Map of life expectancy at birth from Global Education Project.

Wednesday, October 13, 2010

Drowning in pills

I think this link probably won't work for you, although it should get you to the abstract. I can't tell because I'm sitting at an all powerful computer that has JAMA totally pwn3d. Anyway, I'll tell you what it says.

This is physician Michael Steinman and pharmacist Joseph T. Hanlon telling the story of an apparently real 84 year old man with moderately advanced dementia who showed up in Dr. Steinman's office with prescriptions for 13 different medications and 16 doses per day. His wife pretty much had to deal with all this. Dr. S fairly quickly figured out that he didn't need most of it, in fact most of it was doing more harm than good. He was on pain medications that he had been prescribed after surgery, but he didn't need them any more. Once he stopped them, his walking improved and he stopped falling. He was on heart medication that he also didn't need. In fact after he stopped it he started going to the gym. He was on iron supplements. Not needed.

It turns out that older folks are typically taking at least one unnecessary drug. Furthermore, they are often taking medications that might make sense for younger people but are counterindicated in the elderly. They might do well on an alternative, or just be better off with nothing at all. As I believe I have told y'all, my father was twice -- twice -- given antipsychotic medications while he wsa in nursing homes with dementia, which left him a drooling vegetable and threatened his life. This is even though my mother had signed an order forbidding them to give him these drugs, which have a black box warning telling physicians not to prescribe them to elderly people with dementia.

Finally, it doesn't necessarily make sense for people with advanced dementia to be taking drugs for conditions like high cholesterol or diabetes. People and their caregivers need to decide on the goals of treatment and whether there is anything to be gained.

With increasing numbers of prescriptions, not only do we get adverse side effects, a lot of cost, and a lot of hassle, but it also turns out that people are much less likely to follow their scheduled doses -- what we call be "adherent" -- meaning they are less likely to take the pills they ought to be taking.

The mystery is why it's so hard for doctors to figure this out. It requires a major article in JAMA to remind them of something that ought to be a basic part of the repertoire of doctorly skills. Doing this right might not make a huge cost saving but it wouldn't hurt in that department either.

You, as a consumer, need to be very alert to this as well. If you are getting along in years, or have loved ones who are, make sure their doctors review all the medications the person is taking, understand the whys and wherefores of each one, and eliminate any that aren't really necessary or appropriate. It shouldn't be that hard.


roger said...

we must each take responsibility for our own and our family's meds. it's a tough job, but someone has got to do it. both my mother and mother-in-law have been given scrips for useless or contraindicated meds. (blood pressure control and cholesterol control) my mother-in-law suffered increasingly debilitating lupus-like effects from a cholesterol lowering drug until my wife did the research to find out that simvastatin has that effect in some people. and both these women are of a generation that trusts doctors, so it's not easy to convince them that their meds are wrong. in both cases we see doctors handing out scrips for meds instead of explaining that there is really nothing to be done for some problems of aging.

Cervantes said...

Yeah, that's part of the problem -- the culture that it's better to "do something." Often it's better not to.

Anonymous said...

My father died of cancer/various ills/old age at 90 recently, but was compos mentis till his last breath.

All specialists like to write prescriptions within their narrow remit, but they don’t add up to anything remotely sensible or even comprehensible.

The only people who can manage this is the patient himself (provided some determination and knowledge); one family member -- having many of them arguing about Pop’s meds is not only blatantly ridiculous but a trigger for disturbing and counter productive family conflict ending in nutty decisions -- or the ‘generalist’ who is supposed to supervise the whole lot.

One prob I hit was that the ‘generalist’ - an excellent doctor - was nevertheless beholden to his specialist colleagues (who earned far more than he did and whom he relied on) to uphold their recommendations.

I am quite convinced that skipping all the meds except a very few (pain relief, anti coagulant...) not only prolonged my Pop’s life but let him live the time he had left doing what he enjoyed.