It's no secret that medication management is a major health concern for seniors.
A Brown University study published in the Journal of General Internal Medicine (2013) brought widespread attention to the overuse of high-risk medications. After analyzing data from more than 6 million seniors in the Medicare Advantage programs, the Brown researchers noted that in 2009, 21% of all seniors were on at least one potentially dangerous "high risk" drug for which there are safer substitutes; 5% were on at least two.
Three years ago, Emory University researchers published calculations of hospitalization rates of seniors for unintentional medication overdoses in the New England Journal of Medicine. Their estimate is that there were nearly 100,000 admissions for adverse drug events between 2007 and 2009. Two-thirds of these are attributable to unintentional overdoses (Budnitz DS, et al. N Engl J Med. 2011; 365: 2002-12).
There's no shortage of articles offering advice on how to help seniors remember to take their meds in the right doses at the right times of day. But painfully little has been said about a potentially more serious problem: Overmedication.
Overmedication occurs when individuals take too many different prescription medications at once. These drugs often interact poorly, causing side effects that range from lethargy, lack of appetite and sleeplessness to dizziness, imbalance, inability to concentrate and high or low blood pressure. Paradoxically, these side effects can be confused with symptoms leading to erroneous diagnoses and further, unwarranted treatment. As a professional care manager for seniors, I've seen it often.
Little Talk = Lots of Drugs
One of the most striking cases I've observed involved an 83 year-old man named Paul, who was in extremely poor physical condition when we first met. He drooled, had difficulty speaking and could barely hold a cup or a fork. Having lost his appetite, he was also losing weight.
As I evaluated his needs, I learned that he was being treated by at least 11 different physicians for a variety of conditions. These included a cardiologist, an endocrinologist, an urologist, a dermatologist, a podiatrist, an ophthalmologist, a neurologist and a pulmonologist. Each had issued multiple prescriptions, but none were communicating with each other about Paul's case or the medications they prescribed.
Suspecting that Paul's deteriorating physical condition was perhaps the result of the drugs and their interactions, I reached out to each of his doctors with a list of these meds. I put the doctors in touch with each other, initiating a conversation about Paul's case so they could create a sensible, coordinated treatment plan.
Ultimately, Paul was taken off 7 of his 15 medications, and fairly quickly after the new plan was implemented his appetite improved, he stopped drooling and became more alert. He became able to hold conversations again, communicating -- and reconnecting with -- family and friends.
While relatively dramatic, Paul's case is sadly not the only one I've seen. In fact, based on my 16 years of experience with the elderly, including 6 as a professional geriatric care manager, I'd estimate about 25% of the seniors I've worked with are on a hodgepodge of medications they may not need, prescribed typically by different physicians who are not talking to each other.
Medco Health Solutions recognized this trend in a 2006 analysis showing that 1 in 4 elderly patients were prescribed medications by 5 or more physicians, and 1 in 20 patients received prescriptions from eight or more physicians.
Taking What They're Given
The seniors I work with most often don't know what each medication is for; they take each one simply because it was prescribed by a doctor. "My cardiologist told me to take it," they explain. Or, "My gastroentererologist." "My rheumatologist." They rarely if ever receive detailed information from their doctors about the purpose, risks or side effects.
Moreover, as I've noticed during initial health and medical history assessments, seniors' families are typically unaware of which doctors their loved ones are seeing, which drugs have been prescribed, and why. Too often, the details revealed in the assessment come as a surprise.
Clearly families, caregivers and professional care managers have a role to play in educating themselves and providing oversight and advocacy. Paul, for example, was too overmedicated to advocate for himself. Many other seniors simply don't realize that a drug therapy is an option, and they can be reluctant to ask doctors questions.
Most importantly, however, physicians -- especially primary care practitioners-- need to proactively include medication oversight in their approach to treating seniors, initiating conversations with patients and families, and being mindful of signs of overmedication.
Because meds rarely solve underlying health problems and can lead to undesirable complications even when taken correctly, holistically-minded clinicians in particular are in a good position to recommend alternative approaches that support wellness and prevention and can reduce the need for meds in the first place.
