24 Sep When Less is More…
When Less is More…
Mr. Smith is 67 and he is living with congestive heart failure due to severe coronary artery disease. He has had three Emergency Room visits in as many months because of chest pain and shortness of breath. This time was different. His symptoms were so severe that he was hospitalized for 3 days. He came to see me because he wanted to break this pattern.
“Why do I have to take so many pills?” he asked.
I clicked on his medication list: aspirin, Ativan, allopurinol, astragalus, atenolol; metformin, Diabeta, Glucovance; Lotensin, Lasix, lisinopril; indomethacin, insulin, Tenormin, terazosin…
“I’m having trouble swallowing some of them and they upset my stomach even when I take them with food. With the new medications I’ve started to have headaches every day, and I’m dizzy.”
The new medications included isosorbide, spironolactone, and metolazone. Mr. Smith was taking more than 20 pills a day.
If you have a medical problem, there is almost always a pill for it. According to a study by Nicky Britten et al published on-line in August 2002, many people expect a doctor’s visit to result in a prescription and some said the visit was not worth their time if it doesn’t.
Most Americans will see an average of 19 different doctors during their lifetimes. For people over age 65, that number is 28. Although the US population has increased 12% since 1992, the number of doctors’ office visits has increased by 16%.
During 2001, an estimated 880.5 million visits were made to physicians’ offices in the United States, an average of 3.1 visits per person. More medications are being prescribed as well. In 2001, 1.3 billion prescriptions were written, compared to 922.6 million in 1992.
Based on data from the NIH, between 1988 and 2010 the median number of prescription medications used among adults aged 65 and older doubled from 2 to 4, and the proportion of those taking ≥5 medications tripled from 12.8% to 39.0%.
The higher the number of medication taken, the higher the risk for adverse events including medication errors, side effects, and drug-drug interactions. It is not unusual to get another medication to treat side effects of other medications, setting off a prescribing cascade. The dynamics become more complicated for people with changes of age or illness that bring insufficiencies of the kidneys, liver, or the GI tract.
Over-prescribing results in the simultaneous use of multiple medications to treat a single ailment, or to treat multiple conditions. Polypharmacy is unfortunately common, particularly in people living with serious illness and people over age 65. The numerical definition of polypharmacy ranges from two or more to 11 or more medications but the commonly agreed upon number is five or more. It is estimated that greater than 40% of people over age 65 are affected. The most prevalent categories are blood pressure medications, steroids, anticoagulants, proton pump inhibitors, and supplements. People taking 8 or more medications have increased likelihood of hospitalizations, falls, nursing home placement, and death. The antidote to polypharmacy is deprescribing.
In medicine, there are many studies supporting when something should be started, but there is a paucity of information about when something should be stopped. The work of Holly M. Holmes MD, director of the Division of Geriatrics and Palliative Medicine at the University of Texas, is shedding light on this topic. Dr. Holmes studies deprescribing, the process of reducing, tapering, and stopping medications. Her work has shown that deprescribing is safe and reasonable.
There are three primary reasons to give someone medication: to help them feel better, to help them live longer, and occasionally, to cure. When a medication is no longer providing its intended benefit, or when its burdens exceed its benefits, it’s time to consider stopping it. Dr. Holmes recommends reviewing medication lists with an eye for medications that are essential, of uncertain benefit, or causing harm. When it comes to medication, less is more.
As for Mr. Smith, he was certainly suffering from polypharmacy: multiple medications for multiple conditions, suffering from side effects leading to more medications. We were able to simplify his pill burden from more than 20 to 4 pills per day: 3 pills for congestive heart failure and 1 pill for diabetes. Another pill was replaced with a patch. The daily headaches and dizziness have gone away, his appetite has improved, and he has not been in the ER or the hospital since.