Ageism in medication use: a policy brief

1. Establish a global action plan

An international organization, ideally WHO, should take the role of leader and coordinator of policies and strategies in order to help countries tackle the issue of ageism in medication use by creating and disseminating guidance, tools, targets, and international indicators. The organization should identify, bring together, engage, and coordinate all key stakeholders to formulate the global action plan, foster international collaboration, avoid duplication of efforts, share best practices, and encourage mutual learning. Also, experts from different fields and sectors should be involved in tackling this multifaceted problem by taking a multidisciplinary and intersectoral approach and avoiding working in silos. Furthermore, to combat this complex issue, we need a systems approach that takes a holistic view of the problem and considers all system levels: macro, meso, and micro. Also, these policies should ensure equitable access to medications and care that should be of the highest attainable quality, available, and affordable to everyone. Finally, the needs of older adults facing multiple and intersecting forms of discrimination, such as older women, should be taken into account when formulating policies, strategies, and plans.

These policies and tools should be adapted to national contexts due to differences in health system design and funding, available resources and infrastructure, culture and traditions. If countries have strategies or plans related to the issue of ageism in medication use, they should review and align them with the global action plan. Also, it is necessary to designate national coordinators to oversee and coordinate the implementation of the global action plan at the national levels, as well as a coordinators responsible for each care facility.

2. Enhance integration and coordination between health and social care and across different levels of health care

Fragmented silos-based care, where each specialist treats a specific organ without holistically considering all patient needs and without communicating with other professionals involved in patient care, can lead to serious negative consequences.²⁶ For example, professionals usually do not know all patient conditions and medications, which leads to drugs being duplicated and reintroduced after being discontinued due to lack of efficacy or adverse drug reactions. The causes of this multifaceted issue are complex and dependent on the context: limited resources, workforce shortages and maldistribution, high workloads, lack of time, increasingly specialized care (increasing number of specializations and sub-specializations), and lack of electronic health care systems/interoperability of electronic health care systems.²⁷ Also, the skills of certain professionals are underused, such as pharmacists who are knowledgeable about medication therapy.

Care professionals from multiple disciplines should work collaboratively and make complementary contributions to team-based, multidisciplinary care. Their team roles and responsibilities should be clearly defined in national legislations. The teams should be coordinated and integrated by one primary care professional – a registered nurse, general practitioner or, in the case of older adults, a geriatrician. Also, pharmacists’ knowledge and skills could be used more efficiently by involving them in healthcare teams at all levels of healthcare. Furthermore, to enable teamwork and the flow of information among care professionals and their patients, electronic health records should be implemented or adapted to make them interoperable across health systems. Electronic health records should also be user friendly and secure to protect patient privacy.

All these changes require restructuring healthcare systems and organizations, changing legislations and regulations, redesigning workflows, redistributing tasks and responsibilities, ensuring the educational foundations, tailoring activities to the local contexts, developing health information technologies, and allocating resources. Thus, all activities and interventions should be carefully planned, developed, implemented and monitored to avoid increasing the workload of the already overburdened workforce and unnecessary expenses.

3. Implement a quality and safety perspective

The issue of ageism in medication use should also be addressed from a health care quality and safety perspective that aim to prevent avoidable medical errors, including medication errors. Patient safety should be integrated and implemented in all health and social policies and programmes, which requires establishing a safety culture and having committed and devoted political and organizational leadership to promote it. Furthermore, it is important to develop an open, transparent, and blame-free incident and near-miss reporting culture and to learn from reported mistakes and investigate their root causes. However, it is required not to take only a reactive but also a proactive approach to prevent medical errors. Also, the focus should be on preventing system and organizational failures rather than errors of individuals because “to err is human”.

To measure the quality of care provided and to monitor progress, indicators that are suitable for international comparison should be used. In order to enable comparability between countries, it is necessary to use uniformly defined indicators, the same sources of information, methods of data collection, age- and sex-disaggregated data expressed in standard units (e.g., Defined Daily Dose per 1,000 inhabitants per day). The OECD has developed several health care quality indicators that encompass the most relevant problems in prescribing for older adults.²⁸ These indicators could be used and/or adapted to enable broader international comparisons. Also, several other validated and cross-nationally comparable indicators could be developed.

Three OECD indicators that are examples of ageism in medication use are antipsychotics, long-term benzodiazepines/related drugs, and long-acting benzodiazepines/related drugs.²⁸ These medications are still prevalently prescribed despite their serious negative consequences on older peoples’ lives.²⁰ Antipsychotic use in people with dementia increases mortality and rate of cognitive decline.²⁹ Despite this, antipsychotics are often used as chemical restraints in nursing homes. This malpractice can be considered abuse, inhuman, and degrading treatment³⁰ and must be ceased, primarily by providing legal protection to people with dementia. Furthermore, benzodiazepines are often prescribed to older adults for sleep disorders despite their risks – falls, fractures, cognitive decline, delirium, and road accidents.²⁹ In both cases, instead of medications – antipsychotics in people with dementia and benzodiazepines for sleep disorders – non-pharmacological alternatives, such as behavioural interventions, are preferred for most older adults.^29,31

4. Empower and engage older patients

Healthcare professionals less often involve older patients in treatment decisions than younger ones.³² Moreover, some older persons are less likely to ask physicians questions and challenge their authority than younger adults.³³ However, professionals should never make assumptions about a patient’s desired level of involvement but try to elicit it.

