An often overlooked contributing factor to ADRs is the interaction of self-prescribed over-the-counter medications with prescribed medications. In addition to being the largest consumers of prescription drugs, the elderly also are the largest consumers of over-the-counter drugs. As more of these over-the-counter medications become available, the potential adverse interactions will also increase. Moreover, the direct adverse effects of these drugs themselves need further study.51

Mental impairment resulting from the use of psychoactive drugs, in both institutionalized elderly and younger patients past the age of 50, is an issue of some controversy. Clearly, some reduction in cognitive capacity can result from chronic use of benzodiazepines and neuroleptics in some patients, but more needs to be learned about the nature and magnitude of such changes.26,40 In one area of the mental health realm, however, age may provide protection from drug-induced disability. The depression associated with beta-blocker use appears to occur with less frequency in the old than in those who are younger, a phenomenon that may be related to the reduced sensitivity of adrenergic receptors with aging.6

PREVENTABILITY OF BURDEN

A large body of data indicate that there is considerable room for improvement in the way medications are used in the over-50 age group. Physicians are not as proficient as they might be in optimal prescribing for the elderly, a deficit reflected in actual prescribing practices11,33 and in surveys of physician knowledge.4,20 In addition, physician-patient communication is often problematic, both in the areas of history taking for therapeutic decision making and communication about drug effects, precautions, and compliance.17,19

Fortunately, a number of interventions have been developed to address these problems; some have even been field-tested in randomized controlled trials. Traditional educational methods using group lectures and mailed informational material appear to be of limited efficacy in changing prescribing practices;7,24,44 however, consistent, reproducible data indicate that in-person, face-to-face education provided by clinical educators (either pharmacists or other physicians) has proven effective in making physicians' prescribing decisions more precise. In several studies that track physician prescribing across six states, such interventions have resulted in a reduction in inappropriate prescribing that was both statistically and economically significant.9,41 A formal benefit-cost analysis of the largest of these studies has further shown that the dollars saved by a third-party reimbursement program



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