As individuals grow older, they often need to keep track of a growing list of medications. Doctors commonly prescribe drugs to elderly patients to treat hypertension (high blood pressure), diabetes, high cholesterol, chronic pain, blood clots, depression, sleep disorders, and many other conditions.
More than a third of adults who have reached retirement age are taking at least five prescription medications. About 15% of older adults are at risk of adverse drug interactions.
Patients should tell their doctors about every drug they take, including over-the-counter products, before the doctor prescribes a new medication. Doctors need that information to help patients avoid adverse drug interactions. Using the same pharmacy to fill all prescriptions provides a second level of safety. Pharmacists are trained to review all prescriptions that they dispense and to warn patients when drugs taken in combination can cause a health risk.
Polypharmacy — sometimes defined as taking more drugs than are medically necessary — can place the elderly at risk in multiple ways. In addition to adverse drug interactions, patients may have difficulty keeping their prescriptions filled and taking each drug in the right dose at the right time.
The health concerns associated with polypharmacy include “falls, hip fractures, cognitive impairment including confusion and delirium, and urinary incontinence, which account for a significant percentage of potentially preventable emergency department visits and hospitalizations.” Polypharmacy also increases the health care costs of older patients.
Research by Dr. Daniel Safer identified classes of medication that have been increasingly prescribed to older Americans in recent years. Opioids are at the top of that list. The widespread prescription of OxyContin, Percocet, and other opioids caused a public health crisis as patients became addicted to the drugs.
While many elderly patients have a legitimate need for drugs to treat chronic pain, Dr. Safer notes that patients develop a tolerance to opioids that makes them only “marginally effective to reduce pain” when the same dosage is administered over a prolonged period. Steadily increasing the dosage to maintain effectiveness can cause dangerous side effects. The benefits of pain relief may outweigh the risks for a patient in a late stage of cancer, but older patients with less severe pain might not be well served by long-term opioid prescriptions.
Proton pump inhibitors (PPIs) are prescribed to treat ulcers and other conditions caused by excess stomach acid. Dr. Safer reports that PPIs are usually recommended for only a few weeks or months, depending on the condition for which they are prescribed. Many patients nevertheless take them for more than a year.
Elderly patients have a higher rate of gastrointestinal disorders and are therefore likely to have a prescription for PPIs. Yet long-term use of PPIs “increases the risk of fractures, gastric polyps, low magnesium levels in the blood, Clostridium difficile infections, and anemia.” Dr. Safer suggests that lifestyle changes (including dietary changes and increased exercise) may be more beneficial than long-term use of PPIs.
Levothyroxine (LTX) is used to treat hypothyroidism. Dr. Safer reports that “LTX is often being prescribed more to treat older adults with complaints of fatigue, lethargy, weight gain, cognitive dysfunction, and despondency.” There is no clear evidence that LTX will improve those symptoms in all of the people for whom it is prescribed. In addition, treating older patients with LTX “can inadvertently lead to overtreatment, increasing the risk of fractures and cardiac arrhythmias.”
The Risk of Stopping Medications
Concern about taking too many medications must be balanced against the risk of not taking prescribed medications. Some older patients have decided to stop taking statins — drugs that lower cholesterol — because they are associated with well-publicized risks, including liver and muscle damage, neurological side effects, and adverse interactions with several drugs. A decision to withdraw from statin therapy, however, can create its own risks.
A recent study asked whether discontinuing statins is the right approach to addressing polypharmacy. The study examined a large group of people who had reached the age of 65. Members of the study group took statins continuously for a period of 16 months. About 42 months later, the study’s authors compared patients who discontinued the use of statins to those who did not. The study controlled for patients who replaced statin therapy with an alternative drug therapy.
The study found that discontinuing statins increased the long-term risk of having a heart attack or other cardiovascular event. That result was true even when patients followed alternative drug therapies. Older patients were more likely to experience heart failure, emergency hospital admissions, and death than patients who did not discontinue their use of the drug.
The study does not mean that all older patients who take statins must continue to use the drug forever. It does suggest, however, that discontinuing medications is not always the best solution to the risks posed by polypharmacy. Older patients should work with a trusted physician to find the best balance between risks and harms associated with the prescription of multiple drugs.