Medicine For People!

April 2012

Depressed Elderly Man

The Patient Was Dying, or Was He?

During the early eighties, I would occasionally travel to Ilwaco near the mouth of the Columbia River to cover the practice of a family physician there. One day the nursing home called me about a dying patient. The man was on about 15 medications. Each time the nurse tried to administer this pile of pills, the poor man gagged and choked. He was in his late eighties or early nineties, and family was hoping I would end these nurse/patient battles and let the man die in peace. When I arrived in his room, the man was unresponsive and did indeed look fairly moribund. I gave him a brief exam to be sure there was nothing we could fix and agreed with the family that the kindest thing was to just let him go.

After I left, other pressures drove him from my mind, so I was surprised to get a phone call a couple of days later. It was the nurse from the nursing home. "He passed away?" I asked. "No, he's eating breakfast." The real diagnosis was not old age, but gross over-medication. I went back to Ilwaco several times, and he never required further service.

Advocating For the Elderly

Most of the placebo-controlled studies on which we base medical treatment are carried out on young or mid-life patients. More and more we are learning that late-life people have different reactions to medicines, to hospitals, and to nursing care. It is difficult enough for mid-life patients to advocate for themselves. It's nearly impossible for the elderly. If you have reached a ripe old age, time to recruit a close friend or relative to be your medical advocate, to ask questions, look after your interests, and make sure you don't end up choking down medicine you don't really need. If you have a loved elder in your life, it may be time to become an advocate – with delicacy and tact, of course. This is the first of a two-part newsletter series designed to help.

Safe Medications for the Elderly

Over-medicating the elderly is easy to do. Often seniors will become excessively sedated with medications that wouldn't bother younger person. Most medications are tested on the young, who have livers able to detoxify well and kidneys powerful enough to eliminate medication quickly. Time changes all that.

In my prescription case I carry a list of medications safe for the elderly. In 1991 a specialist in geriatric medicine named Mark Beers made up a list of desirable and undesirable medications for the elderly. His list, now called the Beers List, has been revised over the years and used not just in nursing homes but in any facility were older people are cared for. You can find his list here and if you are responsible for the healthcare of an older individual, this should help you work with their doctor to be sure their prescriptions are appropriate.

Time changes Medical Equations

If you read the small print that comes with your prescription, you know that every medication has some risks. The risk-benefit equations we apply to medical procedures also change with age.

For example, healthy people under age 50 usually recover fairly quickly after general anesthesia, despite the fact that general anesthesia appears to increase inflammatory processes[1] in the brain. The older people become, the slower their minds recover from the effects of the anesthetic. Our capacity to measure mental dysfunction is rudimentary[2], yet a recent symposium[3] noted that one in six elderly people showed evidence of diminished mental function a year after surgery, and concluded that:

"We are likely to be confronted by an epidemic of postoperative cognitive decline that we are ill-equipped to address."

So if your elderly loved one has heart disease, think carefully. A great argument rages over which treatments work best. Many studies show that surgical placement of a stent in a heart vessel provides no benefit over careful pharmaceutical treatment, yet surgery tends to be the standard protocol. (Why, is another question. Don't even get me started on the economics of medicine.) The stent operation, which seems to be a reasonable risk in a young person, becomes a real negative as the years accumulate. Less invasive, less high-tech care is often the wisest and kindest course of action.

Similarly as people age, certain medications make less sense. Not all doctors agree, but as time goes by I do not think statins are as beneficial as when a person is younger. And as time goes by, the safety and need for all medications needs to be reviewed and reevaluated.

What Can Go Wrong

In Ilwaco, the doctor I substituted for had a large practice and spent his day putting out fires. Many of his patients were on long lists of medications and one thing I could do for the doctor and his patients was weed out the unnecessary drugs. Here are some of the things I found.

Unnecessary Drug Doubling

Say, for example, the patient is on a diuretic for high blood pressure and the diuretic does not work adequately. Many standard protocols suggest adding a second medication. However, many times one can just change medications, and find that the second medication works well on its own. One treatment team reporting in the British journal Lancet found, through serial trials of different medications, that 70 percent of the time they could control blood pressure with just one drug. They just had to try enough different ones to discover which one worked for each individual.[4]

Taking a Drug Too Long

Sometimes patients are not told, and the medical team forgets, that a medication only needs be taken for a certain period of time. Iron replacement should be for a limited time. Steroids, anti-inflammatories, even high blood pressure drugs (especially if you lose weight) may be discontinued after a period of time. People often discover, after a year or two, that they no longer need anti-depressants or sleeping pills. They may relocate to a different climate and not need allergy medications. If you, dear reader, take medication for seizures, do not discontinue when you finish reading this newsletter. However, you may have been told by your neurologist that if you meet certain criteria and have not had a seizure in a period of years, you may, with precautions for safety while operating machinery including a car, be eligible for a trial of dose-reduction and discontinuation.

Drug Confusion

People often see several doctors, who may be unaware of what they are already taking. This can lead to duplicate or conflicting medication. The simple remedy is that the doctor take time to sort through all the details. My doctor asks that I bring all my prescription bottles to each visit, so they can read the labels and know what I am taking. They do this because some drugs have similar names and can be mis-dispensed (this does not happen often).

A common error happens like this. The person needs 20 milligrams of simvastatin and wishes to cut a 40 mg tablet in half for economy. They go back for the next refill, the 40 mg size is out, they get the 20 mg size. Their cholesterol comes back too high, so we call and ask them to double the dose. They wind up on two 20 mg tablets, run out of those, go to the pharmacy and this time get the original 40 mg size they were on, keep on taking two, and now are at double what we planned. There are lots of ways to get dosing and medication lists confused!

Sundown in the Hospital

Physicians are not always trained to recognize symptoms specific to the elderly. I am reminded of an incident that took place during my internship. One morning I'd admitted an elderly woman we'll call Pat, with pneumonia. She seemed alert and cheerful, and in today's world we'd probably treat her at home. But this was the late 1960s and hospital doors were open wider in those days. My late supper was interrupted by a call from the ward clerk. I arrived to see Pat walking up and down by the windows of her room wringing her hankie and crying that she was lost. Wet behind the ears, I tried to figure out what had gone wrong. Had I missed a diagnosis? Fortunately a senior nurse walked in at that point and explained that Pat was "sundowning[5]," a common occurrence with the elderly in a strange environment. Pat had been able to cope during the day when her family was with her, but without family and without daytime cues as to where she was, she became disoriented and distressed. The nurse remained to calm her while a family member came to spend the night.

Coming Next

In our May newsletter we will look at end-of-life issues and a form of under-medication that can be just as damaging as over-medication.

Endnotes

[2] ­ Neuropsychol Rev. 2002 Mar;12(1):1-14.

Postoperative cognitive dysfunction versus complaints: a discrepancy in long-term findings.

Dijkstra JB, Jolles J.

Which leads to controversy on how serious the problem is. See

Review of clinical evidence for persistent cognitive decline or incident dementia attributable to surgery or general anesthesia. Avidan MS, Evers AS. J Alzheimers Dis. 2011;24(2):201-16.

[3] Perioperative Cognitive Decline in the Aging Population Mayo Clin Proc. 2011;86(9):885-893. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257991/pdf/mayoclinproc_86_9_010.pdf

[4] Lancet 1999; 353: 2008–13

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington. Edited by Carolyn Latteier.