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Prescription overload is becoming a growing concern for those 65 and above.SelectStock/iStockPhoto / Getty Images

It was while working in acute care at McGill University Health Centre that the epidemic of overmedication of older Canadians became clear to physician Emily McDonald.

“We were seeing older people coming in with fall fractures, hip fractures, delirium, confusion,” Dr. McDonald says. “And a lot of it could be pretty easily traced back to medications or combinations of medications that they were taking.”

Going over the list of prescription medications they were taking, it was clear many were not appropriate, she says. The diagnosis was prescription overload.

“It’s a massive problem,” says Dr. McDonald, an associate professor of medicine and director of the clinical practice assessment unit in general internal medicine at McGill University Health Centre.

“More than half of people over the age of 65 are taking more than five medications and when you look in long-term care – the most vulnerable people – they’re taking at least 10 medications a day.”

About 10 per cent of their hospitalized patients take 20 medications, says Dr. McDonald, who is also a scientist at the Centre for Outcomes Research and Evaluation.

“Some people are taking 30 pills a day. They don’t even have an appetite for their meal after they’ve taken their morning pills,” she says. “Their brain is all foggy and cognitively, it’s affecting them.”

Raising awareness about overmedication

In 2015, health care leaders, clinicians, government decision-makers, academics and patient advocates formed the Canadian Deprescribing Network. The network works closely with the Canadian Institute for Health Information, a not-for-profit federal corporation, to raise awareness and work toward eliminating overprescribing and ensuring access to safer drug and non-drug therapies.

“Sadly, while we set out to try and target a 50-per-cent reduction, changing the way we use medications is really difficult,” says Justin Turner, co-director of the network.

For example, Dr. Turner says sleeping pills are one of the most commonly prescribed medicines more likely to cause harm than provide a benefit. One in 13 patients benefits from sleeping pills, while one in six is likely to experience harm, he says. That includes an increased likelihood of falls or cognitive impairment.

Research shows that driving the day after you take a sleeping pill can result in the same chance of a car crash as driving drunk, notes Dr. Turner, who is also an assistant professor in the pharmacy faculty of the University of Montreal.

He says that, through public and health care provider awareness campaigns, sleeping pill prescriptions are starting to decrease a bit across the country.

Dr. Turner points to Denmark, which has taken a more stringent approach.

“If you’re over 70, where the risks of harms get considerably greater, you can have your driver’s license or you can have your sleeping pills. You can’t have both,” Dr. Turner says of the Scandinavian country’s policy. “That was the single most effective policy in the world for reducing sedative use, with a 20 per cent reduction.”

Cognitive therapy is often effective for sleep disorders but in this country, sleeping pills are paid for from one budget and cognitive behavioural therapy or psychological therapy are paid for from another, he adds.

“It’s the same with opioids,” Dr. Turner says. “It’s easy to prescribe an opioid for back pain, for example, because it’s covered, whereas physiotherapy and treatment for that may not be covered. So what are you going to do for a patient who can’t afford physiotherapy? Well, we’ll give them a drug because it’s covered.”

A similar problem leads to high use of antipsychotic drugs in long-term care settings, he says.

Most provinces have signed on to an initiative by the Canadian Foundation for Healthcare Improvement to reduce the use of these medications in long-term care. Dr. Turner says there are success stories across the country and the focus now is to work with policymakers to scale those successes nationally.

Industry statistics show Canada spends $400-million a year on drugs classified as inappropriate and $1.4-billion a year fixing the side effects of those drugs. In some cases, medications snowball over time, getting renewed even when they stop being appropriate.

Most clinical trials also exclude seniors, so their effect on changing senior physiology is unknown. Clinical trials also don’t study the interactions of drugs with other drugs. Add to that Canada’s siloed health care system, with multiple health care providers, and there is no definitive system in place to review a patient’s prescription use.

A 2017 study by the Institute for Research on Public Policy (IRPP) found that on average, two-thirds of Canadian seniors take five or more prescription drugs over the course of a year and a quarter of them take 10 or more.

It was estimated as much as half of those medications were taken incorrectly or overprescribed, increasing the likelihood of adverse drug reactions or interactions, the report said.

How holistic health care can help

A more integrated team health approach has proven effective, with physicians, dieticians, physiotherapists, pharmacists and a whole team collaborating on treatment, says Colin Busby, research director with the IRPP

“It’s this issue of design,” he says. “You need a centralized person who gets information whenever a patient is getting prescribed something. It pops up on somebody’s screen somewhere and they know that this person’s being prescribed a medication, and they can evaluate it.”

Manually, such a review takes 15 to 20 minutes, which means most general practitioners don’t have the time, Dr. McDonald adds.

She and her colleague at the Research Institute at McGill University Health Centre, physician Todd Lee, came up with an electronic tool called MedSafer that aims to fill the void. MedSafer automatically cross-references the medical history, medications and guidelines for safe prescribing for older adults to flag intermediate- or high-risk drugs and potential adverse interactions.

Too often, drugs are being prescribed to treat the side effects of other drugs, she says. Or those side effects are simply attributed to aging.

“We just think, well, dad’s memory is bad because he’s getting older,” she says. “We don’t realize that if you stopped his bladder pill or his sleeping pill, his memory might actually get a little bit better.”

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