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We can all embrace the idea that many of us are taking too many medications to the point that it is doing more harm than good. The term that best describes this is polypharmacy, and in this episode, Carrie Miller speaks with Dr. Holly Holmes to give us a great view of it. Dr. Holmes is the Director of the Division of Geriatric and Palliative Medicine at McGovern Medical School. A former Geriatrician and Pharmacist, Dr. Holmes, shares her expertise about polypharmacy and how it has been affecting our health, most especially those who are 65 and older. She names the drugs that can be harmful to our body and brain and where the risks outweigh any potential benefits for the elderly. Going further, Dr. Holmes then taps on medications for patients with dementia and gives some key strategies to know what drugs are good for you and who to ask for help.
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Polypharmacy: Understanding The Appropriate Use Of Medication With Dr. Holmes
We’ve got a special guest here on the show. I met this young lady at a presentation she was giving at The Hope and Healing Center & Institute here in Houston, Texas. She’s a geriatrician and former pharmacist. Her research and clinical interest focus on the appropriate use of medications in older patients particularly those approaching end of life. She’s the Director of the Division of Geriatric and Palliative Medicine at McGovern Medical School. She joined UT Physicians in 2015 and is a Joan and Stanford Alexander Chair in Gerontology. Please help me welcome, Dr. Holly Holmes.
Thank you, Carrie.
How are you?
I’m very good. It’s very good to be here.
I’m so excited to talk with you. I believe that our readers are going to receive some valuable information on the topic of polypharmacy. Since you have extensive knowledge of drugs as a former pharmacist, you are the drug expert.
I know that the pharmacists are the experts.
Before we talk about our drugs that can be harmful to our body and brain, please first tell us the definition of polypharmacy.
That’s a difficult question to answer. There’s not a great consensus about what polypharmacy is. We all agree that the word doesn’t even mean what we think it means. A lot of people would say polypharmacy means too many pharmacies. It’s a term that we haven’t embraced very well but I like the definition proposed by Lown Institute. I served on a working group to define polypharmacy, which is medication overload. We can all embrace the idea that many of us are taking too many medications. We feel burdened by them. We feel burdened by the side effects and costs. Traditionally, polypharmacy has been defined as the use of 5 to 10 or more medicines than indicated or using medicine to treat the side effects of other medicines. The reason to define it that way is so that we can research it, but the idea of medication overload is much more understandable to the people who are experiencing it.
Let’s talk about these medications that are potentially harmful to people who are 65 and older. Let’s talk one by one. If you could please give examples and why they would be harmful. Let’s begin with anti-histamines.
Antihistamines cause sedation or sleepiness. Those old school anti-histamines like diphenhydramine, chlorpheniramine and brompheniramine, those ones that are over-the-counter. Those are on a list of drugs to avoid because they cause excessive sleepiness and confusion. They have other side effects that are those anticholinergic-called effects. You mentioned a list of medications. I want to back up and say that there are lists of medications that are recommended to be avoided in people 65 and older simply because the risk outweighs any potential benefit. There may be a benefit, it’s just that the risk is greater than the benefit. As we get older, those risks accumulate because of our being more and more vulnerable to side effects, interactions and not being able to metabolize them appropriately. Antihistamines are a perfect example. A younger person would be able to take a dose of diphenhydramine, the brand name of which is Benadryl for an allergy on a regular basis and not have any bad side effects. An older person, even a single dose of Benadryl could cause significant confusion.
There is no medication that we can use for sleep that is without harm. Click To TweetWhat about sleep aids?
Sleep aids are the worst. They’re the bane of my existence. A lot of the over-the-counter sleep aids have those first-generation antihistamines in them. People don’t understand that they’re getting the diphenhydramine-like drugs or doxylamine or other drugs similar to that which are overly sedating and can cause confusion. The sleep aids that are prescription, those so-called Z drugs, zolpidem, eszopiclone and benzodiazepines. Drugs like lorazepam and diazepam brand names of which including Valium and Ativan, those are sedatives that had been used for many years and they cause excessive sedation. The risk outweighs the benefit and particularly those sedatives like the benzodiazepines and the Z drugs, people who take those drugs have up to three times higher risk of falling and breaking a joint, particularly the hip when they take those medications. They cause confusion, excessive sedation, changes in memory function and long-term changes in physical function, all of which are harmful.
