November 5, 2015

Many Elderly Need Less Medications

Many studies are finding that the elderly are over medicated. Two studies recently pushed the numbers at us and how few doctors will decrease medications.

1. Based on Veterans Affairs primary care data on older adults with longstanding diabetes, deintensification of hypertension therapy, not including angiotensin converting enzyme inhibitors (ACE-I) amongst patients with moderately low and very low blood pressures (BP) occurred less than 20% of the time.

2. Similarly, deintensification of diabetes therapy, not including metformin, amongst the same population with moderately low (HgbA1c 6-6.4%) and very low (HgbA1c less than 6%) blood sugars occurred less than 20% of the time.

This does not speak well for our doctors and may mean that they are more interested in piling on medications to the harm of patients. I will say that patients need to be proactive in their medications. I have been able to have the VA reduce my medications and after looking at the test results, they had no trouble lowering the dose I am taking. Fact is the physician thanked me for bringing this up.

With the shortage of studies that include testing for the elderly, it seems that for many people over 70 years of age, it might be safer to consider reducing medications. I like the word deprescribing that was first brought to my attention in a blog by David Mendosa on September 08, 2015. His blog has a different challenge, but it still needs to be said.

The two new studies published in JAMA Internal Medicine suggest doctors and patients should work together to deprescribe such treatment more often. In people 70 and older, very low blood pressures and blood glucose levels can actually raise the risk of dizzy spells, confusion, falls and even death. The consequences can be dangerous.

In recent years, the experts have started to suggest that doctors ease up on how aggressively they treat such patients for high blood pressure or diabetes, especially if they have other conditions that limit their life expectancy. What needs to be added is when older patients have decreasing cognitive abilities, this should be when medication needs a complete review with the goal of reducing medications.

Jeremy Sussman, M.D., M.S., lead author of the study that used medical records, stated, “Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says 'personalize treatment for older people'."

It may be hard for an older person to recognize the signs of too-low blood sugar, such as confusion and combativeness, or of too-low blood pressure, such as dizziness. Meanwhile, keeping up with taking multiple medications, and checking blood sugar daily or even more often, can be a struggle for the oldest patients. De-intensifying or deprescribing their treatment can often be a relief, if their treatment is personalized.


Leslie Kernisan MD MPH said...

Very important and insightful post. Like most geriatricians, I am a big fan of carefully reviewing medications and deprescribing as often as possible.

Before working out a strategy to help an older person take all their meds, or afford all their meds, step 1 should always be to take a good look at what's being prescribed and reconsider whether it's all necessary. Because as you know, often it's not.

Bob Fenton said...

Thank you Dr. Kernisan for your comment. I am still learning some of the lessons and how to communicate with some doctors to reduce medications. Often it is the dosage and at other times it is just stopping a medication and seeing what the results are under a doctor's supervision.