Nonprescription drugs can make an important contribution to an elderly patient's well-being. They provide temporary relief for some problems, and they balance the need for medical intervention against financial costs. On the other hand, nonprescription drugs can be hazardous, because elderly patients are often managed with multiple drug regimens. In a complex therapeutic regimen, OTCs can cause serious adverse reactions, additive effects, and interactions with prescription drugs.
The risk is enhanced in the elderly, who are often sight impaired (thus unable to read the directions), and who may not be able to self-diagnose, select the right agent, and follow directions.
Incomplete statistics indicate that about 60% to 70% of the elderly use nonprescription drugs. However, only a very small number of them discuss that use with either their physician or their pharmacist.
It must be realized that the FDA review of OTC products, which began in 1972, has been completed. Approximately one-third of all ingrethents submitted for review were judged to be safe and effective. Thus, there are no more innocuous OTC drugs. In addition, there is still concern that the elderly select and take OTC drugs correctly.
In June 1982, then-HHS Secretary Schweiker sent the final report of the 1981 White House Conference on Aging to the President and the Congress. From these recommendations, Schweiker developed a National Policy on Aging. A primary recommendation in the "Health" section of the policy emphasized the need to develop and disseminate educational materials for the elderly: "Be it resolved that . . . (1) The elderly be further educated in the safe and effective use of nonprescription medicines."
One reason for a heightened need for elderly to understand the safe and effective use of OTC drugs is the massive attempt by the FDA to switch several prescription drugs to OTC status. More than 20 products have so far been reclassified based on their long history of safe use (but not necessarily by the elderly). These conversions have not always been entirely without controversy, particularly in the case of metaproterenol metered-dose mist inhalers.
Another Controversy in the Offing
On the advice of the FDA Arthritis Advisory Committee, the FDA has now permitted the marketing of an OTC ibuprofen. The major concern of the Advisory Committee was aspirin sensitivity, which might also present as cross-reactivity to ibuprofen. Elderly persons, who often complain about aches and pains, may well reach for OTC ibuprofen, not realizing that this new OTC preparation is to be used for a limited time only. There are a number of potential problems that have been listed for this drug, which the elderly may well encounter.
Asthma, bleeding problems, colitis, stomach ulcers, other stomach problems, heart disease, high blood pressure, or kidney disease may all contraindicate the use of ibuprofen. Use of anticoagulants, aspirin, furosemide, heparin, or any other non-steroidal antiinflammatory agent may also call for caution in the use of this new product.
It is important to realize that ibuprofen can cause mental status changes in the elderly. It also may make management of hypertension more difficult, since ibuprofen interferes with the antihypertensive action of converting enzyme inhibitors, diuretics, and beta blockers.
Non-steroidals, including ibuprofen, can cause dysphagia, a problem to which the elderly are particularly sensitive. It is most important to recognize that patients with volume depletion, those receiving diuretics, those in heart failure, or those with underlying kidney or liver disease may be especially prone to kidney deterioration when taking these drugs. Finally, since 80% of all anti-arthritic drugs are prescribed for the elderly, it is not unlikely that elderly persons may be taking ibuprofen as a prescription drug and, by self-selection, as an OTC medicine. Surely, caution is indicated.