A common practice that can shorten your life
How many pills do you take each day?
This is a question that more and more primary care physicians are asking their patients as it becomes alarmingly clear that older Americans are often prescribed more medications than they need.
In fact, a new study reported in the Journal of the American Medical Association – JAMA – shows that 60 percent of all Americans take at least one prescription drug and 15 percent take five or more, a phenomenon known as “polypharmacy.”
“It’s not a problem for every age group, but when you cross the age of 65 or 70 and above, it is a huge problem,” said Munir Ahmed, MD, an internist with Emerald Physicians in Sandwich and South Yarmouth. “These folks are being seen by multiple specialists and right now we don’t have enough coordination between primary care doctors and specialists about medications.”
To combat that problem, Dr. Ahmed always recommends that his patients bring every single bottle of medicine they take to their appointments with him. He then sees whether there are any duplications, which happens far more often than expected.
For example, he might start a patient on a low dose of blood pressure medication. If that patient sees another doctor, that doctor might up the dose. Some elderly patients don’t understand that the second prescription is a replacement prescription and they take both doses every day.
“As a provider, our job should be to cut down on the medications,” Dr. Ahmed said. “Every medication has side effects and, especially at a certain age, you don’t need those medications. You are creating more problems like dropping their blood pressure, which makes them more unsteady. I see this problem on a daily basis.”
The other thing he pays attention to is the individual patient in front of him, rather than clinical guidelines. Despite the guidelines, a lot of older people don’t need medications like statins that are lowering their cholesterol, but may be negatively affecting their liver.
Another example of a dangerous combination is the blood thinner Coumadin and ibuprofen, according to Dr. Ahmed. The combination of the two drugs can lead to a dangerous gastro-intestinal bleed. Osteoarthritis and increased aches and pains mean that a lot of older people, who may be on Coumadin, are taking over-the-counter pain relievers and they don’t always mention it to their physicians.
Help For Patients
Deborah Allwes-Largoza, the director of clinical operations for the Physician Hospital Organization, Cape Cod Health Network, said that patients with more medications and more healthcare visits are definitely at greater risk for problems related to medication.
“So often patients will have more than one provider,” she said. “If you become chronic or complex in your care, you may be seeing three or four doctors. Then all of a sudden you have seven prescriptions or 10 prescriptions that you are on.”
She pointed to a study published in the American Journal of Managed Care on the growing importance of medical reconciliation.
The study noted that a prescription is written in three out of four office visits which is a contributing factor in the estimated 3.3 million serious preventable outpatient medication errors and 1.9 million adverse drug event-related visits to emergency departments each year.
Cape Cod Health Network’s Helping Hands program is a care coordination program that has a licensed clinical pharmacist. The pharmacist goes to qualifying patients’ homes to do medication reconciliation after they’ve left the hospital. Medical reconciliation is the process of comparing one prescription to all the other medications the patient is currently taking. It’s been an invaluable resource, according to Dr. Ahmed, who regularly recommends to patients.
Beware of Herbal Remedies
Anne Marie Kelly, MD, a hospitalist at Cape Cod Hospital also sees a lot of polypharmacy in her practice, and she is always shocked at the number of medications taken by some of the patients she encounters.
“I come across 90-year-old women who are on 30-plus medications,” she said. “If you are 90 years old, you really don’t need all those medications. People don’t understand that everything you take has a side effect and that’s what internal medicine is about – balancing the side effects.”
The topic is controversial because some people do have medications that they have to take for certain conditions. But she questions the wisdom of any patient taking over 20 pills a day and, in her experience, herbal remedies are particularly worrisome.
“Most of the negative outcomes are unfortunately in the elderly population, and elderly patients metabolize medications and herbal medications differently due to declining muscle mass and declining organ function. They are more prone to developing an adverse drug event,” Dr. Kelly said.
Note: As of 5/1/2019, Emerald Physicians joined Medical Affiliates of Cape Cod (MACC), a division of primary and specialty care physicians from Cape Cod Healthcare.