As dominoes fall, seniors often take too much medication because one health problem launches to a new one.
For example, a patient taking a drug to lower blood pressure develops swollen ankles. So a doctor prescribes a diuretic. The diuretic causes a potassium deficiency, resulting in a medicine to treat low potassium. However, that triggers nausea, which is treated with another drug, which causes confusion, which in turn is treated with more medication, according to a recent report by Kaiser Health News.
Some experts are pushing for what is called deprescribing. This means systematically discontinuing medicines that are inappropriate, duplicative, or unnecessary. But some health care specialists are reluctant to stop the practice because of fragmented medical care, which often causes patients to take too much medication. Deprescribing: Some experts are calling it America’s other prescription drug epidemic. In plain terms, many patients who are discharged from the hospital leave with new medications, layered on top of old ones.
While recent studies show that the number of seniors older than 65 who take at least three psychiatric drugs more than doubled in the past nine years beginning in 2004, according to a University of Michigan report. And nearly half of those taking potent medications, which include antipsychotic drugs used to treat schizophrenia, had no mental-health diagnosis.
Real life stories are more telling than a trove of studies. For example, one woman left an emergency room visit with five new drugs that her cardiologist prescribed after he monitored her arm pain to see if it might signal a heart attack.
Her cardiologist prescribed five new drugs – including an opioid – to the small dose of a diuretic she had been taking to control her blood pressure.
“Lots of different medications get started for reasons that are never supported by evidence,” said Rita Redberg, editor in chief of JAMA Internal Medicine. “In general, we like the idea of taking a pill” a lot better than nondrug measures, such as improved eating habits or exercise.
One way to launch widespread deprescribing is to require doctors to record why a drug is being prescribed. In plain terms, discontinue (“deprescribe”) medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. The Boston VA Healthcare System made this recommendation in a June 2017 web-based survey of 2475 prescribers, physicians, nurse practitioners, physician assistants, and clinical pharmacy specialists practicing at U.S. Veterans Affairs primary care clinics.
“There’s a reluctance to tinker or change things too much,” said University of Michigan geriatric psychiatrist Donovan Maust, who labels the phenomenon “clinical inertia.” When inheriting a new patient, Maust said, doctors tend to assume that if a colleague prescribed a drug, there must be a good reason for it – even if they don’t know what it is. Maust said he tries to combat inertia by writing time-limited orders for medication.
Cardiologist Rita Redberg, a professor of medicine at the University of California at San Francisco, said, “This problem has gotten worse because the average American is on a lot more medications than 15 years ago.”
Older people taking lots of medication was what Canadian pharmacist Barbara Farrell encountered when she began working at a geriatric hospital in Ottawa nearly two decades ago. Her experience, she said, was a catalyst for the Canadian Deprescribing Network, a consortium of researchers, physicians, pharmacists, and health advocates she cofounded.
Farrell, a clinical scientist at the Bruyere Research Institute, has also helped write guidelines, used by doctors in the United States and other countries, to safely deprescribe certain classes of widely used drugs, including proton pump inhibitors and sedatives.
One of Farrell’s most memorable successes involved a woman in her late 70s who was using a wheelchair and was nearly comatose.
“She would literally slide out of her chair,” Farrell recalled. The woman was taking 27 drugs four times per day and had been diagnosed with dementia and a host of other ailments.
After reviewing her medications, Farrell and her colleagues were able to weed out duplicative and potentially harmful drugs and reduce the doses of others. A year later, the woman was “like a different person:” She was able to walk with a cane and live mostly independently, and she reported that her doctor said she did not have dementia after all.
By Rosaland Tyler