Frustration and concern continue to increase in the long-term-care community over the growing number of geriatric patients who suffer complex drug-drug and drug-disease interactions that may severely compromise their mental health.

According to Dianne Tobias, Pharm.D., president of the American Society of Clinical Pharmacists, the percentage of patients in U.S. nursing facilities who are receiving nine or more routine medications a day, the currently accepted definition of polypharmacy, rose from 17 percent in 1997 to nearly 27 percent by May 2000.

Nearly 25 years ago, the Health Care Financing Administration (HCFA) implemented regulations requiring a consulting pharmacist to review the medication record of each patient in a nursing home monthly. Some 10 years later, the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) included guidelines for the use of psychoactive medications in the geriatric population.

Nonetheless, some critics charge that inappropriate use of psychotropic medications and unwarranted, excessive polypharmacy continue to run rampant in the geriatric community, that adverse drug effects are more common than desired effects, and that drug interactions are more complex and dangerous than ever.

"Our elderly are still being drugged to death, both literally and figuratively," said Marie A. O'Connor, R.Ph., Ph.D. O'Connor is a consulting geriatric pharmacologist in Englewood, Colo., and regularly encounters patients who are taking numerous medications.

Two years ago she was asked to do a postmortem review of a 78-year-old patient who was taking 17 medications at the time of death. The patient died after becoming entangled in her restraints, hanging herself from the side rails of her bed.

"Obviously, her death is a rare, extreme example," O'Connor told Psychiatric News. "But elderly patients exhibiting cognitive decline and dementialike symptoms caused by medications is not; it's extremely common."

The patient was admitted with "rapidly advancing dementia of the Alzheimer's type." On autopsy, however, no Alzheimer's pathology was found. O'Connor's review of the patient's medication record revealed that her behavioral disturbances and advancing dementia were likely caused by significant interactions between the multiple medications she was taking in the six weeks before her death.

"The significant points here," O'Connor said, "are that, although her medication record was reviewed by a consulting pharmacist, it appeared that it was simply initialed as OK with no comment whatsoever."

O'Connor noted that "with managed care, pharmacists may be required to review more than 100 charts a day. Under those circumstances, how can anyone be expected to catch all the details? What is even more significant is that, with the symptoms she was presenting, this woman had never been seen or evaluated by a psychiatrist-only by a general practitioner, cardiologist, and a pulmonologist."

If she had been seen by a psychiatrist, O'Connor said, the medication interactions and adverse reactions she experienced may have been averted.

A report last year, "White Paper on Quality Pharmaceutical Care in Long Term Care" by the American Medical Directors Association (AMDA), noted that studies show that 28 percent of all hospital admissions of elderly patients are due to medication noncompliance or adverse drug events. The U.S. Food and Drug Administration (FDA) estimates the costs of drug-related acute care admissions of elderly patients at $20 billion annually. According to the FDA, medication errors cause one death a day among the elderly.

"It's a question of appropriate treatment versus the 'prescribing cascade,'" said Lori A. Daiello, Pharm.D., a geriatric psychopharmacologist in private practice in Orlando, Fla. Daiello consults with physicians to review a patient's medications and make recommendations regarding possible interactions, side effects, and adverse reactions.

The prescribing cascade occurs, she explained, when a medication-drug number 1-causes an adverse effect that is interpreted as a new medical condition. Drug number 2 is prescribed to treat the "new" condition. Drug number 2 causes an adverse drug effect or interaction, interpreted as a new condition, so drug number 3 is prescribed, and so on.

At a recent consensus conference on long-term care in Washington, D.C., sponsored by the American Association for Geriatric Psychiatry (AAGP), Daiello led a forum on the consequences of polypharmacy and the impact of psychoactive medications in long-term-care settings. She noted that polypharmacy in long-term-care patients is usually due to the significant comorbidity of medical and psychiatric conditions inherent in this population.

Jacobo Mintzer, M.D., a professor of psychiatry at the Medical University of South Carolina and a member of APA's Committee on Ethnic Minority Elderly, reviewed key issues concerning geriatric polypharmacy and its potential effects in the July Journal of the Royal Society of Medicine (JRSM). Mintzer and his coauthor, Alistair Burns, M.D., were amazed by the amount of publicity that the article generated.

"We live in an ivory tower," Mintzer told Psychiatric News, "totally separated from our friends in general medicine. What we believe is old news to us is entirely new knowledge to our colleagues. It is an educational issue; we talk about the complex ideas of certain receptors and specific neurotransmitter-binding sites, but not about the basics."

