Too may older adults are taking medications where the likely harms outweigh the potential benefits. Is it time to start ‘deprescribing’?
Delon Canterbury, a pharmacist based in Durham, North Carolina, witnessed first-hand the harm some medications can do. His grandmother, in her 80s and suffering from dementia, was rapidly declining. She became more withdrawn and irritable, and frequently misplaced items like her glasses and dentures. Her condition forced her to leave her nursing home and move in with Canterbury’s mother.
During a routine prescription refill, a pharmacist warned Canterbury’s mother that one of the medications, an antipsychotic drug, was exacerbating her mom’s dementia symptoms. “This medication comes with a Food and Drug Administration black box warning — the most serious kind of warning for any drug.” It indicates that for dementia patients with behavioral problems, this drug can not only worsen their condition but also increase their risk of death.”
Patients like Canterbury’s grandmother aren’t unique; they highlight the risks of overmedicating, particularly among older adults. A significant portion of the population takes multiple medications, a practice known as ‘polypharmacy’ — in Europe, polypharmacy rates among people ages 65 and older are between 26 percent and 40 percent; nearly 20 percent of Canadians aged 40 to 79 use five or more medications a month; 49 percent of Indians aged 60 and above, and more than a third of Australians over 70 experience polypharmacy.
“The average number of meds that my patients take in internal medicine is 10, and that has increased just in the last 10 years. I’ve seen that number go up, and up.”
In other countries, too, pharmacists and researchers are trying to contain a worsening problem. In long-term care homes in Australia, 90 percent of residents take at least five regular medications every day. Working as a pharmacist in the geriatrics ward of a major hospital in Adelaide. Encountered patients daunted by their extensive daily medication routines.
“Often, they’d joke about it, saying things like, ‘I take so many pills I rattle when I walk.” Patients might start their day with a heart medication, follow up with one or two pills for blood pressure, add in medications for diabetes and a vitamin supplement, and by the end of the day take something for joint pain or insomnia.
Some of the medications might be unnecessary or even detrimental to her patient’s health. And recent research backs that up. 37 percent of prescriptions for older adults worldwide are potentially inappropriate. A presentation by the World Health Organization said that medication accounts for 50 percent of avoidable harms in medical care.
Adverse reactions connected to the simultaneous use of numerous medicines are behind one in six hospital admissions, and in the US, the Lown Institute believes that overmedication will lead to more than 1,50,000 early deaths and 4.5 million hospital admissions from 2020 to 2030.
For decades, the healthcare industry has favored increasing rather than reducing prescriptions, but a powerful shift is underway. A united front of doctors, pharmacists and nurses is pioneering the deprescribing movement, which is dedicated to reducing medication use safely and effectively, marking a profound change in patient care.
TOO MANY PILLS:
Overprescribing leads to several problems. First, people who take too many medications, especially older adults, are at a higher risk of side effects that can range from uncomfortable to severe. This is because as we age, our bodies process drugs differently, making us more sensitive to their effect.
Secondly, prescribing can snowball overtime. Initially, a new medication might be exactly what’s needed, but as we develop new health issues, more medications are added. Sometimes, new drugs are prescribed to manage the side effects of previous ones. Before long, “you could be on 10,15, 20 medicines.” Some patients feel that managing their medications has become a job — one they didn’t apply for.
Complicating matters further, randomized control drug trials are generally conducted on healthier and younger people who aren’t taking other drugs. Equally problematic, multiple specialists might prescribe medications without a coordinated approach. Experts say prescribing should be a partnership between patients and healthcare providers, to ensure that as patients age, the medications remain appropriate and effective.
Nearly all medications, including those for critical conditions like diabetes or high blood pressure, should be regularly reviewed and adjusted, even if not entirely stopped. “There’s no medicine that doesn’t have any side effects. It’s all about balance.”
Medications should be prescribed when the potential benefits are greater than the dangers. This is especially true when serious conditions are involved, such as preventing strokes or treating cancer. For instance, while chemotherapy can cause harsh side effects, not treating cancer could lead to even more severe outcomes.
Overprescribing for chronic and serious conditions is a big problem. As people age, treating high blood pressure too aggressively, for example, can push it so low that patients become vulnerable to dizziness and falls, which can cause the sorts of injuries that hasten death in the elderly.
Some of the most overprescribed drugs are opioids and sedatives such as benzodiazepines. While crucial for managing severe and acute pain, opioids carry risks such as dependency, decreased cognitive and motor function, and increased likelihood of overdose, especially when patients are on higher doses.