The Big Pharma promotes their sale of sleep aids through extensive direct to consumer ads and through contributions that influence public sleep education. The National Sleep Foundation, the leading nonprofit organization dedicated to improving sleep health has received substantial funds from numerous pharmaceutical companies.
We would all consider that a very significant conflict of interest. The problem is and the elephant in the room is that we all feel we’re not sleeping well and we aren’t given acceptable alternatives. The fact is there aren’t very many if any, acceptable alternatives to taking medications that are not that effective and are harmful. Sleep medications have been over-promoted, their benefits have been overstated, and their risks have been minimized. In previous studies when comparing Cognitive Behavioral Therapy where you have therapy focused on reducing anxiety and promoting better sleep behaviors that had a stronger effect than these sleep medications. If you think about that, the harm is minimal. In the past, there hasn’t been the marketing of Cognitive Behavioral Therapy and adequate coverage. It’s hard to find providers who take Medicare who will provide CBT for sleep. We’re left with this gap. The problem is the sleep medicines aren’t filling the gap adequately. They’re making us more unsafe.
I’m sure you’re aware of the natural approaches, the things that we can do to prepare ourselves for good sleep.
I frequently refer people to and use free resources available from the Canadian Deprescribing Network and those are available at Deprescribing.org. It has all kinds of resources for how to reduce those medicines and it is a challenge. I would not recommend anybody who’s been taking a sleep aid for years and years to suddenly stop it tomorrow because they’ve read this blog and they agree. They do need to wean off of it slowly. They have a very slow weaning process that a person can do without having to consult their doctor. It’s a lot safer over about a four-month, but at the same time as doing that, they have a very large handout on all of those behavioral things that people can do to improve their sleep. Things like avoiding screens late at night, not watching the news right before going to bed, only sleeping in bed, getting out of bed when you’re not able to sleep, sitting in a chair and reading and then going back to bed when tired. Even basic things like hot milk. There was a basis for that. Our moms were right. All of those kinds of things are in the handouts from the Canadian Deprescribing Network.
The next are sedatives.
Sleep aids and sedatives, I lumped them all together. I didn’t make the distinction but there are certainly over-the-counter sleep aids and then there are sedatives that are prescription. Some of the sleep aids are those ones that we said we didn’t touch on melatonin. I would say of all the things that we might talk about, melatonin would be the least harmful. I find that there aren’t that many people who find an earth-shattering effect of melatonin. If it is effective, then it’s much safer than the other options we’ve discussed. There are other medicines that have been used for sleep also that had been used as sedatives that might be traditionally antidepressants. We get into this balance of risk-benefit. There is no medication that we can use for sleep that is without harm.
Do you know anything about the magnesium? Are you a proponent of that?
Sometimes I will recommend trying it. It’s even marketed under the name Calmate and may have that calming effect. There are times when I do urge caution though. I do think that if people want to take magnesium at bedtime for sleep, they need to make sure to check with their doctor or healthcare provider that they don’t have any reason to have any overload. People who have chronic kidney disease may not clear it adequately and may have higher levels than what would be appropriate. A little bit of caution on that.
Antipsychotics.
It is a medication category that is on the list of high-risk, low-benefit but particularly for the use in patients who have dementia who have behavioral symptoms related to dementia. The challenge here is that we have to find acceptable alternatives to antipsychotics. We know studies repeatedly show the harms of antipsychotics and the lack of benefit, frankly. In my own practice, there are patients for whom the paranoia and the psychotic symptoms that come along with dementia mean that that patient is so unsafe. We try all kinds of alternatives but we must try the behavioral alternatives first.
A lot of patients can be redirected, can be put into an environment that’s got more structure, has different kinds of activity and more support. This is where we need to be funneling our efforts in supporting the patient and the caregiver to stay as independent as possible but in an environment free of medication. That sounds so ideal. I realize that’s not always possible. In the more structured environment with redirection and a focus toward how to understand, minimize and not escalate those symptoms. I think patients do a lot better and they do a lot better without medication.
It’s so home with me because my mom being at home with dementia. Next are muscle relaxants.
Those are not on my list that I prescribe. Muscle relaxants have not been shown to have a significant benefit in any population. For some patients, they are so sedating. People say, “I slept so well and I woke up so relaxed.” It’s probably that it was such a sedating effect that you got very relaxed asleep but at the price of much higher fall risk, dizziness, unsteadiness and significant increased risk of falls with those medications.
