Tuesday, November 24, 2015

Polypharmacy: Over-Medicating Patients

While describing the threats faced by the elderly in his book Being Mortal: Medicine and What Matters in the End, Atul Gawande makes this comment on the probability that a broken hip will occur due to a fall.

“Each year, about 350,000 Americans fall and break a hip.  Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again.  The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness.  Elderly people without these risk factors, have a 12 percent chance of falling in a year.  Those with all three risk factors have almost a 100 percent chance.”

Note the recognition given to taking more than four prescription medications as a risk factor.  Even to be recognized as a risk factor means that taking five or more medications must not be unusual for the elderly.  If combining multiple medicines (polypharmacy) is such a serious risk factor for causing falls, then one would expect it to cause other problems as well.  One has to wonder just how common is it to be medicated at such levels.  The answer will be that it is very common.

Medications are rarely tested in combination with other medications as part of the drug approval process.  Consequently, whenever a patient is prescribed two or more medications at the same time, she is participating in an experiment.  The only way to know if there might be serious risk from such a combination is for the patient to report symptoms and have them entered into a data base.  Adverse effects could be subtle, and might take decades to become apparent.  Even if a known issue is involved with combining two drugs, they may have been prescribed by different doctors who might not be aware that both drugs are being taken.  When five or more drugs are being taken concurrently, the probability of producing adverse effects climbs rapidly.

Ezekiel J. Emanuel provided a relevant observation in his curiously titled article in the New York Times: Are Good Doctors Bad for Your Health?  He presented this seeming contradiction.

“One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals.”

“Truly shocking and counterintuitive: Not having the country’s famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest.”

Emanuel has no clear explanation for this result, but he suggests that heart doctors become famous by doing daring and risky things.  Therefore, it may mean that when the heart doctors most likely to do daring and risky things are not around, the patients are better off.

To support the notion that over intervention by doctors may be a problem, he provides the results of a study of medications prescribed to the elderly.

“This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.”

“In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.”

It is likely that the results in Israel would be duplicated in the United States. 

Information on prescription levels in Medicare patients can be found in The Dartmouth Atlas of Medicare Prescription Drug Use.

“In general, total prescription drug use is high among Medicare beneficiaries enrolled in the Part D program. The average Medicare patient enrolled in Part D filled 49 standardized 30-day prescriptions in 2010; however, the number of prescriptions filled per patient across hospital referral regions varied by a factor of more than 1.6….The average beneficiary in Miami, Florida filled about 63 prescriptions in 2010, while the average beneficiary in Grand Junction, Colorado filled just 39 prescriptions.”

If one assumes that all drugs are taken continuously for chronic conditions, the average is about four medications taken concurrently.  The average number varies by region from a low of about three, to a high of about five.  That fact in itself suggests that the prescription of some medications is arbitrary and probably provides no positive effect.  This method of tracking by prescription levels is also likely to underestimate the actual medications that are being used in combination.

This article provides another perspective: How Many Pills Do Your Elderly Patients Take Each Day?

“….the average elderly patient is taking more than five prescription medications; the average nursing home patient is taking seven medications.”

The article contains a discussion with a physician named Aubrey Knight who is experienced in dealing with the elderly.  He provides a warning about the danger of what he refers to as “the prescribing cascade.”

“With more than 15% of hospitalizations involving elderly patients caused by or related to adverse drugs reactions, and the increased risk of drug-drug interactions or adverse drug reactions associated with polypharmacy, Knight noted it is especially important to be aware of what he called ‘the prescribing cascade’ with elderly patients, wherein the side effects from one prescription medication beget a prescription to counteract them, which leads to more side effects, and still another prescription, and so on and so forth.”

Knight also warns that the elderly do not respond to drugs in the same way as the younger members of the population.

“When treating elderly inpatients, physicians should anticipate a 50% risk of adverse drug reactions (ADR) among patients who are on five or more medications, and weigh the use of high-risk/low-benefit drugs against the increased possibility of ADRs. The care team should also conduct a thorough medication review at admission and discharge to avoid polypharmacy.”

Knight clearly believes that we are too careless when prescribing drugs for the elderly, and, in so doing, causing harm. 

He added this advice to those responsible for the care of the elderly.

“….given what we know about the effects of polypharmacy in the elderly patient, any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”

“ ….heed Osler’s dictum that ‘a medication is a poison with a desirable side effect’ and advised that physicians ‘consider medication as a possible problem, and not just as the solution’ when prescribing medications for elderly patients with multiple chronic conditions”

And we should remember, polypharmacy and “the prescription cascade” are issues for all of us, not just the elderly.

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