By Helen Santoro September 9, 2021
From Knowable Magazine Seniors often take several medications a day. But there is growing evidence that this could sometimes be a mistake.W
When my grandmother Carol Mitchell was diagnosed with Parkinson's in 2010 at the age of 72, she was given prescribed a medicine called carbidopa / levodopa. She swallowed the small oblong pill four times a day - at 7 a.m., 11 a.m., 3 p.m. and 7 p.m.
In the years that followed, her doctors prescribed a steroid cream for her skin problems and drugs for depression, motion sickness, anxiety, acid reflux and early breast cancer. "I walked into his room and there were vials everywhere " says Elizabeth Mitchell, Carol's daughter and my mom. "I would google each one to see what they were for.
For Carol, now 82, taking all of her meds precisely when she was supposed to have been a difficult goal. " I don't want to take drugs like that. It 's too much, I think, "she said. " You can't leave the house because you have all these drugs to take. "Inevitably, she would find herself missing doses of her Parkinson's disease medication - and when she did, her symptoms of tremors, stiffness, and difficulty speaking and walking would either come back or get worse. Over the past four years, this has led to four emergency room visits, two of which involved extended hospital stays.
To make taking the essential Parkinson's pill easier, Elizabeth has suggested that her mother wean herself off as much of the medication as she couldwith the help of his doctor, and today Mitchell is only taking the Parkinson's medicine. "I feel a lot better with less medication," she said. Elizabeth says her mother is much more likely to take her carbidopa / levodopa at the right time now, which helps keep her from going to the hospital.
But for many other elderly patients who take several drugs, withdrawal is not so easy.
A growing problem
Polypharmacy, often defined as the use Regular intake of five or more drugs per patient is increasing and is expected to increase as life expectancy increases and the world's population ages. livers tend to be less efficient at bolizing and removing drugs from the bloodstream. This risk is exacerbated by the fact that interactions between certain drugs can be harmful and that up to half of patients takeat least four drugs do not take them as prescribed d , according to a 2020 review in the Annual Review of Pharmacology and Toxicology.
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The World Health Organization consider the polypharmacia as a major public health problem , contributing to the millions of hospitalizations that occur worldwide due to adverse drug reactions and responsible for billions of dollars in unnecessary health care costs. Researchers and pharmacists are wondering how to solve this over-medication problem.
But this is difficult, especially because a patient's depreion or drug withdrawal is rarely taught when the drugs are in. covered in a medical or pharmacy school. "There 's not even a discussion you need to see if the balance between disadvantages and advantages is constant over time " says Tobias Dreischulte, clinical pharmacist at Ludwig University. Maximilian in Germany and one of the authors of the annual review article.
Communication difficulties between different medical specialists can lead to accidental overpreion of medication (Credit: Alamy)
But it is doable, Dreischulte adds. University of Dundee in Scotland and part of a teamwhich published a series of guidelines to help doctors and pharmacists nationwide reduce the use of unnecessary or potentially dangerous drugs. Since the implementation of the guidelines in 2012, the number of excess drugs and combinations of high-risk drugs prescribed to patients has decreased.
The question is whether similar practices can be applied. to other countries of the European Union and around the world. "Historically, the clinical treatment guidelines contain no recommendations or comments on how and when to stop drugs," says Emily Reeve, researcher and pharmacist at the University of South Australia at Adelaide, who has researched ways to reduce the impact of polypharmacy in the elderly over the past decade. "How do you make depression part of regular practice?
Worldwide, the number of the number of adults 65 and over are on the increase . In the UK, for example, the number of older people is expected to increase by 67% - or 8.2 million additional people , a population roughly the size of London today - from 2019 to 2068. In the United States, the elderly part should increase d 'about 81% , or 42.3 million more people , from 2018 to 2060.
As people age, chronic medical conditions , osteoporosis to cardiovascular disease through cancer, are becoming more common. And for the medical systems of many countries, the preion of drugs is the method of choice to treat these diseases. According to a Lown Institute report , a nonprofit think tank, 42% of all seniors in the United States take at least five preion drugs a day. Almost 20% are taking 10 or more drugs, and over the past 20 years, the incidence of polypharmacy has tripled across the country.
