As a student and early in my career I had the wonderful opportunity to work with my father, who was also a family doctor. If there was one lesson that he burned into my brain it was that when things weren’t going well for the patient “cherchez la médicament” – look for the medicine (he wasn’t French but he loved the phrase).
That is, at the top of our list of differential diagnoses we should include an adverse drug reaction. This is most especially in the elderly and in people who are on multiple medications. As the number of medications you take increases, your chances of having an adverse drug reaction or interaction increase steeply. And as people age their disease burden tends to increase and more medications are added. Guidelines for care also contribute to this problem. If you have diabetes, for example, there are certain medications most people should be taking to control sugars, to protect the kidneys and to reduce the risk of stroke and heart disease. If you also have high blood pressure or heart disease or COPD, there may be a different list and they add up fast. In addition:
- 40% of older adults living in their own home are on 4 or more medications, as are 21% of people with intellectual disability. In nursing facilities the problem is more pronounced.
- For every dollar Medicare spends on medications it spends $1.33 addressing medication induced problems.
- 10% of hospitalizations are due to adverse drug reactions and 2/3 of them are preventable.
So it’s evident that we should be working to eliminate unnecessary prescriptions and unsafe drugs or combinations of drugs. There are resources to help. The Beers list is a group of medications that simply should not be used in the elderly except in very unusual circumstances and there have been many publications on strategies for addressing polypharmacy. At PCHC we have the good fortune to partner with clinical pharmacists who can provide guidance to prescribers and education to our patients. And there are some common sense rules of thumb:
- Is the original indication for the medication still present or has it resolved? If it is resolved a trial off the medication is prudent.
- Is the drug still appropriate for the patient? Aging, declines in kidney and liver function, new conditions and the addition of other drugs can all impact this.
- If it’s an elderly or other vulnerable patient, is it a drug on the Beers list?
- Is the drug duplicating the effect of another drug the person is taking?
- Is there more than one drug from the same class?
- Does the risk outweigh the benefit?
My experience has been that people are thankful to eliminate unnecessary or risky medication. It is a process that requires communication, education and shared decision making and a prime example of the precept that less is more.