The problem of elderly people taking too many medications is not new, but continues to pose a serious risk to health as well as contribute significantly to rising Medicare costs. The fact is that nearly 20% of adults aged 65 years and older who are not hospitalized take 10 or more medications daily. This number is not the result of shoddy care, but rather achieved when doctors simply follow practice guidelines for several common, co-existing conditions like diabetes, high blood pressure and depression, for example. If you look at all seniors (those both in and out of the hospital) the American Society of Consultant Pharmacists reports that the average 65-69 year old takes nearly 14 prescriptions per year; by ages 80-84 that number averages an astounding 18 prescription drugs per year.
What’s troubling is that instead of improving the health of seniors, evidence is growing that the more medications an elderly person takes, the more likely he is to experience falls, cognitive decline, loss of mobility, depression and even cardiac problems. These adverse drug effects may be mistaken for Alzheimer’s disease or other dementias too. The bottom line: Experts estimate that up to one-third of the elderly in our communities may be over-medicated and some 20% of their hospital admissions are due to adverse drug events. The costs related to over-medication in the elderly are thought to exceed $80 billion each year.
Although the problem of so-called “polypharmacy” among seniors results in significant economic and public health costs, little has been done to remedy the problem. In fact, in a recent commentary in the Journal of the American Medical Association, Jerry Avorn, associate professor of medicine at Harvard Medical School and author of the book “Powerful Medicines,” says that “many aspects of the US health care system act to discourage optimal prescribing” for the elderly.
For example, elderly Americans are highly underrepresented in the clinical trials for many of the drugs that doctors commonly prescribe for them. Seniors may metabolize these medications differently and they are often more sensitive to side effects and counter-indications with other drugs than younger people. They also take many more drugs (often all at the same time) than any subjects who take part in controlled clinical trials. Disturbingly, doctors sometimes end up prescribing a new medication to treat the adverse effects of a pill the elderly patient has been taking for years.
The poorly coordinated care that many elderly people receive—they see multiple doctors for multiple medical conditions; they move from private homes or long-term living facilities to the hospital or rehab centers and back—exacerbates this problem even more. Medicare beneficiaries also forget to take medications or use them at incorrect dosages; sometimes they discontinue a prescription when co-pays and/or deductibles present a financial barrier. When asked by a specialist to recount all the medication they take, elderly patients might not remember the whole list or forget to mention over-the-counter drugs they regularly take. The net result is that if nobody is keeping a complete record of a patient’s every medication (including OTC drugs, herbal remedies and vitamin supplements), adverse reactions are likely to occur.
Last week’s JAMA also included a powerful case study illustrating the impact of polypharmacy on the elderly. The report concerned an 84-year-old man with multiple medical conditions who was taking 13 medications at 16 scheduled doses per day. His wife (and primary caretaker) had noticed that her husband, once an active writer, editor and tennis buff, was deteriorating mentally and “doing almost nothing.” The wife and the man’s internist decided to conduct a detailed review of the patient’s drug regimen to see if some of this recent deterioration (both physical and cognitive) could be due to the adverse effects of medication. The resulting case study, “Managing Medications in Clinically Complex Elders” by Michael A. Steinman, an associate professor of medicine in the Geriatric Division at the University of California, San Francisco and Joseph T. Hanlon a professor of medicine at the University of Pittsburgh who specializes in geriatric pharmacology reads a bit like a detective story—albeit for a medically inclined audience.
In a reverse of the process doctors use to find the source of a food allergy (withdrawing all potential culprits and slowly adding them back to the diet one by one), the internist in this case began removing medications one by one to see if each one was really necessary. In the end, the patient’s drug regimen was reduced from 13 medications to a half-dozen and he gained back much mobility and some cognitive function. The authors add that doctors should pay particular attention to warfarin, hypoglycemic medications, and digoxin, “which account for one third of all emergency department visits in older patients due to adverse drug events.”
Johanna Trimble, a Vancouver-based leader of the advocacy group Patients for Patient Safety in Canada, writes on the blog Healthy Skepticism about her personal experience watching her mother-in-law deteriorate mentally and physically once she was hospitalized for the vague but worrying complaint that she “couldn’t stand without passing out.” (thanks to Gary Schwitzer who mentions Trimble on his blog Health News Review). Trimble’s mother-in-law was eventually taking 9 different medications, three of which were from the anti-cholinergic class of drugs (known to cause adverse effects in many seniors) and two different anti-depressants. Over the weeks that she remained hospitalized, the patient became completely bedridden and was diagnosed with Alzheimer’s disease.
