Sunday, November 5, 2017

Polypharmacy in the Elderly: Who's Responsible?

There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition.  It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications.  I see this daily in the office and in the hospital.   It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. 

Of course, every doctor feels that he is prescribing only what is truly necessary.  If an individual has an internist, a cardiologist, a gastroenterologist, a urologist and a dermatologist which is not unusual - and each prescribes only 2 or 3 essential medicines, then polypharmacy is created.  Each day, the patient swallows a chemistry set.

First of all, I don't know how these patients, who are often elderly, manage the logistics of taking various medicines throughout the day and evening, before meals, after meals and at bedtime.  Who can keep track of this?  Nurses in the hospital can barely manage this overwhelming schedule.  This has to negatively affect one's quality of life as the daily calendar of events is predominantly pill popping events.  

Keep in mind that the drugs we doctors prescribe are not that smart.  Does the Nexium I prescribe to hundreds of patients only act on just the right amount of stomach acid to relieve the patient's reflux?  Doesn't the drug reach every organ of the body having potentially deleterious effects that we might not be aware of?  Could Nexium be interacting with other medicines in an unfavorable manner?  While we are quick to demonize stomach acid as an enemy of mankind, isn't the acid that Nexium is reducing there for a reason?  Are we smarter than a few million years of natural selection?

I'm betting on Darwin's theory.

Extrapolate the Nexium example above to a situation when 10 or 12 drugs are cruising throughout the body on a Fantastic Voyage journey, colliding with each other and smashing into organs far away from the drugs' intended targets.  

We also function in a culture where every symptom demands a pharmaceutical response.  While depression, hyperactivity and insomnia are real illnesses, can anyone dispute that the medical community is over prescribing medicines for these conditions?

I wonder how many folks who are suffering from unexplained nausea, balance issues, confusion, dizziness, falls, bowel disturbances and abdominal pain are actually getting a taste of their own medicine.   When they present these symptoms to their doctor, they may end up with yet another prescription thrown onto the pile, when the solution is to diminish the pile which is causing side-effects.

Challenge your internist and your specialists to verify that every drug is truly needed. Insist on the lowest dose that will accomplish the mission.  Are the doctors on your team communicating adequately with each other?  Is someone in charge? 

In my experience, the biggest risk factor for polypharmacy is polydoctor.   More medicines and more physicians aren't better medicine.  Primum non nocere, first do no harm, still deserves to be the mantra of the medical profession.  In medicine, less is more.  On your next visit, ask your doctor to please do less for you. 

4 comments:

Dr Joe said...

One of the most useful interventions I have found as a physician is to "unprescribe". Its interesting how many symptoms can be cured with the removal of even one or two medications, particularly those with anti-cholinergic activity.

Michael Kirsch, M.D. said...

Thanks, Joe. Two pleasures I enjoy are removing an unnecessary medication, and deleting a diagnosis of some disease that has 'pasted' in year after year, but is not accurate. I've seen many patients, for example, who have 'lupus', 'rheumatoid arthritis' or 'Crohn's disease' erroneously listed.

Anonymous said...

Oh yes, the number of older people on a whole slew of medications seems to be the norm. I know it was for my in-laws. What about overtreatment / "prescribing" in the way of unnecessary procedures? There's a lot of that too especially in the Ob/Gyn specialty. There are only ~80,000 annual cases of gynecologic cancers (endometrial, cervical, ovarian) yet there are 700,000-800,000 hysterectomies and 500,000-600,000 oophorectomies, many of which involve removal of both ovaries. You've probably seen the after effects of hysterectomy on bowel displacement and function in your practice. That is just one of the many harms of hysterectomy and oophorectomy has another whole set of harms as shown by numerous studies and medical literature going back over a century.

Michael Kirsch, M.D. said...

Good comment above. Why the anonymity? Much of this blog is devoted to the perils of overdiagnosis and overtreatment and I invite you to a leisurely perusal.

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