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Overdose Alert

Polypharmacy among the elderly

The New Physician May-June 2010

MedRX pillsLast summer, as a researcher in geriatric medicine, I witnessed firsthand the tremendous medication burden afflicting the elderly. Not only is polypharmacy, the overprescribing of medication, a drain on the economy, but it can be a significant drain on patients’ quality of life.

When seeing a health care provider for the first time, a patient must divulge a long list of conditions—past medical history that can span multiple pages. The list of medications she is taking may be even longer. Matching listed problems with listed treatments is much like solving a puzzle. And yet, there will always be ambiguities, conditions and medications that do not easily line up.

“Remind me, Mrs. Johnson, why are you taking this medication?”

“I can’t quite remember. I know it was prescribed to me last year.”

This scenario is all too common. Patients, especially elderly ones who may already be taking numerous medications, are often given more medications at every visit. Busy physicians, preoccupied with narrowing the differential, may forget the most important decision: what not to prescribe.

The risks of overprescribing are significant. First, there is the issue of drug-drug interaction. With multiple medications, the treatment outcomes can be unpredictable and devastating. The hepatic cytochrome P450 system is a notable example: Multiple medications may act synergistically, resulting in unpredictable drug metabolism and unpredictably high or low drug levels in the body.

The second problem with polypharmacy is greatly decreased quality of life from numerous negative side effects. By simple probability, the more medications one takes, the more likely one is to experience negative side effects. Drugs act on metabolic pathways in the body, but biochemical pathways are inherently interconnected. There are three major organic compounds as sources of energy, 20 essential amino acids, and a handful of commonly studied metabolic pathways. It is extremely difficult to modify something in the body without regrettably modifying something else. Clinically, this suggests the best treatment is the minimum treatment.

While it is deeply unfortunate that chronic coughing from high dose ACE inhibitors decreases a patient’s quality of life, it is even scarier when a diabetic decides to avoid her antihypertensive medications altogether. Compliance is most essential among the elderly. Yet perhaps the single most important determinant of patients’ adherence to a medication regimen is its effect on their ability to function and quality of life.

Finally, polypharmacy strains the economy. Now, as governments and private businesses strive for efficiency, it makes tremendous sense to decrease dosages or prescriptions that are unnecessary. The first step shouldn’t be decreasing Medicare coverage, but decreasing waste. And the fastest way to reduce waste starts with a complete interview and a few brief questions.

Polypharmacy, in many ways, is a problem of luxury and excess. When we live in a society of easy-access medications and $4 prescriptions, it is easy to forget that reducing medication burden not only saves money, but also improves lives. Seeing elderly patients afflicted with numerous side effects from a myriad of medications, I have learned this lesson firsthand. As I see new and old patients alike, I will remember to ask myself not only what medications the patient needs, but what medications the patient won’t need.

Siu-Hin Wan is a third-year at Northwestern University’s Feinberg School of Medicine.

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