The healthcare system in America has developed into one with the ability to prolong quality of life. When it comes to the older population who often take multiple medications due to chronic issues, they can end up with duplicate medications for the same issue. Frequently seniors don't ask questions of their caregivers. They are of the generation in which the doctor knows best, not recognizing that they need to be their own advocates.
Overmedication of the elderly is a complicated problem. According to the article, "Overmedicating Our Elders", over half of the adults in America take prescription drugs, and within that group, the average number of scripts was four. In fact, the amount of prescriptions filled by Americans 'increased 85 percent from 1997 to 2016". That's a tremendous increase, raising the question whether patients are being treated for conditions they may not have, and what is the motivation behind so many medications.
There has been an increase in lawsuits in our society that may answer for some of the physicians feeling they must prescribe a medication in situations that aren't necessary to avoid litigation. Often times, this leads to alleviating symptoms rather than treating the underlying problem.
According to the article, dementia and alzheimers are often treated with the wrong medication. Behavior in patients with these diseases can be challenging, leading to doctors prescribing antipsychotic to patients in nursing homes with no diagnosis of schizophrenia for example. Overmedication of the elderly can be misdiagnosed as dementia or even alzheimers disease. Unfortunately this has regularly taken the place of physical restraints, replacing them with chemical.
In 2018, the Human Rights Watch published a research project that revealed that 179,000 patients in nursing homes were given antipsychotic medications with the purpose of controlling their behavior. With the awareness of this, Medicare and Medicaid are asking for a 15 percent reduction in this practice by 2019. The FDA issues antipsychotic drugs with a warning - "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death".
Another concern with the elderly and medications is the far ranging side effects. Multiple medications increases the chance of side effects and then the patients are treated for the side effects with more medication. Once a patient is discharged from the hospital, more medications are prescribed. Over a few years, the patient continues to have a growing list of medications. Being older increases the chance of side effects, misuse or overdose related to the slower eliminations of medications.
An example of the latter is found in an article called, "Overmedication in the Elderly, Polypharmacy a Growing Problem Among Seniors". An 83 year old female was admitted to the hospital for asthma. The steroids she is given cause her blood pressure to elevate, so she was given a blood pressure medication which made her dizzy. Her ankles had become swollen and she was given a diuretic that caused her potassium to lower dangerously. She was given potassium to combat the hypokalemia. And the cream on the coffee is that she was given an arthritis medication while in the hospital that eventually gave her stomach ulcers. The escalation of medications and side effects can reach a level that is dangerous or maybe deadly to the elderly.
"Clinical inertia" is a term Dr. Donovan Maust from the University of Michigan uses to describe when a physician is reluctant to change or discontinue a medication given to a patient by another physician.
Then there is the opioid overprescribing that has lately been in the news, gaining a lot of public attention. Almost ten years ago, the American Geriatric Society put out recommendations to physicians to decrease the use of over the counter medications such as ibuprofen, that they should prescribe opioids for their patients with "moderate to severe pain". We can see the manifestation of this in our society now as the battle to decrease the overuse is fought.
Cost is a large factor for the elderly who are on a fixed income to be able to buy their medications. In the article, "Prescriptions Drugs, Practicing Physicians, and the Elderly", the authors state that "price and quantity demanded are inversely related; if patients pay less for medications, they will they will demand more prescriptions. The physician will respond by writing more prescriptions". This leaves us scratching our heads, there needs to be more education on the patient's end and the physician should feel empowered to tell a patient no regarding a script that is not necessary. Drug utilization review programs are set up to make sure the process of prescribing and dispensing of medications meet guidelines. They don't micromanage a single patient's medications, but gather data to modify patterns of prescribing.
The concept of deprescribing has become a slow grass roots movement in which duplicate medications are discontinued, as well as unnecessary medications. Dr. Ranit Mishori a professor of medicine at Georgetown University puts it this way, "we're taught as physicians to prescribe drugs. We are definitely not taught how to take people off meds".
There are many dangerous downsides to overmedication of our elderly population. We see it in our family members, our patients clinics, and in the hospitals. As the trend for minimizing medications slowly takes hold, we need to be aware of the patients without advocates especially in nursing facilities. We can make recommendations to our physicians and the patients families to help decrease the overuse of medications.
Have you encountered this in your practice? Tell us what you see being done to counteract overprescribing.
References
Lavizzo-Mourey, Risa J. & Eisenberg, John M. "Prescribing Drugs, Practicing Physicians, And The Elderly." Feb 27, 2018. HealthAffairs.org. Web. Feb. 27, 2018.
Mercola, M.D. "Overmedicating Our Elders". Feb. 2, 2018. Mercola, Taking Care Of Our Health. Web. Feb. 27, 2018.
"Overmedication In The Elderly; Polypharmacy a Growing Problem Among Seniors". 2018. Parentgiving.com. Web. Feb. 27, 2018
