About a year ago, my mother told my father there was a movie she really wanted to see and suggested they catch it that evening. Great idea — except that, as my dad gently reminded her, they had just seen it.
Though he tried to make light of it, Mom was aware she was becoming increasingly more forgetful, often repeating herself, misplacing things, and neglecting commitments she didn’t remember making. She now found it difficult to carry on a conversation because she was so easily distracted. Most disturbing of all: She was only 61.
“I’m not as smart as I used to be,” she told me recently. Fearing she might be suffering from some kind of early onset dementia, she made an appointment with a neuropsychologist and asked me to go with her.
I suspected another culprit: the potent brew of medications she was taking for the litany of medical problems that has plagued her for years. She consumed so many drugs every day — 21 of them, prescribed to her by five different physicians — that she lugged them around in a toolbox. A partial list: two blood pressure medications, four for asthma, a cholesterol-lowering statin, and several others to treat her diabetes, fibromyalgia, depression, fatigue, and acid reflux. I assumed that my mom’s doctors talked to each other regularly, monitored her medications to prevent interactions, and carefully crafted a treatment plan for her.
How naïve. In fact, the neuropsychologist dismissed outright my suggestion that polypharmacy (the use of multiple meds) might be to blame for Mom’s memory lapses and perhaps some of her other ailments as well. This blithe dismissal irked me, so I did some research on my own.
Here’s what I learned: The use of multiple, often unnecessary medications — especially among older people — is an entrenched, escalating, frightening, and mostly unexamined problem in modern health care. Although medications can ease many conditions, multiple-drug use often exacerbates existing ailments and causes troubling side effects that are treated with yet more drugs. Many doctors, researchers, and pharmacists I talked to agree.
“Overmedication is a true epidemic,” says Armon B. Neel Jr., PharmD, a clinical pharmacist in Georgia who evaluates medication plans for private and nursing home clients. “It’s completely out of hand.”
I also learned that with the help of professionals, Mom could dramatically scale back her prescription drug use and reduce or eliminate the jumble of side effects that was clearly contributing to her downward spiral.
Polypharmacy is most common among people over age 65, about one-fifth of whom take at least 10 medications a week. At least 1.5 million adverse drug events occur in the United States every year, many of which are preventable.
Doctors often mistake symptoms such as memory lapse, fatigue, abdominal pain, swelling, or other ailments as a sign of worsening disease. This can lead to a “prescribing cascade,” says Jeffrey Delafuente, FCCP, a professor of pharmacy at Virginia Commonwealth University. “The solution is to reduce the number of drugs. Adding more just exacerbates the problem.”
Seeing multiple doctors or specialists contributes to that cascade. Primary care physicians are supposed to oversee the management of their patients’ various medications, says Paul Takahashi, MD, a geriatrician at the Mayo Clinic, but unless a new drug is clearly contraindicated, they’re often reluctant to second-guess specialists’ decisions.
The more I learned about the risks inherent in taking a large number of prescription drugs, the more I saw how systemic the problem is. Yet doctors still lack clear, evidence-based guidelines for coordinating medications. “Every physician in the country is seeing these complex patients,” says Johns Hopkins geriatrician Cynthia Boyd, MD, MPH, “but we have a long way to go in understanding how to integrate their care.”
My family started with the basics. One evening, we dumped the pills from my mother’s toolbox onto my kitchen counter and started cataloging them, recording each one’s strength and dosing instructions. We sent this information to Neel, the Georgia consultant pharmacist, for his review, along with lab results, blood pressure and glucose readings, and a description of her symptoms, medical diagnoses, and history.
In the 29-page report Neel sent us a week later, he identified 27 drug interactions among my mom’s medications, most of moderate or high severity. It turned out that seven of her medications — fully a third! — can cause memory loss, confusion, or impaired cognition; others, he suspected, contributed to her chronic cough, fatigue and weakness, and muscle pain. Neel recommended lower dosages of some drugs, taking others at new times of the day, and dropping some altogether.
Of course we were worried. What if we were wrong? Nonetheless, we plunged ahead and booked an appointment with my mother’s internist. To our relief, the doctor said the plan was worth trying. She emphasized, though, that if Mom intended to reduce her use of medications, especially those aimed at controlling cholesterol, blood pressure, and blood sugar, she’d have to exercise regularly and keep a close watch on her diet.
So we left the doctor’s office with a handful of new prescriptions, feeling both relieved and apprehensive. That night, I hammered out a 10-page spreadsheet to help Mom keep track of her new schedule. She now takes six daily medications, plus a few vitamins, and in time may be able to eliminate still more drugs.
A few days into her new regimen, the fog that enveloped my mom’s mind receded and her mood brightened. The asthmatic cough that plagued her for years vanished, and tests showed normal lung function — no asthma after all. Her muscle pain was dramatically diminished. When I asked recently how her acid reflux was, she retorted, “What reflux?”
Five months into the routine, it’s too early to say whether she can keep her blood sugar and cholesterol in check without more meds. Although her cardiologist is satisfied with her blood pressure, her internist is not. If her systolic reading isn’t down to 120 by her next visit, the doctor insisted, “You’re going back on the old drugs.”
This encounter left my mom profoundly discouraged. She still believes she’s better off without the drugs. With the assistance of a credentialed health care provider, she has dedicated months to gaining control over her health. She’s accepted a marginally higher cardiac risk in order to avoid a multitude of symptoms that impeded her quality of life. But her doctor still holds the trump card: She could decline to write the prescriptions that would allow my mom to continue to follow Neel’s recommendations, or even ask her to find another doctor. Afraid she’ll be “fired,” Mom wants to appease the doctor somehow — surely not a solid basis for making medical decisions.
Still, things are looking up. A year ago, Mom was a wreck. Now she’s simply a middle-aged woman who has to watch her blood pressure and her blood sugar. That qualitative shift has given her a fresh outlook. “My life has changed and will continue to,” she confidently declared recently. In the past several months, she has renewed her commitment to controlling her diabetes with a healthy diet and exercise. Last weekend, she and I took an overnight bike trip together.
There was no room on her bike for a toolbox filled with pills — and no need for one. The toolbox is history. CD
Used with permission of Prevention. Copyright 2009. All rights reserved.
Are your meds risky?
A list of medications that are of particular concern for older adults can be found at prevention.com/links.
Are you (or a loved one) in danger?
You should ask your physician or a clinical pharmacist to perform a comprehensive medication review if:
• You take five or more medications, or 12 or more drug doses each day.
• More than one physician regularly prescribes your medications, or more than one pharmacy provides them.
• You take several medications and have had falls, insomnia, incontinence, or changes in mental status; generalized symptoms such as dizziness, fatigue, swelling, or muscle or joint pain; or gastrointestinal problems.
• You start a new medication and a side effect occurs.
To make the most of a review:
• Take notes, ask questions, and (if you’re accompanying an older relative) be an advocate if needed.
• Bring a list of medications, along with their strength and dosage. Include OTC drugs, vitamins, and supplements.
• Explain that you would like to consider reducing or simplifying your or your parent’s medications. List your specific concerns — potential side effects and interactions, or the impact of drugs on quality of life. The physician should respect your concerns and goals; if not, get another opinion.
• Ask whether any of the medications are ineffective, unnecessary, or potentially dangerous.
• Inquire about changes in exercise, diet, sleep, or stress management that might enable you to reduce medication.
Let a pharmacist help
The American Society of Consultant Pharmacists, a professional association of clinical pharmacists who specialize in geriatric pharmacology, provides an online national directory of consultant pharmacists (learn more at prevention.com/links). Consultation costs generally range from $100 to $150 per hour.