Are you taking too many pills?

by Donna Chisholm / 20 May, 2019

By the time we reach our late 60s, a quarter of us will be taking a smorgasbord of medicines that we hope will extend our lives. But by how much and at what cost? Donna Chisholm investigates.

At lunchtime every day for the past two years, Southland retiree Anne Irwin, 67, has grabbed a glass of milk and downed a palmful of the nine medicines she needs to stay alive and well. There are six pills to manage her hypertension and heart failure, and aspirin to prevent blood clots. Then there’s the tablet to stop the nausea associated with the other pills and an antidepressant to lift her mood. At night, she’ll take her tenth: a pill to help her sleep.

There have been times, Irwin says, when she’s felt she is on so many pills that she’d rattle if you shook her, but after nearly five years of doctors “tinkering” to get a medicine mix that suits her, she’s not about to argue with the number she takes, even though a couple have side effects she’d rather do without.

“One makes me sleepy… that’s a nuisance but because I take them all together, I haven’t figured out which one it is. I think it might be the venlafaxine [antidepressant].”

But, there’s a very big upside. Without the drugs, Irwin would likely die. Within days of stopping one or other of her heart drugs, she becomes breathless and her ankles swell. “Fifteen years ago, I was told if I didn’t take the pills I probably wouldn’t have long to live.”

It’s likely she’s had hypertension most of her life, a complication of a kidney infection she had as a child.

Late last year, an American locum at the rural practice she attends said she was doing so well, he’d try to wean her off one of the drugs, a beta blocker. She stopped taking it for the three months until her next appointment, but her blood pressure rose alarmingly and she felt fatigued, so was put back on it. “I feel quite healthy and find it hard to believe that I feel this well after spending many years struggling.”

For Irwin, who worked as a medical secretary and later trained as a nurse, the potpourri of pills is just an accepted part of her life. “I know the ones that were giving me bad effects and they’ve been whittled out.” But she is still trying to find the best possible combination. After her latest visit to her GP in January, she decided to try stopping the angina prevention drug she was on for chest pain, after tests showed no evidence of coronary artery disease. “I’m pleased because it tended to make my neck muscles a bit weak and I had difficulty holding my head up.” At her own initiative, she’s trying to eliminate the Losec she takes to settle her stomach. From her nursing training, she knows it shouldn’t be taken long-term, despite the fact it has made her life “much more pleasant”.

Southland retiree Anne Irwin, 67. At lunchtime every day for the past two years, she has grabbed  a glass of milk and downed a palmful of the nine medicines she needs to stay alive. Photo/Jenna-Lee Shave.

Southland retiree Anne Irwin, 67. At lunchtime every day for the past two years, she has grabbed a glass of milk and downed a palmful of the nine medicines she needs to stay alive. Photo/Jenna-Lee Shave.

Changing prescriptions to get the most benefit takes fine-tuning, patience and a good doctor, says Irwin. Even then, her experience shows, stopping medicines can be much more difficult than starting them. But GPs and specialists say there is an increasing awareness of the potential downsides of overmedication, especially in older people who are prescribed many different drugs that may interact with each other, or cause confusion and falls.

By the age of 65, 25% of us are on five or more long-term medicines – a figure that rises sharply to 53% by the age of 75 and nearly 60% at 85. It’s understandable, in that we’re obviously developing more conditions that can be treated. The problem is that at the same time, our bodies are becoming less efficient at metabolising and excreting medicines. From the mid-70s, our kidneys work less well, so more of the “active” medicine we take accumulates in the blood, causing a greater effect. For people on anti-hypertensive medication, this can mean their blood pressure drops too low, causing postural hypotension, or dizziness on standing. In addition, the likelihood of gaining a meaningful survival benefit from each drug reduces with every year that passes.

University of Otago researchers have been at the forefront of efforts to raise awareness of the problem. Recent papers led by Professor Dee Mangin, director of the university’s Primary Care Research Group and a chair in family medicine at McMaster University in Canada, as well as by geriatrician Hamish Jamieson and psychiatrist Roger Mulder, have found:

  • Almost half of patients (43%) are being prescribed common medicines – for depression, heartburn and osteoporosis – for longer than recommended, tipping the balance of risks and benefits.
  • Elderly patients taking a combination of high-risk medicines for sleeping, pain or incontinence, are twice as likely as others to fall and break bones, with many dying within a year of their injury.
  • Increasing numbers of New Zealanders are thought to be using drugs designed to treat bipolar disorder and schizophrenia as sleep aids. The highest users are European women over 65.

The Health Quality and Safety Commission (HQSC) has since 2013 published in its Atlas of Healthcare Variation the polypharmacy rates in district health board areas. It says multiple prescriptions are more likely to be appropriate in the robust “young elderly”, but problematic in the frail “old elderly”, and suggests the focus should be on the latter in the battle to wean people off pills that may be doing more harm than good.

Mangin calls her own father Ron, 90, a “de-prescribing poster boy”. “He had a huge bleed from his warfarin-aspirin combo, cognition problems with his cholesterol-lowering statin, too low a heart rate with his beta blocker and he was over-treated with blood pressure drugs, resulting in weakness and dizziness,” she says. Since being taken off the medications, he’s walking up to 5km each morning.

Professor Dee Mangin calls her own father Ron, 90, a “de-prescribing poster boy”.

Professor Dee Mangin calls her own father Ron, 90, a “de-prescribing poster boy”. Photo/Tom Mangin.

The drugs were prescribed after a small heart attack at the age of 70, the result of a previously undiagnosed faulty heart valve that was then replaced. Dee Mangin says he initially had trouble persuading the doctors that “less is more”: both his GP and cardiologist encouraged him that even with normal cholesterol, and no heart attack risk factors, aspirin and statins would reduce his risk still further. But he soon noticed he had trouble remembering things and the statin dose was halved. “His mind re-emerged in a way that was very striking,” she says. He then went back to his GP and stopped the statin altogether. But health problems related to his medicines didn’t end there. After he felt unwell walking up a gravel road near his home, a doctor took his pulse and found it was just 40 – about half what it should have been. Cue the end of his beta blocker, as well. A life-threatening bleed a year or so later led to the end of his aspirin. His blood pressure remained fine, even when the medicines were stopped.

She says beta blockers used after a heart attack are of some benefit for the first year, but not for longer than three. “They can be useful in heart failure, but my father didn’t develop this until much later, so there was a period of years when he was taking it unnecessarily and people just assumed it was for blood pressure. His heart was repaired with a life-transforming intervention of modern medicine. But modern medicines then nearly killed him.”

Ron Mangin, who lives in Christchurch, says his experience shows it’s always worth talking to your doctor about a careful trial to reduce your medicines to see how you feel and then decide whether they’re still doing you good. Before he stopped the beta blocker, he says, he could hardly walk. “I’d lost my capacity to exercise, but now I feel full of energy. It has given me a different life.”

A 2010 paper co-authored by Dee Mangin reported a trial involving 70 elderly patients with a mean age of 83. When the Good Palliative-Geriatric Practice algorithm (see below) was applied to their medicines, it recommended more than half be stopped. Most commonly, these were anti-hypertension drugs, diuretics, statins, benzodiazepines, proton pump inhibitors (such as Losec), and antidepressants.

The Good Palliative-Geriatric Practice algorithm.

The Good Palliative-Geriatric Practice algorithm.

RelatedArticlesModule - polypharmacy

She and her colleagues in Ontario have been trialling a programme known as Taper, to reduce polypharmacy as a “routine prevention” in older adults. Taper (team approach to polypharmacy evaluation reduction) involves patients, pharmacists and doctors, and focuses on what matters to patients – which symptoms bother them the most, which if any drugs they’d like to stop, and whether symptom relief or illness prevention (for example, by using statins to reduce cholesterol) is more important to them.

People aged over 65 are now taking an average of seven medicines each, she estimates. “We need to focus as much, if not more, on when to stop or reduce the dose of drugs as we do on starting them, especially in older age.” She says doctors can be so used to checking, for example, whether a blood pressure reading is too high, that they may not notice if it’s too low for someone that age. Patients also feel nervous about raising the issue of stopping a medicine, because the drugs have been recommended for them, but they also fear not being allowed to restart once they stop. “The whole medical system is geared to support us in when and how to start treatment; the guidelines and algorithms are all about do this or start that if you reach this threshold and if that doesn’t work, try this. But we don’t have anything similar for stopping.”

Taper suggests a temporary drug holiday, with agreed criteria for a medicine to be restarted if required. “De-prescribing is a bit of a buzzword,” says Mangin, “but I don’t like it particularly, because it implies you have to stop and push the person out and say, ‘See you later.’”

That’s one reason it’s a difficult conversation for doctors to have. “From a patient’s perspective, it’s a challenge when a doctor says, ‘Stop taking this medicine that you’ve been taking for five years.’ The patient’s saying, ‘Well, it’s worked so far. I haven’t had a stroke, why should I stop?’ It’s very easy for the patient to see it either as a cost-saving move, or that they’re being ‘written off’.

