Report: Older Americans still take too many medications.

Diagnosis? Prescriptions!

It’s no secret that drugs can interact. Some interactions increase while others decrease the intended effects. In many cases, drugs can have overlapping side effect profiles, making serious adverse events more likely.

Photo by Towfiqu barbhuiya on Unsplash

For clinicians managing multiple medical problems in a single patient, keeping tabs on all of these potential problems is no small feat. While there are online drug interaction checkers, the problem is that an almost infinite number of combinations exist, and no two patients are alike. In addition, many side effects listed on drug labels are rare, and some are not even related to the drug itself in any statistically meaningful sense. There’s a lot of noise to sift through.

Not all drug interactions are equal. But what matters is often misunderstood.

Then there’s the severity of drugs interactions to consider. Consider someone taking certain statins who is prescribed Paxlovid for Covid for 5 days. This is a “no-no,” according to the drug labels. But the real risk of a significant problem is probably pretty small.

In my experience, the biggest concerns that patients and doctors have are specific drug-drug interactions—especially ones that were favorite trivia questions on medical licensing tests (there must have been some kind of St. John’s wort fad when a bunch of these questions were written.) I’ve seen indignant clinicians erupt with self-righteous indignation upon discovering that a patient is on two drugs that might interact (and which certainly did on those old board exams).

But those same people don’t bat an eye at something much more dangerous than most of these individual drug-drug interactions: a patient whose list of daily medications is simply way too long.

The latter problem—too many drugs, rather than the identity of many of the drugs themselves—is usually far more dangerous.

Diagnosis? Prescriptions. A new study shows older Americans are likely over-treated.

Taking too many different kinds of medicine—even ones that are otherwise quite safe—can be very dangerous. The situation has a name: polypharmacy. A common definition is routinely taking more than 5 medications per day.

A new study published in JAMA Internal Medicine found that over the first two decades of the century, rates of polypharmacy in older US adults have not improved, despite growing awareness of the problem. In the early years of the century, polypharmacy actually increased, leveling off after around 2007. The overall rate of polypharmacy in older US adults is (as of 2020) 43%, up from 24% in 2000.

While that sounds bad, more alarmingly (to me) is that the rate of hyperpolypharmacy (that is, taking 10 or more medications on a regular basis) among older US adults increased from 1.8% to 6.1%.

The reason I’m more worried by the 6% rate of hyperpolypharmacy than the 43% of “mere” polypharmacy, is personal experience. I’ve seen that patients on more than 10 medications are much more likely to have dangerous side effects or related events (like devastating falls) than those who are “just” on 5 or 6 medications. Plus, the more medications there are on board, the harder it is to figure out which ones are causing the problem. That makes preventing the next fall harder than it might seem.

Here’s an important wrinkle. Doctors really are trying to do the right thing. We are aware that prescription medications can cause harms to older patients, and this latest study provides system-level evidence of its persistence. The percent of older people taking particular medications known to have higher risks of important side effects in the geriatric population fell, from 48.8% to 44.6%. That would suggest that clinicians are doing their best to shield their patients from drugs that they know are on “prescribe with caution” lists.

This all tells me two things:

1. Doctors know about the problem of polypharmacy and higher-risk medications for older people.

2. It’s easier for doctors to swap in “safer” medications than it is to discontinue a treatment altogether.

That leads to…

Prescription: Stop prescribing!

During the last couple of decades, experts have looked into a simple but challenging solution to the problem: Stopping. That is “deprescribing” medications.

It goes like this: Does a patient take too many medications? Just stop prescribing some of them. Studies have shown that doing this is safe and feasible, and that doing so makes a real difference, helping patients and saving money.

That said, apparently, deprescribing medications is not always so easy. It takes effort, and some methods work better than others.

Deprescribing is easier said than done. Here’s why…

I can see why deprescribing is easier said than done.

First, we can assume that every medication a patient takes was prescribed with good intention; to help a patient with a problem. So, it’s anxiety-provoking for doctors and patients alike to contemplate de-escalation. It’s hard to know whether stopping an antacid will lead a patient to have more suffering. (Turns out probably not, another recent study shows, but in the trenches, it’s not easy).

Second, it’s not clear which medications are dispensable at any given time. A drug (like a statin) might help a patient over many years. So stopping it could have effects down the road. I can see why it’s scary for a doctor to discontinue a medication like that (even though in many cases, the benefits are slim at best). Meanwhile, stopping a pain medication like an opioid might carry short-term discomfort, but be extremely beneficial in the long-term.

In short, polypharmacy is a problem that is easier to solve in theory than in reality. But it can be done. From what I’ve read, the most successful strategies are the ones where clinicians aggressively deprescribe a high number of medications all at once—let’s not say “with recklesss abandon,” but you get the point. Rip off those Band-Aids! In other words, a patient on 20 daily medications perhaps needs to be on just 6. Decreasing the count from 20 to 16 may feel like progress, but it’s likely inadequate. Go big, my fellow clinicians! At least, that is what the research suggests.

My real-life experience.

In the ER, I often see patients who have just had some scary event, like a fall or passing out suddenly. Sometimes I notice the patient’s list of home medications is long. When that happens, I often mention polypharmacy to the patient or their family. Frequently, they agree. (Sometimes they ask me about it. I am always glad to engage in that conversation.)

Once pointed out as a problem, polypharmacy makes sense to patients and their families. A series of well-meaning decisions have added up to something more dangerous than helpful.

What can I do? The problem is that I, an ER doctor, can’t be the one to deprescribe these medications most of the time. This needs to be done by an outpatient clinician who follows the patient closely over time. So, the best I can do is to email a patient’s doctor, or write a note about the concept in a patient’s chart or in their discharge instructions.

Do I do this? Yes. Is it enough to make a difference? Maybe once in a while.