The consequences of overprescribing, whether it’s seniors falling and breaking hips coming in confused and delirious, or not being able to return home to look after themselves.
“It’s no wonder that people are falling and losing their memory, the capacity to drive and their autonomy. It’s just so striking that this is preventable.”
The more medications you’re on, the greater the chance they won’t work well together. This can make them less effective or cause negative, sometimes dangerous, reactions. Taking multiple medications also makes it harder to keep track of how well they are working and when to take them. The more medications a person is prescribed, the higher the change that they will keep taking unnecessary medications and that they will miss taking essential ones.
The cost of taking multiple medications adds up quickly — not just the price of the drugs themselves but also the extra doctor visits or treatments needed to manage side effects or interactions between drugs. Even over-the-counter-drugs, like vitamins, supplements or painkillers, add to the risks and costs. For example, taking blood thinners and non-steroidal anti-inflammatory drugs (NSAIDs) pain relievers can increase the risk of serious bleeding. Or combining blood pressure medications, such as ACE inhibitors, with a potassium supplement can cause heart rhythm problems.
QUICK-FIX MEDICINE:
Overprescribing happens for several reasons, according to experts, including the quick-fix nature of our healthcare system, where doctors prescribe medication for almost any complaint, form insomnia and anxiety to acid reflux.
Patients might continue with medications simply because they don’t know they can stop, or because doctors assume that they prefer to keep taking them. After all, medical school focuses on putting people on medications, not taking them off. “We have a pill for every ill. It’s a lot faster, unfortunately to prescribe a pill than to explain to somebody why it might not be the best option.”
Additionally, in areas that don’t share that don’t share medical records, the lack of communication among providers can obscure the full picture of a patient’s treatment. Drug marketing can also play a big role , overselling the benefits of medications and influencing patients to ask their doctors for more prescriptions.
DEPRESCRIBING SAFELY:
Experts stress that no one should stop taking medications without talking to a healthcare professional. But instead of starting with “Which medication should I take? “Is this medication really necessary?”
This reframing is at the heart of a growing movement among doctors, pharmacists and researchers to turn the tide on overmedication, and Canada is leading the charge.
Deprescribing.org developed evidence-based guidelines for deprescribing different classes of medications, from heartburn treatments to benzodiazepines. The easy-to-follow guidelines are being used in studies and clinical practice worldwide, including Europe, South America, and Asia.
Canadian researchers are also introducing advances in patient education. In two clinical trials, called EMPOWER and D-PRESCRIBE, patients were given pamphlets explaining how to safely discontinue unnecessary medications and engage their healthcare providers about starting the process. These materials are now being used in the European Union.
“In the EU, we still have a much higher diversity between countries, and so one of our challenges is also to adapt what we do to the different national contexts.”
Universities and researchers in the EU, Switzerland, and Canada are collaborating on a project called BE-SAFE, to reduce the overuse of sleeping pills among older adults. “Patients underestimate the risks of medications.” The Danish Health Authority recently launched a national campaign to teach patients that many medications shouldn’t be taken for life.
“Seeing and learning about many of them struggled with their medication — being unsure about the appropriateness of it, communicating with healthcare professionals about it — made me interested in ways to optimize medication use, including deprescribing.”
Some patients have to be convinced to stop taking medications . “People might assume that their doctors are fully aware of all their medications and have rigorously gone through gone through them and confirmed them as being appropriate and still needed.”
“But despite clinican’s best efforts, that’s often not the case. And that’s why it’s so important for people to ask their healthcare providers about each one.” Instead of trying to raise these questions during an unrelated visit, he adds, you should consider booking a separate appointment.
Deprescribing Advocates are heartened to see pharmacists leading the movement. After the community pharmacist insisted that DeLon Canterbury’s grandmother discontinue her antipsychotic medications, she was able to return to a nursing home, where she she lived well until at the age of 90 years. “It really struck a chord with us as we were trusting the doctor, trusting the health care system and trusting the medicine to help her get better, but it ended up with the pharmacist is advocating for us.”
The experience showed him that people need the right care. “Unfortunately, we attribute a lot of issues to ‘Oh, Grandpa is just getting old,’ but those are inherently against remarks and we have that in our medical system. We attribute a lot to just ‘he/she’s old’ and This is normal’. It’s not normal.”
By advocating for thoughtful prescribing practices, healthcare providers like Canterbury want to make each prescription not only necessary, but also effective and safe.”