Dr. Feyza Marouf, a psychiatrist affiliated with Massachusetts General Hospital, who specializes in medication management, emphasizes that the process of changing a patient's drug regimens needs to be done carefully. This is especially true in elderly people, who may have been taking certain of their drugs for many years.
Dr. Marouf shared the approach she takes in helping her patients pare down their pharmaceutical intake.
Accurate Assessment: The first step is to clarify what meds a patient is actually taking. Have him or her bring in bottles from home. Ideally, patients (or family members) should keep a list at all times, and it should be shared with physicians.
The next step is to assess which of the patient's conditions remain current, active problems. For example, if a patient is taking painkillers for headaches, does he or she still experience the headaches despite treatment? If so, then perhaps the meds he or she is taking are useless.
It's also important to look at conditions that seem to be under control, such as diabetes or high blood pressure. Often a patient might be on 3 or 4 blood pressure meds but as they age, they tend to develop low, not high, blood pressure. Has this been reassessed?
Acute vs Chronic: The next step is to ask which problems are acute and which are chronic. Acute problems have a greater need for meds. Chronic problems need to be well managed, but not necessarily by more meds. Contrary to popular assumptions, people tend to need less medication as they age, not more. Most FDA evaluations are done with data from younger people, and drug approval trials don't necessarily include seniors, though they are physically much different than younger individuals.
Another essential part of the process is to make sure that a senior patient has actually had a recent physical exam. Ideally, this should be done by a geriatric internist or someone well trained in caring for elders, who should, in principle, integrate seniors' medication lists. But as we all know, healthcare realities are often very far from the "ideal."
Watch for Redundancies: Blood pressure drugs and psychiatric meds, especially benzodiazepines such as Ativan, Valium and Klonopin, are among the top categories of redundant drugs being taken by seniors well after they've ceased to be useful.
Others include meds for cholesterol levels, and drugs for acid reflux (including H2 blockers and proton-pump inhibitors such as Omeprizol). Anticholinergics, which are often available over the counter in products like Benadryl, are frequently used redundantly for congestion but tend to cause undesirable side effects such as dry eyes, urinary retention, confusion and even delirium.
Determine What's Really Needed: By slowly tapering down on doses of medications in question while monitoring symptoms and vital signs, you can start to get a sense of which drugs are actually doing something useful and which ones are unnecessary.
This is a trial-and-error process: the reduction of any medication will always be an experiment. But we find that up to 85% of people can reduce unnecessary medications without having conditions worsen, and often, people can eliminate such meds altogether without experiencing any side effects.
That said, be very cautious with benzodiazepines. They are probably the most habit-forming medications, with strong withdrawal symptoms accompanying the strong dependency.
Monitor Carefully: A patient's overall response to medication reduction depends in part on the specific drug being reduced. As mentioned above, benzodiazepines are highly habit-forming and have strong withdrawal symptoms. So the weaning process from these should be monitored with particular care, and carried out more slowly than the process of changing, for example, a blood pressure drug.
Response also depends on the patient's underlying health and medical conditions. Patients with heart failure, for example, who are often on a number of different cardiac meds (not just diuretics) or patients at high risk of developing blood clots (including those with atrial fibrillation) often have the hardest times stopping medications.
The key in most cases is a slow tapering while monitoring symptoms and vital signs to see what happens.
Regular home nurse visits to check blood pressure, sugar levels, and other vital signs are very important during the process of reducing or eliminating medications. A lot of monitoring can be done from home. Seniors should also see their doctors within 3 months following any change of medication rather than waiting for 6 months to go by. Finally, family members and caregivers should be on the lookout for symptoms such as depression, excessive weight gain or loss, etc.
Communicate with Colleagues: Generally there's a sense of professional courtesy about contacting other physicians involved in a patient's care. The process is informal, and it need not be overly burdensome or confrontational. Many clinicians share the view that it's best to simplify and reduce medication regimens, and are fairly conscientious about contacting the others doctors involved.
Bettina Krasner is a Care Manager at LivHOME, one of the nation's largest providers of professionally led, at-home care for seniors. Her extensive experience working with older adults, their families and caregivers includes 9 years as a lead senior services coordinator with Multipurpose Senior Services Program and 8 years with Children & Family Services in Orange and San Joaquin Counties, California.