When I was in pharmacy school I was taught about a concept called “Poly-Pharmacy”. It was loosely described as the situation where a person is taking multiple prescription and/or over-the-counter medicines. We were not taught to look at this as a bad thing… in fact, maybe even just the opposite. The inference was that if someone was prescribed a multitude of medicines, then it meant that the medical profession was actively doing its job and ultimately saving lives! And as a pharmacist I was playing my vital role.
Today, my perspective is vastly different. Especially in regard to folks as they age – this is a terrible and costly (financially and in consideration of quality of life) practice – and I am making it my personal mission to put “Polly” out of business.
An official definition for Poly-Pharmacy is “the concurrent use of more than 5 medications by an individual.”
People over the age of 65 make up roughly 15% of the population but they use more than 30% of all prescription medicines written. Of course it seems obvious that older people are inclined to use more medicines – it is with aging that we tend to suffer from the conditions that supposedly require these medicines to control or manage.
The problem with this scenario is that when potential medicines are being tested for safety and effectiveness, they are tested alone and they are tested in people who suffer from just the one condition that the medicine is designed to treat. And generally, the new drug is tested on subjects that are younger than the ultimate population that will end up using it.
In other words – we have no way of knowing, or even accurately predicting, how multiple prescription medicines are going to act and react with each other in an individual person with multiple health challenges as he or she ages.
One of the key facts that we seem to forget in medicine is that as we age our organ function and underlying biochemistry will likely change.
It seems like common sense to realize that liver and kidney function in a 50 year old will change when that person is 70 and 80 and 90. If he is taking a drug that is removed through the body via one of those routes (nearly all prescriptions medicines do) then it is obvious that the amount of that medicine needed will also change. But we rarely see MDs alter the dosage of drugs as a person ages.
Side effects and unwanted effects are more likely to happen. Often times, a “symptom” shows up and MDs are not looking towards the medicines that someone is already on as a potential cause… in fact, this “new” problem usually ends up being a reason to prescribe another medication!
I need to introduce two terms here for my story to continue… Adverse Drug Reactions (ADRs) and Adverse Drug Events (ADEs). These two terms can be used interchangeably.
An ADR is defined as, “a drug interaction that results in an undesirable or unexpected event that requires (if recognized) a change in the management of the patient.” This can happen with drugs interacting with each other, with other disease states, or with foods, and it can happen because of side effects or toxicities from the drugs.
Statistics from a study done in 2003 show that in elderly people…
- 35% will experience an ADR,
- 29% will require some sort of medical intervention because of it,
- In nursing homes – 2 out of 3 people will suffer from an ADR, 15% of which will be hospitalized because of it, and
- Up to 30% of all elderly hospital admissions involve an ADR.
And these statistics are 8 years old… they likely represent numbers that are under-reported. In other words – it is reasonable to expect that things are actually worse now then these numbers show.
Why is this becoming more of a problem as time goes on? There are many reasons… we have more drugs available with every passing year, we are more likely to have multiple conditions as we age, and with today’s trend towards specialization we are more likely to have multiple doctors taking care of us.
Ideally – when a doctor decides to prescribe a medicine – she is supposed to go through the mental exercise of weighing the potential risks of taking that medicine against the potential benefits… a risk/benefit analysis. This process should be executed with more regularity for chronic medications than what currently happens in practice. It seems that once someone is on a medicine for something like high blood pressure or high cholesterol or even depression, they could stay on that medicine for the rest of their lives without ever accounting for changes in the body.
If there are multiple prescriptions involved than the possibility of ADRs needs to be considered even more. But how is that supposed to happen properly when there are no studies to help guide the doctor in her evaluation?
Obviously, it doesn’t happen well at all – if it did then we wouldn’t be seeing all of these hospital admissions because of ADRs! Just to reiterate the statistics – up to 30% of all elderly hospital admissions are related to Adverse Drug Reactions!
Here are some more sobering statistics from the year 2000: ADRs cause 10,000 deaths a year with an annual cost of $85 billion. If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the U.S. This issue is worthy of serious attention.
I believe the reason we don’t pay attention to it is because the solution is one that actually would cost the pharmaceutical industry money instead of making the pharmaceutical industry money… and that just doesn’t seem acceptable to the powers that be. They want to explore solutions to problems that ultimately lead to more business, not less.
The kicker to all of this is that the elderly likely do not even need to be on many of their prescription medicines.
An amazing study was done and reported in the Archives of Internal Medicine in October of 2010. In this study an algorithm was used to determine which medications could reasonably and safely be discontinued in a group of 70 community-dwelling older patients. They were using an average of 7.7 medicines each and, as a result of using the algorithm, recommendations were to stop an average of 4.9 medicines.
Of the medicines that were discontinued, only 2% needed to be restarted because of reoccurrence of the original indication. To me that fact alone is a startling indictment of our medical system and how we prescribe medicines for the elderly. 98% of those medicines were not even needed!!
Furthermore, 88% of the patients in this study reported global improvement in health: quality of life. This is a result of stopping multiple medications and likely cutting down on bothersome side effects or other unwanted effects – like decreased energy, poor sleep, digestive issues, mental clarity, etc.
Some gerontologists are now recognizing that the goal for their patients is to work to get them off of medicines instead of getting them on more medicines. I wonder if these MDs get as many visits from pharmaceutical reps as the rest?
I think that medicine should be looking more at quality of life and less at changing secondary parameters like cholesterol or bone-density as the first consideration for treating the elderly. These people would likely find their life more enjoyable and would find that what has turned out to be the fifth leading cause of death in them would be treated.
If there is concern about someone that is on a handful or more of medicines then a gerontologist should be sought out and they should be asked a simple question… do they believe that less is more? If the answer is yes, then that is the right person to see.