Geezerville is awash in drugs — and I’m not talking about the recreational variety. By some estimates, two-thirds of seniors take five or more medications every day. For some, the pills are life-giving; for others, they cause more problems than they solve. It’s this mix of promise and peril, experts say, that makes it so difficult to convince older adults to “deprescribe.”
In the most recent example of this conundrum, researchers at the Regenstrief Institute last week released the results of their efforts to alert physicians and their patients about the proven dangers of popular anticholinergic drugs. Numerous studies have suggested that people taking these medications — used to ease the symptoms of conditions ranging from Parkinson’s to incontinence — for three months or longer are much more likely than short-term or non-users to develop dementia. The research team inserted warnings in the electronic health records of patients using the drugs at a number of clinics and tracked the response. What they discovered was not inspiring: The alerts didn’t just go unheeded; 85 percent of them were never even read by the physicians.
“Deprescribing is very complex and rarely prioritized over common medical problems during visits with primary-care providers,” explains lead study author Noll Campbell, PharmD, research scientist at the Indiana University Center for Aging Research at Regenstrief. “Very few of the alerts were viewed by either recipient, so we are now evaluating how we can change or improve this approach.”
To hear Leslie Hawkins tell it, the only way to drop the drugs that are no longer useful is to demand a doctor’s attention. Hawkins’s 93-year-old mother, Mary Harrison, was taking 14 medications each day to address multiple chronic conditions, including diabetes, neuropathy, hypertension, and anxiety. Still, she was lively and sociable — until she suddenly wasn’t.
“She was out of it,” Hawkins tells Paula Span in the New York Times. “She couldn’t hold a conversation or even finish a sentence.”
Alarmed, Hawkins took her mother — and a list of her medications — to see Stephanie Nothelle, MD, a gerontologist at Johns Hopkins Hospital. While the results of a cognitive test were dismal, the list of drugs offered some hope. “I started chipping away at them,” Nothelle says.
First to go were oxybutynin, designed to calm an overactive bladder but notorious for causing delirium and confusion; and Tramadol, a pain reliever that tends to contribute to falls. Next up: gabapentin, a neuropathy drug; a diabetes medication that pushed Harrison’s blood sugar to dangerously low levels; and a prescription for an unnecessary reflux pill.
Ten months later, mostly due to her daughter’s insistence on discussing medications at every doctor’s visit, Harrison trimmed her drug list from 14 to four. “She was a completely different person,” Nothelle recalls. “She was awake, she answered my questions. It was night and day.”
Harrison is luckier than most. It’s not uncommon for older folks to gradually accumulate medications as they report additional symptoms over the years, and despite the likelihood that mixing a number of drugs will eventually yield unintended results, our dependency on prescriptive recommendations often discourages rational decision-making.
Nothing illustrates that confusion more clearly, it seems to me, than a 2018 JAMA survey Span cites that found most respondents willing to reduce the number of drugs they were taking, while also arguing that all of them were necessary.
“We spend hundreds of millions every year to bring meds to market and figure out when to start using them, and next to nothing trying to figure out when to stop them,” notes Johns Hopkins epidemiologist Caleb Alexander, MD.
Deprescribing advocates like Campbell and his colleagues struggle to gain traction not simply because seniors are often confused about their options or wedded to a particular treatment approach. The real problem is that our entire healthcare system tends to focus on addition rather than subtraction.
The various specialists we consult over the years send us to the pharmacy with little regard for the drugs other specialists have previously prescribed. Your primary-care physician, meanwhile, probably won’t be aware of all these medications unless you arrive, like Hawkins, with a list — and the determination to force a discussion.
“There’s a general bias toward doing things in medicine,” explains Ariel Green, MD, MPH, a Johns Hopkins geriatrician and researcher. “If we prescribe something, that’s seen as a positive action. If we stop something, or don’t start it, that’s not.”
Unless you ask Mary Harrison.