Polypharmacy
Avoiding a pile of pills for the elderly
Imagine that you have passed your 75th or even your 85th birthday and your personal physician suddenly says that despite your having a number of chronic diseases, you should discontinue taking some of your pills. You are likely to get angry, thinking that your health fund wants to save on you.
Yet “deprescribing” some medications in older people, based on advice from a clinical pharmacologist or geriatrician, can be a good idea – the main aim not to save money but to improve the patient’s functioning and quality of life.
The phenomenon countered by deprescribing is polypharmacy, the objective term for the use of numerous medications, usually five or more daily. But the term usually refers to excessive or superfluous use of drugs and potential harm – a worsening of their condition and even death.
Prof. Doron Garfinkel, a 69-year-old expert in polypharmacy and who was head of the geriatric palliative department at the Shoham Geriatric Center in Pardess Hanna, has devoted many years to assessing the genuine drug needs of the chronically ill. He is an untiring advocate of gradually getting elderly patients to stop swallowing unneeded pills; if properly implemented, he said in an interview with The Jerusalem Post, they will suffer no untoward effects and will probably function better.
He wages his campaign as geroatroc-palliative consultant at Wolfson Medical Center in Holon and as deputy head of the Israel Cancer Association’s Home Care Hospice; the home hospice employs a highly experienced interdisciplinary team of professionals who have treated many terminal patients, and he has educated others in palliative care.
Garfinkel is one of the leading figures in the growing international struggle to reduce polypharmacy and inappropriate medication use. His wealth of both clinical and management experience, combined with decades in academia and research have shaped his unique perspective and approach. He is the epitome of a vanishing breed of physicians showing compassion and ethics in treating the individual, yet with up-to-date knowledge and exceptional diagnostic skills, and a revolutionary vision of what medicine should be.
“I established the International Group for Reducing Inappropriate Medication Use and Polypharmacy (IGRIMUP),” Garfinkel told the Post. “THE VICIOUS circle of age-related diseases, many experts, guidelines and drugs fuels the 21st century epidemic of inappropriate medication use and polypharmacy,” he declared. “There are no evidence-based medicine guidelines for treating older people with numerous chronic diseases, and there remain gaps in knowledge regarding dosage requirements. For all drugs, the positive benefit/risk ratio is decreasing or inverted in correlation to very old age, comorbidity, dementia, frailty and limited life expectancy.”
Many doctors are reluctant to deprescribe for their elderly patients because it’s easier to prescribe what they have for decades given patients and they fear lawsuits and complaints, said Garfinkel. “Doctors are frustrated facing uncertainty regarding the effectiveness of strategies to reduce polypharmacy and the lack of evidence-based medicine indicating when to deprescribe when patients have several conditions.”
His “Garfinkel Good Palliative Geriatric Practice” method, in the form of an algorithm, encourages canceling the use of as many drugs as possible at the same time, giving high priority to the preferences of patients and their families. It has been proven highly effective and safe in nursing departments and elders dwelling in community settings, having significant economic benefits as well.
The internal medicine and geriatric specialist has more than three decades of experience giving instruction and lectures to doctors, nurses, medical students and various health care professionals at Tel Aviv University, the Technion-Israel Institute of Technology and others and has published several dozen original articles on a variety of geriatric topics.
Too little is known by physicians and pharmacologists about the drug interactions and efficacy of many medications, which have been tested on younger people but not among very elderly and institutionalized patients, he said.
“In this population, polypharmacy can result in high copayments for drugs, leaving patients with less income for food and other needs and ultimately causing a lower quality of life and decreased mobility and cognition.”
“Many researchers recommend stopping the taking of anticoagulants in people with dementia,” Garfinkel continued. “Don’t continue all drugs automatically until a patient dies. Medications can be great, but sometimes, less is more,” the fourth-generation resident of Rishon Lezion and graduate of Tel Aviv University’s Sackler Faculty of Medicine said.
“I don’t deal with younger people,” he says. “At 50, there are still good guidelines on what drugs to prescribe. Above 70 or so, we have much less knowledge, especially if someone has numerous chronic disorders. Medical students are taught when to start medication, but not when to stop.” HE RECALLED the typical case of a 73-yearold man on hemodialysis for kidney failure who was diagnosed with Alzheimer’s disease. “With his family’s consent and declared preferences, six of his 10 prescribed medications were stopped.” Dramatic improvement was evident within two weeks, with sharply increased cognitive and functional improvement, Garfinkel recalled.
“On a Mini-Mental cognitive score evaluation given at the beginning, his score was 14/30; following cessation of the medications he attained a score of 30/30 – normal. He was able to return to active community life and underwent a kidney transplant a year later,” says Garfinkel.
Another case was an 88-year-old woman who had been taking a drug for 17 years after being diagnosed with breast cancer. But this pill should be taken only for five years, Garfinkel notes. “She also took aspirin, but it caused hemorrhaging and a high dose of diabetes medication, even though her blood sugar level was low. She weighed only 37 kilos and was extremely thin. I recommended to her daughter that she stop taking seven out of eight drugs, and the woman gained 15 kilos with no sign of diabetes. She felt great and lived for another two happy years.”
