Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Wednesday, October 12, 2016

Overprescriptions for the Elderly

"When about two thirds of doctor visits ... lead to a prescription, it really becomes a patient expectation."
"More is not always better, but that seems to be the assumption behind a lot of what we do in health care."
Sara Allin, professor, Institute of Health Policy, Management and Evaluation, University of Toronto

"We're in the red warning belt. It's become excessive."
"This is seriously concerning, if that large a proportion of hospitalizations is a result of drug side effects and interactions." 
"Being a woman is double jeopardy when it comes to taking medications. Women metabolize drugs differently than men. Gender roles and social circumstances also place them at risk. However, I expect that by empowering women with knowledge about the harms of sleeping pills and other medications, we can help drive decisions to try switching to safer therapies."
Dr. Cara Tannenbaum, geriatrics professor, University of Montreal
Credit: Carlos Paes/

The alarm is being raised, not only in Canada, but elsewhere in the world, with research papers coming out of the United States as well, pointing to over-prescription of prescription drugs for the elderly in society. A new study by University of Toronto researchers concluded that seniors visit hospitals on an increasing level with each additional medication prescribed for them. Most elderly patients, it seems, are being prescribed no fewer than seven different drugs each year.

So that the use of these multiple medications in addressing health issues, mostly related to age, are not actually maintaining health so much as increasing the potential of seniors landing in the emergency department of the hospital, according to data gleaned from Ontario's health data. What is being termed a "polypharmacy" presents pitfalls that include powerful sedative side effects as well as those from the use of antipsychotics or opioids.

And then there are the reactions that occur, bedevilling the elderly when they consume incompatible drugs.

The team of researchers published their findings in the journal Health Services Research, with the recommendation by the authors of the emphasis on a protocol of increased monitoring of prescribing habits by physicians. Alongside the need to have patients become more aware of this critical issue impacting on their health outcomes. The issue is a complex one, with the acknowledged need that patients should not be under-treated in a reaction to over-treatment, when a variety of ailments are present.

Lack of co-ordination between doctors and pharmacists, pressure emanating from patients wanting to have something reliable prescribed to address a new ailment, and the reality of a multi-medication "cascade" with additional drugs being prescribed to treat side effects that arise from the use of existing medications describe the complexity of the situation, according to Dr. Roger Wong, a geriatrician at the University of British Columbia.

Dr. Tannenbaum describes the issue oft repeated among patients, of an elderly woman taking a diuretic for hypertension, a medication that necessitates she arise during the night to urinate. The diuretic, teamed with sleeping pills to address her distress at continual awakening during the night, culminates in a scenario where her reflexes respond more tardily and when she feels the urgent need to urinate, hurriedly arising from her bed, rushing to the washroom and falling, breaking her hip.

Unforeseen consequences. But the various problems have multiplied and become more common as the use of prescription drugs is on a steady rise. Consumption of the most common of pharmaceuticals was reported to have doubled in Organization for Economic Cooperation and Development countries during the period 2000 to 2011. An earlier Canadian study published in 2016 discovered that four in ten older people in 2013 were prescribed at least one drug considered on reflection to be inappropriate under guidelines meant for specialists.

A sample of 6,100 Ontario residents aged 65 and older was studied by Dr. Allin and her colleagues at University of Toronto for their paper, to compare 2005 claims to the provincial drug plan with hospital records. Using a number of statistical tools relating to patients' underlying health problems, the study concluded that the greater the number of drugs patients took, the likelier they were to wind up in hospital.

Trips to the emergency department climbed three to four percent, relating to each extra medication prescribed, with hospital admissions rising by two to three percent. Physicians are being urged to contemplate whether an additional drug will benefit the patient, outweighing risks. They are also urged to "clean up the mess" of multiple prescriptions. "There is no magic bullet, right? That is a really tough message to deliver", commented Dr. Wong.

Most frequent types of potentially inappropriate prescription drug received by British Columbians aged 65 and older:
Drug type Women % Men %
Over 90 days of benzodiazepines or other hypnotics 12.9 8.4
Nifedipine (used for hypertension) 4.0 3.6
Tertiary tricyclic antidepressants 4.0 1.9
Long-duration sulfonylureas (used for type 2 diabetes) 2.2 3.5
Estrogens with or without progestins 4.9 0.0
Over 90 days of Non-COX selective NSAIDs (used for pain) 2.5 2.1

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