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Pills, Pills, Pill
By Yau Weng Keong, Star
August 24, 2008
The practice of prescribing too many medications (polypharmacy) to elderly patients has many pitfalls.
NOT too long ago, a doctor wrote about his unforgettable elderly patient who presented to him with giddiness. The patient had a note with a list of drugs, the reason for the drug and by whom it was given. They were as follows:
_Drugs A, B, C and D prescribed by Dr Hart, cardiologist, for heart disease
_Drugs E, F, G and H prescribed by Dr Bone, orthopaedic surgeon, for diabetic foot
_Drugs I, J, K and L prescribed by Dr Glen, endocrinologist, for diabetes
_Drug M was prescribed by all his doctors and he mentioned that it was the most bitter pill to swallow.
Most doctors and patients have been in such sticky situations where polypharmacy (the practice of prescribing too many medications) occurs, with no solution in hand. Elderly patients truly need many drugs as they often have multiple co-existent medical conditions. Sorting out these medical conditions is difficult as they are complex and the symptoms can be hidden, atypical or altered.
Elderly patients have ageing changes which lead to diminished organ reserve (poor adaptation), and this results in vulnerability to diseases and abnormal physiological responses. These aged-related changes sometimes get confused with an actual disease process. Given the difficulties in proper assessment (and correct diagnosis), it is sometimes easier to pacify elderly patients by prescribing drugs rather than engaging in detailed explanation and collaborative decision making about the multiple complex diseases they have.
The decision to not prescribe is a difficult one to make. In many cases, patients are prescribed drugs to console (patients and doctors) plus to “protect” the doctors themselves. Many decisions about medication therapies are frequently made without older patients’ input too. This causes patients to adhere poorly to taking medications, especially those with chronic illnesses with no symptoms, for example hypertension and high cholesterol.
Nowadays, the elderly are getting healthier and they do live longer. The threshold for treating risk factors to prevent diseases is rightly lower. Educated patients will also demand for the latest technologies and newer or better drugs.
Some patients may oppose to the discontinuation of a certain drug even when the drug is clearly unnecessary or the symptoms for which it was prescribed have long since disappeared. Self-medicating, failing to follow prescribed directions, failing to report all drugs (especially over-the-counter drugs), and borrowing or trading medication with other persons worsen the situation. It is common too for Malaysian patients to go doctor-shopping and get advice from traditional healers. This can be potentially disastrous.
Dangers of polypharmacy
Polypharmacy is a widespread problem with many (doctors, pharmacists, patients, caregivers etc) culprits. Still, it is necessary to prescribe as drugs, when prescribed appropriately, will increase quality of life and reduce complications, disabilities and handicapping conditions.
Elderly patients have aged-related decrease in physiological organ reserve, impaired homeostasis mechanisms and chronic illness. This makes them more vulnerable to unwanted adverse outcomes with medications. The more drugs patients take, the greater the risk of unwanted adverse effects, and poorer compliance too.
It will be more costly too and patients may be hospitalised from adverse events. A large proportion of adverse reactions are due to drug interactions, which includes drug-drug interactions, drug-nutrient interactions, drug-alcohol interactions and drug-patient interactions. OTC and traditional medications worsen the problem.
How can we prevent polypharmacy?
Like a good song where there is a need for both good lyrics and music, both the doctors and the patients and their caregivers must perform their roles appropriately. Doctors must always ask themselves the question, “Will this treatment lengthen or improve the quality of this patient’s life?”
The emphasis on treating people and not just managing their “outcomes” or the disease is one of the strengths of geriatric care. Ignoring this puts doctors at risk of “not seeing the forest for the trees!”
Doctors must ask themselves if each medication is necessary or contraindicated and all medications should be reviewed regularly with respect to the indication, therapeutic aims, dose, efficacy, safety and cost.
Coordinate prescribing with other doctors involved in the patient’s care, and if possible, aim for one prescriber per patient. Ask if there is duplication of medications. Always start low, go slow, titrate and get there (optimal dose).
Doctors should also ask if the medication is intended to treat the side-effect of another medication. Consider also if they can simplify the drug regimen; are there potential drug interactions; is the patient adherent and is the patient taking OTC medications, herbal or traditional products, or another person’s medication?
On the other hand, it is the patients and their caregiver’s duty to be educated about their drugs and to inform their doctors of suspected side-effects of any drug. They should ask their doctor why each medication is prescribed and what it is intended to do. Effort must be made to understand when and how to take each medication (with food, on an empty stomach, before bedtime, etc.)
Patients should take their drugs exactly as directed. Find out what they should do if they miss a dose. Go to the same doctor all the time and take a list of all medications and their dosages along for review during each follow-up visit. Make sure labels on medications are read carefully and do flush away any medication that has expired.
Do contact the doctor immediately if there are any problems or side-effects with drugs. Don’t put different drugs in the same container as they do get mixed up and furthermore these drugs can interact with each other while in the container.
Do not stop or alter the way medications (time/dosage) are taken without talking to the doctor. Never share medication with someone else or take other’s medication without a doctor’s knowledge.
Conclusion
Polypharmacy remains an issue, especially for elderly people. Making an appreciable impact on the quality of patients’ lives with small interventions will always be one of the joys of working with older people.
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