Let’s cover statins.
Statins are very appropriate. To be clear, this is where we get into a lot of gray areas. Statins are among the most useful medications we have for the prevention of heart disease and stroke. The challenge is that those benefits have been shown in younger populations who have a high risk of heart disease but who don’t have other conditions that compete with that risk. Even the American Heart Association and the American College of Cardiology and numerous other societies have finally embraced a guideline that says, “When you’re 75 and older, we are not certain about the benefits of statins anymore.” It’s very important to have an individual discussion and conversation with your provider.
If you’re someone who would rather take medication and prevent something knowing that you did as much as you could to prevent it then maybe statin is for you. If your bad cholesterol is high, then your risk is high enough. If you’re a person who does not want to take medications, who want to avoid them or has had side effects on the statins, it is perfectly reasonable to say, “If I’m preventing a condition that I don’t have, you have no known heart disease and history of stroke or mini-stroke, it would be reasonable to not take a statin.” We’re in this middle zone right now where we’re unsure how to treat older people even though the vast majority of people eligible to take a statin are over 75.
What about the side effects from statins?
A lot of people do well but it is likely that around 10% to 20% of people in some of the studies where they followed people’s symptoms but maybe even up to 30% in some of those studies depending on the population can experience some vague muscle pains, muscle cramps and can have joint pains. That has some long-term consequences in terms of mobility and function. That’s what we can’t minimize. We don’t want to press and push the statins even if that means that somebody is going to lose their mobility down the road. That would be so much more harmful to them. It’s one of those where we’ve tended to overstate the benefits and minimize the risks and we need to recognize that there is some risk. There are patients who have vague issues with fatigue and not feeling great. We stopped statin in a very time-limited trial and see how people feel if you don’t feel any different than it was something else. If you feel differently and we’re talking about a 2 to 3-week trial off of a statin, then it’s worth either rotating onto a different one or going off of it.
A good rule of thumb is you don't want to be on two or more medicines that affect your brain. Click To TweetIs it addictive?
The statins are not addictive and those can be stopped suddenly. They don’t have to be weaned down. I don’t recommend that everyone go off their statin. It’s an individual discussion with your provider which is what is my risk of heart disease and stroke? Would it be reasonable for me to stop statin to see how I feel? After that, have a discussion about whether I would restart it or not especially if you have no known history of heart disease or cerebrovascular disease, history of stroke.
Antibiotics.
We’re getting into allergy season where we get to this confusing zone of, “Do I have sinusitis, bronchitis? Is this pneumonia? Is this the common cold?” We know that we overuse and overtreat with antibiotics. Bladder infections being another big culprit. We have to be very cautious to treat what we think is a bacterial infection with a drug for a bacterium. We know that many of these respiratory illnesses that people come in with are viral and that they will get better over time. There’s always this confounding thing that people say, “Every time I have this, I get a Z-pack and I get better.” You would get better without that antibiotic. It’s hard to convince people. I’ve started to do a practice a little bit differently than I think it works a little bit better. Some providers are starting to do this, especially going into a long weekend or symptoms have gone on a couple of weeks and now it’s Friday. It’s reasonable to have a prescription in hand with very clear directions for when you would fill it.
What people get anxious about is that they’re not going to be able to get back into their doctor and they won’t be able to get an antibiotic when they need it but the thing is, they don’t need it. I often will tell people, “It’s too early for an antibiotic at this point. This is still most likely viral.” The way we know that we were wrong is if the symptoms massively progress. If there’s coughing with secretions or if there’s chunky stuff coming out of your sinuses, if that’s progressing, getting worse, more and more discolored throughout the day and it’s associated with a different pattern or fevers, shortness of breath, if we check for an elevated white blood cell count, a much more reliable indicator of infection and if we check chest X-rays in the appropriate setting, that information helps push us towards bacterial infection and away from viral. That is what we need to use to help decide because objectively that information is perhaps more useful. Subjectively, these infections often look the same.
When you’re talking about pneumonia and a person ends up in the hospital with pneumonia. They’re thrown off all kinds of antibiotics.
When someone has pneumonia, it is very likely that broad-spectrum antibiotics are used pretty early on that cover of a wide array of potential organisms and that coverage needs to be narrowed down relatively quickly if the cause is identified. There are standard protocols used for pneumonia and then we narrow that down as quickly as we can.
