The greatest challenge for all who practice geriatrics is reducing polypharmacy, the addition of medications that either provide no benefit or cause harm to seniors. Millions of seniors end up on many medications that are not helping them and could be causing side effects. Geriatricians are the experts in what we call de-prescribing, cutting down on unnecessary medications.
The key reasons seniors end up on too many medications are the following. First, all physicians, including young geriatricians (as I was 30 years ago), have hope that newer medications will actually benefit our seniors. The four medications we have used to treat dementia turn out to provide no benefit at all. We can’t appreciate this until we have been in practice for decades and know how to review all of the studies that suggest there might be some marginal benefit. Also, one must practice for many years to understand how all medications, including over-the-counter medications, can cause difficult to diagnose side effects. For the dementia medications, we had hoped that they either alleviated symptoms, delayed the onset of dementia, or slowed the progression of dementia. It takes years of practice and experience to realize that these medications fail to help our seniors.
Second, many primary care clinicians (say, family medicine physicians) and specialists (say, cardiologists) tend to overvalue medical benefit for medications used for the most common conditions. The best example would be blood pressure medications. All geriatricians know that we approach frail seniors differently than we approach a robust 70-year-old or a healthy 45-year-old. Many clinicians will treat everyone the same, such as trying to keep the systolic blood pressure around 120 and the diastolic pressure around 80. Often, these pressures are simply too low for frail seniors and even for some robust seniors. The medications can cause lightheadedness, falls, and fractures (to name just a few side effects).
Third, clinicians in traditional medicine often fail to appreciate the value of alternative healing and the value of the placebo effect. Let’s return to medications for dementia. In recent years, we haven’t seen any commercials for the four medications I referred to above. We’ve seen many advertisements for Prevagen and Neuriva. These medications have not been studied extensively like the four that required many studies and FDA approval. If seniors feel more comfortable on these OTC medications, it’s probably from the placebo effect. That is, they feel that they are at least doing something to counter the onset or progression of dementia. The cost is affordable, and these individuals don’t need a prescription from their doctor. If the individual thinks Prevagen isn’t helping, or may be causing side effects, he or she can stop it at any time. They don’t need permission from their physician.
Fourth, the pharmaceutical industry has specialized in direct-to-consumer advertising. These are entertaining and convincing ads. It doesn’t matter what disease condition we are considering. Every expert in marketing knows that these creative, subliminal messages get through, and result in more prescriptions.
Before sharing my suggestions for cutting down on your medications, let me share a story about Elsie, a 90-year-old woman I took care of in 1992. She was feisty and funny. She was on the six medications our team had prescribed for her. Benign positional vertigo was one of her conditions. One of my most memorable clinic visits was the one when Elsie reported that she “followed that Harvard newsletter you gave me, Dr. Murphy, and it worked.” She did this complex maneuver all on her own, and it eliminated her dizziness. Then she added, “oh, and by the way, doctor, I threw all those doggone pills in the garbage, and I feel great now.” So be it. This approach worked well for Elsie, but I don’t recommend it for others. Here is what I suggest.
First, find the courage to question your clinicians. It’s not easy when you have put so much trust in your doctor’s recommendations. Try the soft approach. For example, you could say, “Doctor, I’m on a lot of medications and I worry that one of them might be causing some problems.” You could mention a symptom you’ve been wondering about. Then you ask, “could I cut down on the dose of one of these medicines to see how I do?” If your physician agrees with this trial of dose reduction, you could ask which medication he or she would select to reduce the dose.
Second, you continue with the honest communication you have established. You don’t need to let your doctor know how you are doing a week or two later. However, you should report that you are doing fine by calling the office staff that can document your success with the dose reduction. Believe it or not, you are educating your primary care office about the value of dose reductions.
Third, when you have more confidence in the dose reduction approach, you can specify which medication(s) you would eventually like to discontinue. You can share feedback you’ve received from family members and friends or from the research you or they have done.
Ever since the 1950s we have been moving from a paternalistic approach to health care (i.e., the doctor decides everything for your health) to a more patient-centered approach to health care. This makes sense. You know what’s best for your overall health, including physical, psychological, social, spiritual, and any other dimensions of health. Your clinician’s job is to reflect your preferences. Dose reductions of useless or harmful medications is just part of this evolution in health care.
Donald J. Murphy is a geriatrician.
