At 79 years old, Betty Collins is in pretty good shape. She enjoys gardening and cooking big meals for her family during the holidays. Prior to a recent hip replacement surgery, you could find her exercising at St. John Siegfried Health Club. That surgery sidelined her for a while, but she remains as active as possible. “I’ve always been able to exercise a lot and stay active,” says Collins. “I still walk a lot, lift weights and do some yoga stuff.”
Collins, a self-described type A personality, is keenly aware of her health. She’s taken medication to control her blood pressure for years and regularly monitors her condition with her own blood pressure cuff. About six months ago, she began experiencing unexplained fluctuations in her blood pressure.
“For a while I took care of it myself. If it was low, I skipped it. If it got high, I would go ahead and take it. That worked to a point, but sometimes I wouldn’t take it, and it would still go down,” says Collins of her effort to control her blood pressure by altering her recommended dosage of medication.
Eventually, Collins sought the help of her primary care physician, Dr. James Phoenix, a doctor of internal medicine with Omni Medical Group at St. John Medical Center. Together, doctor and patient began the complicated process of trying to determine what was causing Collins’ blood pressure issues. Among the list of possible culprits were her blood pressure medicine or one or more of the four other prescription drugs that Collins takes on a regular basis.
In the end, Collins’ medications may not be to blame, but the realities of a population, especially an older population, taking multiple drugs for multiple conditions, often prescribed by multiple physicians and filled by different pharmacies, is something Phoenix and most physicians deal with daily. Medications save lives, improve quality of life and have revolutionized health care, but inappropriate use of prescription drugs can have the opposite effect. This has become a major challenge of modern medicine, one that harms patients and puts additional strain on an already overburdened health care system.
The phenomenon is referred to as polypharmacy, or the use of multiple medications. For some conditions, the use of several interactive drugs is necessary and beneficial, but the more medications a patient takes, the more opportunities arise for a range of problems.
There is no universal definition of polypharmacy. “The way I define it is when you are putting the patient at risk,” says Phoenix. “Whether that’s five prescriptions or eight, it varies from person to person.”
While polypharmacy can affect any age demographic, its harmful effects are most profound among the elderly. There are a number of reasons for this. Older patients are simply more likely to take multiple drugs. According to the American Society of Consultant Pharmacists (ASCP), 13 percent of the U.S. population is over 65, yet this group accounts for 34 percent of all prescription medications used. Folks 65-69 years old take an average of nearly 14 prescriptions every year, and that number jumps to 18 for people over 80 years old. This average doesn’t include over-the-counter medications and herbal or natural remedies.
This scenario is one with which Phoenix is very familiar as a primary care physician with a high number of older patients. While he is the primary prescriber for many of his patients, many also see specialists that are writing additional prescriptions. He says this is where the problem typically occurs, and patients being treated with pain management or for multiple chronic conditions, such as high blood pressure or heart disorders, may easily end up with a medicine cabinet full of pill bottles.
“One person may end up on a dozen or more medications,” Phoenix says. “We see that a lot.”
Unfortunately, Phoenix says he isn’t always aware of every drug his patients take, and this may cause an overlap where more than one drug is prescribed to treat the same condition.
Another factor that may increase the number of prescriptions is what Phoenix describes as a cascade effect where patients may be inadvertently treated for side effects of the drugs they are taking. For instance, gastrointestinal problems are a common side effect of many medications, and sometimes patients end up with additional prescriptions to treat these symptoms. Those drugs, in turn, come with their own list of side effects. Phoenix says cholesterol drugs are another common culprit in prescription cascades.
“Cholesterol drugs can cause pain, which people may mistake for aches associated with arthritis or another condition,” he says.
Most experts agree that any new symptom in an elderly patient on medication should be considered a drug side effect until proven otherwise.
Another factor that can amplify the harmful effects of multiple prescriptions in older patients is the fact that as our bodies age, drugs affect us differently.
“They stay in the system longer,” says Phoenix. “They don’t clear. You can end up stacking doses.”
Recommended doses for most drugs are based on younger patients, so an older person with slowed bodily functions may wind up taking more medication than they actually need.