It’s usually 2 or 3 antibiotics that I’ve found with both my parents.
There’s some value to getting cultures of the sputum if we can, but sometimes we cannot get adequate cultures. In the right setting, that can be helpful and in other settings, it’s not. It’s a real challenge. The biggest thing with antibiotics that we see and we see it in an individual patient. Bladder infections are a perfect example. We over test the urine, we over-treat it and we find a bug that used to be sensitive to Ciprofloxacin, for example. On the repeated treatment of the same drug for vague symptoms or when we’re not even convinced there’s an infection, but we grow out the bacteria. We keep using the same antibiotic. We select out the resistance and we can see in that very single patient. A couple of infections down the road, now are resistant to all oral antibiotics and they can only receive intravenous antibiotics in the hospital. That’s what we have to avoid.
If we take antibiotics, especially rounds and rounds of antibiotics and people have had side effects from that, it destroys the gut health.
It does a lot of things that can be harmful including selecting out resistant organisms. Gut health is a big part of that. To be honest, I don’t think we know enough about how to correct that yet. We do a lot to correct but what we’re going to end up doing down the road is we’re all going to have this single population of lactobacillus in our guts because we’re overpopulating that too. We have to have a more nuanced understanding of how to combat that.
The thought of any memory loss as a result of medications that are supposed to be aiding your healing is a scary one. Should we be concerned with drugs and with anticholinergic when we’re trying to preserve brain health?
Anticholinergic and sedative medicines, both of those categories, there is convincing evidence and there’s a good long-term study where they took people 75 and older who were perfectly healthy. They did not have dementia. They did not have cognitive impairment or mild cognitive impairment or early signs. They didn’t have any functional impairment and any physical dysfunction. They compared the people who took a higher burden of anticholinergic drugs, they compared to people who took a lower burden. When you follow these people over several years, the higher the burden of anticholinergic medication, the more likely that they developed cognitive impairment by objective neurologic testing and functional impairment by the difficulty in doing the day-to-day activity and physical dysfunction like performance on physical tasks. We see that the burden of these medications is that we are making ourselves cognitively and physically impaired which is scary.
For our readers, can you explain the drugs and then give us some examples?
We already talked about the first-generation antihistamines. They have anticholinergic side effects. Some classes of drugs have individual drugs in which some are more anti-cholinergic than others. For example, antidepressants. There are some antidepressants that are highly anticholinergic. Tricyclic antidepressants are a little bit old school but those are things like amitriptyline and nortriptyline. They’re very rarely used for depression because they cause so much sedation. They’re sometimes used for pain from neuropathy. Those are highly anticholinergic as opposed to the selective serotonin reuptake inhibitors used for depression.
Generally, those are not very anticholinergic. They have slight differences across the class where some might be a little bit more than others. Those kinds of medications that cause sedation, constipation and general slowness, those are anticholinergic side effects and the ones that we want to minimize. If it’s possible, we try to choose a drug in the same class that’s less anticholinergic. If it’s not possible, we try to minimize the number of those kinds of drugs that are used. A good example would be somebody who’s been taking a benzodiazepine and we do try to avoid those medicines like the lorazepam and alprazolam, that list that we talked about earlier. Let’s say we’ve been using that medication for decades. It is a harmful medication that we’re going to try to minimize.
We would try to change to something else depending on what we’re treating. If we’re treating a generalized anxiety disorder, we try to use something for anxiety. If we’re using it to treat muscle symptoms, we would try to use something else. If we’re using it to treat sleep, we would try to get off of that but that drug alone is bad enough. It’s the idea of what if you’re taking one of those drugs, one of the benzodiazepines plus antipsychotic plus antidepressant that’s very sedating, plus antihistamine plus one of another category of drugs that might have an anticholinergic effect. You think about you’ve accumulated so much daily burden of that type of side effect. That’s where we’re in trouble. When people are on quite a few of these drugs rather than one. A good rule of thumb is you don’t want to be on two or more medicines that you know affect your brain, whether it’s acting on your brain or it has a side effect in your brain. That’s a basic way to think about it. I know we’ll get to this. It is something that a pharmacist, physician or healthcare provider could help review.
Can you talk about that?