The drug industry 's for-profit model may inspire doctors to prescribe more drugs, according to a survey from the ProPublica editorial staff . They reported that doctorswho receive money for a specific drug prescribe that drug more often that physicians who do not benefit financially . In 2015, about half of all Doctors in the United States have accepted payments from pharmaceutical companies, totaling $ 2.4 billion (£ 2 billion).
Another contributing factor is the disconnection between the different doctors of a patient, which leads to preions without proper communication. Therefore, what appears to be a new disease may in fact be the side effect of a drug. "All medical specialists focus only on their field," says Grace Lu-Yao, cancer epidemiologist at Thomas Jefferson University in Philadelphia. Ofmany patients, including those with cancer Lu-Yao studied, do not have a capable doctor to help them see the big picture of their treatment and their health. "Who," she asks, "will be the person to watch for potential interactions or to stop certain drugs?
Sometimes, of course, it is necessary to prescribe multiple drugs to For example, to prevent a patient who has had one heart attack from having another, treatment may include drugs that lower cholesterol, lower blood pressure, and prevent blood cells from sticking together. others.
But when the risk of drugs outweighs their potential benefits, patients risk significant health consequences. Every day, 750 elderly people are hospitalized due to '' serious side effects of their medications, including falls, allergic reactions, and bleedinginternal ies. And with each additional medication prescribed, the risk of side effects increases by 7-10%.
It can be difficult to " deprescribe "drugs - doctors often have to carefully monitor the patient. (Credit: Alamy)
The whole system is misconfigured, according to Lu-Yao. In a study released last March, she and her colleagues looked at the rates hospitalization of patients with prostate, lung and breast cancer after chemotherapy treatment. Compared to patients taking less than five drugs , prostate cancer patients taking five to nine, 10 to 14 and more of 15 drugs had 42%, 75% and 114% higher rates of hospitalization after chemotherapy, respectively. Female patients with breast and lung cancer had similar trends. (The group taking more than medrugs did not appear to have been sicker than those taking fewer drugs, based on hospitalization rates in the six months prior to chemotherapy treatment).
If the trends continue, it is estimated that polypharmacy will cause nearly 150,000 premature deaths in the United States over the next decade, according to the Lown Institute report. It will also be responsible for at least 4.6 million hospitalizations in the United States between 2020 and 2030, at a cost of around $ 62 billion (£ 45 billion), according to the report.
Thinking about a smarter health care system Drug use and prevention is extremely difficult, says Reeve. But patients seem ready to give it a try: In 2018, a nationally representative survey by Reeve and colleagues suggested that 92% of seniors in the United States are ready to stop taking one or more of their medications. if their doctor says it 's possible . But many doctors lack the educational resources to do so safely. There are general and drug-specific depreion guidelines, as well as websites such as the electronic depreion tool MedSafer that guide doctors and pharmacists through the process, but few of them have been shown to be effective in clinical practice .
"Depression in itself is not a simple action," says Reeve, who is working to create depreion guidelines that could be used internationally. "This is not something that can happen in a 10- or 15-minute appointment. " It involves the identification of a potentially unnecessary or dangerous drug, aagreement between doctor and patient to deprescribe medication, and often a slow decrease in medication while patient is closely monitored.
Scotland's polypharmacy guidelines by medication and healthcare experts Health, first published in 2012, were designed to fill this resource gap and help clinicians through the process of preion and depression. The "7-Steps " technique effort encourages physicians to carefully review a patient's diagnoses and treatments, determine what medications the patient needs, identify potential side effects of medications, and make sure that the patient is involved in the decision-making process.
An evaluation of guidelines reported that from 2012 to 2018 there was a notable reduction in the number of high-risk drug combinations prescribed to the elderly, according to data collected by the health system Scottish. This included a particularly dangerous combination: the use of nonsteroidal anti-inflammatory drugs like aspirin, high blood pressure medications such as angiotensin II receptor blockers which in the veins and arteries , and diuretics, which help rid the body of excess salt and water through urine. Known as the "triple whammy," this fusion can lead to kidney and heart failure, especially in older patients with a history of liver disease.
