The problem of polypharmacy, as the multitude of drugs is called, and the side effects they cause is largely a result of our fragmented health care system, rushed doctor visits, and direct promotion of drugs to patients who are ill equipped to make rational decisions about what to take, what not to take, and when.
This means it is often up to patients and their caregivers to assure that minimum risk accompanies whatever medications or remedies may be prescribed or taken on their own. Even when older patients are discharged from the hospital to a skilled nursing facility, one study found they were prescribed an average of 14 medications, one-third of which had side effects that could worsen underlying conditions common among the elderly.
The complexity associated with the use of multiple medications frequently results in patients failing to follow medical instructions accurately or not taking recommended drugs at all.
The elderly are particularly vulnerable to polypharmacy and a too-frequent consequence known as a “prescribing cascade” — in which still further medications are prescribed to treat drug-related side effects that are mistaken for a new medical condition.
One common example is the use of anti-Parkinson therapy for symptoms caused by antipsychotic drugs, with the anti-Parkinson drugs in turn causing new symptoms like a precipitous drop in blood pressure or delirium that result in yet another prescription.
Further contributing to this problem is the fact that doctors do not routinely question patients about their use of nonprescription remedies, and patients rarely volunteer this information unless asked directly.
Consumers typically decide what supplements to take based on internet postings or advice from friends. Yet one review of 338 retail websites for the eight most widely used herbal supplements revealed that 80 percent made at least one illegal and unsubstantiated health claim, with more than half suggesting that the substance could treat, prevent or even cure a specific condition.
Even doctors who are well-informed may have difficulty determining the best or safest medications to prescribe for their elderly patients because most of the studies done to gain marketing approval deliberately exclude older people or those with an unrelated chronic health problem.
Thus, prescribing doctors may not know if the drug they order is safe for patients with, say, kidney or liver impairment who may require a lower-than-usual dose or a different drug entirely. A good drug that is not appropriately prescribed could be worse than no drug for patients.
Medical judgment is often required to enhance safety. To foster compliance with prescribed remedies and minimize the risk of side effects for older patients who require multiple medications, doctors may choose to “underprescribe” and prioritize treatments for serious conditions already diagnosed over preventive therapies for conditions with a less immediate impact on patients’ quality of life.
On the other hand, some drugs prescribed years earlier may no longer be necessary and can be safely discontinued. The patient, for example, may now have a short life expectancy that renders pointless a preventive medication taken to lower cholesterol or increase bone density. However, it is important to gradually taper many drugs to avoid dangerous symptoms caused by an abrupt withdrawal.
Affordability is yet another consideration. Even with insurance coverage for prescription drugs, many newer, more effective medications involve co-payments that strain the budgets of the elderly. Patients may decide to skip doses or cut drugs in half to make them go further, and in doing so render them less effective or ineffective.
Changing one’s habits and lifestyle may be a more effective way to save money and, at the same time, prevent adverse drug effects. For example, patients who lose weight and reduce their sodium intake may be able to avoid or discontinue medications taken to lower blood pressure. Likewise, drug therapy may become unneeded by those with Type 2 diabetes who adopt a Mediterranean-style vegetable-rich diet, lose weight and exercise regularly.
As many as one in five adverse drug reactions among older patients who live out in the community result from mistakes made by the patients themselves, especially if they take three or more prescribed medications. To minimize this risk, experts recommend that patients maintain an accurate list of all their medications that includes what the various drugs are supposed to treat, their generic and brand names, dose, frequency and method of administration.
In addition, patients should keep a list of all over-the-counter remedies and supplements they take regularly or frequently. Then, at each medical visit, bring both lists along and make sure the doctor reviews them.
If list-making is more than the patient can handle, another option is to do a “brown-bag checkup,” in which the patient brings all pill bottles they are taking to each visit. And always keep all medications in their original containers with attached labels that may include cautions like “take with food” or “take on an empty stomach,” which means taking it at least one hour before or two hours after eating.
For patients unable to reliably self-administer needed drugs, medication organizers available in every pharmacy can be filled by a caregiver or family member according to the day or time the drugs should be taken. For those who have trouble swallowing a prescribed drug, ask the doctor if there is a smaller or liquid alternative or if it can be safely dissolved in water or crushed and mixed in food.
The National Institute on Aging cautions against taking medications in the dark, taking drugs prescribed for someone else or mixing medications with alcohol. The agency has created a helpful work sheet, Tracking Your Medications, available on its website.
This is the second of two columns on drug side effects. The first is here.