Overprescribing common among elderly

Some healthcare professionals see this as a serious problem

DRUG BUST by Alan Cassels

• If you plan on getting old, or are looking after someone who is old, you need to be ready for one stark reality of medical care in the elderly: it involves a lot of drugs. Anyone who looks after senior citizens says the same thing: any new ache, pain or concern often means a new prescription. What’s a trip to a specialist without a few new prescriptions added to your daily regime? And a stint in the hospital? If that doesn’t end in a bunch of added medications too, then something seems wrong. They all add up, sometimes horribly so.

Over the last 20 years or so, I’ve spent a fair amount of time researching the relentless marketing of pharmaceutical companies that are driving so much of the overdiagnosing and overprescribing, but lately I am starting to sense a growing uneasiness among health professionals. In fact, physicians groups, medical directors in seniors’ centres and individual doctors are starting to get serious about the problems of too much medicine. They are initiating medication reviews and ‘deprescribing’ programs, recognizing that polypharmacy – the use of multiple drug prescriptions – is a serious problem in the elderly. But I’ve also discovered that anyone trying to change attitudes towards overprescribing faces many obstacles.

As prescribers, physicians may be reluctant to stop a patient’s meds because they don’t want to contradict an order by a specialist, even if the patient is obviously not having a good time with their new drug. Because patients often have multiple doctors treating them, sometimes your doc won’t know why someone prescribed a particular drug to you in the first place. Perhaps they don’t have the time or energy to go through your entire list of medications to eliminate the ones that don’t seem that helpful or that are possibly dangerous. Things might seem overwhelming, but I’ve met many doctors who want to get things back to the basics, especially when they see intolerably large drug regimes burdening their older patients.

Starting a new medication is like the bliss of marriage; stopping it is like the agony of divorce. Surprisingly, stopping drugs is difficult even when the patient is experiencing adverse effects or when there is zero rationale for the person to continue taking some medications. Don’t believe me? I learned recently that a fair proportion of seniors in palliative care – those given ‘end of life’ care – are still taking statins to lower their cholesterol! That’s right – it’s as if these dying people were enrolled in the “he who dies with the lowest cholesterol wins” contest.

I’m learning there is considerable emotional stress when it comes to taking away medicines because drugs are imbued with a certain symbolic significance and prescription writing is a powerful ritual. Does stopping them signal that your doctor has given up or that your health isn’t worth preserving? Even in studies of patients who think they are on too many medications, patients say they are reluctant to ask their doctors for fewer drugs because they don’t want to anger them or appear difficult. This means some people take drugs just because they don’t want to displease their doctor. If the doctor doesn’t engage the patient and find out what is important to him or her, the miscommunications can fuel an unending supply of useless and potentially harmful drugs.

No one knows this better than a local BC expert in ‘deprescribing,’ a Vancouver doctor named Rita McCracken who is making a name for herself in this field. She is doing original research on deprescribing as part of a PhD program at UBC and spends a lot of time tending to frail, elderly patients and taking a scalpel to their medication regimes. She talks of the simple mathematical reality of prescribing in the elderly, where the chance of something bad happening increases exponentially as you keep adding new medications.

The intuition that doctors like Dr. McCracken work with is grounded in the imminence of death. She sees that one of her major tasks is to discover her older patients’ goals and try to translate those into making the patient comfortable and maximizing their ability to function. Again, there is no pill for being old and to better meet those goals, it usually means subtracting a lot of unneeded medicine.

People who talk about prescribing in the elderly call it an “evidence-free zone.” The reality is that most of our widely used drugs are tested on younger people with single diseases like high blood pressure and then get used on older people who might have a whole host of conditions such as arthritis, dementia, gout and high blood pressure. “You see,” Rita McCracken explained during a lecture I attended in Vancouver in April, “frail elders are typically excluded from most trials and therefore the clinical guidelines don’t really apply to these older people.” Then what do you do?

Actually, blood pressure makes a very poignant example of the kind of care the elderly can often be subject to. Many older people are on multiple antihypertensive drugs – drugs to lower blood pressure – sometimes two or three of them to drive down their blood pressure to a level that might make some sense if the patient was 40. The problem is that trying to get blood pressure that low for someone who is 80 is almost totally irrational. Why? Because the physiology of old people is different and most blood pressure studies have specifically excluded people aged 80 and over. Those few studies that have focused on the elderly find something terribly surprising: the patients in the trials who had lower blood pressure had a higher risk of death.

Overprescribing of antihypertensives in the elderly is a concern to Dr. McCracken not just because the evidence suggests it might be counter-productive, but also because the quality of life of the person with low blood pressure could be suffering. In the talk I attended, she spoke about one study done in Florence, Italy, that found a lower daytime blood pressure was associated with “accelerated cognitive loss,” probably the last thing you want to cause by chasing lower blood pressure targets.

Dr. McCracken is going to see if there is good evidence to support the link between low blood pressure and dementia. Now, wouldn’t that be something if we discovered that, in our aggressive attempts to lower grandma’s blood pressure, we’re causing her to lose part of her memory and thinking abilities?

At the end of the day, if you are old or are concerned about an older loved one, you have to stay engaged and make sure the doctor is aware of your goals. You have to communicate your needs and be clear about your preferences. If you think you’re taking too many drugs, you could be in luck because the doctor might have been waiting for you to initiate the ‘deprescribing’ conversation. This is the time for frank conversations and truth-telling. In the words of Dr. McCracken, speaking to her fellow doctors, “We have to be honest about the quality of evidence and what a patient can expect from a pill.”

There is no magic pill to treat frailty, but there might be a magic word – and it’s called deprescribing. It might be worth asking your doctor if you are ready to take that concept for a test drive. Stopping a medication does not have to be like the agony of divorce. Maybe like any other transition in life, it’s all about moving on to a better place.

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Alan Cassels is a drug policy researcher at the University of Victoria. He writes about medical screening and drugs, consults with unions on drug benefits plans and is helping research tools to make deprescribing easier for physicians. You can read more of his writings at www.alancassels.com or follow him on twitter @akecassels