Care provided should be person-centred and individualized, and older patients should be empowered and encouraged to take an active role in their care and decision making. Care professionals should respect all patients, irrespective of their age, gender, race and other characteristics, as experts and partners with whom they share power and responsibility. Professionals should also respect that patients might have different needs and priorities, which can change over time. They should provide reliable information about disease, medications, and risks and benefits of different options of treatment to enable patients to make informed decisions; elicit patient’s beliefs, preferences, values and priorities; encourage and help patients to decide on the therapy approach that would be in line with their needs and agree on next steps. Decision aids that provide information about the possible treatment strategies should be developed/adapted for common medical conditions and made available across clinical settings. Also, question prompt lists that can help patients actively discuss their health problems and medications with clinicians should be developed/adapted and made available.

Campaigns should be launched to raise awareness about ageism and inappropriate medication use. These campaigns should also aim to reduce self-ageism and ageism towards others by promoting that people of all ages have equal rights to the best available healthcare. The campaigns should also promote a life course perspective, i.e., that we all, if lucky, will be older one day, so that younger and older persons should take appropriate self-care and lead a healthy lifestyle to age as healthy as possible. Also, this ideation about our future selves could encourage care professionals to provide the best possible care to everyone and treat older persons with dignity and respect. Furthermore, these campaigns should promote a healthy lifestyle and the benefits and effectiveness of non-pharmacological strategies that should be used instead of drug therapies in certain cases. Finally, the campaigns should raise awareness that some medicines can harm older adults and educate the public about the most severe and prevalent medication problems and where to find reliable health- and medication-related information. The campaigns should use different channels to reach the diverse older population with different health and digital literacy levels, preferences and access options: social media, the internet, and traditional media (television, radio, billboards, newspapers, posters, and leaflets in healthcare institutions).

5. Improve education and training of care professionals

Comprehensive curricula for all care professionals should be developed to include diverse but interrelated topics: ageism and other ‘isms’, ageing, older age, geriatric medicine, geriatric pharmacotherapy, health literacy, medication adherence, and patient safety. All these topics should be part of undergraduate, postgraduate, and continuing education courses, board certifications, and renewal of licenses. Especially important is the knowledge about older age and ageing because people who have greater knowledge in these areas tend to have more positive attitudes towards older adults.³⁴ This knowledge would decrease clinicians’ ageistic practices such as treating only symptoms, often inappropriately attributed to ageing, instead of establishing a proper diagnosis.³⁵ Also, care professionals should develop communication skills to avoid patronizing and disrespectful communication and elderspeak, i.e., speaking more slowly, more loudly, or using simpler vocabulary when talking to older adults.³⁶ Elderspeak is the consequence of wrong generalizations that all older adults have lower cognitive capacity and hearing problems.³⁷ Finally, it is important to promote specialization in gerontology, geriatrics and geriatric pharmacy, which remain unpopular despite population ageing.

Education and training should be interprofessional to practice teamwork. Teamwork could be further enhanced by conducting peer discussions and clinical peer reviews. Furthermore, education and training should be intergenerational to expose care professionals to the whole spectrum of older adults. It would help professionals understand that older adults are not a homogenous group of vulnerable and frail people and enhance intergenerational solidarity. Care professionals commonly see a more vulnerable older population and therefore, sometimes, they tend to be more ageistic than the general population.³³

Clinical guidelines are usually single disease-focused, not addressing the needs of multimorbid or frail or older patients.³⁸ Consequently, complying with guidelines can lead to polypharmacy, drug-drug interactions, and patient harm.³⁹ Also, guidelines are usually based on clinical trials that mainly included younger adults. Even when older adults were included in clinical trials, they tended to be healthier and thus not representative of this diverse population.⁴⁰ Prescribers are often forced to follow these guidelines that do not consider individual patient needs and preferences, especially in pay-per-performance payment models.³⁸ Therefore, existing treatment guidelines should be revised, or new ones should be developed considering older people’s needs and preferences and disseminated to all clinical practices. Furthermore, digital technology provides an excellent opportunity to translate these clinical guidelines into computerized clinical decision support systems, prescribing algorithms and alerts, which professionals can use on computers, mobile phones, and tablets. However, clinicians should be constantly reminded that clinical judgment about individual patients’ needs and preferences is always required.