At the University of Istanbul, Prof. Gulistan Bahat conducted research using my method and found that patients who stopped taking certain drugs unnecessarily suffered fewer falls and enjoyed improved health. It’s a win-win situation.” ALTHOUGH THE Health Ministry is aware of the problem of polypharmacy – and realizes that reducing unnecessary use of drugs can improve patients’ quality of life while saving much money for the health system – it has not done very much about it in the field, Garfinkel continues. This year’s State Comptroller Report criticized the ministry for failing to ensure the training and employment of clinical pharmacologists to advise elderly patients. And, he says, even though Health Minister Ya’acov Litzman said he “will meet with anyone who asks,” the minister “has not yet agreed to see and hear me.”
“It’s frustrating to be ignored here,” Garfinkel commented. “Why are Turkey and other countries excited and even invite me to discuss my method, while the Health Ministry in Jerusalem and all the health funds that pay for superfluous medications are not adopting it here?”
For many years, the ministry has said deprescribing for polypharmacy was “not applicable in Israel, even though I present lectures about it at conferences all over world and my articles are published in important medical journals. I wasn’t told why it was not applicable and why the minister was not ready to hear about my method,” said Garfinkel.
Health funds that pay for superfluous drugs are likely to appreciate Garfinkel’s work, but “I am told that the pharmaceutical companies have create a voodoo doll of me and stick pins in it,” Garfinkel joked, referring to the reduction of medication usage in such patients.
One of the public health funds, Leumit (which is the smallest of the four), is conducting a project on polypharmacy and deprescribing. Dr. Avivit Golan-Cohen leads a team that has included elderly patients taking more than eight drugs. Then there will be an educational intervention to teach the Garfinkel algorithm to groups of doctors and give lectures on how to reduce the taking of certain drugs.
For example, in patients over the age of 70 or so, it has not been proven that statin drugs – which reduce cholesterol levels in the blood – benefit patients or extend their lives. Statins and other such pills that are not immediately lifesaving but rather preventive can be stopped by a qualified expert for three months. “Very elderly people who get drugs to lower their blood pressure can become weak and confused, and when they get up in the middle of the right to go to the bathroom, they can fall and break a hip. I recall a 93-year-old’s list of drugs. He was getting statins, allegedly for high cholesterol, even though it hasn’t been proven that taking it over the age of 70 reduces mortality. It actually weakens the muscles and can debilitate the very old even more.” There are elderly people who take three identical hypertension drugs, some with generic names and others with commercial names. The method is not just about stopping drugs. Once they are taking fewer, I also discover some patients suffer from depression, which can be treated. I change drugs and people change for the better; they become more active,” said Garfinkel.
After the consultation, Garfinkel typically writes patients and their physicians a lengthy letter that includes a review of the evidence for their medications and his suggestions of medications to discontinue or reduce. In some cases, he also proposes starting new medications – most often, antidepressants and/or psychotherapy or non-drug therapies. “Sometimes I’m the first one to tell the patient’s family that their loved one is depressed. I enjoy seeing how the method’s use changes the condition of patients,” he said. “One has to sit with each patient for an hour or so and then spend hours evaluating and writing a report. The problem is that family doctors usually have seven minutes to give each patient. Instead, the chronically ill need personal case managers.”
When terminally ill patients are taken care of in “home hospices” by their health funds, Garfinkel has found that some of them are given many unnecessary drugs that cause suffering and don’t help. “Some oncologists say: ‘Give terminal cancer patients drugs, because they give them hope.’ But at this stage, they are not effective,” he insists. In a new, yet-unpublished study with follow up of more than three years, Garfinkel proves that a rational deprescribing of six or seven medications was associated with improved functional, mental and cognitive status and a better quality of life, as compared to older people who continued taking 10 or more drugs. This and other studies of several IGRIMUP international experts in deprescribing will be presented in two symposia at the upcoming World Congress of Gerontology and Geriatrics in San Francisco next week. One session with Garfinkel as a speaker and chairman was chosen as a presidential symposium.
If somebody has a heart attack, it’s absolutely legitimate during the first year to give him aspirin, an ACE inhibitor and a statin. That is not superfluous medication. But if every time a patient goes to the hospital he is given two or three new medications and continues to take others he doesn’t need anymore, that could be polypharmacy, Garfinkel explains.
After assessing a patient’s needs, Garfinkel usually eliminates one medication at a time and follows him up to see if his condition has changed for the worse. If there is a decline, he represcribes the medication – but this has occurred in only a minority of cases. Garfinkel’s research in geriatric nursing departments demonstrated that as many as nine out of every 10 medications prescribed for patients hospitalized in long-term nursing departments were unnecessary.
As for public or private pharmacists, Garfinkel said he doesn’t understand why some fill prescriptions without questioning whether the patient needs all of the medications. “And why don’t all the health funds supervise the drug-taking of their members? Eliminating unnecessary or harmful drugs saves in hospitalization and lowers drug costs,” he concludes.