Pharmacists are a great resource to figure out what’s my burden of anticholinergic and sedative drugs? It’s not good to go to them on Friday at 5:00 PM, they don’t have time to talk to you then. You could see if they have time to review your medication list and let you know which ones have these kinds of properties because they can tell you right away, “These are your anticholinergic drugs. This is the list you want to take to your doctor and see if we could reduce some of these.” You could schedule an appointment with a consultation and see when they are most available.
How about the anti-seizure meds?
A better way to approach using medication is to be very upfront with patients and families that the benefits are very small. Click To TweetIt depends on the use. They can be very difficult as well. Some of them have a lot of drug interactions. Whenever someone’s taking something like phenytoin, the brand name is Dilantin, we’re always cautious because it interacts with the drugs across the board. It can affect the metabolism of all these other drugs and lower their levels. Some seizure drugs are very well tolerated and can be okay. It gets back to what is the use. If we’re treating epilepsy, we need to find a drug that’s going to be reasonable, not have too many drug interactions and it’s going to keep it under control. Seizure drugs are often used for a lot of other indications. We also want to be cautious about that because that contributes to the burden of polypharmacy.
What about allergy medications?
This gets back to antihistamines. I tend to avoid decongestants as a rule. I don’t think a lot of people see that on the packaging. We get back to those first-generation antihistamines that are sedating, try to avoid those. I try to avoid decongestants because of their effect on increasing blood pressure and heart rate. Other allergy medicines that are commonly used would be steroid nasal sprays and antihistamine nasal sprays. It’s very difficult because we’re here in Houston and we’re starting to have allergy season. Tree pollen is everywhere. It’s difficult to at least try to minimize the duration. What happens is sometimes people start medication and they keep taking it forever and it doesn’t need to be taken indefinitely especially if it’s going to be for a self-limiting condition. If that you’re allergic to a particular thing and you see that it’s high, now is the time to be using this medication, but then you want to back off as soon as you’re able.
As a pharmacist and geriatric doctor, do you believe we should be giving our loved ones any of these drugs if they have dementia? I know you had mentioned that. The side effects are outweighing the little to no benefits of the drugs.
We have to be cautious in patients with dementia that the medications that we give them are extremely vulnerable to their side effects. We have to be extremely cautious about using medications that are going to worsen their conditions. We get back to this antipsychotic issue. We want to try all kinds of other interventions but that requires so much more caregiver support than caregivers get even if they’re in a home. There’s no doubt that what we see happening now is nursing homes are carefully watched for their use of these kinds of medications but other facilities aren’t. We want people to be in the most independent setting possible. There are times when other types of facilities, not necessarily in memory care but regular assisted living that there is a push to medicate patients so that they will be calmer or safer or whatever it is that’s going on.
We can all appreciate that there are times when we are looking at that risk-benefit equation. How critical is it that we keep a person in their home and the only way to keep in their home is that this medication is the thing that prevents them from trying to murder everyone in the middle of the night. We’re talking about extreme situations. There are times when patients are so aggressive and so combative and that we’ve done everything we can do. We have to try to improve the environment, support for the caregiver and education for people with the patient during day and night. There are still times that failing all that, we end up using these medications. We have to consider that the exception and rare time. When it comes down to the safety of the patient and others around them. That’s when we get into a lot of trouble. In the right environment, I feel that we can often support these people and minimize medication.
Let’s talk about dementia meds. Billions and billions of dollars have been spent to come up with a drug to treat Alzheimer’s. None of them work. Some are more correlated with the faster decline of the disease. Why do you think these drugs continue to be sold?
I think we don’t have anything else and we are looking for something. The medications that are used to treat dementia are two basic categories, acetylcholinesterase inhibitors and memantine, NMDA receptor inhibitors. They have mild to modest benefits at best. There are some patients who see some benefit from it but that benefit is small. This is where we get stuck and it’s so frustrating. The challenge is that we see some delay in the progression of the disease or some stabilization. It’s hard to say that being stable is an earth-shattering, positive result. People stay stable for about 6 to 9 months longer, they still decline and the disease is there for years. The challenge has been in the studies in which they did with drugs and medications, people decline faster. They declined back to where they would have been at regain. That’s the frustrating thing. That’s how people get put on the drug and then they stay on it forever because we’re afraid to stop the medication. We’re afraid to see that decline happen and knowing that they wouldn’t regain it.