Finally, polypharmacy is viewed as a primary reason many patients, particularly the elderly, don’t take their prescriptions as directed. This pill burden, as it is called, may be too much and too complicated to keep up with. Plus, many seniors have a hard time paying for all the medications they are prescribed. According to the Merck Manual of Geriatrics, roughly 40 percent of elderly patients don’t take their prescriptions correctly.
The ASCP describes adverse drug reactions as one of the top five greatest threats to the health of seniors. You only need watch a few television commercials to know that every drug has potential adverse side effects, usually a laundry list of possible complications. The more medications that enter the equation, the greater chance the patient will suffer from one or more of these side effects. This matter is further complicated by the fact the every medication can potentially interact with every other medication a patient is taking.
“If you’re taking eight or more medications, including over-the-counter medications, there’s a 100 percent chance you’re having a harmful drug interaction,” says Phoenix.
The results of adverse drug reactions and interactions tied to polypharmacy can be profound and costly and can include loss of mobility, impaired cognition and a general decline in quality of life. Among the staggering statistics compiled by ASCP: 28 percent of hospitalizations among seniors are due to adverse drug reactions; 32,000 seniors suffer hip fractures each year due to falls caused by medication related conditions; the total cost of medication-related problems in the U.S. each year tops $100 billion.
Polypharmacy and the issues it causes are not easy things for the health care community to address, and there isn’t a clear-cut solution.
“It’s going to become a bigger problem before it gets better because there are a lot of habits in place,” Phoenix says.
Still, individual physicians, health care systems, nurses, pharmacists and other providers are acutely aware of polypharmacy complications, and many are making efforts to alleviate the problem. One of the biggest obstacles is sharing information. Even with all the advances in electronic medical records, there still isn’t a comprehensive patient database where doctors can view a patients medical history and see the prescription medications that are being used.
“If you’re on vacation and you end up in an emergency room, it’s basically impossible for a doctor to know your history,” says Phoenix.
Individual health care systems, however, are putting comprehensive, transparent systems into place. For instance, Phoenix says St. John is changing its medical record keeping so that everyone in their network has access to the same, real-time information, including outpatient visits. But what about specialists the patient may be seeing out of network, or other drugs they may be taking? To gain this information, Phoenix says health care providers must use old-fashioned diagnostic techniques to develop a comprehensive medication history and be informed about what their patients are using.
He adds that insurance companies, recognizing the multiple costs of polypharmacy, are beginning to raise flags or warn doctors when they see potential misuse of drugs. Phoenix also says the Affordable Care Act includes some improvements to medical records that may aid physicians in preventing inappropriate polypharmacy.
Health care providers and experts also agree there are many things patients can do to help their physicians help them avoid over-prescribing and potentially harmful polypharmacy. In today’s complicated health care environment, patients must be their own advocates – or have a trusted friend or family member who can act as such – and fully understand every aspect of their treatment as completely as possible.
“People mistakenly assume that any doctor they see knows more about them than they actually do,” says Phoenix. Thus, the patient must take the initiative to fill in any blanks.
According to experts, there are a few things that patients should do to prevent medication-related problems:
• Know and have a list of every medication that you’re taking, including any over-the-counter medications, vitamins and supplements, and the dosage for each.
• Share this information with all of your doctors, even if you have to take your medications with you to appointments.
• Know why you’re taking each medication on your list.
• Find a primary care physician you like and stick with him or her. Allow this doctor to become your partner in managing your health care. Patients with a doctor looking out for them are far less likely to get into trouble with medications.
• Know your Beers. The Beers Criteria is a list of medications that generally should not be prescribed to people over 65. This list is widely available online. If you’re taking one of these drugs, ask your doctor why.
• Pick up all medications at one pharmacy. Pharmacists can help you avoid harmful drug interactions, but only if they know about everything you’re taking.
• If you’re taking multiple medications or new prescriptions are added to your regimen, periodically ask your primary care physician to do an evaluation. Are there drugs you no longer need?
• Always ask whether a new symptom could be a drug side effect.