“Most patients, if you have the time to go through it with them, are quite understanding. But all their experience up to that point is that these medicines are really important; you mustn’t forget to take your tablets. And if I’m a GP and I suddenly stop something, what happens if my patient has a stroke the next week?”

The HQSC divides polypharmacy statistics into people on 5-7, 8-11 or more than 11 drugs. Coincidentally, Anne Irwin, who we met at the start of this story, is in the Southern DHB, which has a significantly higher percentage of its over-65s receiving multiple medicines than those in other areas. Just over 40% are on five or more long-term drugs, the highest rate in the country, slightly ahead of Hutt (39%), but way ahead of neighbouring Canterbury (33%), and Auckland (32.6%). Irwin is among the 11.5% of Southerners on 8-10 long-term meds – again, the highest rate in New Zealand.

The Southern DHB’s chief medical officer, geriatrician Dr Nigel Millar, is a former chief executive of the HQSC and one of the architects of the Atlas of Healthcare Variation, which compares DHB data in a range of clinical areas, from cancer to cardiovascular disease. He concedes the information shows the prescribing to older adults in his DHB is out of step with best practice, but he says it’s not alone in the need to change.

“When I was a junior doctor, we used to worry a lot about the harm of medication and be very careful when prescribing anything, but now there is a guideline for everything so doctors tend to worry whether they are letting the patient down by not prescribing.

“I have a jaundiced view of guidelines and how much influence the pharmaceutical companies have on them. You can accumulate medications quite rapidly if you go with the common guidelines for managing chronic conditions, yet there is very little evidence beyond a certain age that that is beneficial. When a person is 83, the question of whether they should be on a [cholesterol-lowering] statin, for example, is really difficult. As a geriatrician, I would say probably not unless you are a really fit 83-year-old, because it might do you more harm than good, but GPs are going to worry they may be criticised for not prescribing it.”

The DHB regards the prescribing rates as a “custom and practice” issue, but a high doctor-patient ratio (1:1000 compared to the average of around 1:1500) and lack of access to good data also contributes, says Lisa Gestro, the DHB’s executive director of primary and community strategy. “It’s fair to say we haven’t been on the forefront of IT or advanced technology, so a lot of our systems don’t talk well to each other.”

The HQSC data is leading many DHBs to hire pharmacists to work alongside time-strapped GPs to review the medicines of older patients, and those on multiple drugs. It mirrors similar moves in the UK, where the NHS is spending more than £100 million to employ 1500 clinical pharmacists in general practices by 2020; from June, each primary care network in the UK (covering 30,000-50,000 patients) will get £38,000 towards hiring a pharmacist.

The commission’s medicine safety specialist William Allan, in his former job as chief pharmacist at the Hawke’s Bay District Health Board, introduced DHB-funded pharmacist facilitators in general practice to reduce costs and improve patient safety. Initially, cost was a driver – the board faced a $1.15m overspend in its community pharmaceuticals budget in 2011, despite unmet need among Māori, Pasifika and those in the lowest decile areas. A pilot launched a few years later resulted in an estimated $500,000 saving on the community drugs budget and also reduced falls, and the programme was rolled out in 2017. The DHB now pays for eight full-time pharmacists in general practices, covering 80% of patients. The pharmacists can spend up to an hour with patients reviewing medicines – a luxury of time GPs usually don’t have.

The Southern DHB’s primary health network, WellSouth, employs six full-time pharmacists, partly because of the Atlas information, but there were other indicators. “Given we spend $100 million annually on prescription drugs (for a population of 350,000) – more than 10% of our total expenditure – we need to think long and hard about it,” says Gestro.

Retired clinical pharmacologist Tim Maling has been at the forefront of efforts to improve the safety of prescribing.

Retired clinical pharmacologist Tim Maling has been at the forefront of efforts to improve the safety of prescribing.

So how many medicines are too many and which ones should be the first to be stopped? “I think anyone on more than about eight medicines is potentially at risk,” says retired clinical pharmacologist Tim Maling, who was at the forefront of efforts to improve the safety of prescribing, founding the now-defunct National Preferred Medicines Centre that ran for 10 years from 1991, and a clinical management plan for GP prescribing in Wairarapa that was later rolled out in Whanganui. “It’s not sensible to pick out a single number, but it does give people a point from which to work.”

He says inappropriate multi-medication is a “huge problem” and prompted him to set up the Wairarapa intervention about five years ago. “We’d see patients taking 20 or more drugs a day, and this was a crazy situation.”

