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According to the Centers for Medicare and Medicaid Services, the typical Medicare patient sees two primary care providers and five medical specialists in a year. Sixty percent of seniors are taking three or more medications at a time. And many emergency room visits for older adults are due to adverse drug events.
As a geriatrician, I spend my time overseeing the care of elderly patients and often see problems with medication management. When I meet a new patient, it’s common to discover that he or she is taking 10 to 15 medications. Those medications have accumulated over many years, leading to a higher burden of side effects than benefits. It can lead to a perfect storm of a medication toxicity.
The Situation
Too many medications
Doctors prescribe medications for specific reasons, and the list gets longer over time. Different doctors see the patient for various conditions, and each doctor prescribes medications separately.
As patients age, their metabolisms slow, so medications remain in the body longer, and have a greater impact. Less muscle and more fat cause the body to hold on to some meds longer. Kidney function slows down, and medications metabolized by the liver are slower to clear.
Side effects
As the number of medications increases, so does the risk of side effects, especially for patients in their 80s and 90s. With many medications prescribed by several different doctors, common side effects can include:
- Constipation
- Confusion
- Low blood pressure
The problem can get worse when other medications are prescribed to treat side effects.
Complicated regimens
A National Institutes of Health (NIH) study found 90 percent of seniors age 65 and over take at least one prescription and as many as 55 percent of them take their medications incorrectly. Many elderly patients are on a complicated medication regimen, with doses at several times a day. Medications often have confusing names or look similar, which makes for more mistakes, especially for patients with dementia.
Different physicians could prescribe medications that are dangerous when mixed. For example, a patient could be prescribed an opioid from one doctor, and a sedating sleeping medicine from another, and the combination can be risky.
OTC meds can be overused. NSAIDs such as aspirin or ibuprofen can cause gastrointestinal distress and bleeding while acetaminophen can cause liver toxicity.
The Solutions
Designate one primary care physician
Patients need one captain of the ship—a single doctor or a primary care team. That person or team manages the whole medication list, understanding the benefits and risks of every drug. Periodic review of medication lists can eliminate drugs the patient no longer needs, so the patient gets the right medication, at the right dose, for the right condition.
Keep an up-to-date list of all medications
Patients—and their family members—can do their part. Keeping an up-to-date list of all medications at all times is essential. That list should be electronically updated, and should include OTC medications, vitamins and herbal remedies.
Start low, go slow
As patients age, they may react more strongly to medications. For that reason, “start low, go slow” is a valuable maxim. For example, for the anti-depressant sertraline, one should start patients at the lowest dose and gradually increase the dosage, until the patient has a positive effect with minimum side effect.
Simplify the medication regimen
We can often safely cut the total number of medications in half for a new patient. Prescribing a medication three or four times a day is asking for failure. Once-a-day dosing is the gold standard, to ensure that the patient takes the right medication each time.
Use one pharmacy when possible
The pharmacist can identify medications that are contraindicated or duplicated, if the medication list resides at one pharmacy. If patients use one pharmacy, the pharmacist can look for interactions, and educate patients about possible side effects.
It’s important that we provide comfort and relieve suffering for people at all stages of life. The vast majority of elderly patients do not develop a drug dependency on opiates; in fact, a good number use less than they need. And in the later phase of life, medications can be stopped or adjusted, to focus mainly on relief of symptoms with minimal side effect.
