Monday, March 28, 2011

Against the Grain: Fewer Drugs, Better Health for the Elderly

In the previous post I gave you the bad news, about how drug marketing, coupled with our fond beliefs in the powers of prevention and early screening to confer immortality, ends up making us sicker. I'm now happy to be able to supply a bit of good news, even though the study is highly preliminary and needs confirmation with larger numbers and a randomized design. Scene setting plus personal confession: During the 26 years I saw patients as a family doc, I attended numerous lectures given by geriatrics specialists, and each time heard the same plea--carefully review all the medications your elderly patients are now on, and do your best to stop as many of them as you can. The logic seemed solid. But when I tried to implement it, I almost always ran into a wall, at least in my own mind. I'd ask the patient to bring in all their meds in a shopping bag (some apparently needed a U-Haul trailer) and I'd carefully go through each one. Sadly, in almost all cases, either the patient or I concluded that hardly any could safely be dispensed with. So I ended up wondering how realistic this advice was. I was therefore quite delighted, as well as humbled, to read this recent study by Garfinkel and Mangin from Israel (subscription required). They developed a protocol for reducing the med list of patients in nursing homes, and it worked so well there that they decided to try it on community-dwelling elderly. The present study describes what happened when they used their protocol on 70 such patients. The protocol itself is very simple and very general. Unlike other popular approaches to eliminating ineffective and dangerous drugs in the elderly, it does not consist of a list of drugs to avoid. It is basically a form of zero-based budgeting. It starts from the assumption that if there's no good evidence that people of that age do better when placed on that drug, then the drug should be stopped. The indirect message is that many standard guidelines are based on studies done in younger patients and then inappropriately extrapolated to the elderly--who are first, more prone to side effects of medications, and second, often have limited life expectancies and so cannot benefit from some risk factor reductions that take 5-10 years to produce payoffs if any. As one example, they mention evidence that a reasonable target glycohemoglobin for elderly diabetics is 8.0, whereas most guidelines beat you up if you don't get your patients below 7.0. (If you try to get the elderly down to 7.0, too many of them fall down and break something from the effects of low blood sugar.) So what happened? On average, these older folks were taking about 8 medications each, and after they used their protocol they reduced it to more like 4. They watched the people carefully afterward and only 2% of the medications had to be restarted because of either symptoms or abnormal lab values. And--best of all--88% reported feeling significantly better once they were off all those meds. A few patients with severe cognitive impairments while on the medications actually cleared their mental status significantly. And the Israelis did not even bother to consider what sort of cost saving they generated. So the more general point, assuming that these promising preliminary results can be later backed up, is that if you fight against the mantra I described in the previous post, in this particularly vulnerable population at least, you can do a tremendous amount of good. The specific point is to ask--if we were to listen to the siren song of drug industry marketing, who would even begin to imagine that such a thing were either possible or desirable? Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Archives of Internal Medicine 170:1648-1654, Oct. 11, 2010. NOTE ADDED 3/28: I have now tried to repost this entry three times, each time going back and inserting the paragraph breaks as I intended them, and each time the blogsite has posted the post eliminating the paragraph breaks. Sorry about this readability problem. I will ask the usually highly reliable Blogspot what gives.--HB


Michael S. Altus, PhD, ELS said...

I bring your attention to the ASCP:

The American Society of Consultant Pharmacists ( empowers pharmacists to enhance quality of care for all older persons through the appropriate use of medication and the promotion of healthy aging.

Luis Justo said...

Dear Howard:
the paper, which is very good, can be accessed for free in
Luis Justo

Patricia said...

Wow, what good news indeed! I used to know a woman who was on a lot of drugs (not quite a u-haul full, but still) who died under mysterious circumstances- I always expected that it was a matter of an adverse drug interaction or something like that, considering the amount of medicine involved.

In other, unrelated news, do you accept guest posts? Drop me an email if you do, thanks.

Alison Rutledge said...

When I was in practice and we had inpatient admissions from nursing homes who had a sudden change in mental status, we always did three things first: 1) look for a bladder infection 2) look for constipation and 3) try to get the list of their medicines down, down, down. They usually saw several docs and never threw a medicine away and conscientiously refilled. We also found people who had not had, say, a digoxin level taken in years. Polypharmacy is a real risk at any time, but especially in later life.

Unknown said...

It's good to hear there are providers trying hard to reduce med use for the elderly. I think too many older patients just accept what docs say as truth, when instead they should be asking more questions and requesting alternatives. I found this video helpful: