Use of multiple drugs, especially in older adults, can exacerbate ailments About a year ago, my mother told my father there was a movie she really wanted to see and suggested they catch it that evening. Great idea — except that, as my dad gently reminded her, they had just seen it.
Though he tried to make light of it at the time, Mom's memory lapse was not an isolated event. She often repeated herself, misplaced one thing after another, and neglected commitments she didn't remember making. A woman with a gift for banter, she now found it difficult to carry on a conversation because she was so easily distracted. Most disturbing of all: She was only 61.
Mom, too, sensed something was wrong.
A teacher of English as a second language, she was known for her supple mind but now felt as if her brain was shrouded in fog. "I'm not as smart as I used to be," she told me recently. Fearing she might be suffering from some kind of early onset dementia, she made an appointment with a neuropsychologist and asked me to go with her.
I said I would, even though I suspected another culprit: the potent brew of medications she was taking for the litany of medical problems that has plagued her for years. She consumed so many drugs every day — 21 of them, prescribed to her by five different physicians—that she lugged them around in a toolbox. A partial list: two blood pressure medications, four for asthma, a cholesterol-lowering statin, and several others to treat her diabetes, fibromyalgia, depression, fatigue, and acid reflux. I assumed that, to coordinate this chemical assault upon her ailments, my mom's doctors talked to each other regularly, that her internist was closely monitoring her medications to prevent any dangerous interactions, and that every pill Mom popped was part of a carefully crafted treatment plan.
How naive.
When I took my mom to see the neuropsychologist, I was startled to learn just how naive my assumption was. The specialist dismissed outright my suggestion that polypharmacy (the use of multiple meds) might be to blame for Mom's porous memory and perhaps some of her other ailments as well. Without even knowing what my mom was taking (never mind the sheer quantity), she confidently asserted that drug-related problems come on more suddenly. I'm not a medical doctor, either, but I do have a PhD in psychology and know that complex situations can be unpredictable. The neuropsychologist's blithe dismissal irked me, so I did some research on my own.
Here's what I learned: The use of multiple, often unnecessary medications — especially among older people — is an entrenched, escalating, frightening, and mostly unexamined problem in modern health care. Although medications can ease many conditions, multiple-drug use often exacerbates existing ailments and causes troubling side effects that are treated with yet more drugs. Many doctors, researchers, and pharmacists I talked to agree. "Overmedication is a true epidemic," says Armon B. Neel Jr., PharmD, a clinical pharmacist in Georgia who evaluates medication plans for private and nursing home clients. "It's completely out of hand."
I also learned that, with the help of professionals, a determined patient can dramatically scale back her prescription drug use and eliminate, or at least reduce, the jumble of side effects that has clearly contributed to her downward spiral. That's what my mom did, emerging from her med-induced fog to reclaim her former vibrant self. This is the story of her comeback — a cautionary tale for everyone who takes several medications every day.
What's behind the Rx cascade
Polypharmacy is most common among people over age 65, about one-fifth of whom take at least 10 medications a week. Because the body absorbs, metabolizes, and rids itself of drugs more slowly with age, a dose considered safe for a middle-age woman can be toxic to her parent. In fact, the Institute of Medicine estimates that at least 1.5 million adverse drug events occur in the United States every year, thousands of them fatal. Studies indicate that about one-third of these drug reactions among senior citizens — and 42 percent of serious, life-threatening, or fatal events — are preventable. Doctors often mistake the ensuing physical response — memory lapse, fatigue, abdominal pain, swelling, or other ailments — as a sign of worsening disease. This can lead to a "prescribing cascade," says Jeffrey Delafuente, FCCP, a professor of pharmacy at Virginia Commonwealth University. "The solution is to reduce the number of drugs. Adding more just exacerbates the problem."
Seeing various doctors or specialists contributes to that cascade. According to the Agency for Healthcare Research and Quality, 81 percent of people with serious chronic conditions have two or more physicians, more than half have three or more, and a third have four or more. Specialists don't always know everything a patient is already taking, says Paul Takahashi, MD, a geriatrician at the Mayo Clinic. Primary care physicians are supposed to oversee the management of their patients' various medications, he says, but unless a new drug is clearly contraindicated, they're often reluctant to second-guess specialists' decisions. To be fair, doctors are not entirely to blame for rampant over-prescribing. In recent years, federal health panels have handed down more stringent targets for controlling chronic diseases such as hypertension and high cholesterol. Medication is often the quickest and surest way to get results — a strategy endorsed by insurance companies, which are reluctant to pay for less well-documented natural therapies.
Patients, too, unwittingly compound their own problems. "As a culture, we've come to expect that there's a pill for every ailment," says Stephen Bartels, MD, director of Dartmouth Medical School's Centers for Health and Aging. "Patients ask for medications they've seen advertised, and sometimes it's easiest for physicians to just prescribe them rather than encourage behavioral changes or preventive steps." Each added prescription increases the likelihood not only of a problematic interaction but also of misuse. Studies show that half of older people sometimes fail to follow their Rx instructions. It's no wonder. Consider my mom's regimen: She took 32 pills a day, at five different times — some once a day, some twice, some three times, and some as needed. One pill had to be split in half for the morning dose but not for the evening dose. Some were taken with food, others on an empty stomach. She also used three different asthma inhalers plus a nebulizer, all on different schedules. I'm half her age, and I couldn't keep that straight.
