Overmedication: The Silent Killer Of the Elderly

[Brenda F. Johnson, MSN]

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

[elkpark]

Not a criticism of the article generally, but you might want to be careful about your sources. Dr. Joseph Mercola is a well-known quack, and I immediately lose interest in anything that mentions him as a source or authority.

Dr. Joseph Mercola Ordered to Stop Illegal Claims

9 Reasons to Completely Ignore Joseph Mercola – Science-Based Medicine

Joseph Mercola: Alternative health merchant promotes quack cures, funds organic, anti-GMO groups | Genetic Literacy Project

Dr. Mercola: Visionary or Quack? |

Chicago magazine

| February 2

[VKALA]

I think,since I have been a Student there has been talks,about polypharmacy but nothing has changed.When I reconcile medications I do ask the Doctor if there are any medications that are needed to be discontinued.Yes,shorter the list,better is the health of an elderly.One of the Doctor did say-less is more!

[Emergent, RN]

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!".

[Neats, BSN]

We live in a society of better life through pharmaceuticals. As a working Case Manager at this time in my career I review medical records form all over the country on a daily basis dealing with everything from a simple procedure (Botox injections) to oncology care reviews. I see time and time again people receiving medication for every thing from narcotic pain medication prior to (cosmetic Botox) to even my husbands experience of just saying to the doctor I worked out in the yard today and I am stiff at his routine follow up pacemaker appointment. He was offered pain medication. He declined the pain medication. He came home had a beer and sat in the hot tub for 15 mins, felt better, stiffness went away.

We are bombarded with commercials for medication, I can see patterns emerge of when Prozac, Prolia commercials are running up about 2 weeks later we start getting requests for this medication, same with Humira, Opdivo...the list goes on and on. My wish is that our prescribing providers' do not fall into the medication trap with patients wants...anything for the patient and there is a pill for what symptom(s) you have. Heck we even give injections prior to the start of IV's (I decline the Lidocaine)

As a RN/LNHA in a SNF environment I always struggled with polypharmacy as 9 or more medication is considered a sentential event and just about every patient that came through the door was on greater than 9 medication. When you reconcile those medication a lot of patient would say well I take this because this other pill causes XY and Z. I finally made such a stink as the LNHA at one facility we did not admit anyone on greater than 9 medications. Providers' were yelling at me you cannot tell me how to practice, I was not, I was only saying at this facility we can only handle 9 or less medications. Word got out and today this place is considered a center of excellence/innovation.

I think we need to start looking at alternatives ie for pain more physical therapy/OT, change life style not rely on a pill as a crutch it is only masking ongoing issues. I think as a patient we need to stop believing a pill will change my life (and yes in some situations they do think- diabetic and HTN) and that I need to change my lifestyle in a more natural way that includes SELF RESPONSIBILITY instead of thinking about our health and improvement from a bottle of pills. Education is the key and it starts at a young age.

Lastly I am astounded by my chosen profession in that this should never be an issue at all. Prescribing providers prescribe more and more medication for a variety of reasons, really there should only be one reason and that is after a careful assessment and a formalized treatment plan that require updates, this is in my patients best interest, this supports the patients labs, symptoms, imaging...

being on oral pain medication (intrathecal medication excluded) for a long time period or having polymedication issues only supports a non collaborative healthcare provider interaction and not in my patients best interest. I remember one of my nursing instructors fondly and their saying "you do not need all these pills in the end all you will have is expensive pee because your body is a simple machine that only uses what it needs and will excrete the rest."

[CoCook]

As an RN have worked in long term care as well as with a geriatric psychiatrist who was also a pharmacist. One of the greatest things I learned from him is the importance of drug interactions. For example: if too many drugs require the same enzyme in the liver to be metabolized, then one or more of them will simply be ineffective. Also with polypharmacy in the elderly, there needs to be a regular review of which drugs are absolutely necessary and which ones can be discontinued.

[VioletKaliLPN, LPN]

I work in a SNF. I have ONE patient on clonidine, lisinopril, hydralazine, metoprolol, Altace, and carvedilol!

When I asked if there was a way to reduce the amount of meds by increasing a few doses, they looked at me like I had 6 heads.

[LovingLife123]

I stopped reading after Dr. Mercola was quoted. I'm sorry.

[KatieMI, BSN, MSN, RN]

Well, leaving Dr. Mercola, who is a quack, alone...

