Seniors take a mind-boggling number and variety of drugs.
Two-thirds of Canadians over 65 have five or more different prescriptions, and one-quarter take 10 or more prescription drugs. The older you get, the more drugs you take. More than 40 per cent of senior seniors (85 and over) take 10 or more drugs.
In institutionalized care, nursing homes or long-term-care facilities, the numbers are even higher. It is not unusual for patients to have 20 to 25 prescriptions, their lives a non-stop ritual of pill-popping and trying to manage the side effects.
While most prescribing is well-intentioned, it’s also unco-ordinated; there is a tendency to overmedicate and leave people on drugs for too long.
With a growing body of research showing that polypharmacy – the simultaneous use of multiple drugs – can lead to all manner of unexpected interactions, a new group of clinicians, researchers and patient advocates has decided that this madness must end.
The Canadian Deprescribing Network has set the lofty goal of reducing unnecessary and inappropriate medication use in seniors by 50 per cent by 2020. The initiative is part of a growing and welcome trend to question the “more is better” approach to medicine. Choosing Wisely Canada, for example, has a high-profile campaign to try to reduce the number of unnecessary tests and treatments. They have already published 160 recommendations.
The Canadian Deprescribing Network is focusing its efforts on three classes of medication that are the most overused, misused and potentially harmful:
Benzodiazepines: Sedatives that are often used to treat insomnia or other sleep problems. But drugs such as Valium and Xanax leave patients drowsy, and that is a major contributing factor to falls and motor vehicle accidents. Benzos are also quite addictive, so if patients stop taking them, they have trouble sleeping, perpetuating a vicious cycle;
Proton pump inhibitors: Drugs used to treat heartburn and ulcers such as Nexium and Losec are quite effective, but long-term use is problematic, as studies have shown an increased risk of fractures, pneumonia and C. difficile, all conditions that can be particularly harmful for seniors;
Glyburide: A diabetes drug that is used to control blood-sugar levels. Because the body’s ability to produce insulin wanes as we age, diabetes is commonplace among seniors, affecting one in four. Glyburide does cause significant hypoglycemia and is considered to be an inappropriate medication in the elderly.
Another obvious target for deprescribing is antipsychotics, which are often used to treat agitation and aggressiveness in patients with dementia. A recent study found that half of nursing home patients are prescribed antipsychotics, even though few actually suffer from psychosis. This is a situation often described as “chemical restraint.”
Heart drugs like statins are another area where there is a crying need to scale back prescribing. Looking at these drugs in isolation, however, understates the larger problem of polypharmacy.
Research clearly shows that the more drugs a patient takes, the greater the risk they will suffer an “adverse event” – harm caused by their treatment. An Australian study showed that if a patient is taking two drugs, the likelihood of an adverse event is 13 per cent; at four drugs, that increases to 38 per cent; and once you take seven or more drugs, it jumps to 82 per cent.
Right now, prescribing drugs is easy – and often expected. Patients want a magic pill for every woe. If appropriate prescribing is going to be the norm, then deprescribing has to become a routine part of care. That means we need not only guidelines for prescribing, of which there are thousands, but guidelines for deprescribing, of which there are a handful.
We also have to give physicians the time (and proper payment) for doing detailed medication reviews to make sure drugs that patients are taking are appropriate and that interactions can be minimized.
In 2014, Canadians spent $28.8-billion on prescription drugs. How many of those prescriptions were unnecessary, inappropriate or harmful?
The waste is certainly in the billions. But, beyond the money, the real issue is quality of life. The extent to which our elders are drugged and left in a pharmacological haze is nothing less than slow-motion geronticide.
Editor's note: An earlier version of this column incorrectly included the drug metformin in a reference to drugs that should be avoided for the elderly. The reference to diabetes drugs also incorrectly said they can damage the kidneys. The story has been corrected.Report Typo/Error