Ten or 15 years ago, an elderly relative of mine (suffering from dementia after what was probably a series of mini strokes) was living in a nursing home. Then, her nursing aide forgot to fill her prescriptions.
Did disaster strike? Nope. She got better. Her mind cleared—not completely, but significantly enough to recognize her grandchildren. Enough to enjoy what was left of her life a little bit more, for a little bit longer.
At the time, I had never heard the word “polypharmacy.” “Less is more” hadn’t become a catchphrase in health policy circles. (At the time, of course, we didn’t have so many health policy circles). Now, many people reading this nod to themselves and say, “Of course she got better. She didn’t need to be on half this stuff.” We know that older Americans see a whole lot of doctors, go in and out of hospitals, and acquire more and more prescription medicines, some of which may interact, counteract, overact, or fail to act.
Some research has established that medications can be cut in nursing home patients with good outcomes. But in the community, where there is often no single doctor keeping track of all the patients’ medicines, it can be challenging.
A recent Israeli study—small, limited but quite provocative—describes one potential approach to cutting the number of medicines older adult patients take. The study involved 70 community-dwelling older adult patients, with a mean follow-up of 19 months. It wasn’t double-blind and the researcher himself called his approach unconventional: he stopped a bunch of meds all at once, not one at a time. The study, “Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults” was published this fall in the Archives of Internal Medicine.
“Remarkably, they discontinued 311 medications in 64 patients with no significant adverse reactions; 84 percent of patients reported an improvement in health. Clearly, outpatient medication use among older persons is a case where less is more,” commented Michael H. Katz MD, the deputy editor of the journal.
The lead researcher, Dr. Doron Garfinkel, who is on sabbatical from the Geriatric-Palliative Department, Shoham Geriatric Medical Center, Pardes Hanain Israel, reported that he used a protocol he has developed called “The Good Palliative–Geriatric Practice.” (It was published in the Israel Medical Association Journal and reproduced in the Archives article.) With that as his guide, he did a detailed review of medications of the patients, whose mean age was a few months shy of 83. Forty-three patients (61 percent) had three or more comorbidities; 26 had 5 or more. Most used seven or eight medications, although the number ranged from none to 16.
After detailed discussions with the family, he eliminated a total of 311 medications for 64 of the 70 patients—or 58 percent of the total drugs they were taking (including in some cases aspirin, iron, or certain vitamins). Out went many drugs in many classes—antipsychotics, antidepressants, anti-inflammatories, anti-coagulants, hypertension drugs, benzodiazepines, calcium channel blockers, ACE inhibitors, statins, diuretics, some Parkinsons drugs (for patients who turned out not to have Parkinsons). The list goes on. Just visualize all those pill bottles.
Two percent of the drugs were subsequently restarted, but he reported an 81 percent rate of successful discontinuation. In some cases, drugs were continued but on a lower dose. Ten patients died after a year (the mean age was 89). The deaths, he reported, were not linked to the changed drug regimen. To the contrary: fewer drugs meant happier, healthier patients.
“No significant adverse events or deaths were attributable to discontinuation, and 88 percent of patients reported global improvement in health,” he wrote. That includes cognitive improvements, like my elderly relative experienced.
In the journal article, and later in an email exchange with me, Dr. Garfinkel pointed out that drugs don’t always act in the same way in the body of an older frail person as they do in a younger healthier one. But most guidelines and practice patterns and even some pay-for-performance models are based on the younger patient population. In addition, patients—in Israel as well in the U.S.—see numerous specialists, all of whom tend to prescribe more … stuff. Primary care doctors may not have the time to review all the drugs, or they may defer to the specialists. Or they may just know a whole lot more about starting drugs than stopping them.
“It is much easier to start therapies than to stop them. It is also easy to overlook medication adverse effects on a background of complex comorbidities. The physician may be reluctant to review decisions or discontinue or change drug regimens determined by ‘experts’ or from guidelines for younger populations. A scheduled, formal drug re-evaluation may never be performed, neither in hospitals or long-term care setting nor in the community,” he wrote in Archives.
In an email, Garfinkel pointed out that some doctors are afraid to stop drugs, for medical or legal reasons, without more published data on the efficacy not only of drugs, but of no drugs.
He said colleagues in Israel and abroad approach him and say things like, “If something bad happens or a patient dies (even at the age of 99), the family may blame us, you are the first one to prove that a rational discontinuation of several drugs is safe.”
Having now successfully evaluated about 300 community-dwelling geriatric patients, taking them off four or five drugs apiece, Garfinkel has concluded that doctors need to think differently about the multitude of drugs their patients take. “Polypharmacy itself should be conceptually perceived as ‘a disease’ with potentially more serious complications than those of the diseases these different drugs have been prescribed for,” he emailed.
In this particular study, Garfinkel did not analyze costs (and the Israeli system is quite different than ours). In an earlier study of drug reduction in nursing home patients, he did find cost savings—and better health. He is convinced that his approach saves money, both on the drugs themselves and by avoiding hospitalizations arising from drug side effects or interactions.
Garfinkel’s pleased when colleagues see the light. But he’s more pleased when a patient or family caregiver tells a story like this one about a 90-year-old man whose family reported he had been “sleepy and depressed for a decade.” Dr. Garfinkel took him off nine drugs. The family said, “It’s amazing. He kind of woke up, as if a curtain was raised. His memory recovered. He is happy.” After 10 years, he has resumed calling his relatives by phone. He’s not only looking forward to family celebrations; he’s planning who should sit where at the table.
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Staff Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.
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