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

[trytounderstand]

We have all become too dependent on the quick fix. Our lives are too busy to take the time to slow down and just breath. We watch tv and see all these quick fix medications that will make our lives so much better, but it is like no one is listening to the side effects that are also being stated in the same commercial.

I as a patient have been offered a different prescription to stop a side effect from another pill that had been prescribed. The doctor seemed taken aback when I said no tell me how to step down from this pill and we will go from there.

For the elderly some of them are so confused and have no idea what the pills they are being prescribed are actually doing to them both physically and mentally. Most of them probably do not even read the handout they get with the prescription that lists side effects and what otc drugs could interact with their prescription. They trust their healthcare providers to be watching out for them to be their advocates to not just take the easy road and give them something so they will be more compliant and not a problem or to give them something that will make the patient happy.

[RobbiRN, RN]

No authority is needed to back up the clear and potent point of the article. It's spot on. Everyday at work, our med-reconciliation program flags major interaction after major interaction as I work through the extensive lists of home medications. . . But I'll share just one story:

A friend was named POA for her uncle. After a few years of watching his med regimen grow while he was reduced to a non-verbal, contracted, frail man lying in his own filth waiting to be cleaned, she decided to roll the dice. She asked his doctor what would happen if they stopped the 22 medications he was on.

The doctor said, "He'll either get better or die."

She said, "Well, he's certainly not living now." She had him stop the whole mess cold turkey. Some might call her a quack for her decision, but her gamble paid off. Her uncle started functioning again and left the facility a couple of months later. He lived a meaningful life for six more years before a sudden death from a stroke.

The good, normal, non-quack MDs were the ones who prescribed the pills. She simply measured the quality of her uncle's over-medicated existence and chose to intervene -- there was little to lose and a lot to gain.

[Susie2310]

I believe some physicians are interested in maintaining patient dependence on them. A prescription medication often means a repeat customer for refills, and more consultations for side effects and dose adjustments. I think that for some physicians, prescribing is about control; the physician is in control of the relationship, not the patient. It can also be a way to justify their fee. It appears as though the ethos for some physicians is to keep prescribing regardless of actual patient needs as this generates more business.

[/username, BSN, RN]

Inappropriate prescribing and polypharmacy can certainly accelerate the process, though.

Jesus Christ, if you eat too much cheese or drink too much wine that could do it too. People die eventually. There's no reason whatsoever to nitpick.

[LibraSunCNM, BSN, MSN, CNM]

Jesus Christ, if you eat too much cheese or drink too much wine that could do it too. People die eventually. There's no reason whatsoever to nitpick.

There's no reason to question polypharmacy? What is the benefit of it, then?

[/username, BSN, RN]

There's no reason to question polypharmacy? What is the benefit of it, then?

I never said there's no reason to question it, just that as you get older, many people's co-morbidities require it. I just feel that in an era when literally anything can and will give you cancer, it's really overplayed.

[elkpark]

Jesus Christ, if you eat too much cheese or drink too much wine that could do it too. People die eventually. There's no reason whatsoever to nitpick.

So you're saying you wouldn't have any concerns or objections if someone was prescribing an older family member of yours an excessive and/or dangerous combination of drugs?

[LibraSunCNM, BSN, MSN, CNM]

I never said there's no reason to question it, just that as you get older, many people's co-morbidities require it. I just feel that in an era when literally anything can and will give you cancer, it's really overplayed.

Many elderly people's comorbidities do require medication, certainly, but I think the point of the article and of most of us agreeing with its central thesis is that polypharmacy absolutely can cause dangerous problems. Is it as dangerous as cancer? No, but that doesn't mean it's "overplayed" or "nitpicking" to even discuss it. At the very least, the waste of financial resources it causes is reason to give it some thought.

[Emergent, RN]

Not only can overmedication be harmful, but it is expensive to both the patients and the healthcare system as a whole.

To say 'Why worry, old people are going to die anyways', is an absurd remark. Based on that philosophy, why give them meds at all? After all, they're headed for the grave pretty soon, why bother?

[Sour Lemon]

Not only can overmedication be harmful, but it is expensive to both the patients and the healthcare system as a whole.

To say 'Why worry, old people are going to die anyways', is an absurd remark. Based on that philosophy, why give them meds at all? After all, they're headed for the grave pretty soon, why bother?

That's pretty much my philosophy for myself, although I can't decide for anyone else. I'm OK taking a couple of things, but when I get to the point where I need (or might need) 30, I'd rather just go without and die naturally.

[KatieMI, BSN, MSN, RN]

Many elderly people's comorbidities do require medication, certainly, but I think the point of the article and of most of us agreeing with its central thesis is that polypharmacy absolutely can cause dangerous problems. Is it as dangerous as cancer? No, but that doesn't mean it's "overplayed" or "nitpicking" to even discuss it. At the very least, the waste of financial resources it causes is reason to give it some thought.

I would rather say that overmedication can kill more effectively than cancer. I do not know how many times I saw typical situations like "one episode of minimally hemodynamically unstable afib >> oral anticoagulation >> anxiety due to this >>"something for anxiety" (usually a benzo) plus something for associated symptoms of GI upset or "GI prophylaxis" >> loss of appetite >> mild malnutrition and iron deficiency (very quick and easy to develop) >> fall >> intracranial bleed and death or internal bleed, no resources, death".

So far, I'd seen only a handful of physicians (and still less of NPs/PAs) who would even think that at above 80 years old patient might benefit more from ASA alone and live the rest with slightly elevated risk of stroke than from "following the golden standard".

And, no, I wouldn't say that prescribing providers just want patients coming back and back. What they want is to cover their butts should something happen. In case of a suit, first question would be "did you notice (...), did you do something about it, and was it all properly documented?" If you react within "gold standards" and rules, you're going to be fine almost doesn't matter what. They are drilled on it for years till the order gets into their blood and bones.

That patient with 74 meds got there exactly for this reason. She was seen by like 6 specialists spread over 3 health care systems, each of whom followed the said "golden standard of treatment" plus pertaining complications and those 6 docs had no opportunity whatsoever to see the treatment ordered by each of them because all systems used different EMRs and did not allow communication between them for the Holy HIPAA's name. It just happened to be that I had another rule hammered into my head: "if you do not know what the heck is going on, first look on patient, second look on ALL meds,... and the third look is for labs".

[VivaLasViejas, ASN, RN]

When I was a resident care manager in LTC, I liked to challenge the medical establishment when I got a new admission by seeing how many meds I could get D/C'd. Often the new resident would be somewhere north of 90, bedridden, demented and with swallowing problems; invariably they'd come in with something like 10 vitamins and supplements, five or six blood pressure drugs, potassium, and several psych meds. Generally I'd attack the supplements and antipsychotics first, then monitor their vitals for a couple of weeks to see if all the B/P meds were really necessary. Sometimes I had to negotiate with the resident's family who wanted "everything done" to keep Grandma or PawPaw above ground; sometimes I had to approach multiple providers who had all prescribed for them without knowing what everyone else had prescribed. But I was successful more often than not, and instead of 20-30 pills I got some of them down to a more manageable 10 or 12...and in my opinion, even that was too much.

Yes, I think most elderly Americans are overmedicated. And I HATE drug advertising on TV, especially for psych meds. These are powerful drugs that most GPs have no business prescribing, yet people walk into medical offices all the time and ask for Vraylar or Latuda because they've seen it advertised and think it's the answer to all their problems. A pill for every ill, indeed.