Saturday, 17 November 2012

Stop the medication train, the elderly want to get off


Overmedication (“polypharmacy”) in the elderly is a problem. The debate about the appropriateness of individual medications is one thing, but when you are taking 5 or more different medications multiple times per day, the physical act of simply taking the medication is a problem, let alone the adverse effects and interactions of all these medications. So what happens when you stop taking them? You feel better, that’s what happens.

The problem
  • 2/3 of Australians over 60 take 4 or more drugs (here).
  • Prescribing by individual doctors is often done without consideration of drug interactions or the burden of medications from other doctors.
  • Older people are under-represented in clinical trials, meaning that the drugs are prescribed based on assumed effectiveness.
  • This US govt report from 1995 linked unnecessary drug prescribing in the elderly to adverse events, hospitalisations, increased costs and deaths.
  • Adverse drug reactions are more common in the elderly (here).
  • The complexity of drug dose, frequency, interaction and special instructions (before food, with food, after food etc.) makes full compliance difficult and increases the risk of error.
  • 25-40% of elderly patients in the community are prescribed at least one ineffective drug (here and here).
  • While drugs are often commenced, they are rarely ceased. This paper discovered some of the reasons why doctors are reluctant to cease medications.
  • The Drug Burden Index has shown as association between poor physical function and the use of certain drugs in the elderly.

The evidence
This paper showed that applying a protocol to discontinue medications in the elderly showed that most medications could be stopped (an average of 4 or 5 medications per patient). They tried it on a group of 70 patients and found no adverse events, and an 88% improvement in global health. 2% of the drugs needed to be restarted because of a recurrence of the original problem. The same authors published a non-randomised controlled trial earlier in which they reduced as many medications as possible (using their algorithm), resulting in far fewer deaths and nursing home placements. 

And while adverse events can occur after drug withdrawal, most of the time they do not (here). Also, it appears that some drugs are better to stop than others. Most would agree that psychoactive drugs (sedatives, anti-depressants etc) are good to stop as they can reduce falls, but it has also been shown to be safe to stop blood pressure (here) and some cardiac medications. However, this study found a high relapse rate after stopping heart failure medication. This study found that stopping fall-risk-increasing medications reduced the incidence of falls. The clinical studies on this topic have been reviewed here, and it was found that drug cessation was maintained in most cases, without adverse effects, particularly for anti-hypertensives and psychotropic medications. The main reason for failing to stay off the drugs was heart failure. 

So it appears that most medications can be stopped without harm or with improvements, except for some heart failure medications.

Just looking at the high quality studies:
  • This randomised trial showed that it is safe to withdraw psychoactive medication in nursing home patients.
  • This randomised trial showed that stopping anti-psychotic medication in the elderly with Alzheimer’s disease lowered the risk of death.
  • This randomised trial showed that simply getting a geriatrician to review the medications reduced unnecessary medication and adverse events.
  • Even simpler, having a pharmacist review the medications of elderly patients significantly reduced the number of medications taken, and the number of subsequent falls, but not the mortality.

This article here gives good advice on how to stop medications in the elderly, broken down by class of medication.

The bottom line
The elderly are prescribed large numbers of medications, resulting in a significant ‘burden of medication’ from obtaining, paying for, scheduling and taking the pills, as well as increased adverse events and drug interactions, poor compliance, and increased morbidity and mortality. Stopping many or all of the medications appears to be safe and may be beneficial.

8 comments:

  1. A test of physician knowledge of the special medication requirements of seniors found that 70% flunked, as reported in Worst Pills, Best Pills.Perhaps if geriatrics hadn't descended into virtual oblivion as a specialty while our geriatric population has burgeoned we'd have better control of this runaway train of medical malfeasance.

    But where's the money in that?

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    1. Thanks John,
      This problem highlights the (usually ignored) downside of subspecialisation in medicine. As soon as there are geriatricians, then nobody else wants to know anything about treating the elderly - just consult a geriatrician. And if there isn't one around, the patient loses.

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  2. completely agree
    http://www.golinons.com/artistasbcn/polimedicacion.html

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  3. One of the problems I believe is that it some of the medications are used as a form of sedation for people in retirement homes - even with those who aren't ill; and they tend to be brain-deficiency based medicines like donepezil HCl....

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    1. Thanks,
      Yes, sedatives and psychotropic drugs are a problem for the community ambulators as they increase the risk of falls. In nursing homes, they are used to "control" undesirable behaviour. But isn't that the reason for using all drugs treating mental illness?

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    2. Thank you for your reply Dr Skeptic and your informative post,
      I do agree, but what may be classed as "undesirable behaviour" may be more of a cognitive deficiency and less of a mental illness; and I believe in that case, what is required is close monitoring (or even a carer) rather than sedative administration. These are people, not animals and I believe they should be fully assessed before prescribing any drugs

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  4. I am very glad that there are clinicians like you out there who actively speak out about this sort of thing. Thank you for doing so.

    I find that doing a periodic medication audit with my primary physician helps. She has discontinued to drugs that were no longer necessary that I otherwise probably would have been on in perpetuity... and one of them is associated with osteoporosis, so I definitely don't want to be on anything I don't have to be on - say nothing about the unnecessary cost.

    We do periodic diagnosis audits, too. Now that they have an EMR, there almost always are a crap load of diagnoses in the system that are no longer relevant. That's bad news for the other docs I see who are on the same system.

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    1. Good call. I like the idea of going over the diagnostic list in the Electronic Medical Record. I also agree that doctors often disregard the downside of actually taking the pills. Everything from going to the pharmacy, paying for them, checking the times; right down to swallowing them. Most people just don't like taking pills, and that also needs to be taken into account.

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