The Atlanta Journal-Constitution
The hidden drug epidemic among older people
The elderly are particularly vulnerable to polypharmacy, or taking a multitude of drugs.
While news reports focus on an epidemic of opioid abuse among young adults, another totally legal and usually hidden drug epidemic is occurring at the other end of the age spectrum: the fistfuls of remedies — both prescription and over-the-counter — taken by older adults.
According to the American Society of Consultant Pharmacists, people ages 65-69 take an average of 15 prescriptions a year, and those ages 80-84 take 18 prescriptions a year. And that’s in addition to the myriad over-thecounter drugs, herbal remedies, vitamins and minerals they may take, any of which — alone or in combination — could cause more problems than they cure.
Among people over 65, 44% of men and 57% of women take five or more nonprescription and/or prescription drugs a week, and 12% take 10 or more.
Many of these supposed remedies are unnecessary or used incorrectly and can result in distressing and even dangerous side effects. For example, taking aspirin or a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen could increase the risk of bleeding in patients on a pre
scribed anticoagulant like coumadin.
The problem of polypharmacy, as the multitude of drugs is called, and the side effects they cause is largely a result of our fragmented health care system, rushed doctor visits, and direct promotion of drugs to patients who are ill equipped to make rational decisions about what to take, what not to take, and when.
The elderly are particularly vulnerable to polypharmacy and a too-frequent consequence known as a “prescribing cascade” — in which still further medications are prescribed to treat drug-related side effects that are mistaken for a new medical condition.
One common example is the use of anti-Parkinson therapy for symptoms caused by antipsychotic drugs, with the anti-Parkinson drugs in turn causing new symptoms like a precipitous drop in blood pressure or delirium that result in yet another prescription.
Further contributing to this problem is the fact that doctors do not routinely question patients about their use of nonprescription remedies, and patients rarely volunteer this information unless asked directly.
Consumers typically decide what supplements to take based on internet postings or advice from friends. Yet one review of 338 retail websites for the eight most widely used herbal supplements revealed that 80% made at least one illegal and unsubstantiated health claim, with more than half suggesting that the substance could treat, prevent or even cure a specific condition.
Even doctors who are wellinformed may have difficulty determining the best or safest medications to prescribe for their elderly patients because most of the studies done to gain marketing approval deliberately exclude older people or those with an unrelated chronic health problem.
Thus, prescribing doctors may not know if the drug they order is safe for patients with, say, kidney or liver impairment who may require a lower-than-usual dose or a different drug entirely. A good drug that is not appropriately prescribed could be worse than no drug for patients.
Medical judgment is often required to enhance safety. To foster compliance with prescribed remedies and minimize the risk of side effects for older patients who require multiple medications, doctors may choose to “underprescribe” and prioritize treatments for serious conditions already diagnosed over preventive therapies for conditions with a less immediate effect on patients’ quality of life.
On the other hand, some drugs prescribed years earlier may no longer be necessary and can be safely discontinued. The patient, for example, may now have a short life expectancy that renders pointless a preventive medication taken to lower cholesterol or increase bone density. However, it is important to gradually taper many drugs to avoid dangerous symptoms caused by an abrupt withdrawal.
Affordability is yet another consideration. Even with insurance coverage for prescription drugs, many newer, more effective medications involve copayments that strain the budgets of the elderly. Patients may decide to skip doses or cut drugs in half to make them go further, and in doing so render them less effective or ineffective.
Changing one’s habits and lifestyle may be a more effective way to save money and, at the same time, prevent adverse drug effects. For example, patients who lose weight and reduce their sodium intake may be able to avoid or discontinue medications taken to lower blood pressure. Likewise, drug therapy may become unneeded by those with Type 2 diabetes who adopt a Mediterranean-style vegetablerich diet, lose weight and exercise regularly.
As many as 1 in 5 adverse drug reactions among older patients who live out in the community result from mistakes made by the patients themselves, especially if they take three or more prescribed medications. To minimize this risk, experts recommend that patients maintain an accurate list of all their medications that includes what the various drugs are supposed to treat, their generic and brand names, dose, frequency and method of administration.
In addition, patients should keep a list of all overthe-counter remedies and supplements they take regularly or frequently. Then, at each medical visit, bring both lists along and make sure the doctor reviews them.
If list-making is more than the patient can handle, another option is to do a “brown-bag checkup,” in which the patient brings all pill bottles they are taking to each visit. And always keep all medications in their original containers with attached labels that may include cautions like “take with food” or “take on an empty stomach,” which means taking it at least one hour before or two hours after eating.