A Cat Playing Whack-A-Mole
Medication non-adherence is a hot button topic in healthcare. Physicians lament patient “non-compliance” with their medical advice, and policy wonks tell us that more than half of patients do not take their medications as directed. Missed opportunities to control chronic illnesses such as diabetes, heart disease, and cancer surely do cost us untold billions of dollars and millions of quality life years lost annually in the U.S. But there is a flip side to the equation that no one is talking about. The costs of polypharmacy (over medication).
In my opinion, many Americans, especially those over 65, are taking far too many medicines. The unwanted side effects and medication interactions (both known and unknown) can be devastating. In my line of work (inpatient rehabilitation) I receive a steady stream of patients who have fallen and injured themselves or have been involved in serious accidents. An astonishing number of these incidents are related to drug side effects.
Take, for example, the elderly woman who had mild hypertension. Unbeknownst to her physicians, she was not compliant with the diuretics she had been prescribed. Each successive visit it was presumed that she was taking her medicines as directed, and that they were not sufficient to control her blood pressure. So the dosing was increased. Her husband dutifully picked up the new prescriptions from the pharmacy, and she collected them (unopened) in her desk drawer.
One day this spirited lady caught pneumonia and required a couple of days of inpatient monitoring and antibiotics at the local hospital. Her son decided to assist with her transition back home and stayed with her for a week, taking on both cooking and medication administration duty from his dad. He found all of her pills in her desk drawer and began to give them to her as directed.
Several days later the distraught son told me that his mother’s health had taken a nose-dive, and that she was hallucinating and acting uncharacteristically hostile. He took her to a more distant specialty hospital, where their initial impression was that she had advanced dementia, which had probably gone unnoticed by a son who hadn’t lived nearby for years. She would benefit from hospice placement.
The reality was, of course, that this poor woman was as dehydrated as a raisin and was becoming delirious from excessive diuretic use. Once I figured out that her son’s sudden, and very well-intentioned, medication adherence program was to blame, we stopped the blood pressure medications, gave her some water and she returned to her usual self within 24 hours.
On another occasion, I admitted a closed-head injury patient who had lost her front teeth after fainting and falling head first onto the asphalt in a grocery store parking lot. This was her third head injury in 6 months. A review of her medications revealed no less than six medications (that she was dutifully taking for various diseases and conditions) that carried a known side-effect of “dizziness.” We were able to discontinue all of them, and to this day I have not heard of another fall.
Just last week a wise, elderly patient of mine declined to take her blood pressure medicine. I explained to her that her blood pressure was higher than we’d like and that I wanted to protect her from strokes with the medicines. She smiled kindly at me and said, “I know my body, and I get dizzy when my blood pressure is at the levels you doctors like. The risk of my falling and hurting myself when I’m dizzy is greater than the benefit of avoiding a stroke. I’ve been running at this blood pressure for 80 years. Let’s leave it be.”
What I’ve learned is that although there are costs to not taking medicines, there are costs to taking them too. It is hard to say how many injuries are accidentally prevented by patient non-adherence. But we all need to take a closer look at what’s in our desk drawers, and pare down the prescriptions to the bare minimum required. I consider it a great victory each time I reduce the number of medications my patients use, and I would urge my peers to join me in the pharmaceutical whack-a-mole game that is so sorely needed in this country.
The American Geriatrics Society provides a helpful list of medications that should be avoided whenever possible in older individuals.