The more pills you’re prescribed, the harder it becomes to balance the health benefits and risks, but you can take steps to take charge
By Wendy Haaf
Doctors providing end-of-life care will sometimes stop one or more of a patient’s regular medications, only to see that patient suddenly start feeling better than he or she has in years. It’s a situation that illustrates the common but often hard-to-detect hazards inherent in taking multiple medications (and for that matter, herbal remedies and supplements), particularly if you’re over 65: unintended consequences that may be incorrectly attributed to age, including thinking and memory problems, balance issues, sleep difficulties, and even premature death.
According to the Canadian Institute for Health Information, two out of three Canadians 65 or older take five or more medications a day; 27.2 per cent are taking 10 or more different drugs.
“Medications are responsible for extended life expectancy and they relieve symptoms, but they can cause side effects,” says Camille Gagnon, the assistant director of the Canadian Deprescribing Network at the University Institute of Geriatrics of Montreal research centre, “and as the number of medications increases, the risk for a harmful side effect increases, as well.” In fact, 13 per cent of people taking five or more medications will have a side effect serious enough to warrant medical attention, and in the case of high blood pressure or Type 2 diabetes, you’re more likely to be admitted to hospital for a side effect from the medication used to treat it than you are for an acute problem related to the underlying health issue.
At the same time, the odds of experiencing such side effects increase with age, and not just because we’re more likely to have multiple chronic conditions.
“As we age, we become more sensitive to medications for a variety of reasons,” Gagnon explains. For one thing, our bodies shed water and gain more fat tissue, where medications tend to accumulate, meaning that the effects of a drug may linger much longer, which can be a concern with those that cause drowsiness. (Women’s higher average fat mass places them at an even greater risk.) “As we age, our kidneys and liver don’t work as well,” Gagnon continues, and since these organs are responsible for breaking down drugs, including alcohol, these drugs are cleared from the body more slowly. The brain, too, becomes more sensitive to the effects of drugs, since its protective barrier becomes more permeable. “Putting all those things together increases the risk for having a negative effect,” Gagnon says. Consequently, many medications are considered inappropriate for older people, because the potential risks begin to outweigh any benefit.
Of course, none of this means that you should just chuck all of your pills. But you can take steps to keep a lid on your medications and better balance their benefits against the potential risks.
Establish a relationship with your pharmacist.
That’s the number one recommendation from Marijke Vroomen Durning, a former nurse and author of Just the Right Dose: Your Smart Guide to Prescription Drugs & How to Take Them Safely (2015). “Your pharmacist is your front-line health professional,” Vroomen Durning says. “Pharmacists know more about drugs than doctors do, and they have your file right in front of them.”
Sticking with a single pharmacy, rather than filling prescriptions in different locations, also improves the odds of someone spotting any potential drug interaction or the addition of an inappropriate medication.
Even when it comes to picking up products we all take for granted, such as over-the-counter (OTC) pain medications, your pharmacist can point you to the most appropriate option. For instance, drugs such as Aleve and ibuprofen “aren’t recommended for older adults, because they’ve been shown to affect the cardiovascular system and the kidneys,” explains Phil Emberley, the director of practice advancement and research at the Canadian Pharmacists Association, “so we try to steer people to safer alternatives.” These might include a prescription relative of these medications, acetaminophen, or yet another choice, depending on the patient.
Pharmacists are also an excellent resource if you’re experiencing what you believe may be a side effect after starting a medication. Often, they can offer suggestions that may help—such as tweaking the time you take your medication or, failing that, suggesting a different class of drug. For any side effect other than an anaphylactic reaction, “It’s important to speak to your doctor or pharmacist before stopping any prescribed medication,” stresses Karen Lam, a pharmacist and supervisor of the ambulatory patient care pharmacy at Toronto’s Sunnybrook Health Sciences Centre, since doing so can cause problems. For example, if you’re taking a preventive Aspirin, quitting without replacing it with an alternative may increase your risk for stroke, while abruptly stopping certain other medications (such as many antidepressants and anti-anxiety and sleep medications) can cause rather than alleviate unpleasant side effects. Where appropriate, pharmacists can provide support while you’re gradually weaned off a drug. “We can help in terms of a schedule,” Lam says.