“All of these symptoms started after admittance to the Health Centre and the starting of new drugs she’d never been on before,” writes Trimble. “This was not at all like our Mom. We felt sure, after listening carefully and researching what we had seen and heard her talk about regarding her mental and physical state, that adverse effects of new drugs could be the problem.”
After conducting research on-line, Trimble and other relatives asked the medical staff at the nursing home to put her mother-in-law on a “drug holiday.” The result: “To make a very long story shorter,” writes Trimble, “the ‘drug holiday’ brought our Mom back to the intelligent and aware woman we’d always known (where did that Alzheimer’s go!?). Not only did her mental status return to normal, she improved physically (a huge contrast to her original bedridden and delusional state when she was on the new drugs) and was able to participate in activities and exercise and also ‘train’ her caregivers, if she thought they needed it. She improved to the point that we could take her out to her favourite seafood restaurant for oysters and white wine when we visited. This gave great joy to all of us.”
It’s frightening to think that there are probably scores of other frail elderly people who are experiencing the same medication-related deterioration chronicled in the two accounts I’ve related above. Their bad luck is to lack a capable advocate or insightful physician who takes the time to review medication regimens and will eliminate those that might be causing adverse effects. But ultimately, the responsibility for devising a solution to polypharmacy in the elderly rests with Medicare. With the introduction of Medicare Part D, the government is now officially the largest purchaser of prescription drugs in the nation. It also shoulders the growing financial cost of adverse effects and hospitalization of seniors who are harmed by inappropriate drug regimens. As such, the Center for Medicare and Medicaid Services would seem the perfect laboratory for testing strategies to cut down on this costly (in both economic and health terms) problem.
Avorn recommends several key policy approaches that would help advance smarter prescribing practices for the elderly. First of all, he believes that medical education must include required courses in geriatrics; specifically in clinical pharmacology—programs that are usually electives and poorly attended. “As with primary care, it is as if the key components of an educational program to meet the nation’s most pressing medical needs were identified and then systematically avoided. Not surprisingly, many trainees emerge with a poor understanding of pharmacotherapeutics in older patients.” Avorn goes even further; suggesting that all doctors who accept Medicare prove that they are up-to-date on prescribing practices for the elderly every few years.
Health reform legislation includes mandating Medicare coverage for end-of-life discussions between doctors and their elderly patients with the goal of personalizing and improving the quality of care in the last year or so of life. Good palliative care has been proven to not only reduce costs at the end of life but to extend the quality and length of life. Why not take a similar approach to counseling elderly patients about their medications?
A study published in Clinical Geriatrics, found that when geriatric pharmacologists reviewed the medication records of some 982 seniors, they found almost 2000 potential drug-related problems. The four leading “problematic medication classes” included gastrointestinal drugs, analgesics, antipsychotics, and cardiovascular therapeutics. The researchers found problems with the duration of therapy, duplication of therapy, inappropriate dosing and drug-drug or drug-disease interactions. Their recommendation (back in July 2006): Consultant pharmacologists should be tapped to regularly review the prescription regimens of the frail elderly to help improve patient outcomes and reduce medical costs.
The key to making “this vital and potentially life-saving activity more common,” according to Avorn: mandate “Medicare coverage for 2 visits per year with a physician, pharmacist, or nurse for drug regimen review.”
There are other structural changes in health care delivery that would also help alleviate the polypharmacy problem. A move toward accountable care organizations (a strategy encouraged by health reform legislation) that can coordinate the care of elderly patients who see multiple doctors and get multiple prescriptions is one approach. And the move toward electronic health records that can keep track of all a patient’s prescriptions and can generate warning flags to alert doctors to potential counter-indications or side-effects also has the potential to avoid adverse drug effects.
The final solution to this problem is to begin changing how we as Americans view prescription drugs. The use of these medications has sky-rocketed in the last several decades, and has grown especially fast among the elderly since the introduction of Medicare Part D. I wrote about some of the unintended consequences of this new benefit in this recent post. But back in 1995, Jerry Gurwitz, an expert in geriatrics and professor at the University of Massachusetts Medical School was already warning about the adverse effects of too many medications when he wrote, “any symptom in an older patient should be considered a drug side effect until proven otherwise.” Fifteen years later, these important words are still often unheeded. The result is that elderly patients suffer needlessly and we miss a unique opportunity to reduce health care costs while greatly improving quality of care.