Your grandmother fell and broke her hip. A common occurrence for aging adults in America. Just another accident. And yet, you wonder, was it entirely an accident? Could it have been prevented?
Let us consider your grandmother’s medical situation. Like many aging adults she is on several medicines for a variety of medical problems. And it turns out, according to medical experts who have been sounding the alarm recently, she may have, like many in her age group, accumulated entirely too many medications. She got pills from her Family Physician, several more from her cardiologist, another from her orthopedist, another from her chiropractor, another from the urgent care, another over the counter, another from her friend next door. And no-one knowledgeable about pharmacology quite knew just what she was taking. This is quite common; in America today, fully 40% of older adults are on 5 or more prescription medicines, and this can be quite dangerous.
- First, statistically, when you reach the magic number of five medicines, it becomes much more likely that there will be a drug-drug interaction between two of those drugs. Which two is never clear, but the statisticians say that the risk is there.
- Second, many drugs in the elderly have side-effect profiles that include, at times, light-headedness or confusion, both of which increase the risk of falls and fractures.
- Third, aging adults generally suffer from declining excretion of drugs over time. That is, their kidneys and livers, the two major avenues of eliminating drugs from their bodies, lose effectiveness over time. Therefore, a drug that they tolerated last year…they may not tolerate this year.
- Fourth, their capacity for excretion via the kidneys and liver may, with their current load of drugs, be at maximum, so that, should, for any reason, someone decide to add an additional drug, they might easily get into an overdose situation.
For instance, should grandmother go to urgent care and get a new medicine; or decide to take some OTC medicines for a cold; or be given some herbal medicines by a friend to “pep her up.” As you can see, there are so, so many reasons why older Americans might inadvertently take too many medicines, which can cause harm.
Just how big is this problem? A recent review in “Health Affairs” reports that, every day, 750 people over 65 are hospitalized for an adverse drug event; which will result in 150,000 premature deaths over the next decade; costing $60 Billion.
This is a problem deserving of attention from both physicians and patients.
The first step is to become familiar with the Beers criteria (after the geriatrician Dr. Mark Beers), the definitive list of potentially inappropriate drugs in aging adults. This list, put out by the American Geriatric Society and updated frequently, includes many tranquilizers, sedatives, antihistamines, muscle relaxers, anti-reflux drugs, NSAIDS, and some antibiotics. Doctors need to consult this list before prescribing these drugs in the elderly and elderly patients need to cross-check their medicine lists with the Beers list and discuss any drugs found there with their doctors. If a drug must be used that is on the Beers criteria, the patient must be made aware of the potential side effects and should be seeing the doctor regularly to monitor for those side effects.
And for the 20% of elderly patients who are on ten or more drugs, (yes, you read that correctly), there is something called “deprescribing.” Under certain conditions, carefully, and only under medical supervision, some medicines may be deprescribed:
- IF there are adverse effects experienced by the patient that are greater than the benefits
- IF the medicine was for symptoms which are now resolved
- IF the medicine is for prevention in a patient who has a limited life expectancy because of cancer or other severe life-shortening illness
Medicines may be deprescribed with careful monitoring, but only one-at-a-time and, again, only under a doctor’s supervision.
Going forward, and practically speaking, every older patient, at every visit, by every specialty, needs a medicine review, especially if they are on five or more medicines, and this includes OTC medicines and herbal remedies. Medicines that are no longer useful, or that may cause more harm than good, need consideration for being cut out of the list. Granted, this may get complicated when there are several different physicians involved, and this might require some sort of communication back and forth between physicians, or at least between the patient and those prescribing physicians; but how else to prevent needless suffering, hospitalizations, and deaths? And it could just be YOUR grandmother you save.