Asking your pharmacist whether your medication could be causing a new symptom you’re experiencing can also help prevent a prescribing cascade, in which medications are prescribed to treat side effects of other drugs. Suppose that after your physician prescribes a blood pressure medication, your legs begin to swell uncomfortably, so you go to a walk-in clinic. If the physician there doesn’t know you’re taking that particular drug, then rather than switching you to a blood pressure pill without that side effect, he or she might prescribe a diuretic, or water pill. The second medication could cause you to wake up more often during the night in order to urinate, which could lead to a prescription for sleep medication, Gagnon notes.
Carry an up-to-date list of medications and OTC products.
“I recommend asking your pharmacist for a printout of the medications you’re on and carrying that in your wallet,” Vroomen Durning says. This way, for example, medical professionals have that information at hand if you end up in Emergency and aren’t able to speak for yourself or can’t remember all of the drug names and dosages you take. If you use a smartphone, you can track your prescription medications and OTC products using an app such as MyMedRec.
And if you do go to hospital, make sure you document any medication changes, such as a new prescription, a change in dosage of one of your existing medications, or the removal of a drug previously in your regimen.
Ask questions when you receive a new prescription.
Whenever one of your health-care providers prescribes a new medication, it’s important to ask a series of questions, Gagnon says. (If your doctor is pressed for time, ask your pharmacist.) Questions can include: What is the medication for? Is there a non-drug alternative, such as a change in diet or exercise, that you could try first? How and when should you take the medication (for example, on an empty stomach or with a meal)?
You should also ask how you’ll know if the medication is working—for example, you might need to go for a blood test to see if it’s having the desired effect on your cholesterol level. Another possible question: How long do you need to continue taking the medication? “Often when people are prescribed medications, they’ll automatically assume that it’s for life, when that’s not necessarily the case,” Gagnon says. “Patients should also ask about when to follow up,” she adds. Finally, ask about any side effects you should be aware of and take any printed information about the medication home to digest at your leisure. In case you think your memory might need a nudge, you can download a handy list of five questions to ask, from ismp-canada.org.
Review your medications regularly.
If Dr. Dee Mangin has her way, periodic medication reviews for older adults will one day be as routine a part of preventive care as is colon cancer screening. Mangin, who is a professor and the David Braley & Nancy Gordon Chair in Family Medicine at McMaster University in Hamilton, ON, is part of a team of researchers who are testing a new tool to help in that process. Called TAPER (team approach to polypharmacy evaluation and reduction), the program is centred around fostering a dialogue between older patients and their health-care providers.
“The patient input is very much a conversation about your priorities, in terms of the symptoms you’d most like to see addressed and the things that you’d really like to do that your health keeps you from doing,” Mangin says. “And then we talk about the relative priority that people put on treating their current symptoms versus taking a medication to prevent a future illness. People have quite different opinions about that.” The results of these types of queries help determine whether it might be worth pausing or gradually cutting down on certain drugs and monitoring to see what happens. “Often, just reducing the dose can reveal side effects,” she says.
While TAPER is still being studied, you can nonetheless periodically review your medications with your doctor or pharmacist. If you opt for reviews with the former, ask for an extra-long appointment devoted to that alone. If you’d rather see your pharmacist, it’s best to call ahead to ensure that he or she offers the service and to ask whether there’s any associated cost—although according to Emberley, an annual medication review by a pharmacist is now covered by most provincial health plans.
“I think it’s worth having a conversation for each medication,” Mangin says. “Do I still have the indications for this medication? Has the balance of risks and benefits changed over time? Is the evidence for this medication the same for people of my current age as it is for people of the age I was when I started taking it? Is there new evidence around this medication? We know, for example, that beta blockers, which we once used as first-line for high blood pressure, are no longer recommended.” Similarly, some medications that were once routinely prescribed indefinitely—including certain heartburn drugs and sleeping pills—have since been shown to cause more problems than they solve in most cases when used long-term.
This small time investment holds the promise of a big payoff. In fact, in Mangin’s view, a systematic method of reducing unnecessary medications, thereby maximizing effectiveness and minimizing risk, may be the next big leap forward in improving health and well-being in later life. “I think the potential to improve medical care for older adults over the next 30 years will be determined more by the wisdom with which we make decisions on which drugs to stop,” she says, “rather than which drugs to start.”