The scenario often unfolds like this: Medical researchers investigate a frequently used drug and report that it’s not as effective for older patients as previously thought, or that in older adults, its risks outweigh its benefits. More studies follow, confirming those findings.
After a few years, medical associations revise their guidelines, warning that the drug in question should be avoided or at least prescribed more selectively. It might be added to the Beers Criteria, an influential list of potentially inappropriate medications for older patients, published by the American Geriatrics Society.
If the drug’s role is preventive, the U.S. Preventive Services Task Force, an independent expert panel, may weigh in with cautions. The Food and Drug Administration may issue “black box” warnings about concerning side effects.
After a few more years, researchers look at broad national data to see whether use of this drug declined. Often, the answer is: Yes, but not enough. Sometimes, though, use didn’t decline much at all or actually increased.
“Medications are like barnacles,” said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of the U.S. Deprescribing Research Network. “They’re easy to start, but they can be hard to stop.”
This medical inertia partly reflects the time lags involved in disseminating findings. “Clinicians have a million things they need to know and attend to, and information may take a while to get to them,” Dr. Steinman said.
But it also reflects the way “clinicians and patients get used to treating conditions in certain ways,” he said. “They become ingrained habits.” Finding alternative approaches is challenging, so “it’s easy to go with what you know.”
Recent studies of three medications or classes of drugs widely used among older Americans illustrate the problem.
The Drawbacks of Benzodiazepines
Scientists began raising alarms about benzodiazepines more than 20 years ago. Prescribed for insomnia and anxiety, “they offer prompt relief,” said Dr. Mark Olfson, a psychiatrist and epidemiologist at Columbia University.
The problem? Benzodiazepines (including Valium, Xanax and Ativan) and the related “Z” drugs (Ambien, Lunesta) “may impair balance, coordination and cognition that can translate into falls and fractures and motor vehicle accidents,” Dr. Olfson said. In patients also taking opioids for pain, benzodiazepines can cause overdoses.
Moreover, “once you’ve taken them for a period of time, you develop a dependence,” Dr. Olfson added. “When you come off them, you may develop withdrawal symptoms.”
So what’s happened to benzo use among older adults, who are more sensitive to these effects? In a recent examination of prescribing trends, published in Annals of Internal Medicine, Dr. Olfson and his team reported progress. Among people over 65, overall benzo use from 2015 to 2024 dropped to 11.5 percent from 14 percent.
But that decline has stalled since 2020, perhaps related to the Covid pandemic. Moreover, use actually rose among those over 75, from 12 percent in 2020 to about 13 percent four years later. Dispensing through pharmacies in long-term care facilities more than doubled. And about a third of users were taking the drug for longer than six months, increasing the likelihood of dependence. “It’s worrisome,” Dr. Olfson said.
But he cautioned that patients shouldn’t stop benzodiazepines suddenly or on their own, which can provoke withdrawal. “It requires supervised tapering” with a medical professional, he said. “It takes many weeks.”
Overprescribing Antibiotics
For years, the standard treatment for diverticulitis, the inflammation of small pouches that form in the colon, was antibiotics, primarily fluoroquinolones (like Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin).
“It was unquestioned,” said Jesse Sutton, a pharmacist and researcher at VA Minneapolis Health Care. “Antibiotics are safe and effective, great, lifesaving drugs, so the mind-set was, when in doubt, use them.”
But in 2015, the American Gastroenterological Association recommended against routinely prescribing antibiotics for “uncomplicated” diverticulitis, which represents a great majority of cases. Other medical groups followed suit.
Clinical trials had shown that for this condition, antibiotics had little or no effect on mortality, the need for surgery, complications or recurrences. “They hadn’t improved anything,” Dr. Sutton said.
And as with any drug, “there are downsides, unintended consequences,” he said. “Side effects from antibiotics account for a substantial amount of emergency room visits” for symptoms like nausea, vomiting and diarrhea. Antibiotics heighten the risk of the virulent C. difficile infection, too.
Plus, “the more you use antibiotics, the less they work in the future,” Dr. Sutton said. The World Health Organization has deemed antimicrobial resistance “a major global health threat.”
So Dr. Sutton and his colleagues, studying treatment in 70,000 visits to 120 Veterans Affairs facilities, expected to see antibiotic use for uncomplicated diverticulitis decline over 10 years.
Instead, they reported recently in Annals of Internal Medicine, antibiotic prescriptions remained nearly universal at 97 percent of visits, guidelines or no guidelines. The patients (average age: 63) would most likely have done as well with a few days of Tylenol and a clear liquid diet.
Antibiotic overuse remains common for other conditions of later life, too, including urinary tract infections that cause no troublesome symptoms and upper respiratory infections that are typically viral, not bacterial.
In such cases, when a doctor prescribes an antibiotic, “I’d encourage patients to say, ‘Please explain the rationale for doing this,’” Dr. Sutton said. “If they don’t, it’s OK to press pause.”
When Aspirin Isn’t the Answer
Aspirin is different. Because it’s cheap and over the counter, anybody can start taking it on their own — and millions of older Americans do, thinking it will help prevent cardiac problems.
For people who’ve already had a heart attack, stroke or cardiac intervention like a stent or bypass surgery, daily low-dose aspirin for “secondary prevention” does lower the odds of another event, studies have demonstrated.
But for “primary prevention” in people who haven’t had one, the guidelines changed in 2019, when the American College of Cardiology and the American Heart Association recommended against aspirin for this purpose in those 70 and older. The U.S. Preventive Services Task Force went further, warning against aspirin for primary prevention starting at age 60.
Large clinical trials had shown scant benefit for aspirin as a primary prevention measure, but there were harms, notably gastrointestinal bleeding. “As we age, the risks of bleeding go up,” said Dr. Timothy Anderson, an internist at the University of Pittsburgh who directs its Prescribing Wisely Lab. More rarely, but more seriously, aspirin can cause bleeding in the brain.
In a JAMA study last year, Dr. Anderson and his co-author found the message was getting through: Aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had dropped substantially from 2011 to 2023. But more than a third of those 70 or older were still taking it.
Some caveats: A subgroup of older adults with high risk factors for cardiovascular disease may benefit from aspirin for primary prevention. And, confusingly, some evidence suggests that older patients already taking aspirin face a higher risk of cardiovascular disease if they discontinue it.
“Step 1 is a conversation with your primary care physician” about aspirin, Dr. Anderson said. “‘Is this still right for me as I get older?’”
Older patients taking aspirin, many without any medical guidance, “are interested in reducing their risk of heart attack and stroke,” he said. “They’re trying to be proactive and healthy.” But with blood pressure medications and statins for cholesterol, “we have better strategies than aspirin for that.”
The New Old Age is produced through a partnership with KFF Health News.
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