadian Coalition on Medication Use and the Elderly, Ottawa, 1991.

Bergob, M. Drug use among senior Canadians. Canadian Social Trends, Statistics Canada, Ottawa, No. 33, Summer 1994, 26, Catalogue 11-008E.

Col, N., Fanale, J.E. and Kronholm, P. The role of medication non-compliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine, 1990, 150, 841-845.

Davidson, W., Molloy, W. and Bédard, M. Physician characteristics and prescribing for elderly people in New Brunswick: Relation to patient outcomes. Canadian Medical Association Journal, 1995, 152 (8), 1227-1234.

George, M.V. et al. Population projections for Canada, provinces and territories 1993-2016. Statistics Canada, Ottawa, 1994, Catalogue 91-520,vi.

Gouvernement du Québec. The rational use of drugs by the elderly: A strategy for action, May 1993.

Graham, K. et al. Alcohol use, depressant medication use, and reasons for drinking among older people. In 21st Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society of Social and Epidemiological Research on Alcohol, Porto, Portugal, June 5-9, 1995.

Grymonpre, R.E., Mitenko, P.A., Sitar, D.S., Aoki, F.Y. and Montgomery, P.R. Drug associated hospital admissions in older medical patients. Journal of the American Geriatrics Society, 1988, 36, 1092.

Health Canada. Canada's alcohol and other drugs survey: Preview 1995. Ottawa, 1995.

Health Canada. Canada's Drug Strategy. Horizons one: Older Canadians' alcohol and other drug use: Increasing our understanding. Edited by David Hewitt, Garry Vinje and Patricia MacNeil. Ottawa, 1995.

Health Canada. Office of Alcohol, Drugs and Dependency Issues. Partners for action: A Canadian workshop on seniors and medication, alcohol and other drugs, January 9, 10 and 11, 1995, Ottawa, 1995.

Health Canada. National Pharmaceutical Strategy Office. Developing a "National Drug Program": Workshop proceedings, September 1994. Unpublished report.

Health Canada. National Pharmaceutical Strategy Office, Drugs Directorate, Health Protection Branch. National pharmaceutical strategy discussion document, 1993. Unpublished report.

Health Canada. Policy and Consultation Branch. National health expenditures in Canada 1975-1994. Ottawa, January 1996.

McEwan, K. and Dawes, D. Seniors medication framework for B.C. Pharmacare: Final report, 1993. Unpublished report.

Nova Scotia Pharmacare Reform Working Group. Quality treatment .... Needed medications at an affordable cost, March 1994. Unpublished report.

Ostrom, J., Hammarlund, E., Christensen, D., Plein, J. and Kethey, A. Medication usage in an elderly population. Medical Care, 1985, 23, 157-164.

Pedlar, D. and Davidson, W. Final draft report: A study of benzodiazepine use in a veteran population using treatment accounts processing (TAPS) pharmacy program in Nova Scotia, September 1993. Unpublished manuscript.

Quinn, K., Baker, M. and Evans, B. Clinical and community studies. A population-wide profile of prescription drug use in Saskatchewan 1989. Canadian Medical Association Journal, 1992, 146 (12), 2177-2186.

Quinn, K., Baker, M. and Evans, B. Who uses prescription drugs? Results from a population-wide study in Saskatchewan. Regina: Saskatchewan Health, Prescription Drug Services Branch, 1991.

Tamblyn, R.M. et al. Questionable prescribing for elderly patients in Quebec. Canadian Medical Association Journal, 1994, 150 (11), 1801-1809.

Tuominen, J. D. Prescription drugs and the elderly in B.C. Canadian Journal on Aging, 1988, 7 (3), 174-182.

Wigdor, B. Some critical issues related to mental health and medication use in the elderly. Canadian Journal on Aging, 1991, 10 (4), 296-299.

Additional copies are also available from:

Division of Aging and Seniors
Public Health Agency of Canada
Address Locator 1908A1
Ottawa, Ontario
K1A 1B4
Tel:(613)952-7606
Fax:(613)957-7627
E-Mail: seniors@phac-aspc.gc.ca
Internet: www.phac-aspc.gc.ca/seniors-aines
©Minister of Public Works and Government Services Canada 1997

Cat. No.: H88-3/19-1997E
ISBN: 0-662-25481-3

Également disponible en français sous le titre :
Une approche concertée sur l'usage des médicaments par les aînés : Stratégie fédérale-provinciale-territoriale