I had one patient on 74 (yes, SEVENTY FOUR) meds, about 20 of them "doubles"and "triples" like 3 PPIs. Her chief complain was loss of appetite. She took a cupful of pills first thing in the morning, all those carefully sorted and placed by her coming home health care RN. When I questioned that RN, she told me that "it was not her job to question orders".

I receive approximately 1 call from an RN with question about re-considering one medication for every 15 to 20 such calls asking me for "something for something" and making fuss when I tell them that patient has legitimate right to have BM once every 3 or even 4 days if it doesn't bother him or her because that RN feels like I dismissed her concerns. Repeated explanations do not work because "there's a policy requiring me to call you if there's no BM for 72 h and no orders for PRN meds for that", so they call and call and call till they get it this way or another. Even if symptoms are totally and completely expected, like cough after RT. Those who cater to their "requests" are known as "good and considerate doctors who listen to us and care for patients". I wish these caring and concerned nurses would hear the words those doctors say about them in physicians' private suite.

For every "something for pain" order, there come two or three following orders to treat expected side effects of pain meds. Something for nausea, itching, constipation, urinary retention.. you name it. And, yes, so far I was never asked for an order for a heating pad, or ice pack, or any other alternative pain management technique which would require one. It is me who suggest them, and with no variations I get another call in couple of hours stating that "pain relief is not adequate and can I get an order for some stronger med".

There seems to be no way in nature to explain to people who supposedly spent 2 to 4 years learning quite advanced science courses that certain things are NORMAL for a human being, leaving alone explaining it to those who do not have benefits of such education. People are experiencing anxiety since they first realized what it was - in fact, shouldn't there be no anxiety, our ancestors would have been eaten by other carnovores right after they first made their way down from trees. Why anxiety about trivial issues is now considered to be something immediately life-threatening which must be "medicated"?

And, yes, you read it all correct. Nurses play not a minor role in problem of overmedicating America in general and elderly in particular. I wouldn't say it is total, but a good 2/3 of RNs I'd contacted so far in any of my roles were, or are, right there. The rest is either on their way to different "out of bedside" modes of nursing or actively thinking about them. This is just my observation, but I highly suspect that there is some logical connection between these two groups' behaviors.

And, yes, I was there too and I know what does it take to do the nursing job the way it supposed to be done, using the knowledge you have and without getting "something" for everything.

[CharleeFoxtrot, BSN, RN]

I stopped reading after Dr. Mercola was quoted. I'm sorry.

Yup, anyone who quotes that (expletive deleted) and claims that it is fact should review what evidence based practice and science as a whole are all about.

[CharleeFoxtrot, BSN, RN]

Well, leaving Dr. Mercola, who is a quack, alone...

I had one patient on 74 (yes, SEVENTY FOUR) meds, about 20 of them "doubles"and "triples" like 3 PPIs. Her chief complain was loss of appetite. She took a cupful of pills first thing in the morning, all those carefully sorted and placed by her coming home health care RN. When I questioned that RN, she told me that "it was not her job to question orders".

===

And, yes, you read it all correct. Nurses play not a minor role in problem of overmedicating America in general and elderly in particular.

Absolutely 100% correct. Nurses must accept part of that responsibility when they don't educate patients or question why this patient is taking 74 medications.

[juliezehrn]

I receive approximately 1 call from an RN with question about re-considering one medication for every 15 to 20 such calls asking me for "something for something" and making fuss when I tell them that patient has legitimate right to have BM once every 3 or even 4 days if it doesn't bother him or her because that RN feels like I dismissed her concerns. Repeated explanations do not work because "there's a policy requiring me to call you if there's no BM for 72 h and no orders for PRN meds for that", so they call and call and call till they get it this way or another.

Oh no, I'm that nurse! I definitely am a "less is more" advocate when it comes to medication for the folks in my care (I work at a provider of group homes for adults, many elderly, with intellectual disabilities), but I draw the line at no BM in 3 days. I've seen too many histories of small bowel obstructions and too many instances of hospitalizations with bowels chock full of stool. Maybe if I had the luxury of being able to assess every single person who hadnt had a BM in a day or two, but their day-to-day care is performed by unlicensed personnel with 32 hours of med training.

Is it "in the literature" that 3 or 4 days without a BM has better outcomes than an aggressive 72-hr bowel regimen of suppositories and enemas?