In many cases, they were prescribed by different specialists working in silos, but he says the patient’s general practitioner can be reluctant to alter the prescriptions. “With multiple drugs on board, the risk to the patient increases considerably and in many cases outweighs the benefits. We found in the region there were more than 2000 people taking more than six standard drugs a day.” An initial audit of 50 patients in the scheme found it had reduced prescriptions significantly and lowered drug costs by about 35%. Maling says that although a couple of GPs were resistant to the idea and found it “threatening”, most were very open to change.

Canterbury DHB, though adjacent to Southern, has one of the country’s lowest rates of polypharmacy (33% compared to Southern’s 40%) and that’s probably the result of early recognition of the problem by Mangin and Les Toop, a professor of general practice at the University of Otago, Christchurch.

Toop is a former chair of the Pegasus primary health network in Canterbury, which covers 400,000 patients and has introduced an education programme – now adopted in seven other parts of the country – that gives practices feedback on the numbers of patients they have on multiple pills, and summarises prescribing evidence.

Toop says many patients are seeing not only their GP but two or three specialists. And, when they’re admitted to hospital, doctors “tend to add more medicines rather than take them away. People come out with a whole lot more pills, because [doctors] are slavishly following guidelines. But when you’re over 80, nearly every pill has a poor evidence base or harms as well.”

Christchurch Hospital developed a “pill pruner” project for elderly inpatients in 2009, to audit their pill-taking, stop the use of inappropriate drugs, and start ones they should be on, but where possible restrict the number of new ones prescribed on discharge.

Geriatrician Carl Hanger, who was part of the group that introduced the scheme, says it takes effort and wasn’t used routinely hospital-wide. “The junior doctors who do quite a bit of the prescribing are less aware of it.” The hospital is now trying to resurrect the programme. “We have to change the habits of multiple prescribers.”

Staff from the DHB’s medication management service talked to patients about why and how they were taking each medicine. “It’s really worthwhile, because you find out they’re taking a neighbour’s sleeping tablet – or you think they’re taking something you prescribed and they stopped taking it three months ago.”

Hanger says the pill pruner programme improved the transition of patients after discharge back into the care of their GPs. The discharge summary to GPs noted not only what medications had changed but, crucially, why they had been changed. “We managed to make sure that got put on the discharge prescription as well so it went to the dispensing pharmacist, so they’re also in the loop as to why.”

But ask which common drugs should be stopped first, and doctors and pharmacists will give you the same answer: “It’s complicated.” Toop puts heart, psychiatric and pain meds at the top of the list for review, saying many anti-psychotic drugs are being used as sleeping pills and sedatives. Combinations of antidepressants and painkillers can also cause a cascade of prescribing to prevent the side effects.

“More isn’t always better. I think the public gets that – I’ve never met anyone on 13 pills who wants a 14th. But it’s complex, and every combination is a bit different. To address that, you need people not only with the skills and knowledge, but also with the time. You have to think of the interactions, and which medicines have the potential for the most harm and which have the most benefit, and then try to avoid taking one pill to counteract the effect of another. It’s what strains the brains of prescribers the most and, if you are time-pressured, it’s really hard.”

Eleven-plus pills a day is regarded as “extreme” polypharmacy but that doesn’t mean multiple prescriptions are always problematic or inappropriate. “The most I had a patient on was about 24, and there were almost none we could cut out.”

From left, HQSC evaluation manager Catherine Gerard; Geriatrician Hamish Jamieson; Professor of general practice Les Toop.

From left, HQSC evaluation manager Catherine Gerard; Geriatrician Hamish Jamieson; Professor of general practice Les Toop.

Clinical pharmacist Dr Linda Bryant, who works in two Wellington general practices, prescribing, reviewing and advising on patient medication, looks at the benefit-risk ratio in patients over 75, or who have a limited life expectancy. “We want to make sure younger people are taking their cardiovascular medicine, but as people get older, the benefits reduce because the life expectancy potential is less and they will get more unwanted effects.

“Stopping medicines is quite a conversation; people can feel, ‘I’ve reached 85, I’m not worth it anymore.’ If we take people who go into residential care – and it sounds really harsh – these people don’t have a long life expectancy, so we need to be able to talk to them about being realistic about that. In that group of people, we very consciously reduce medicines. We leave ones that are useful for symptom control, but you can say well, we really don’t need to control the blood pressure quite so much, because if someone has a life expectancy of two years, you’re not going to be extending it much.”

A study published last year, led by University of Otago, Christchurch, researcher and geriatrician Hamish Jamieson, showed a high correlation between certain medications and the risk of falls. Patients taking three or more sedatives or so-called anti-cholinergic drugs that affect cognition were more than twice as likely to break their hip than those taking none, and between 20% and 30% of elderly people who broke their hip died within a year. Anti-cholinergics are commonly prescribed for urinary incontinence and Parkinson’s disease.

