Deprescribing in the Elderly
My mom had emphysema, heart failure, high blood pressure and high cholesterol. I’m a nurse practitioner and I felt overwhelmed looking at her med lists and I wasn’t the in-town caregiver so I didn’t have to manage them. I was always shocked that my mom could keep her meds straight until the very end of her life. She was whip smart about her inhalers, what meds were for and how they helped her. She knew the side effects and could explain why they were worth taking anyway. Her cardiologist and pulmonologist really partnered with her- they trusted her and she trusted them.
My dad had diabetes, high blood pressure, high cholesterol, gout and a host of other issues that he was prescribed meds for. In the polar opposite way they tended to live their lives, he didn’t really like to take his meds- a source of FREQUENT discord between my parents.
My patients are often on more than ten medications at a time. Not including supplements. It is not uncommon that I am not 100% familiar with every medication prescribed to them. Especially if specialists are involved.
So the question remains: does your senior need all these meds? With all of the unpredictability that comes with aging, sometimes it's hard to know, and harder to know if there anything you can do about it anyway. So let’s dig in.
Older adults are more likely to take more medications for several reasons. They are more likely to have multiple chronic health conditions requiring prescriptions. For these conditions they are more likely to need specialists who tend to care the most about the conditions they treat and therefore less likely to take a person’s overall health into account. Primary care providers are in the position to orchestrate long medication lists for patients but they may be hesitant to change medications they are less familiar with- hence the need for specialists! Patients themselves are afraid to stop medications they have taken for years, sometimes decades. If it ain't visibly broke, why fix it? There is also something called a prescribing cascade. Translated, this means that things start off innocently enough. An older woman has arthritis so she takes ibuprofen which causes her blood pressure to rise so she is prescribed a blood pressure medicine that causes her ankles to swell. She then gets a prescription for a diuretic to help the swelling go down. This makes her go to the bathroom a lot and she might be having accidents. Someone else might prescribe medication for an overactive bladder. And so on and so on. You've read If You Give A Mouse A Cookie, right?
You should know, though, that there are good reasons for older adults to consider decreasing their medications. Research has shown that patients taking five to nine medications have a 50% change of an adverse drug interaction. Polypharmacy, defined as taking 5 or more medications, accounts for almost 30% of hospital admissions.
Seniors are more susceptible to medication side effects. It is no surprise that the body changes with age. The gastrointestinal (GI) system has decreased blood flow and slowed transit time which can alter how medications are processed by the body. Liver and kidney function can decrease as we age and this also affects how medications are processed. Older people have decreased muscle mass and therefore a higher percentage of body fat so some medications are not processed as quickly.
With doctor’s appointments being so short, it’s hard to focus on comprehensive care at every visit. There is a lot going on in an appointment and it is easy to get sidetracked. Many times people have been on medicines for years and they are taking something more out of habit or because they are trying to be “good” patients. Doctors sometimes forget to check in on long term medications and consider- does this person really need to be taking this? I can’t tell you how many people assume that once you start a medication you have to be on it forever. This is not true! I try (but do not always succeed) to review each medication with my patient and ask- What does this medicine do for you? Do you still need it? Do you still want it?
If you haven’t already, print out a medication chart. Make a list of every medicine your senior takes- including vitamins and medicines used only occasionally (like ibuprofen). If it is feasible, do this with your senior so that you can get a better sense of the medication situation. Frequently seniors keep medicines in different places. Sometimes they have multiple supplies or older expired medications. Organize the set up if they are willing and if it makes sense to (some, like my mom, can keep it straight). If they aren’t willing to move or organize the system, at least write it all down and keep the list handy- take a picture of it and save it on your phone. Text it to anyone who might be taking your senior to the doctor. Review it after every doctor visit (or quarterly? Once or twice a year?). Sometimes in this review process you will notice that your senior is confused about their medications. This could be a symptom of cognitive impairment if this was not previously a difficult task for them. It could also just be hard if there are a lot of medications that sound the same!
If your senior is not cognitively impaired they will most likely be able to tell you exactly what they like or do not like about a given medication. Ask them if they know about alternatives or if they want to talk to the doctor about stopping the medicines. Who knows? It might be an option. Some medications are used to relieve symptoms of a condition more than treating the actual condition so it is always wise to check and see if people are still having the symptom they are taking the medication for. Some seniors are afraid to ask about stopping medications because they were raised to be deferential to doctors. Remind them that they are partnering with the doctor. I always tell my patients “I know a lot about medicines but you are the expert in you. We need to put our heads together to figure out how best to take care of you.”
It is also very true that there are medicines that people want to take that their doctors wish they wouldn’t take. There are many medications that can increase risks of adverse effects. For example, regular NSAID use (like ibuprofen or aleve) can increase risks of GI bleeding or worsen kidney disease. Antihistamines are often used for sleep and they can increase risk of confusion, falls or urinary problems.
If your senior has dementia or is otherwise not capable of having this conversation you might be in the position to direct this conversation with their doctor. If your senior lives in a long term care facility ask for a meeting to review the medication list and decide if your senior still needs all the medications.
VERY IMPORTANT ALERT!
Do not attempt to stop or change your senior’s medication on your own. Because of the aforementioned physiologic changes with aging, many medicines cannot be abruptly stopped, they need to be tapered. Always ask your senior’s doctor for advice.
If you want to have a conversation about decreasing or stopping medications for your doctor, be sure to make this the focus of the visit or at the very least notify them a day or so in advance of the appointment. This gives them time to study the medication list and be able to make recommendations or offer guidance.
Patients are savvier and the healthcare system is catching on that we need to be careful about the number of medications our seniors take. Partner with your seniors doctor and if they aren't the partnering type then advocate- be the squeaky wheel. Fewer medications can decrease hospitalizations and heaven knows you have used enough of your PTO for the doctor visits.
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