Doing More By Doing Less
September 30, 2019
by Amy Givler, MD
When one of my patients turns 80, I shift from focusing on prevention to maintaining the status quo. After all, these octogenarians and nonagenarians have made it—they have celebrated enough birthdays to get to the goal that all those years of prevention were aiming at. They have succeeded in becoming old.
I still treat any illness that appears, of course, but I am careful to choose medications with as few side effects as possible, and I start at lower doses. Sometimes at much, much lower doses. With this age group, I’ve seen too many patients develop complications with aggressive treatments.
The term “polypharmacy” has been bandied around in the medical literature for several years. The trouble with this term is it doesn’t have a standard definition. Sometimes it means more than three, and sometimes more than four, separate medications. And sometimes it means, “more medications than are clinically appropriate.” In other words, it is not a helpful term.
Limiting the number of medications to fewer than four is almost always impossible in my “older” older patients, though believe me I try. For any new patient, but most especially for an older one, I probe the medication list, looking for ways to slash it. Often trimming it significantly isn’t possible, however. For people with multiple medical conditions, they often need multiple medications. My patients are not alone—39 percent of Americans over 65 take five or more medicines.
I’m motivated to minimize my patients’ drug lists because the more medications people are on, the more likely they are to have a drug-drug interaction. Each medicine underwent individual testing, but how are each of those medications interacting with all the other medications in my patient’s body? Also, studies of “polypharmacy” (remember, there are various definitions!) have shown increased risks of:
- Functional decline and falls,
- Delirium and cognitive impairment,
- Hospitalization and healthcare utilization
I also try to keep up with the over-the-counter medications my patients are taking. This is a continual struggle because it is always changing. I ask my patients to bring all their medicines—herbals, vitamins, whatever—each and every visit. And though my patients often don’t think so, any pill they swallow is a medication, not just the ones that are prescribed. I’m regularly astonished, though I try not to show it, at all the bottles. How do people keep track of it all? But by looking over—and discussing—these bottles, I try to teach my patients that everything they ingest is interacting with everything else inside their bodies.
Unfortunately, most of the healthcare professionals my own father goes to don’t seem to be “minimalists” when it comes to medications. My father has been older than 80 for 15 years, so he and I have a 15-year history of my gently, calmly and diplomatically trying to monitor his medical care from 1,500 miles away.
It goes something like this:
Dad: “Amy, I’m so glad to get you on the phone. I’m [insert here: short of breath, peeing all the time, having diarrhea/stomach pain/dizziness, etc. etc.].”
Me: “I’m so sorry to hear this, Dad. Have you started any new meds lately?”
Dad: “Just the two that Dr. XX started me on this week.”
Now in Dr. XX’s defense, my dad tends to badger physicians to address his latest symptoms until they finally prescribe something. But still, I’m not sure his various doctors are always reviewing all his prescriptions to make sure bigger problems are not being created in the process of trying to solve one of them.
Before any of us recommends a new medicine for a patient, it behooves us to make sure we know what they are already taking.
And I don’t want you to think my advice is always to stop the medications Dad has just started. They often make sense, though the dose generally needs to be ratcheted downward. But communicating my medical opinion is often a delicate task, and by no means are my suggestions always heeded. Quite the contrary. In Dad’s eyes, I am still a daughter first and a doctor a distant second. I know he is proud of me, but there must be something about taking medical advice from a daughter that he can never quite get used to.
Having my father still here—and functioning well—is a great blessing. He has always called himself an “iron man,” and indeed he has stamina even now that amazes me. But even iron men, when they pass their eighth decade, have developed some rusty spots. Sure, a vigorous scrub will remove rust from iron, but did you know a long soak in vinegar—so much less harsh—takes it off also?
For our oldest patients, less is more.