People don't like to take lots of medications, especially prescription medications. They're expensive and inconvenient, and they can cause side effects. To some people they just seem non-natural: witness the huge popularity of alternative therapies such as manipulation and acupuncture.

On the other hand, advances in drug therapy offer both improved survival and a better quality of life for untold numbers of Americans. Nowhere is this more evident than in the treatment of the chronic disorders so common among older adults. Yet, many people with such disorders are under-treated with medications, not the other way around. In fact, for many of us the question for our doctors should not be "Am I taking too many pills?", but rather "Am I taking enough?" If this seems surprising to you, consider just four examples.

Heart Failure
Heart failure is a weakened condition of the heart muscle resulting from heart attack, hypertension or other factors. It is a serious progressive disorder that causes fatigue and shortness of breath, but in its early stages may be asymptomatic. It is the commonest reason for hospital admission among people over 65. Until the 1980's, the overall mortality rate at five years was about 60%. Then, in the 1990's, it declined to 50%; for optimally treated patients it has declined even further. The reason: newer and better drug treatments.

Today, the best treatment for heart failure requires a combination of three, and sometimes four different classes of medications: an ACE inhibitor, diuretic, beta blocker and sometimes digoxin. The medications are important both for prolonging survival and reducing disability.

Regrettably, most heart failure patients are not getting the drugs they should have. Even the ACE inhibitors (Altace, Prinivil, Vasotec, Monopril and others), whose life-saving benefits have been known for over a decade, are still underutilized. Of patients with early stage heart failure, as many as half are not receiving these valuable drugs.

Diabetes
As many as 20% of people over 65 have diabetes. The better their blood sugar is controlled, the lower their risk of complications like blindness, kidney injury, amputation and heart attack. Current recommendations call for bringing blood sugar levels to normal or near-normal throughout the day.

Of course, diabetes care encompasses many different interventions including diet, exercise, preventive care and treatment of coexisting conditions. Nevertheless, achieving optimal blood sugar levels almost always requires medication, with many patients requiring combinations of two or more drugs.

How many diabetics are reaching optimal treatment goals? Unfortunately, only a minority. In fact, the National Committee on Quality Assurance found that about 40% of diabetics are under manifestly poor control and therefore face serious complications that could be prevented.

Hypertension
Hypertension (high blood pressure) is the most common primary diagnosis in America. Almost all seniors either now have or will some day develop hypertension. Lowering blood pressure has been shown to reduce the incidence of stroke by 35-40%, heart attack by 25% and heart failure by more than 50%.

Widely publicized evidence and expert consensus calls for lowering blood pressure to less than 140/90 to achieve the foregoing benefits, and this usually requires antihypertensive drugs. In older adults a combination of two or more drugs is often needed.

How many people with hypertension are receiving treatment adequate to get their blood pressures below 140/90? The answer is only about one out of three. The rest should be receiving more aggressive treatment. Yes, weight loss, exercise and dietary measures play an important role; but overall, Americans with hypertension are still being grossly under-treated with medications.

Osteoporosis
Over ten million Americans, most of whom are women over 50, have osteoporosis. They are at increased risk for debilitating fractures that can threaten their independence, lead to serious disability or even death. Yet about two-thirds of people with osteoporosis don't even know they have it. Fully 85% aren't being treated.

Prevention is always best, and certainly measures like regular exercise, getting adequate dietary calcium and avoidance of smoking and excess alcohol are important. However, these measures alone won't reverse osteoporosis once it is already established. For that, one must take one or more of the several prescription drugs approved for treating the disorder. Unfortunately, most seniors who would benefit aren't getting them.

Too Many Pills or Too Few?
Examples like these aside, it is still a fact that many seniors receive prescriptions for unnecessary or harmful drugs. Serious and preventable adverse drug effects are all too common, and seniors would be right to be cautious. But, for many chronic conditions like those discussed above, critical medications are frequently not prescribed enough. Therefore the next time you look skeptically at your list of medications, don't just ask which ones you could do without. Ask also whether you are getting enough of the ones you need.

November 2003