In last week’s Newsletter I talked about innovation in health sciences. How it is benefitting the ageing around the world. However, has it gone too far? One third of all prescription drugs in the US are taken by the elderly. This is not necessarily surprising. They are most likely to suffer from chronic diseases. But ambulatory elderly are filling between 9 and 13 prescriptions a year. Their companions in nursing homes are averaging 17. These are wonder drugs and enable people to live normal lives. But are we overdoing it?
Over the last 20 years the number of older people taking 5 or more medications has quadrupled from 12% to 49%. More importantly the number of people taking no medication has dropped. It has gone from 20% to 8%. One fifth of patients discharged from hospital have a drug related complication afterwards. A study of 200,000 older US veterans with diabetes found half were over prescribed. They could safely drop a blood pressure or “blood sugar reduction” medication.
Multiple Drugs and the Ageing
Age brings with it chronic diseases. UK data shows that 65% of the over 65’s have two or more. For the over 85’s that rises to 82%. The bad news is that older people are managing complex medical regimes. The good news is that diseases such as hypertension, diabetes; arthritis can be managed.
There are dangers with the taking of multiple drugs especially when you are old. Your body’s ability to metabolize drugs goes down. You are more susceptible to adverse side effects. A sleeping aid that would leave a young person wide awake in the morning leaves you still dopey. Many drugs are not tested specifically for the old. Drug trials often are under-represented when it comes to older people. A survey of 302 US cancer drug trials in 2018 looked at the age of the participants. It turned out that the people in the trials were 6.5 younger on average than the likely age of patients for the drugs.
Drugs trials seldom look for interaction effects with other drugs. There are two many permutations to consider. There is always a danger of a “prescription cascade”. The sleeping drug leaves you mentally slow. Doctors prescribe another drug to help with those symptoms. That drug causes side effects and on it goes. Sadly, some side effects are ascribed to ageing. Such effects include tiredness, sleepiness, constipation, diarrhea. The average Medicaid patient in the US will see seven different doctors in a typical year. A recent survey showed half had a prescription from more than one doctor. As one doctor put it “Medical systems are designed to put people on to drugs not take them off”. The impact is compounded by the purchase of over-the-counter drugs by patients.
The Burden of Medication Management
The burden on old people of managing their pill taking increases with age. For those suffering from loss of concentration the burden falls on the family. When asked, older patients want to feel better and will take a new medicine. Their biggest concern is how to fit the pills into their daily routine! This is something that doctors seldom take into consideration. Whether the pill is taken twice a day, or three times has a big impact on people’s lives. This is important because the patients are an integral part of managing disease. The doctor needs the patient to describe symptoms. They need them to take the pills when told. Side effects must be understood and described.
How to Cancel a Prescription
It is not easy. Surveys show that only a third of patients ever ask a doctor to take them off a drug. The doctors themselves may not have the systems or knowledge to unpick a treatment regime. Drugs may have been prescribed over many years. The doctor needs the patient to explain the history and the symptoms.
Sadly, health literacy is low. This has been measured across the world. It is thought of in two domains. Can a patient “understand health information well enough to know what to do”. This includes everything from being able to read labels or follow instructions. The other measures a patient’s ability to “engage actively with healthcare professionals”. In the UK, low literacy levels on “understanding” range from 15-21% depending on the question. It is higher at 22%-35% for “engaging with doctors and professionals”. In the US 35% of adults are not capable of understanding instructions. There are people who cannot even read the label or the poison warning.
There is a communications gap. The average patient will remember only half of a conversation with a doctor. Two-way communication is key. Unfortunately, the most common thing a doctor forgets to tell you about a treatment turns out to be when to stop. After operations serious painkillers are prescribed for a maximum of four weeks. Studies have repeatedly found patients still taking the drugs after three months.
There is a psychological effect. Being told that your drug can be replaced with exercise, or a better diet, is not necessarily always accepted. Removing painkillers and replacing them with exercises for a bad back may not seem like a fair exchange. If the combined side effects have become the norm, why change? At the same time removing a drug can be seen as an attempt by the doctor to save costs. Worse still it can be interpreted as “giving up on the patient”.