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Too many pills?

June 1, 2010
by Rebecca D. Elon, MD, MPH
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How to deal with polypharmacy

At a glance…

Open and ongoing conversations among residents and caregivers concerning the medications they are prescribed and for what purpose will ensure that any and all medications are necessary for achieving the best outcomes.

Doc, I just don't want to be taking so many pills!” Geriatricians hear this statement from their new patients frequently. One of the geriatrician's favorite interventions is called “pharmacologic debridement”-the elimination of unnecessary medications. But how many pills are too many? How does someone know what medications are necessary versus unnecessary? While overprescribing of medications for older adults is problematic, underprescribing can also be a problem.

First step

The first step in getting it “just right” is for the physician, nurse, and the patient or resident to work together. Evaluation of each and every medication should be a routine part of the medical encounter. If the physician does not initiate this process and discussion, the resident should request a medication review. What is the purpose of each medication? Is it still necessary or advisable to take each and every one? Are there any ill effects from the medicine? If the benefit of the medicine cannot be clearly stated, or if the benefit does not clearly outweigh the burden (including side effects, cost, etc.), then the medicine may be unnecessary.

Hypertension, arthritis

For Americans over the age of 60, the single most common reason for taking prescription medication is the presence of high blood pressure (hypertension). Approximately two-thirds of older Americans have hypertension, and the lifetime risk of developing it after the age of 60 is 90%. Most people who have high blood pressure experience no symptoms from the condition for many years and discover it upon routine screening. It is generally recommended that hypertension, defined as a blood pressure of 140/90 or greater, be treated in order to decrease the risk of future stroke and heart attack, the leading causes of death for people 60 and older. Long-standing hypertension can also cause kidney problems and threaten vision. Lifestyle modifications (such as weight loss, exercise, decrease in sodium and alcohol intake) may help reduce blood pressure, but one or more medications often are necessary to lower the blood pressure.

Osteoarthritis, also known as degenerative joint disease, is very common in older adults. Men over the age of 65 have a 40% rate of arthritis, while women over 65 have a 55% rate of doctor-diagnosed arthritis. Many older adults take nonprescription anti-inflammatory medicines to control their arthritis pains (e.g., ibuprofen or naproxen). Residents should tell their care providers about each and every over-the-counter medicine they are taking, including nutritional supplements, vitamins, medicines for allergy, sleeping, pain, etc. Anti-inflammatory medicines can cause fluid retention and in some people can contribute to high blood pressure. Some of the same lifestyle modifications to help hypertension can also help arthritis pain, such as weight loss and exercise, but consultation with a physical therapist is advisable to know which exercises help rather than worsen the symptoms of arthritis. Acetaminophen is often effective for pain management, and when taken in doses of 3 grams daily or less, it is generally safer for older adults than the anti-inflammatory medicines.

Diabetes

Twenty percent of Americans age 60 or older have diabetes mellitus, and half of all American diabetics are 60 or older. The same sort of lifestyle modifications discussed for hypertension and osteoarthritis (weight loss, diet, exercise) can help the older person with diabetes achieve better sugar control, and in some cases return the glucose levels to normal. Although we think of diabetes as being a disease of blood sugar, it is also a disease of blood vessels. People with diabetes are at very high risk for heart attack and other vascular problems, so the benefit of controlling high blood pressure and cholesterol in addition to controlling sugar is very important.

Evaluation of each and every medication should be a routine part of the medical encounter.

Diabetics often take multiple medications to control the symptoms of their disease and to decrease their risk of future heart attack, kidney failure, vision problems, and poor circulation in the feet. The best way for people with diabetes to lower their total number of pills is to engage in healthy lifestyles.

Guidelines

Clinical practice guidelines establish standards for treating individual conditions and diseases. If older adults have multiple conditions, however, strict adherence to the guidelines for every one of the conditions can lead to polypharmacy and too many pills. Communication between the older adult and the physician is therefore essential to define treatment goals and priorities.

Despite the best lifestyle choices, many older adults have multiple chronic conditions and may benefit from taking medications.

Open and ongoing conversations with their physicians, nurse practitioners, or physician assistants are the best way to make sure that any and all medications being taken are necessary for achieving the best outcomes.

Dr. Rebecca D. Elon is Medical Director of Lorien Health Care Center in Columbia, Maryland, and serves as Associate Medical Director of Gilchrist Hospice in Towson, Maryland. She serves on the voluntary faculties of Johns Hopkins University and University of Maryland School of Medicine. For more information go to

www.lorienhealth.com.

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