Reducing Useless or Harmful Medications
Sep 20, 2024
Colorado - Denver Metro
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-prescription, 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 6 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 1950’s 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.
Dr. Don Murphy, MD, FACP
The article was written by Dr. Don Murphy, Geriatrician and Hospice Physician who plans to run for Governor of Colorado. He can be reached at murphdoc@comcast.net, or calling 720-490-6757, or his main YouTube channel, TheCrazyMurphys5560.
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