The more I learned about the risks inherent in taking a large number of prescription drugs, the more I saw how systemic the problem is. Seniors with five or more chronic health problems account for two-thirds of Medicare spending, yet doctors lack clear, evidence-based guidelines for coordinating their medications. A kind of head-in-sand ignorance is built into the system: Patients with multiple diseases are typically excluded from studies of a drug's safety and effectiveness, says Johns Hopkins geriatrician Cynthia Boyd, MD, MPH — and therefore are mostly ignored in the accepted guidelines that evolve from that research. "Every physician in the country is seeing these complex patients," she says, "but we have a long way to go in understanding how to integrate their care."
Paring down, one pill at a time
After our dispiriting visit with the neuropsychologist, who ordered tests, I wished my mom could go off most of her medications and just start over. Experts I interviewed said they could often simplify a patient's regimen but that changes are usually modest. I didn't think it would help her to go from 21 medications to, say, 19.
But I soon learned that some pharmacists, who typically know the products they dispense better than doctors do, often recommend more substantial changes. Neel, the Georgia consultant pharmacist, told me about patients who went from taking a dozen or more prescriptions to only a few, with marked improvements in health and quality of life. Sometimes, he said, removing just one inappropriate medication can eliminate the need for several others. "You send me your mom's information, and I'll see if I can help," he urged me.
Before I did, though, I had to know that Neel wasn't a quack. I talked at length with a couple of his clients, including 71-year-old Carla Moore, who related this riveting story: She hired Neel several years ago after a series of medical misfortunes left her on 13 medications, yet feeling worse and worse. "Every time I told the doctor how terrible I felt," Moore told me, "he wrote another prescription." Her health deteriorated for months, to the point that she told her husband she hoped she'd die. When Moore stumbled across a magazine article that called Neel "the pharmacist who says no to drugs," she picked up the phone.
Neel's analysis of Moore's medications suggested that some were redundant, others probably unnecessary. Still others, he believed, were doing more harm than good. But when Moore brought Neel's report to her longtime internist, "he took one look at it and threw it across the room at me," Moore says. "'I can't believe you'd insult me like this,' he said, and dismissed me from his office." The doctor later sent Moore a registered letter telling her to find another physician. The next eight doctors Moore consulted wouldn't even look at Neel's report. The ninth one did, and readily agreed to write the prescriptions necessary for her to follow the recommendations. Within a week, Moore felt substantially better, and within a month she was back to her old self. These days, she takes three prescription drugs, a daily aspirin, and a few vitamins and minerals — and feels 15 years younger. She walks on a treadmill and lifts weights at the gym several times a week, and blood tests confirm she is in excellent health for her age.
I was buoyed by Moore's turnaround but dismayed by her struggle to regain control over her medical decisions. Would we encounter the same resistance from our doctors?
Despite our concerns, my mom and I decided to hire Neel. One evening, we dumped the pills from her toolbox onto my kitchen counter and started cataloging them, recording each one's strength and dosing instructions. We sent this information to Neel, along with numerous lab results; a log of my mom's recent blood pressure and glucose readings; and a thorough description of her symptoms, medical diagnoses, and history.
In the 29-page report Neel sent us a week later, he identified 27 drug interactions among my mom's medications, most of moderate or high severity. It turned out that seven of her medications — fully a third! — sometimes cause memory loss, confusion, or impaired cognition. Neel recommended lower dosages of some drugs, taking others at new times of the day, and dropping some altogether. Among the most important suggestions:
Neel's report was dense and nuanced, but its message was clear: My mom's medications were making her sicker. She, like me, was inclined to follow his recommendations, but the truth is that making such radical changes was intimidating. What if we were wrong?
Nonetheless, we plunged ahead and booked an appointment with my mother's internist. To our relief, the doctor said the plan was worth trying. She emphasized, though, that if Mom intended to reduce her use of medications, especially those aimed at controlling cholesterol, blood pressure, and blood sugar, she'd have to exercise regularly and keep a close watch on her diet.
So we left the doctor's office with a handful of new prescriptions, feeling both relieved and apprehensive. That night, I hammered out a 10-page spreadsheet to help Mom keep track of her new schedule, which would change daily for 2 weeks, then every 10 days for another month. She now takes six daily medications, plus a few vitamins. Neel believes that in time, she may be able to eliminate still more drugs.
A promising new start
A few days into her new regimen, the fog that enveloped my mom's mind receded and her mood brightened. The asthmatic cough that plagued her for years has vanished, and recent tests showed normal lung function — no asthma after all. Her muscle pain has dramatically diminished. When I asked recently how her acid reflux was, she retorted, "What reflux?"
Five months into the routine, it's too early to say whether she can keep her blood sugar and cholesterol in check without more meds. Although her cardiologist is satisfied with her blood pressure, her internist is not. If her systolic reading isn't down to 120 by her next visit, the doctor insisted, "You're going back on the old drugs."
This encounter left my mom profoundly discouraged. She still believes she's better off without the drugs. With the assistance of a credentialed health care provider, she has dedicated months to gaining control over her health. She's accepted a marginally higher cardiac risk in order to avoid a multitude of symptoms that impeded her quality of life. But her doctor still holds the trump card: She could decline to write the prescriptions that would allow my mom to continue to follow Neel's recommendations, or even ask her to find another doctor. Afraid she'll be "fired," Mom wants to appease the doctor somehow — surely not a solid basis for making medical decisions.
Still, things are looking up. A year ago, Mom was a wreck. Now she's simply a middle-aged woman who has to watch her blood pressure and her blood sugar. That qualitative shift has given her a fresh outlook. "My life has changed and will continue to," she confidently declared recently. In the past several months, she has renewed her commitment to controlling her diabetes with a healthy diet and exercise. Last weekend, she and I took an overnight bike trip together.
There was no room on her bike for a toolbox filled with pills — and no need for one. The toolbox is history.
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