Older adults take more medications than any other group and sometimes they take the wrong drug for the wrong reason and at the wrong dosage. In a 2012 study on Maltese older adults, Lorna Marie West and Scott Cunningham, both from The Robert Gordon University, Aberdeen, with Maria Cordina from the University of Malta, reported that, “there is considerable inappropriate prescribing which could have significant negative effects regarding patient care”.

Considerable in that more than half the patients received inappropriate medications, while a quarter received incorrect directions and one in five received incorrect dosages. In Malta, it is likely that older adults are being prescribed inappropriate medication or receive poor instructions about the drug. Other than causing ill health, West also showed that there is great waste of prescription medications in Malta.

What is perhaps less obvious is that some drugs should never be taken by older adults in the first place. And the likely culprit is arrogance. At a conference in 2015, Sophie Woodhead from Clare College Cambridge, UK and her colleagues presented a paper where the conclusion stated that in Malta “doctors remain isolated from all these relationships and only relate to patients from a position of power”. This does not apply to all physicians, but this finding highlights some unique negative features of the doctor-patient relationships we have in Malta.

We assume that if drugs are safe, then they are safe for everyone. But this is not the case. Anton Bugeja in 2013 reported another Maltese study where he looked at drug-drug interactions – where one drug clashes with the effect of another. They found that among 100 patients using dispensaries across Malta, where half of the patients were aged 65 and older, there were 255 such clashes of medication. Some of these clashes are harmful and dangerous. And we know this because they have been documented extensively on older adults.

Every few years the American Geriatrics Society (AGS) releases an updated and expanded Beers Criteria (after the originator of the first list, Mark Beers) – a list of potentially inappropriate medications for older adults that is developed from 6,700 clinical studies.

The report is complex, technical and detailed and needs to be reviewed with your physician. However, as a summary, it is important to realise how common bad side effects are for most of the medications we take.

Sometimes the medications cause death. Danish physician and researcher Peter Gøtzsche from the Nordic Cochrane Centre estimates there are 15 times more suicides among people taking antidepressants than are reported by the US Food and Drug Administration.

By looking at Danish prescription statistics for antipsychotics, benzodiazepines and antidepressants, he estimated that the death rate for older adults was between one and two per cent. Based on these Danish death rates he estimates that for the US and EU combined, an estimated 539,000 older adults die from these drugs every year.

Older adults also use drugs that they buy from the dispensary without getting a doctor’s prescription. These over-the-counter drugs are readily available and people again feel they are safe. Nearly half of prescription users also take at least one over-the-counter medication. This is likely to be higher in Malta.

What is perhaps less obvious is that some drugs should never be taken by older adults in the first place. And the likely culprit is arrogance

In addition to drugs we buy from the dispensary, there is an increased use of herbal or dietary supplements (ginseng, ginkgo biloba extract and glucosamine) by older adults. Almost three-quarters of older adults use at least one prescription drug and one dietary supplement. Sometimes we do not tell our doctor that we are taking these supplements because we think they are not important. But herbal medicines may interact with prescription drugs and lead to adverse events.

Such adverse events as when ginkgo biloba extract is taken with warfarin, causing an increased risk of bleeding or when St John’s Wort is taken with serotonin-reuptake inhibitors, increasing the risk of too much serotonin, causing symptoms ranging from mild (shivering and diarrhea) to severe muscle rigidity, fever and seizures).

Severe serotonin syndrome can be fatal if not treated. A study of the use of 22 supplements found potential interactions between supplements and medications in half of these supplements. We do not know all of the ill effects of medications on older adults, especially among older women, because these drugs are rarely, if ever, tested among older adults. The drug-drug interactions, side effects, cost of medications, medications that should have been stopped ages ago and medications that are inappropriate for older adults suggest that the fewer drugs you take, the safer you are. Because our metabolism changes with age, the filtering of the drug in our bodies is compromised and becomes less efficient. As a result, the effect of drugs changes as we age.

The lesson to learn is that the more medications we take the more likely that there will be negative side effects. Half of all adverse drugs occur when five or more drugs are taken and it is certain that there will be a reaction when eight or more drugs are taken. Some people cannot reduce their medications, but by discussing your medications with your physician, you can start to try and reduce and, possibly, eliminate some of your drugs.

In some cases, replacing medication with other treatments, such as psychotherapy, exercise, social activities or some behaviour modification training, might be worth exploring especially for behavioural concerns. But we have to move beyond the ‘doctors remain isolated from all these relationships and only relate to patients from a position of power’. It is important to start having a relationship with your doctor for them to carefully review all medications and to make sure they are all needed and at the right dosage. Physicians are trained to do this through what is known as evidence-based practice, which includes taking into account the patient as an individual.

Mario Garrett was born in Cospicua and went to St Paula Technical School before moving to England with his family. He obtained a first class Honours at the University of East London and a PhD from the University of Bath, both in psychology. He is currently a professor of gerontology at San Diego State University in California, US. He recently published a critique of research in Alzheimer's disease: The Politics of Anguish: How Alzheimer's disease became the a malady of the 21st century. Garrett maintains a blog on Psychology Today.

Drugs and reactions

Among patients aged 65 and older, insulin or warfarin (Coumadin) was the cause of one in every three drug reactions that resulted in an emergency hospital visit and was responsible for nearly half of all drug reaction hospitalisations. Analgesics for chronic pain cause slowed breathing and constipation. NSAIDs, such as ibuprofen (Advil) and naproxen (Aleve), are generally not recommended for older adults because of stomach and intestine irritation and possibly raising blood pressure.

Acetaminophen (Tylenol) increased the risk of hypertension by a third. Some medication, prescribed for schizophrenia and bipolar disorder, such as Aripiprazole (Abilify), clozapine (Clozaril) and risperidone (Risperda), may increase blood sugar indirectly due to weight gain. Decongestants and other anticholinergics we can get at the pharmacy without a prescription can cause confusion, urinary retention and other problems.

Pseudoephedrine (Sudafed) can raise blood pressure. Researchers found that half of all older adults taking anticholinergics showed mental decline. Beta-blockers like Atenolol (Tenormin), sotalol (Betapace), prescribed for hypertension and arrhythmias, and thiazide diuretics, such as chlorothiazide (Diuril) and indapamide (Lozol), prescribed for hypertension and congestive heart failure, can increase the risk of diabetes.

Corticosteroids such as prednisone and methylprednisone (Medrol), prescribed for arthritis or asthma, increase blood sugar and can lead to type 2 diabetes. Erectile dysfunction medications like sildenafil (Viagra), tadalafil (Cialis) and other medications, may cause visual and hearing disturbances.

The biggest category is statins for cholesterol, where atorvastatin (Lipitor), simvastatin (Zocor) and other statins may create very low levels of cholesterol that may lead to depression, memory loss and confusion.

Some statins may cause liver damage. Congestive heart failure medications, such as digoxin (Lanoxin) and diuretics, are at risk for electrolyte imbalances and therefore risk poisoning the body through increased toxicity.

Hip fracture is increased among elderly patients who take proton pump inhibitors such as lansoprazole (Prevacid), esomeprazole (Nexium) and omeprazole (Prilosec) and to a lesser extent by H2-blockers such as cimetidine (Tagamet) and famotidine (Pepcid).

Because so many medications are excreted via the kidney, it is important for elderly patients to have kidney function assessed regularly. Impaired kidney function may require adjustment of medication dosages. What we eat can also influence how these drugs react in our body. Certain drugs have dietary implications, including foods to avoid and nutrients that are essential. Some medications should be taken on an empty stomach, others with food.