Why give it to them in the first place?
It’s difficult to answer because I do struggle between the nihilism of not trying the medication versus giving it a try. There are patients for whom the benefit is perceivable for the family.
It’s just a few months.
That is true but the benefit that is seen over those 6 to 9 months, the idea is that there’s still this higher level at which the patient is at. I completely agree. There needs to be an approach to withdrawing the medication if that benefit is not seen. The challenge for me is that there are very small numbers of patients who see a much larger benefit. I do think that patients with dementia deserve a try on these medications. That try needs to be accompanied by a very careful conversation about when we would stop the medicine. We say we’re going to try donepezil but we’re going to discuss this in six months and we’re going to stop the medicine if we have not seen that things stabilized or even improved. If we see no benefit there, we’re going to stop it because otherwise you’re going to be on this medication for the rest of your life and we’ll be talking about stopping it at the end of life. That’s what we don’t want.
It’s an expense, for one. If you don’t have insurance, I can’t even imagine. I don’t know what the insurance covers.
A better way to approach using the medication is to be very upfront with patients and families that the benefits are very small. Let’s think about how we would measure the benefits. There was one study in which the benefit was a delay to nursing home placement. Being able to be in your own home for longer would be a benefit that would be meaningful to people.
I’m wondering what the percentages are at that time.
That one was also about a six-month delay on average. Some people were less than, some people were more. There was another study in which caregiver hours were reduced. Patients were a little bit more functional and needed less caregivers. I’m not defending the drugs. This is me saying this is as positive as I can get it.
Let’s talk about the side effects.
If you think about it this is as positive as I can go and think about what we would be saying. This would be unacceptable for a blood pressure medication. This medication might lower your blood pressure, but it might not. It might be that your blood pressure stays exactly the same and that means the medication was working. We wouldn’t accept that. The problem with the medications for dementia is that this is the best we’ve got, which is two categories that are not good, it’s the only thing we have, and we keep trying them because we have no other alternatives.
Would you say it’s a failed drug compared to a lot of the drugs out there on the market?
It’s hard to compare one disease state to another. It’s certainly a drug I’m not in love with. I’m not a big proponent but it’s important to have a very good conversation. Healthcare providers need to be very open about how these drugs are not the end-all-be-all.
Every healthcare provider needs to have the correct medication list for you. Click To TweetLooking at it from a broader perspective, they spent billions. Some publications say $600 billion or $800 billion. It doesn’t matter. It’s still a whole lot of money. Look at all the money and they want to end up with something. They want to push something out there on the market and if this is all we got, but it’s not enough. Do you believe that we have other strategies and other approaches to nutrition?
Prevention is an important strategy and backing up to compare dementia to cancer. Cancer is not cancer. There are all kinds of cancers, you can’t compare. We also would not accept this little of a benefit to a cancer drug. We also don’t put the money into Alzheimer’s research that we put into cancer research. We’re not going to push the science further until we make a commitment to end Alzheimer’s. There’s more and more momentum here but these drugs are going to fall by the wayside sometime in the future.
They’re trying to initiate one of the drugs that have fallen off backend.
Everything’s not working. Let’s go back to the drawing board and see what else we can do. I do think that there is a difference between looking at people who have early onset, who have genetic types of dementia and other different types of dementia illnesses beyond Alzheimer’s and vascular dementia. We have to think about the things that have been effective. Having a healthy lifestyle, healthy diet, regular exercise, quitting smoking, those kinds of things are the things that long-term are the preventive strategies to do the best we can do to minimize our risk of cognitive impairment and also vascular dementia from strokes.
Are you familiar with the side effects of dementia meds?
The challenge is not just the benefits are sometimes not even be perceived. Sometimes the benefit is so minuscule or non-existent as to be not present, but it’s the fact that there are side effects. When people first start the medications, they can have increased confusion and acute worsening. That usually is something that would prompt us to stop the drug immediately and that can improve. There are a lot of gastrointestinal side effects. Poor appetite, there can be diarrhea, changes in bowel habits, changes in sleep and dream pattern. One of the things that people forget to think about is sometimes when the medication is helpful, we return people to a previous state in which they were more unsafe or functional in a way that was unsafe. We can try to focus on the positive of that but it also can be very negative for caregivers and family. The patients better but one year ago, when they were better than they are was when they were much more paranoid and putting furniture out of the curb. We returned them to that state. We also have to be very careful about how they do on the medications, watching their behavior, their day-to-day function and the pattern in their function that that can be a side effect of it as well.
