Alan Cassels: Countering the over-medication of seniors

The case of too much medication in Canadian seniors is finally starting to be recognized for the serious problem it has become.

Seniors are particularly vulnerable to the adverse effects of too many prescription drugs, because aging affects their ability to process medications. Working aggressively to reduce their daily medication burden might be the single best thing we can do to improve their quality of life.

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The statistics behind polypharmacy in the elderly — the term that describes the simultaneous use of multiple medications — are surprising. In Canada, nearly 70 per cent of all seniors take five or more drugs, and almost 10 per cent take 15 or more.

Many hospitalizations in the elderly are caused by adverse medication reactions, according to several recent studies. And one of the biggest health hazards for seniors is falling, often a result of multiple medications that can cause cognitive difficulties and affect balance.

The good news is awareness of the scale of the problem is growing. More and more physicians are initiating “deprescribing” discussions with their older patients.

“Deprescribing” is exactly how it sounds — the deliberate and conscientious stopping or tapering of prescriptions to help improve health outcomes.

Some long-term-care facilities are now required to do periodic medication reviews and weed out unnecessary, ineffective or hazardous pills. A massive Canadian Foundation for Healthcare Improvement demonstration project has shown how to reduce the inappropriate prescribing of antipsychotic medications to seniors with dementia.

Programs, research initiatives and physician-education activities on deprescribing are being carried out in most provinces. Canada’s new Deprescribing Network is developing tools and information to help make deprescribing commonplace and part of the prescribing culture.

This is all a step in the right direction. Unfortunately, there’s still reluctance in some quarters to cut back on medications.

Some health-care providers have shown themselves to be nervous when initiating deprescribing activities, worried that they are reducing medications that specialists or other doctors have ordered. Publicly funded “medication reviews” conducted by pharmacists can be flawed too, a CBC Marketplace investigation has found. Some reviews might be motivated by potential business reasons, resulting in more, not fewer, pills for patients.

The same report noted that even when done properly, medication reviews often miss the patients who would benefit most, such as the elderly or people on a high number of medications.

More than 90 per cent of seniors say they want to reduce their medications if a doctor suggests it. And who can blame them? No one wants to be on a potentially expensive medication with possible side-effects and possible risks if they don’t absolutely require it.

So what should be done?

Consumer-oriented literature on medicine tends to focus on “adherence” and “compliance” to medications, and not necessarily more appropriate drug treatment. And we can’t forget that pharmaceutical manufacturers have a business incentive for volume and are not rewarded for appropriateness of prescribing.

Fortunately, the folks from the Canadian Deprescribing Network have identified a few areas where they see the harms of drugs often exceeding the benefits. These include, but are not limited to, benzodiazepines and other sedative medications (commonly prescribed for sleeping), proton pump inhibitors (to treat ulcers and heartburn) and sulphonylureas(to treat Type 2 diabetes).

Drugs that can be problematic in combination with other medications include those that treat blood pressure and glucose, where high doses of multiple medications can lead to problems. They also flag the overuse of blood thinners, which require appropriate monitoring. According to the network, these are good places to start a consultation with your doctor.

Before joining the deprescribing revolution, have a conversation with your doctor or pharmacist, who will be able to help you decide if you are on the appropriate medications, which medications could be safely reduced or eliminated and how to do so.

As people get older, they should constantly ask if a new medication is going to affect the things that are important to them: their mobility, cognitive abilities and capacity to enjoy life.

Caregivers and seniors, most importantly, have to be ready to assert their wishes when it comes to taking too many medications and always be alert to the possibility that more medication might mean more problems.

 

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria.

cassels@uvic.ca

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