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.

New Glasses for Elderly Often Equals Increase in Fall Risk

When I wrote about antidepressants possibly causing falls for the elderly, binocular vision disorders is higher than expected in the elderly, most binocular vision disorders are treatable with glasses, vision therapy, or occasionally surgery. It is recommended that people keep their glasses up-to-date with regular eye examinations. This will avoid large prescription changes and is a good way to maintain good vision, decrease risk of falls, and maintain a good quality of life as you age.

Now we have a non-scientific review in optometry and vision science that says that over-aggressive eyeglass prescription changes need to be avoided. Blurred vision contributes to the risk of falling in older adults—but getting new glasses with a big change in vision prescription may increase the risk rather than decreasing it. Falls are the major cause of accidental death and non-fatal injuries in the elderly. At least one-third of healthy adults age 65 or older fall at least once a year. For those 90 or older, the risk increases to about 60 percent.

The reviewer, David B. Elliott, PhD, says that falls in older adults aren't accidents. Most of the time, they're related to a wide range of risk factors including older age, disabilities, muscle weakness, and many different medical conditions. The more risk factors you have, the more likely you are to fall.

In the elderly, reduced vision in a large risk factor for falls. This suggests that interventions to correct vision, glasses, or cataract surgery, would reduce the risk of falling. The surprising factor, most studies have shown little or no reduction in falls among the elderly receiving a new vision correction.

Magnification from some new glasses may contribute to increased risk of falls. Receiving large changes in a glasses prescription also increases the risk of falls. This is because the frail elderly may have more difficulty adapting to these large changes and often are at increased risk of falling during the period of adapting.

I needed to smile when I read, 'If it ain't broke, don't fix it' when speaking about large or magnification changes in glasses for the elderly. The elderly take longer to adapt to changes in glasses prescriptions because they are not familiar with some changes. Dr. Elliott advises caution with changes for the elderly.

Maximizing vision corrections for the elderly is not advised and optometrists need to assess properly the risk factors, including history of falls, medical conditions, and medications used. Dr. Elliott advises taking a conservative approach to prescribing new glasses for older adults with a history of falls or risk factors for falling.

Finally, Dr. Elliott suggests keeping the same type of prescriptions, bifocals, or progressive lenses, unless there is a significant reason for change. If a patent is used to wearing single-vision glasses, they should not be moved to bifocals or progressive lenses. A change like this is going to increase the risk of falls.

If you are a caregiver for an elderly person, always be aware of what the person uses for glasses and if necessary, change optometrists if they are being radical in the changes in glasses.

Supplements – Does the Elderly Need Them?

This debate has been around for some time and just does not go away. Do elderly people need to take supplements? Some “experts” say no, other “experts” say yes. Many of these “experts” are assuming that the elderly have unlimited funds, can prepare meals that are nutritionally complete, and reside in areas that are safe and easy to move around within. Most of the “experts” have never had to spend a day in the shoes of some of the elderly.

I wish some of these “experts” would have to do a field study of the elderly and really get out and spend a few weeks seeing how they live, how safe it is for them to even walk around the neighborhood they live in, and how little money has to last for a month for food, shelter, and medications. This says nothing about transportation and some of the other necessities of life. Most of these elderly have no money left for supplements.

To ridicule the elderly like Donald B. McCormick, PhD, an Emory professor emeritus of biochemistry and the graduate program in nutrition and health sciences at Emory, takes ridicule to new levels. He says, “A lot of money is wasted in providing unnecessary supplements to millions of people who don't need them.” It is one thing to sit in the towers of academia and make statements like this, but I would have to ask if he has even seen where some of the elderly live. Then he continues, “We know too little to suggest there is a greater need in the elderly for most of these vitamins and minerals. A supplement does not cure the aging process.”

He thinks that the elderly believe they need vitamins and mineral supplements to blunt the aging process and the older they get the more supplements they need. He seems determined to take these supplements away from the elderly. One statement that McCormick makes I have to agree with and it is this - “At very high levels, some vitamins and minerals can be toxic.” This is especially true for many of the fat-soluble vitamins and minerals that the body can't readily flush.

Yes, McCormick does soften his rhetoric further into the article. He almost allows for obtaining most of them from foods, but with dietary changes. While I agree that it is best to obtain your nutrients from food, not all the elderly do well at cooking and balancing their nutritional needs. Not everyone can make use of nutrition experts and others capable of helping them.

Andrea Giancoli, RD, MPH, a spokeswoman for The Academy of Nutrition and Dietetics does carefully say that when counseling older adults, it is first necessary to determine what nutrients are lacking in the diet. I can believe it when she says it is often vitamin D, calcium, and vitamin B12. She does say she tries to fix it with food. I will give her positive marks for saying, “I don't think we should be recommending supplements blindly without assessing their food intake.”

Does the elderly need supplements? This debate will continue and probably never be resolved. I do think many of the elderly need some of the supplements because they do not eat a large variety of foods and are often short of some nutrients. Having seen some of my friends have anemia and be short of Vitamin D and Vitamin B12, I know what can happen. Another area of concern is those supplements that may cause extreme and even deadly side effects when taken with some prescriptions. Therefore, I have to urge caution for any supplements and urge all patients to make sure their physician knows what supplements are being taken.

Position Statement on Diabetes in the Elderly

American Diabetes Association (ADA), pay attention, you just might learn something!  Three international groups have taken the first step in the establishment of guidelines for a global initiative to improve diabetes care for the elderly.  They will address age related problems for their care.

The three groups are the International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes.  The group realizes that most international clinical diabetes guidelines fail to address problems common in the elderly, such as frailty, functional limitation, mental health changes, and increasing dependency on others for help.  This is a problem that is ignored in the USA.  Yes, the ADA pays lip service to the individual needs, but has not addressed the needs of the elderly.  It is still a “one-size-fits-all” policy.

The authors write, "the effective management of the older patient with diabetes requires an emphasis on safety, diabetes prevention, early treatment for vascular disease, and functional assessment of disability because of limb problems, eye disease, and stroke. Additionally, in older age, prevention and management of other diabetes-related complications and associated conditions, such as cognitive dysfunction, functional dependence, and depression, become a priority."

The authors list in the purpose of the position statement the following:

1. Arrive at a consensus on how we approach the management of key issues of diabetes care for older people.
2. Identify a series of key areas for diabetes-related surveys and/or audits of clinical care within a range of countries. These may take the form of surveys of particular drug usage, mortality and comorbidity rates, models of care, and use of clinical guidelines in clinical decision making.
3. Recommend up to 3 to 4 research areas that could be considered for further investigation using selected research tools, and that could form the basis of one or more collaborative research proposals.

The authors then identified major research areas that need to be explored, including:

1. the use of exercise, nutrition, and glucose-lowering therapies in the effective management of type 2 diabetes in older people;
2. practical community-based interventions to reduce hospitalization;
3. methods to decrease hypoglycemia rates in various clinical settings;
4. health economic evaluations of metabolic treatment;
5. interventions to delay/prevent diabetes-related complications that are important in older age, such as cognitive impairment and functional dependence; and
6. development of technical devices that help to maintain autonomy and safety for older people with diabetes.

Now we will need to wait and see what is issued in the guidelines and if other areas come to the surface during the formation of the guidelines.  If this was the ADA doing this, I could guess that it would be more platitudes and lip service, and the old ways of doing things would not change.