"Polypharmacy " may increase the risk of side effects or even death (Credit: Alamy)
More widely, use of these guidelines over the past six years has resulted in removing the preion of over 120,000 inappropriate drugs per year.
Now it is a question of whether health systems in other countries may implement similar guidelines. " It is entirely possible, but it will take time, "says Dreischulte. He believes these changes will be easier to make in countries with centralized medical systems like the UK, where the National Health Service, or NHS, is funded by state and government runs hospitals and employs doctors . As a result, the NHS "is very effective in moving evidence-based medicine to practicing clinicians," he says.
Healthcare in the United States, on the other hand, is very fragmented. 2019, 68.5% of the American population was covered by private health insurance , nearly 43% havedidn't have public coverage such as Medicare and Medicaid, and just over 9% were uninsured. (Some people have more than one type of coverage at the same time.)
Nonetheless, progress in the United States to combat polypharmacy is being made. One of them is the Age - Friendly Health Systems program, developed in 2017, in which hospitals and healthcare facilities agree to join through the 4Ms - a set of guidelines that ensures reliable care for older people by prioritizing what matters in their life, as well as their medications, their mobility and their mental, or their cognitive abilities. The drug element involves healthcare professionals asking if a drug is needed for the patientt, avoid the preion of high-risk drugs, plan for safe dose adjustment and depreion if necessary.
By the end of 2020, more than 1,950 organisms will Nationwide healthcare have adhered to the Senior Friendly Health Systems initiative. E Those who implemented 4M reported a reduction in the number of hospital readmissions, deaths and cases of delirium. They also reported cuts in health care costs. The goal is to reach a total of 2,600 organizations by June 2023.
It is also possible that some large US healthcare systems with more integrated patient care could implement implementation of depreion strategies. Justin Turner, a researcher at the University of Montreal, cites a study on community pharmacies in the Montreal area as an example: It showed that giving elderly patients who regularly take benzodiazepines such asValium and Xanax - some of the most over-prescribed drugs - a brochure on the pros and cons of these drugs is an effective way to stop drug abuse. Among the patients who received the brochure, 27% stopped take their benzodiazepines over a six month period , compared to only 5% of those who did not.
Taking NSAIDs like aspirin with antihypertensives and diuretics can lead to serious complications, including kidney failure (Credit: Alamy)
Pharmacies that are linked by a The US healthcare system could potentially do the same, adds Turner. He is collaborating with researchers at the University of Washington who are conducting a trial with the healthcare system to aim Kaiser Permanente nonprofit in this state. o Reduce falls in the elderly through the depreion of unnecessary and high-risk drugs. Turner also collaborateswith researchers at Philadelphia VA Medical Center on another project to educate and reduce the use of unsafe drugs.
Studies like this may become more common in United States. In 2019, the US Deprescribe Research Network , a community of pharmacists, clinicians and scientists has been created. The group is funded by the National Institute on Aging and offers resources such as pilot grants to those who develop and disseminate research on depression in the elderly. "I think the trend is changing, " Turner says.
In the meantime, many elderly patients who are already taking multiple medications have the added burden of being their own advocates. Or they have to depend on family members and loved ones to lobby for depression if necessary.ire.
Just this February ary, my grandmother visited her doctor and prescribed him Amphetamine Adderall to relieve her daytime sleepiness, a symptom likely caused by carbidopa / levodopa which 'she must take for her Parkinson's disease. Alarmed, her daughter Elizabeth contacted Carol's doctor. "I cannot stress enough that the new pills are not the answer to Mom's case," she wrote in a letter. Instead, "she needs a caregiver, she needs exercise, she needs social interactions such as Zoom calls with her church group.
The doctor responded quickly, so Carol isn't taking Adderall, and that's how Elizabeth would like him to stay. She is doing what she can to help her mother take her medication. Parkinson's disease on time - even this one drug remains a challenge - and sees a huge change when the diet is followed and her mother doest also regular three kilometer walks.
"She is out of breath taking only one drug four times a day. She can not stand any more additions to it "says Elizabeth Mitchell. "When she adds to that, she misses the carbidopa / levodopa and ends up returning to the hospital.
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