“People can be given a drug for pain, a drug for sleeping and one for urinary incontinence. Singly they are okay, but there are cumulative side effects and older people on multiple medications are more at risk,” says Jamieson.

Another study, published last year by Jamieson’s colleague, psychiatrist Professor Roger Mulder, also identified anti-psychotic drugs as a problem, particularly in women over 65 (5% of that group are using them). The study found use of anti-psychotics, designed to treat conditions such as bipolar disorder and schizophrenia, has increased by almost 50% in less than a decade, indicating doctors are prescribing them “off-label” as a sleep aid, or to treat anxiety. The study found the highest usage on the West Coast, which had almost twice the rate of Counties Manukau, the DHB with the lowest usage.

HQSC evaluation manager Catherine Gerard says because the polypharmacy Atlas data covers only people 65 and older, some of the complicating variations between DHB patient populations are taken out of the equation. One potential weakness is that the information shows which drugs are dispensed, but not why they’re prescribed or whether they are taken. It does, however, show DHBs where they can get the most health gains. “Before, there was no way you could look by DHB and know how many medications people were getting, so it was hard to have the conversation about what’s appropriate.”

She says in patients 85 and older, there is very little clinical trial evidence for many medicines, particularly those aimed at preventing events that might happen years in the future. “So you say, hang on, why are people over 85 receiving most medications when they’re the least likely to benefit long-term?”

Triple-whammy warning

William Allan.

One combination of common medicines is so potentially dangerous it’s known as the “triple whammy”. The Health Quality and Safety Commission has recently begun monitoring use of the trio: an ACE (angiotensin converting enzyme) inhibitor for hypertension, a diuretic and an NSAID (non-steroidal anti-inflammatory drug), which increase the risk of kidney damage and renal failure in older people. In 2016 (the latest year for which figures are available), 3.2% of over 65s – 22,000 people – were prescribed the “triple whammy”. Rates were significantly higher – around 4.5% – in Māori and Pasifika people, and it’s possible the real number taking the combination is even higher because NSAIDs are commonly sold without a prescription. Brands of the medicine, which are used to treat pain and inflammation, include Nurofen, Voltaren and Celebrex.

The freedom of access worries some GPs. Whangārei GP Tim Cunningham describes the rate of over-the-counter dispensing of NSAIDs as an epidemic. Because of the risks of the combination in certain patients, they tended to be prescribed “with a lot of thought. Having 80- or 90-year-olds on Nurofen dispensed by a 15-year-old on [supermarket] checkout beggars belief.”

Asked if GPs should be more proactive about warning patients about problematic combinations, Cunningham says: “Yeah, if you want to try to put the onus on GPs for the use of drugs that are too dangerous to really be out there unchecked.” When he prescribes the common anti-hypertensive Inhibace Plus, which contains a diuretic, his computer automatically produces a statement in capitals for the label of the pill bottle warning anti-inflammatories should not be taken with it. “Many GPs would have real concerns about prescribing anti-inflammatories in people over 65, anyway. This is the group that tends to have a high rate of osteoarthritis and gets a lot of benefits from these, but they are dangerous drugs, both for their interactions and their individual effects, especially gastrointestinal bleeding.”

At a minimum, the drugs should be pharmacist-only, and the pharmacist should have a checklist to go through before the pills are dispensed. “One of the problems is that sometimes patients don’t know what drugs they are on. But you’ve still got to ask, are these critical medications for these patients to be on, given the risks involved?”

The HQSC’s medicine safety specialist, William Allan, says the risks of the “triple whammy” have been known for many years. “But it’s still not getting through to the sharp end of prescribers. People are still on these combinations – that’s the disappointing thing.” 

How to make sure you're taking the right medicines

There’s plenty you can do as a patient to make sure you’re taking the right medicines for you.

  • If possible, use the same pharmacy each time you pick up your medicines.
  • If you’re unsure, ask the pharmacist to explain what’s on the label.
  • If your medicine looks different from usual, ask the pharmacist why.
  • Before taking your first dose, be sure you know how to take the medicine and be alert for side effects.
  • Take your medicines at the right time, in the right amount.
  • Write down any side effects and tell your doctor or nurse about them.
  • Keep a medication card and keep it updated.
  • If you are taking many different medicines, your pharmacy can provide a blister pack.
  • When seeing the doctor or any other health professional, take a list of your medicines, or the medicines themselves, to the appointment.
  • Remind your doctor about any allergies.
  • Ask about side effects and what to avoid when taking the medicine.

Source: Health Quality and Safety Commission.

This article was first published in the April 2019 issue of North & South.

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