Can you please give our readers some key strategies to oversee the list of drugs? Who can they trust and perhaps some resources to help them?
The number one most important thing is to have a current, accurate and regularly updated medication list that you have with you all the time. I cannot stress that enough that we give our patients in the clinic a paper list of medications to review. Sometimes, we’ve made them fill out so many forms, they can’t be bothered and they sign it. That implies that the list was correct and it’s not correct. That is dangerous. The first thing is every healthcare provider needs to have the correct medication list for you. We need to know what you’re taking. It also needs to be what you’re taking, not what we all think you’re taking. If we think you’re taking Metoprolol twice a day but you only take it every other day, that’s concerning. We need to know about it but it happens all the time. People are afraid of disappointing their healthcare providers. They don’t want the doctor to be angry at them but it’s dangerous not to tell them what you’re taking because they would change medications based on what they think you’re doing.
My mother was on seventeen meds. Do you think that a doctor even looked at her list? I’m not quite sure.
First is to even have the list and then the second part is it’s perfectly acceptable to expect your healthcare provider to review your medication list. That is part of what they should be doing. You need someone to be the quarterback of the list. Ideally, that’s your primary care provider or the provider that you see the most often. That might be different for somebody who has active heart disease. Maybe they see the cardiologist more often. For somebody who has active cancer issues, they see the oncologist more often. It is okay to ask them, “Would you please look over my list?” If you feel that you’re exposed to medication overload, it’s okay to ask them to reduce some of your medicines. You say, “I have too many medicines, which ones can I get rid of?” Be prepared that your doctor might want to get rid of the ones that you want to keep and vice versa, but at least open that conversation so that they do a careful review.
I’m not sure that a lot of people feel that they have a choice in that setting with the doctor because a lot of times they feel they’re at the mercy of the doctor. He does. He went to school all those years and he knows what he’s talking about. Who’s going to ask them to wean because the doctors put them on the medication, to begin with so they trust their doctor. Why would they even ask to be taken off?
Oftentimes, it’s multiple doctors that prescribed multiple different things. It’s also about having one person put that whole list together. If you ask a doctor, “Do you intend for all of your patients to take seventeen or more medicines?” That’s not their goal. Doctors are overburdened with complexity and decision making all day long. It’s very likely they don’t ever stop and take a quick moment to look at that list. To assume that your healthcare provider has taken the time to look at your entire medication list, it’s a dangerous assumption because they have not had time. Unless you bring their attention to it, they haven’t done it. Ignorance is no excuse and it’s perfectly okay to say it in a way that doesn’t offend them, which is, “Are there any medicines on my list that you think I don’t need?”
Would you suggest going looking for a geriatric doctor, which there’s not a whole lot out there?
There will never be enough geriatricians to take care of people over 65 or even 75. Even now, we have anywhere between 1 to 3 geriatricians for every 10,000 people, 75 and older. A doctor can only handle a patient, a panel of about 800 complex older patients. If you think about that, we will never be able to serve the need that’s out there. That being said, we have to rely on the primary care doctors to do what needs to be done and they can do it. They have to be reminded. We talked about having an updated medication list and asking your doctor to reduce medicines, but I want to talk about three other strategies. One is to have an accurate, complete medication list with you at all times.
Number two is to take that list and ask your healthcare provider, “Are there any medications that you could reduce?” If you feel you’re subject to medication overload. It is reasonable even on a basic level, once a year, to expect a comprehensive medication review. The third strategy is to use your pharmacist. The pharmacist has so much knowledge that they could tap into at any time but not when they’re super busy, filling prescriptions during rush hour. See if your pharmacist will make a counseling appointment with you or would have a moment to do counseling with you around your whole medication profile and give you some recommendations to take back to your healthcare provider to discuss. The pharmacist is the resource, the unsung champion in this whole process that they could help.
How long do they go to school?
They go to school for six years. They have a Doctorate in Pharmacy, so they know all about medication. They spend their entire pharmacy school life learning about medications. Doctors have one course called pharmacotherapy. Doctors learn in one class that spans two semesters, what pharmacists learn in four years. They do two years of pre-professional school and then four years of pharmacy school. The pharmacist has a depth of knowledge that is way beyond what a physician had time to learn.
