Drugged-out seniors a prescription for disaster

TheStar.com – Atkinson 2008 – Drugged-out seniors a prescription for disaster
November 11, 2008. Judy Steed. Special to the Star

Toronto journalist Judy Steed has been writing about social issues for 30 years. Last fall, she embarked on a one-year project to document the most pressing policy implications of our aging society as part of the 2008 Atkinson Fellowship in Public Policy. She has visited dozens of nursing homes and interviewed hundreds of health-care workers, policy-makers and seniors to present this weeklong portrait.

They are the drugged-out generation, and they’re not who you think they are.

They’re 80. And 85 and 90 and 95 – overmedicated seniors clogging emergency departments, blocking hospital beds and sicker than they have any reason to be.

The Number 1 drug users in North America, outside of patients in long-term care facilities, are women over the age of 65. Twelve per cent are on 10 or more meds, sometimes up to 20 or more drugs; 23 per cent take at least five drugs. In long-term care, seniors are on six to eight medications, on average. Fifteen per cent of seniors admitted to hospital are suffering drug side effects. It’s not uncommon to find seniors dizzy and dotty from being prescribed so many drugs.

“You’d fall down, too, if you were on so many drugs,” says Dr. William Dalziel, a prominent Ottawa geriatrician.

Typically, overmedicated seniors have been seen by numerous specialists who have prescribed various medications to treat a host of chronic ailments – high blood pressure, hypertension, diabetes, osteoporosis, arthritis, heart disease, cancer – but there hasn’t been any oversight by a geriatrician skilled in looking at the big picture and assessing contra-indications and side effects. Ask any doctor with expertise in seniors what their top health concerns are and they all cite overmedication.

Dr. Mark Nowacynski, an exceedingly rare family doctor who does home visits on a full-time basis, shakes his head. “So many old people are prescribed so many drugs, they don’t know what they’re for and they often don’t take them properly,” he says.

Nowacynski recalls taking care of an old man who was seeing six specialists.

“He was very anxious and confused; the specialists’ advice often conflicted. I was astounded at how many meds he was on, more than 20. He wasn’t taking them as prescribed and he was suffering from various side effects and interactions that weren’t being monitored.”

Over time, Nowacynski – or Dr. Mark, as his patients call him – was able to wean his patient down to fewer than 10 drugs.

One of the reasons overmedication is such a serious issue, apart from the biological aspects, is that seniors become vulnerable to serious falls when they’re excessively drugged, and serious falls can lead to a downward spiral of hospitalization, extreme fear of going out, isolation and death. As well, many seniors have trouble sleeping; instead of being encouraged to tire themselves out with exercise and activities, they may become habituated to sleeping pills that leave them groggy during the day.

Another problem, says Dr. Paula Rochon, a Baycrest geriatrician, is that doses for older people should often be much lower than for younger people. She notes that Valium is long acting and very sedating and shouldn’t be prescribed at all to seniors.

Not only does overmedication cost the health-care system millions of dollars annually in unnecessary, expensive prescriptions but also the entire system slows down – and wait times for other patients lengthen – as emergency departments and hospitals struggle to diagnose drug-related problems.

Doctors and nurses trained in the ailments of old age and alert to the problem of overmedication can resolve many of these issues quite quickly, but most doctors haven’t had any significant geriatric training. Stories are legion about elders blocking emergency rooms and being admitted to hospital, with doctors thinking the old people are having heart attacks and ordering expensive tests when the problem is simply overmedication.

In 1995, the Canadian Medical Association Journal found that doctors who wrote the most prescriptions also had the highest death rates among their patients.

“This study found that some doctors, in trying to maximize the number of patients they could process per day, did not take the time necessary to find out what was wrong with these patients,” writes David Foot in his bestseller Boom, Bust, Echo. “That kind of medical practice results in overmedicated and inappropriately medicated patients.”

According to Dr. Jerry Gurwitz, chief of geriatric medicine at the University of Massachusetts Medical School: “Any new symptom in an older person should be considered a drug side effect until proven otherwise.”

At Baycrest, Toronto’s health sciences centre focused on geriatric care, Rochon has spent years working with the facility’s doctors, researchers and residents in long-term care to find solutions to overmedication.

“When you’re dealing with complex conditions (in seniors) and all these drugs, how do doctors make the right choices?” she asks. “It gets complicated for everybody.”

Thanks to her efforts, Baycrest has developed software for a computerized physician order entry system. Instead of scrawling, often illegibly, on a prescription pad, doctors sign in to a database and get full access to residents’ medical histories and comprehensive pharmacological information, before they order prescriptions.

Baycrest’s wireless networks were upgraded and the centre became the first long-term care facility in Canada, and one of the first in North America, to do its drug prescribing electronically.

“At a glance, you can look at the patients’ history, get their age, weight, see what other meds they’re on, see their medication history, allergies, blood work, other consults,” Rochon says. “Everything you need is at your finger tips.”

The U.S. Department of Health and Human Services was so impressed that it funded a landmark study to determine Baycrest’s effectiveness in reducing adverse drug events in long-term care. The U of M’s Gurwitz, who was a principal investigator, stated that Baycrest was “ahead of the curve in adopting health information technology” and “there are few places like Baycrest in all of North America in which to carry out such a study.”

Prescribing is now much improved at Baycrest, Rochon says, and “doctors are making better decisions because they’ve got better information.”

Most Toronto hospitals have followed Baycrest’s lead and use computerized physician order systems.

The Ontario government has responded to the issue with the MedsCheck program (MedsCheck.ca), in which pharmacists are paid to assess seniors’ medications and detect problems. People who have an OHIP card and are taking three or more prescription drugs for a chronic condition are eligible. On presenting their card, they receive a one-on-one, private consultation for up to 30 minutes with a pharmacist, who will make sure they are taking their drugs properly and educate them about possible adverse drug reactions.

“Some over-the-counter medications can interfere with certain health conditions and adversely affect some prescription medications,” the MedsCheck website states. Decongestants, for instance, may be taken to relieve cold symptoms, but they can have the effect of raising blood pressure. Vitamin C can reduce the efficacy of chemotherapy.

Still missing, however, is a Canada-wide policy. In 2002, Roy Romanow recommended a National Drug Agency that would include a national program for managing medications to, among other things, monitor prescriptions and adverse drug reactions among seniors.

“The evidence is that new drugs come on the market every few days and in Canada there is no comprehensive process to address their safety, quality and cost-effectiveness,” Romanow says. “Health Canada says it does this, but it doesn’t, not like the Food and Drug Administration in the United States.”

Romanow says a national program would make a huge difference in the daily lives of seniors, the major consumers of drugs in Canada.

Six years since Romanow’s prescription, it has yet to be filled.

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