Miriam E.Tucker
Overmedication in the Elderly
(The Washington Post, February 6, 2001)
In 1999, the 83-year-old Maryland woman wound up in the hospital after a particularly bad asthma attack. She'd quit using her inhaler, since it made her nauseated. While in the hospital she was given powerful steroids to treat her asthma. These raised her blood pressure. So she was given an antihypertensive drug. It made her dizzy. When her ankles swelled, she was prescribed a diuretic to reduce water retention. But that dropped her potassium level. Naturally, potassium supplements were added. She was also given an osteoporosis drug. This made her stomach bleed.
"I came out sicker than I went in," says the grandmother, who was willing to tell her story but asked her name not be published.
She was so sick, in fact, that she couldn't care for herself after getting out of the hospital and had to stay with her daughter. When she became depressed, an antidepressant was added to her regimen. Then came another drug for stomach acid.
"I see this all the time," says pharmacist Art Weinstein, owner of the Medical Pharmacy of Chevy Chase, who eventually helped the woman reduce the number of drugs she was taking and return to independent living. "You don't know whether you're sick because your condition is worse or because your medicine is making you worse."
Medicines save lives, but few are completely free of risks or side effects. The more drugs that are taken together, the greater the risk for side effects and interactions. The Maryland grandmother's troubled relationship with her medications is far from unique. In fact, it's common enough that experts have even given the phenomenon the requisite Latinate label that confers official status in the medical world: polypharmacy.
The term describes cases in which patients are prescribed many different medications, often by different doctors, for a succession of conditions or for side effects created by other medications. Polypharmacy has been committed when the conditions can be effectively treated with fewer medications.
Weinstein routinely counsels customers about their drug regimens. Often, by looking carefully at what medicines they're taking and for what conditions, he can suggest better alternatives. Sometimes a newer drug with multiple actions can be substituted for two or more older drugs. Or a medicine that causes a bad side effect can often be exchanged for one that doesn't, so the patient no longer needs another drug to treat the side effect.
Weinstein estimates that he can help cut the number of drugs a patient is taking as much as 50 percent of the time. "Therapy changes as time goes on. A person may be on something and feel they're doing okay, so they keep taking it [because] they don't want to rock the boat. But sometimes less is better."
Polypharmacy is more commonly seen in older people, who tend to have more chronic conditions that call for drug treatment. At the same time, aging changes the body's ability to tolerate and process medications: Muscle tissue and fluid levels decrease, fat tissue increases, liver mass diminishes and kidney function declines.
Persons aged 65 and older constitute approximately 13 percent of the U.S. population, but they take about one-third of all prescribed drugs. The typical senior citizen regularly takes four to six prescription drugs, plus a couple of over-the-counter preparations. Nursing home residents typically take more.
"Statistically, if you take six different drugs, you have an 80 percent chance of at least one drug-drug interaction. With eight drugs, the chance is 100 percent," according to Wayne K. Anderson, dean of the School of Pharmacy and Pharmaceutical Sciences at the State University of New York at Buffalo.
There is no magic number of pills that constitutes poly- pharmacy, says geriatrician Samer Nasr, associate chief of staff for extended care at the Department of Veterans Affairs New Jersey Healthcare System in Lyons and East Orange. But "if you feel you are taking too many drugs," Nasr says, "you should probably have your drug regimen checked out."
No advocates of reducing medications suggest that people just stop taking their prescribed medications or attempt to adjust their regimens themselves. Proper adjustments require the efforts of a physician and pharmacist working together.
Recently, a man who appeared to be in his sixties came into Weinstein's pharmacy with a pill he'd been taking daily for several weeks. The man had no idea what it was or why he was taking it. His new physician, whose office is in the same building as the pharmacy, didn't recognize the pill, so he sent him downstairs to ask Weinstein what it was. It turned out to be an anti-diarrhea drug that the man no longer needed.
"The physician will often simply write 'take as directed,' and the patient has no idea why he's taking it," says Weinstein.
According to Anderson, polypharmacy often happens when a patient sees more than one physician, each of whom prescribes medications that interact or overlap with those another physician has prescribed. "Often there's no one person charged with the responsibility of overseeing the patient's total drug therapy regimen," he says.
