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  • "Drug holidays" and deprescribing


    Alan Cassels

    The growing movement to wind back excess medication.

     

    JOHANNA TRIMBLE KNEW SOMETHING WASN'T RIGHT with her mother-in-law Fervid. Fervid Trimble was an energetic 87-year-old living in a seniors’ residence who woke up one morning feeling dizzy. Found to be dehydrated, she was treated and admitted to the health centre for a few days of recuperation. New medications were prescribed: digoxin for her heart, antibiotics for an infection, and drugs for pain. Fervid was unhappy. She grieved for her independent life—so then came the antidepressants. She was now on nine different medications.

    What worried Johanna was the more drugs that were added, the worse Fervid’s mental health became. She became confused and delusional, totally unlike the Fervid her family knew. Johanna’s library background led her to start researching. Her research told her that drug side effects and drug interactions commonly cause older people to suffer from the medicine that is supposed to help, and that those problems were rarely discussed with doctors. Fervid’s decline was likely drug-related.

    Her family then insisted on a “medication review” to distinguish the helpful drugs from those causing problems, and Johanna got her wish: a staff-directed “drug holiday” which started a reduction in medications that essentially brought her mother-in-law back to life.  Fervid was able to enjoy several more years of relatively healthy living surrounded by a family who loved her, instead of living in a scary drug-induced haze, getting more medication than she needed.

    Since those events more than a decade ago, Johanna, who lives in Vancouver, has become a champion for the rights of patients, especially when it comes to overdrugged seniors. As a member of the BC Patient Voices Network and the Canadian Deprescribing Network, she advocates for better, more rational drug therapy for older people. The key problem that she and others have long identified is one called “polypharmacy,” which is often defined as taking five prescription drugs or more at a time.

    This is not a small problem. Two-thirds of Canadians over the age of 65 take at least five prescription medications per day, and one-quarter of Canadians take ten or more.

    Greater Victoria has the country’s fifth-highest percentage of people aged 65 and better—about 70,000 people. According to statistics, seniors have a one-in-200 likelihood of being hospitalized due to the harmful effects of their medication. This translates to 350 hospitalized seniors in Victoria per year—almost one every day. The bigger picture isn’t bright either: drug safety experts estimate that adverse drug reactions (ADRs) are endemic in our drug-centric health care system, and considered to sit somewhere between the fourth and sixth leading cause of death.

    According to material produced by the Canadian Deprescribing Network (deprescribingnetwork.ca), which is made up of interested health care leaders, researchers and patient advocates, older people are particularly vulnerable to the effects of too many medications. While these advocates are trying to bend the curve on overprescribing, and ensuring that there is both the confidence and mechanisms in place to help people stop medications that may be useless or harmful, the reasons older people end up on so many drugs is complex and sometimes difficult to unravel.

    Victoria resident Janet Currie is currently attending UBC doing a PhD in drug safety. She is a long-time advocate for better awareness of psychiatric medications and founded a website— www.psychmedaware.org—devoted to helping people stop these medications. Also on the executive of the Deprescribing Network, she describes a typical patient this way: “This patient is on ten or more drugs and they are taking drugs that they might have been prescribed decades ago, including sleeping pills and benzodiazepines” (which are typically prescribed for anxiety and insomnia). The problem is that nobody is tracking possible drug effects which could cause dangerous falls, problems with memory, insomnia, indigestion or pain. Anytime a person is on multiple drugs, the risk of adverse drug reactions is increased. Also, seniors have reduced ability to metabolize drugs, and should be given lower drug doses than other adults.

     

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    Janet Currie

     

    How does one counter the inevitable accumulation of drugs in the medicine cabinets of elderly people? Currie is quick to respond: “The first thing they need to know is what drugs they are on—and this is not always easy to find out.” You can request a “medication review” by a doctor or pharmacist, where they’ll methodically go through a person’s medications, determining what they are for and if they are still needed. Within the deprescribing community there is some debate about whether to worry most about the types of drugs being prescribed or the numbers. Clearly you have to consider both, but for Currie, mostly the numbers count. “Anyone on 10 or 12 drugs is going to have a real risk of drug interactions. The main thing is to reduce the total number of drugs.”

     

    AROUND THE COUNTRY there are people working to resolve the problems of deprescribing. There are research groups at Hamilton, Ottawa and Montreal that I am aware of that are testing ways to help doctors reduce the medication burden of seniors. There are conferences where new guidelines for deprescribing are being launched, and others developed.

    Though I’ve long understood polypharmacy from an academic point of view (full disclosure: I worked with a group to develop www.medstopper.com as a tool to help doctors deprescribe), it wasn’t until I took my own 81-year-old mother to the doctor for what is called a “complex care visit” that I truly understood the magnitude of the problem. This visit with my mom’s doctor was longer than most visits, and designed for the doctor to take the time to do a complete assessment, and suggest therapies for many of the multiple challenges that many older people have. It also involves an extensive medication review.

    This was a big eye-opener. I intimately knew which drugs my mother was on—a total of 7 outside a few puffers and asthma medications. Over the years I had shielded her from taking what we considered the more useless and potentially harmful drugs typically thrown at seniors. I acknowledged that anyone who has survived a few heart attacks may benefit from some meds, and those “necessary” drugs were on her list.

    As well, however, there was a heartburn pill (pantoprazole) which I couldn’t figure out. Why was she taking that?

    “Mom do you have heartburn?”

    “No,” she said, “Never had heartburn in my life.”

    “Well you’re on a heartburn drug.” (I know that pantoprazole is routinely prescribed in hospitals.)

    “Why am I on a heartburn drug if I don’t have heartburn?” she asked.

    “Maybe you got it when you were in the hospital?” I said. But that was years ago. “Do you want to keep taking it?” I asked her.

    “No. I tell you, I don’t have heartburn,” she insisted, getting a bit feisty. So I gently suggested to my mother’s doctor that the heartburn pill was probably unnecessary and she’d like to stop it. Then I got to see how even the thought of stopping a drug seemed to make the doctors nervous (there was my mother’s doctor and a resident who was shadowing her).

    “Are you sure?” they wondered aloud. “Maybe she was on the drug for a reason? Maybe the specialist put her on it?” they mused. Their hesitancy seemed bizarre. After all, I have studied prescribing for many years: no one puts that much thought and hesitancy into prescribing a new drug. But stopping one? Wow. You’d think the heavens would fall.

    I said something like: “You know the main thing that matters to my mother is her comfort. If she’s not comfortable being on a drug which no one can justify, why not just stop it? If she develops any heartburn symptoms, you can start her up again, ok?” And in the end, this was agreed to.

    I always thought deprescribing would be easy. It’s harder in real life. With a ton of drugs, you certainly should stop the ones that can’t be explained. Then you should eliminate those that are useless, harmful, or seriously degrade the person’s quality of life. At the end of the day, there is one inviolable principle: the patients’ wishes trump all.

    This is not easy, especially in a world where “do what you’re told” medicine dominates. Challenging your medication regime takes energy, commitment, and some assertiveness. I remember what Currie said on that topic: “It is important that the family be involved—and both the senior and the family be clear on why a drug is being taken. Does it make sense to have a senior on a lot of prevention drugs like statins if they have never had a heart problem or stroke? Remember that all drugs cause side effects, so a drug should be really needed before it is taken.”

    After all, for many people the drugs aren’t going to give them a lot more life, but they can seriously affect the life they’ve got left. It’s never too late to start questioning and cutting back.

    Alan Cassels has studied pharmaceutical policy and prescribing for 24 years. He is currently transitioning to a new position at UBC.



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