Overmedication: The Silent Killer Of the Elderly

[Brenda F. Johnson]

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

[Guest219794]

I think all Americans are overmedicated, not just the elderly. A big cause is direct to consumer advertising of drugs, initiated during the Reagan administration. "Just ask your doctor if Prozac is right for you!".

Ironic- the same administration approached drug addiction with "Just say no."

[bbyRN, BSN, RN]

In my experience in TCU and LTC and memory care, our patients and residents come from the hospitals with medication (without Dx's on the d/c orders) that often includes some orders that can either be quickly discontinued or eventually discontinued as we get to know the people. Our physicians who follow our patients and residents do not overprescribe and seek to reduce the meds our people are required to take.

I also find that many hospital staff, nurses, social workers, physicians, have no idea of the realities of LTC, ALFs, and other non-hospital environments, nor the reasons behind those realities. That new admits to our facility and their families have been given incorrect information about what they can expect about their clinical reality, the environments, and finances.

Residents, patients, families have little understanding of the American health care system or their own health, not to mention their responsibilities and accountability for their own health. I don't know much about Mercola, but Human Rights Watch is worse than a joke.

[Tommy5677]

I find it interesting your accusations of quackery and attacking Mercola and then citing the likes of Stephen Barrett, MD. First of all Barrett is no longer practicing and hasn't for years. In fact, his competence had been in question for sometime, especially during his "tenure" as an expert witness. He was completely discredited in a California courtroom as being "biased and unworthy of credibility". So, throw out Stephen Barrett, not a MD.

I will also not lend any credibility to a website called Science Based Medicine. All medical research is now being done by Pharma and they are dictating medical practice. They infiltrate medical schools very early in the game to train physicians that medication is the only valid form of treatment. Also, the term "evidence based" is the latest conventional medicine buzzphrase which means absolutely nothing but to get the public to believe it's their way or the highway.

You are correct, Mercola is a DO, not an MD. But, in the conventional world what does that mean? They practice the same medicine as MDs, for the most part.

Yes, I've had issues with him, Mike Adams, who once aligned himself with the likes of Alex Jones, and I don't like Oz. The other one I've never heard of.

Now, if you want to challenge competency, lets' talk about the pharmacists involved. What are they doing to address polypharmacy in the elderly? Apparently nothing. They are supposedly a part of the patient's health care team but where are they? Sometimes I believe they went to school for 5 years to learn how to count pills. They have to be told and when it's brought to their attention they blow it off. I know. I worked Medicare home health for years. I once had a patient who was on 17 meds and I was appalled that the pharmacy involved had not alerted the MD. There is no defense, not even the fact that more than one provider might be writing prescriptions. Lack of communication between providers and pharmacists is serious and it's killing people. What are we doing about it?

[bgxyrnf, MSN, RN]

Now, if you want to challenge competency, lets' talk about the pharmacists involved. What are they doing to address polypharmacy in the elderly? Apparently nothing. They are supposedly a part of the patient's health care team but where are they? Sometimes I believe they went to school for 5 years to learn how to count pills.

Just as nursing roles are not all created equal, neither are pharmacy roles.

The ones working the counter at the local pill mill, or worse yet, the ones lending their licenses to Express Scripts and the like, are far removed from professional clinical pharmacists such as are utilized at my medical center. These folks round with the teams in the ICUs and actively monitor therapies on the floors. There is a dedicated group in the ED who did ED post-doc work. The issue for the patients is with their 'home' meds, which are handled by their PCPs and consult docs... and without the benefit of the clinical pharmacists.

[bbyRN, BSN, RN]

Oversimplified, inexperienced, rmchair, bookish comments about the use of meds as chemical restraints just decreases the care that the overworked, understaffed, underpaid nursing assistants are able to provide the majority of residents in our SNFs. My staff doesn't need to be injured and I will protect them from uncontrolled residents. You want your violent family members cared for, taken home and do it yourself.

[Wuzzie]

My father is in his eighties and has dementia. It's mild right now but he has associated sleep disorders and sleep apnea. He has not started his CPAP therapy due to a few other issues and his NEUROLOGIST prescribed Ativan of all things to treat his sleep disorder. My mother knows to check with me when he is prescribed something new and I told her under no circumstances should he take it. I thought everyone knew it can exacerbate dementia in the elderly and it is inappropriate to prescribe it for chronic sleep issues. I knew it and said something, his pharmacist knew it and said something and even the insurance company questioned it yet his doctor, who is a specialist, thought nothing of prescribing it even though neither my father or mother requested a medication to treat the issue. This is really scary. Not everyone has someone looking out for them like my folks do. One of my friends parents (with Alzheimer's) was given IV Ativan for a hip MRI. He went into the machine mildly confused and came out a blithering idiot who then required nursing home care. My grandfather, a surgeon, was given too much narcotic and was not monitored closely enough. He had a hypoxic seizure and was neurologically compromised from that point on requiring total care. This was at a world reknown hospital. The consequences of overmedicating the elderly are very real and can be devastating.