Polypharmacy: taking care of the elderly patients
Many people consume a cocktail of drugs targeted simultaneously at several ailments. But poly pharmacy, as this phenomenon is called, invariably has an adverse effect on their health and finances. Polypharmacy is growing as people go to the specialists directly who may prescribe drugs that might duplicate, interact, or work against those already being taken by the patient for other ailments. Patients at times do not know which drug has additive effects, which has opposite action.
Many aged patients had to live with a host of ailments. It included diabetes, numbness of the limbs, hypertension, tremor, mild arthritis, gastritis and insomnia. On the surface, it seemed like s/he needed a dozen drugs a day to get well. It poses a huge challenge to the elderly.
First, it increases the risk of drug interaction and side effects. For instance, some anti-allergy pills make feel drowsy. When taken by someone who is already on a sleeping tablet, it causes sedation. Second, a huge pill burden can cause mounting financial expenses. Being dependent on so many drugs again make the patient stressed or depressed — it could be confusing for an older person.
The concept of family physicians no longer exists. People consult specialists directly. Based on the symptoms they perceive a neurologist for a headache, a gastro-enterologist for stomach pain. If this patient could have come to one doctor for consultation, the doctor could look for a way to reduce his pill burden. Effectively, pill burden can be cut down from 9-12 drugs per day to 4-5 per day.
When an elderly person comes with a problem, the disease can be age-related like cataract, constipation or pigmentation; it might have started in middle age and progressed; or it might be a geriatric disease like dementia or incontinence. It is important to look at the deeper cause, and not just treating according to the symptoms alone. A mild nutritional deficiency can be addressed with a diet change, while counselling and mediation can work wonders for troubled minds.
Older persons react differently to medications than younger persons. Although absorption rates for most drugs do not change with age, ageing alters body fat and water composition, fat stores increase while total body water decreases. These changes can alter therapeutic drug levels causing greater concentrations of water-soluble drugs and longer half-lives of fat-soluble drugs.
Also, because the liver metabolises many drugs, such age-related changes as reduced hepatic blood flow and liver size alter drug clearance. Drug elimination also may be affected by age-related decreases in renal blood flow, kidney size, and filtration rates of kidneys. Decreased serum albumin levels common in older adults with chronic illnesses, malnutrition, or severe debilitation-can lead to higher drug blood levels.
Poor adherence to the medication regimen is an ongoing problem among older adults. Some patients may fail to comply taking medication as prescribed due to the lack of understanding, confusion, or simple forgetfulness.
On the other hand, some patients may attribute unpleasant symptoms to a particular medication and, without consulting the prescriber, they decrease the dosage or even stop taking the drug. Those with visual deficits may have difficulty reading the prescription label. Patients with financial problems or who live on fixed incomes may decide to take lower-than-prescribed dosages to extend their supply.
To help patients manage their drugs, they should be advised to avoid sharing medications, store medications in a secure, dry location away from sunlight, refrigerate medications if necessary, inform the physician beforehand about other drugs taking currently or earlier. Dispose and discard old medications properly.
The writer is a gerontologist and a public health specialist.
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