Nasr says that some of the most dangerous drug-drug interactions occur when patients take over-the-counter medicines along with their prescription drugs. For instance, nonsteroidal anti-inflammatory agents like ibuprofen can cause bleeding ulcers when taken with more powerful prescription painkillers. Combining ginkgo biloba, an herbal product promoted to improve memory, with blood-thinning drugs like aspirin or warfarin also can lead to severe bleeding.
"People often assume that over-the-counter drugs are safe. They forget to tell their physicians about them," says Nasr.
Of course, prescription drugs also interact with each other. The antibiotic erythromycin, for example, can lead to a toxic reaction when combined with certain cholesterol-lowering drugs, potentially leading to kidney failure.
Pharmacy computers will flag many potential prescription drug interactions, but not if the patient fills prescriptions at different drugstores or has an unusual reaction. Moreover, computers can't address the complexity of interactions among six or eight different drugs, Anderson notes.
And older people may not complain, assuming that feeling bad is an inevitable part of aging, or a symptom of the condition for which they are being medicated. The Maryland grandmother didn't mention her medication concerns to her physician because "I didn't want to noodge him."
According to some estimates, as many as one-fourth of all nursing home admissions and an even higher percentage of hospitalizations among the elderly may be due to "preventable drug therapy failures," resulting from adverse reactions or interactions, noncompliance or use of medications inappropriate to the patient's condition.
The solution, Anderson believes, lies in a group of professionals who specialize in drug therapy: pharmacists. He has initiated a new program in geriatric pharmaco- therapy at the University at Buffalo that trains pharmacists to work with older patients to improve their drug regimens.
Anderson's efforts reflect the movement of his profession toward positioning itself as a cost-effective player in today's healthcare market. At least two organizations representing pharmacists -- the American Pharmaceutical Association and the American Society of Consultant Pharmacists -- have been lobbying for the inclusion of medication management services by pharmacists in any outpatient drug benefit that is part of a new Medicare reform package.
Nasr agrees that pharmacists can provide an important service. "Clinical pharmacists certainly do have a lot of skills to bring to the table. There is a big need, because doctors don't have a lot of incentive to work with the elderly. The reimbursement [under Medicare] is so bad." But, he adds, "They can't replace the advice of a physician."
Pharmacists will not tell patients to stop taking their medicine. But they can alert the physician about potential problems and make recommendations. "Think of your pharmacist as your drug advocate," Anderson says.
Anderson believes that universal adoption of such services by pharmacists nationwide not only would dramatically improve quality of life among seniors, but would save billions of dollars in healthcare costs. "The positive outcomes could save more than the total costs of the drugs themselves. When you look at the whole person in terms of unscheduled doctor visits, emergency room visits and hospitalizations, the costs are much lower with pharmaceutical therapy management than without it."
The problem is, with a few exceptions, pharmacists don't get paid anything extra for such services. Insurance companies typically reimburse pharmacies for dispensing, but not for clinical or administrative services, says Phillip Schneider, spokesman for the National Association of Chain Drugstores.
Although pharmacists routinely answer customers' questions about medications as part of their jobs, in-depth consultations may be difficult to schedule in busy drugstores where the dispensing volume is high. "It's best to call ahead for an appointment," Schneider recommends.
Weinstein, an independent pharmacist, has been counseling customers about their drug regimens for three decades free of charge. "It's a goodwill gesture. You hope the patient becomes your patient." Of course, he wouldn't mind getting paid for his advice. "Our time is worth money. If we can show insurance companies that we save them money, they will pay us as consultants."
But that might be tricky. Bruce Stuart, director of the Peter Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy in Baltimore, notes that very little research has been done on the financial impact of programs aimed at improving drug therapy in the elderly and that it is impossible to eliminate all drug reaction and interaction problems.
Moreover, "The savings from eliminating inappropriate drugs must be balanced against the cost of therapies that replace them," says Stuart, an economist.
For the Maryland grandmother at least, the cost savings were obvious. Her monthly drug bill dropped from about $250 to $60 after Weinstein helped pare her daily regimen to just two asthma inhalers, a diuretic and a new blood pressure drug that doesn't make her dizzy. Instead of taking potassium pills, "Now I just eat bananas."
But that extra $190 a month is minuscule compared with what was saved by keeping her out of a nursing home. "Now I'm self-sufficient. I clean, I shop, I do everything," she says. "I feel as well as before [the hospitalization], maybe better. I'd be very unhappy if I hadn't met Mr. Weinstein." ###
Postscript: Arthur Weinstein was convicted of felony Medicaid fraud in 2006