Older patients may face risks from taking too many prescription drugs: more doctors push to deprescribe
Wednesday, October 19, 2016

Your doctor wants you to stop taking so many medications. More health-care providers are adopting an approach known as deprescribing to help adults in the U.S. and elsewhere reduce excessive use of prescription drugs and over-the-counter medications and supplements.

Studies show nearly 40% of older patients, those in their 60s and older, take more than five medications. Doctors conduct comprehensive medication reviews, using screening programs to identify possible side effects and interactions, then wean patients off drugs that are unnecessary or where risks outweigh benefits.

“What was good for you once might not be as good for you now,” says Cara Tannen­baum, a geriatrician and the scientific director of the Institute of Gender and Health at the Canadian Institutes of Health Research in Montreal. “On a regular basis, patients should be asking their health-care providers, ‘Is this still the right drug for me, and if not, what other drug or non drug therapies are safer and equally effective?”

Dr. Tannenbaum and pharmacist Barbara Farrell have developed a website, deprescrib­ing.org, which is maintained by the Canadian Describing Network, a group that includes health professionals, policy makers and patient advocates. The site, used by doctors in both the U.S. and Canada, provides information to help patients determine if they should consider stopping certain medications that may be unnecessary or cause harm, including a common medication for heartburn or reflex called a proton pump inhibitor and certain diabetes drugs that increase the risk for low blood sugar.

Medication use can start to pile up in middle age or earlier, especially in patients being treated for diabetes, heart disease or cancer. People may see different doctors who don’t coordinate care with each other. Soon, they are in a situation known as poly pharmacy, defined as five or more drugs.

The body processes many drugs less efficiently as it ages, leading to problems with long-term medications. Statins, prescribed to control cholesterol, may not be needed over age 75, and they can cause muscle weakness and increase the risk of falls.

After a major medical setback, even young patients may have little choice but to take multiple medications.Janice Taylor, 57, had a stroke in 2011 and a heart attack in 2014. She has had to take about a dozen medications, with side effects including fatigue, nausea, dizziness memory and judgment issues.

THE INFORMED PATIENT 

“A lot of things I take are necessary, but quite often my doctors and I sit down and look over everything,” says Ms. Taylor, who volunteers for the American Heart Association and is a facilitator for a stroke support group in Virginia Beach, VA. Ms. Taylor says doctors changed her blood-pressure medication, which was causing her pressure to fluctuate, to a combination of two drugs that stabilized her condition without heavy side effects. She also has stopped taking powerful prescription medications for migraines, which were giving her hallucinations, substituting an extra-strength over-the-counter medication. She is also now taking a third of her original dose of a muscle relaxer, prescribed after her stroke for involuntary muscle contractions.

To manage multiple side effects, she divides her drug regimen into morning and evening, and times her meet­ings around hours of the day when she isn’t feeling the effects as strongly. And she is vigilant about exercise, rest, meditation and a nutritious diet to keep up her strength.The American Geriatrics Society last year updated its Beers Criteria, a list of 40 medications or classes of drugs that are potentially inappropriate for older adults. An expert panel is working on an update for 2018.

Last year, after reviewing 6,700 research studies, the panel added three new drugs and two new classes of medications to warning lists for older people. The website HealthinAging.org lists 13 potentially dangerous drug combinations, medications older adults should avoid or use with caution and suggested alternatives.

Michael Steinman, co-chair of the Beers panel and a professor in the division of geriatrics at the University of California, San Diego, cautions that regimens have to be tailored to individual patients. “We don’t know in advance if a patient is going to have side effects, and some drugs are more effective on certain patients than others, ” Dr. Steinman says.

What was good for you once might not be as good for you now,’ a doctor says.

A study led by Dr. Tan­nenbaum, published in JAMA Internal Medicine in 2014, found that directly educating older patients about risks of sedative overuse led them to consult with a doctor or pharmacist, with 27% discontinuing the drugs.

Doctors have new warnings about widely prescribed proton pump inhibitors. Studies show a link between the medications and an increased risk for bone loss, fractures and serious bacterial infections. They can also change the way other drugs work, such as reducing the effect of blood thinning drugs and increasing the risk of heart attack and death.

Holly M. Holmes, chair of the Division of Geriatric and Palliative Medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, says patients are often prescribed a proton pump inhibitor while in the hospital to treat a short-term problem with heartburn or reflex, “but then they end up staying on them forever.”

Because stopping drugs suddenly can worsen symptoms, Dr. Holmes explains to patients that they need to gradually taper down over several weeks to avoid a rebound effect. She also suggests diet and lifestyle changes. In medication reviews with patients, she focuses on their priorities. “If my patient is having profound fatigue, the top of my list for deprescribing is whatever medications might be contributing to that,” Dr. Holmes says.

Andrew Whitman, a doctor of pharmacy and clinical specialist in palliative care at the University of Maryland Baltimore Washington Medical Center says medication reviews are especially important for older cancer patients, who on average take 12 medications and are often frail from radiation and chemotherapy. But it isn’t just about reducing quantities of medication. Sedatives and drugs that prevent nausea, for example, are on the list of potentially inappropriate medications for older adults because they cause dizziness, confusion and blurred vision. Still, they may be needed for nausea and vomiting caused by chemotherapy.

Deprescribing guidelines are useful “to help flag which medications we want to target for stopping or reducing the dose,” Dr. Whit­man says. “The goal is to keep patients as healthy as possible on the least number of medications.”

 

Laura Landro. Older patients may risk from taking too many prescription drugs: More Doctors Push to deprescribe. Pills Press, pp. D1, D4

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