In the U.S., people over age 65 consume more than 30 percent of prescription drugs and 40 percent of over-the-counter products, despite making up only 13 percent of the population. Studies have documented that more than 80 percent of prescriptions written in long-term-care facilities are written by general practice or internal medicine physicians, not geriatric specialists, noted Mintzer.

Although mental health disorders are not inherent in growing older, they are prevalent. Studies indicate that nearly half of all nursing home residents show depressive symptoms, while nearly 65 percent have dementia. Memory disorders affect the majority of residents, with some studies indicating as high as 77 percent having a reported problem with memory. Anxiety disorders, sleep disorders, and schizophrenia are less common, but still significant.

Numerous studies have indicated that federal guidelines have helped to stem the inappropriate use of psychotropic medications in nursing homes. According to Soo Borson, M.D., professor and director of geropsychiatry services in the department of psychiatry and behavioral sciences at the University of Washington Medical Center, the number of prescriptions for antipsychotics, sedative antihistamines, and sedative hypnotics has decreased since OBRA '87; however, the number of prescriptions for antidepressant and antianxiety medications has increased.

"The particular increase in antidepressant use is probably a good thing," noted Borson, immediate past president of the AAGP. She said that those who treat the elderly have long known that depression in the geriatric population has been significantly undertreated.

"The problem is, Are the right kind of antidepressants being prescribed?," Borson said. Some antidepressants, she explained, are anticholinergic and thus may have negative cognitive effects, especially in patients with mild to moderate dementia, as well as depression.

Daiello noted that psychoactive medication use in the elderly can lead to significant negative outcomes including falls and fractures, cognitive impairment, weight loss or gain, incontinence, and limitations on activities of daily living (ADLs). Cause and effect, though, are difficult to define, she said.

"There are many concerns with psychoactive drug use in the elderly. For example, the role of dose versus drug half-life, p.r.n. administration, titration of the drug, concurrent medical pharmacotherapy, frailty, poor sensory and motor function, and stability of gait. All of these factor into the way in which a psychoactive medication will affect an elderly patient."

Both O'Connor and Daiello agreed that one of the best ways to prevent problems with polypharmacy and potential drug interactions is to work toward requiring an interdisciplinary approach. "Any patient taking a psychoactive medication," said O'Connor, "should be thoroughly evaluated by a psychiatrist who, of course, understands the clinical implications of these medications. Not even a review by a pharmacist is enough."

"It would be short-sighted," Borson observed, "to think that anything other than cooperative, proactive teamwork is going to solve this problem." But, cautioned Borson, consultant pharmacists must take their role seriously, looking at the whole clinical picture, not just the medication point of view.

James Greene, M.D., chair of APA's Committee on Long Term Care and Treatment of the Elderly, agreed. "It has to be a cooperative effort between Pharm.D.s, M.D.s, and administrators of nursing homes, which thus far has not been the case."

Agreement is almost universal among geriatric specialists that the primary problem is one of education. "It is not so much a lack of knowledge, but a lack of awareness," Mintzer said. "The AAGP conference was a first; it was a unique opportunity where different people from different walks of life heard the same things at the same time. We must work to start to educate other groups on the very basics of geriatric care."

Borson, who cochaired the AAGP conference, thinks there is extensive work to do in educating all levels of nursing-home staff. Greene, a certified nursing facility medical director and a member of AMDA, agreed, noting that a significant problem lies in funding and reimbursement of nursing home care. "Nursing homes in this country are vastly underpaid and therefore vastly understaffed. They do not always give quality care, not that they don't try to. The staff simply do not have the education."

"Even in psychiatry though," said Greene, "better training oriented toward the generalist is essential-those 10,000 nongeriatric psychiatrists who end up doing nursing home care." That would greatly enhance, Greene explained, quality mental health services in long-term care, augmenting the work of the 1,500 geriatric psychiatrists who tend to do more specialized work. Last year APA's Long Term Care Committee put together its Manual of Nursing Home Practice For Psychiatrists, edited by Greene, to help do just that.

In the meantime, the long-term-care industry, geriatric specialists, and regulators are trying to work together to get some of the basics on quality pharmaceutical care out to the primary care community.

"In nursing home care," Greene said, "it's going to take major efforts to shift the paradigm, but a powerful combination of efforts by APA, AAGP, AMDA, and the American Geriatrics Society, to name the most important players, could and should get it done."