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a Merck Manuals, Merck & Co., Inc., West Point, Pennsyslvania
Mark H. Beers, Editor in Chief, Merck Manuals, Merck & Co., Inc., PO Box 4, BLA-14, West Point, PA 19486-0004 E-mail: beerm{at}merck.com.
Decision Editor: John E. Morley, MB, BCh
THE articles by Edelberg and colleagues (1) and Flaherty and colleagues (2) in this issue demonstrate the centrality of medication use in the health and treatment of older adults. The ability to take medications as directed tells us about the overall physical and mental functioning of patients. Medication use provides surrogate indications of health status and predicts future decline. Medications are the mainstay of disease control in geriatrics.
Edelberg and colleagues present us with the question, "How important is it for older adults to be able to take their medication correctly?" We learn two important lessons from the results of their study. The first is that taking medications is a complex task, requiring both adequate physical and cognitive function. Not surprisingly, therefore, the ability to take medications as directed correlates well with other measures of combined function. An inability to take medications even predicts functional decline at 6 and 12 months. From the clinician's point of view—especially those clinicians who rail against the use of functional performance scales and whose appointment scheduling rarely allows their use—spending a few minutes with patients determining their ability to take their medications offers a newly discovered wealth of additional clinical information. Although clinicians have long recognized that understanding their patient's medication use provides critical information about compliance and disease management, we now learn that the ability to take medication provides a reliable indication of overall function, functional decline, and the likely need for additional healthcare and other supportive services.
The study by Flaherty and colleagues poses a different question: "Does the use of many medications tell us anything about the health care status of patients in home care?" They use hospitalization as their outcome measure. I do not think that clinicians will be surprised to learn that the answer is "yes." The real question remains "why?" This study titillates our interest but does not satisfy it. Is it only that the need for medications indicates the presence of disease or rather that polypharmacy introduces such enormous risk that it measurably increases hospitalization even in a small population? The second theory is not supported by other literature, and the small sample size here does not allow for meaningful analysis of the risk posed by particular medications. Thus, the impression is that the sicker patients are, the more likely they are to be prescribed many medications. Reducing the number of medications is unlikely to help. Clinicians must cure and control disease.
Taken together, the data in these two studies establish that medication use is intrinsic to the health and independent living of older adults. People who cannot take their medications are unlikely to be able to live without assistance. People who take many medications probably have many diseases and are likely to become sick. These results provide an important reminder to all clinicians: Many of the medications clinicians prescribe are critical to their patients' health. If patients cannot take their drugs as directed, patients get sicker and lose function. Patients who must take many medications are at high risk and deserve special attention and all the services shown to be helpful. Clinicians must optimize the job they do in selecting the correct medications, explaining their proper use adequately to patients and their caregivers, and monitoring medication use appropriately. Clinicians must find the time to do this job well, even as pressures encourage them to do otherwise. Clinicians must strive to make the portrait of all patients as robust and vital as possible.
Received May 15, 2000
Accepted June 2, 2000
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