In your experience working with people 55 and older, have you seen that nutrition is playing an integral part in the process of healing symptoms of ailments instead of drugs with this long list of side effects?
What I tried to encourage people to do is to use food or nutrition rather than supplements. I do see a lot of people taking supplements for various things when the things that we need can be gotten from food. That’s the key. We sometimes forget some of the benefits of food. Just because it’s in food, it doesn’t mean it’s good to concentrate it and put it into a capsule and eat twenty times the normal amount. There are certain foods that can be helpful. There are anti-inflammatory foods, there are foods that are pro-inflammatory. For people who have inflammatory conditions like rheumatoid arthritis or who have conditions that tend to thrive on inflammation, cancer for example, then we might want to focus on an attitude towards a nutritional approach that embraces the anti-inflammatory diet. It might not need to be extreme but certainly avoiding certain processed carbohydrates, sugars, alcohol and avoiding certain types of oils but using other types. Those kinds of approaches can be helpful. In addition, there are foods that are anti-inflammatory, including things like ginger and turmeric. Having people use those instead of things like Ibuprofen is sometimes a good strategy.
Dr. Holmes, I’d like to cover a sensitive topic here about many of the readers who might be depressed from caring for a loved one, with Dementia perhaps depressed from a long battle with Alzheimer’s. There are 322 million worldwide suffer depression and anxiety disorders, 18% of Americans. Only 30% of all people with depression don’t respond adequately to any available treatments. We look around and a lot of people are on antidepressants. Over time, they’re still depressed. I don’t know if you find that or not. Are we using these drugs as Band-Aids? Do you believe we need to be more focused on the root cause of the depression in the first place?
Use food or nutrition rather than supplements. Click To TweetThere’s a balance especially in older people. We’re getting better and better at detecting depression. I do think that we need to have the treatment and to consider medication. Traditionally, we’ve undertreated older people and in a way not medicated when medication could help. There’s a balance also of a single episode of depression warrants medication for 9 to 12 months and then a trial of weaning and stopping it. What I do find is that people end up on antidepressants for decades for a single self-limited episode of depression without any evidence of having a recurrence. They went into remission, they stayed that way and they stayed on medication that whole time.
A lot of times, the doctors doubled the medication.
We keep it going. We do have to have an approach to discontinue and deprescribe those medications when they’re no longer necessary. We also don’t have great systems in place to support caregivers and people who have depression. It’s much more difficult to find counseling especially counseling that’s covered by Medicare, to find support depending on what kind of support is needed, and to find support for caregivers including provider services, volunteers and in-home caregivers. Those are tangible things that could impact someone’s ability to manage that day-to-day stressor. What we ended up doing is we often use medication because it’s easier to do. There’s a balance that we’ve had times when we tend to an under medicate but we also use medication when medication is not the best approach.
There’s a place right here in town. I don’t know if you’ve heard of it, Amazing Place. They have a lot of resources and counseling, so much for the caregivers that they can plug-in to.
That’s the kind of support that caregivers need.
Dr. Holmes, you’ve been such a wealth of information for us. We appreciate you taking the time out of your busy schedule to talk with us on such an important topic. Please let our readers know where they can find you.
I am at McGovern Medical School and we have a very wonderful group of geriatricians and palliative care physicians and practitioners here. Our group practices both in the UT Physicians and in Harris Health. We have a practice at the Center for Healthy Aging at UT Physicians in Bellaire. We have several people there in addition to myself who see patients 65 and older there.
Thank you, Dr. Holmes, for being a guest here on the show. We appreciate you and the work that you’re doing in the lives of others.
Thank you so much, Carrie.
You’re welcome.
Important Links:
- The Hope and Healing Center & Institute
- UT Physicians
- National Sleep Foundation
- Deprescribing.org
- Amazing Place
- McGovern Medical School
- Harris Health
- Center for Healthy Aging at UT Physicians in Bellaire
About Dr. Holly Holmes
She’s a geriatrician and former pharmacist. Her research and clinical interest focuses on the appropriate use of medications in older patients, particularly those approaching end of life.
She’s the director of the Division of Geriatric and Palliative Medicine, joined McGovern Medical School in 2015 and is the Joan and Stanford Alexander Chair in Gerontology.
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