Geriatric medicine differs from conventional medicine in a number of ways. Complete knowledge of the medication regimen and compliance issues may pose a particular challenge. Monane and associates review common problems associated with medication use in the elderly, including noncompliance, polypharmacy, undermedication or omission, use of over-the-counter medications and alcohol consumption, and offer some suggestions for improvement.

Noncompliance may be detected subjectively by patient interviews, pill counts and refill records, or more objectively by monitoring serum levels and urine assays to measure drug metabolites or marker compounds. Compliance rates in patients taking long-term therapy can range from 40 to 60 percent. Poor compliance can have serious clinical consequences; if unrecognized, non-compliance can increase both the patient's risk and cost, since physicians may increase the dosage or prescribe additional medications. Strategies to improve compliance include patient education, promoting compliance and simplifying the medical regimen. Encouraging the family or caregiver to monitor compliance is also essential.

Polypharmacy, which the authors define as the use of five or more prescription and/or over-the-counter medications, is the principal drug safety problem in the United States. Forty percent of patients who live in long-term care facilities and up to 6 million older Americans living in the community are affected. The definition of polypharmacy is helpful as a quick screening tool to identify patients whose medication records may need additional physician review. The use of several prescribing physicians or several pharmacies, and inadequate communication among the physicians and pharmacies is often implicated as the principal cause of inappropriate polypharmacy. Strategies for preventing the problem focus on improving communication between physicians and patients with regard to the exact number and type of medications used, the use of a single pharmacy or pharmacy network and regular, comprehensive medication reviews.

Inadequate dosage or omission of an appropriate prescription is another common problem. Inadequate dosage has been reported with calcium supplements, transdermal nitroglycerin and bronchodilators. Frequent omissions include iron supplements in patients following surgery, cholesterol-lowering agents, oral hypoglycemic agents and bronchodilators.

Nonprescription drugs represent an important therapeutic tool but can also include risks. Many prescription drugs have been reclassified for over-the-counter use. These agents are used more often by patients with higher education levels, less time for physician visits, or less access to medical care.

Consumption of alcohol while taking certain medications can cause dangerous drug interactions, such as drowsiness and impaired physical and cognitive function. Alcohol may affect the way drugs work and may worsen or accelerate symptoms of chronic diseases common in older adults.

The authors conclude that medication use in older adults is associated with an increased risk for adverse events. Noncompliance and polypharmacy are the principal problems. However, omission or under-dosage may result in an incomplete therapeutic response or progression of a disease state. Patients and their caretakers must be encouraged to monitor medication regimens and to communicate effectively with physicians and pharmacies. Physicians must individualize medication regimens, balancing the risk-benefit ratio to the specific patient circumstances.