Evidence, ethics and medication management in older people

Prescribing in frail older people may be improved by application of the four tenets of medical ethics - beneficence, nonmaleficence, autonomy, justice - rather than solely those of evidence-based medicine. Evidence-based medicine provides data primarily on the efficacy of interventions. In younger adults, this is often sufficient to make a decision to prescribe medications. In frail older people, there are additional issues that need to be considered, such as individualisation of efficacy data, increased risk of adverse drug reactions, patients' views on risk and benefit, difficulties in assessing capacity to understand risk and benefit, consent to treatment, and concerns about the cost-effectiveness of interventions in the very old. In such situations, evidence-based medicine can be useful in informing the prescriber about the ethical principle of beneficence. However, the decision to prescribe or withdraw medications is also influenced by the other three tenets of medical ethics: non-maleficence (adverse drug reactions, polypharmacy), autonomy (consent, competency) and justice (appropriate allocation of healthcare resources).