PILL OverKILL
Reactions to combining medications can manifest
symptoms that make the cure worse than the cause.
by Christopher Tedeschi
Pill-popping is a favorite American pastime. People of all ages eagerly consume medication with high expectations, looking to prescriptions and over-the-counter drugs to cure everything from hair loss to indigestion with the swallow of a pill. And with an increasing population of older people experiencing more health problems and consuming an ever-growing repertoire of prescription and non-prescription drugs, the potential exists for the cure to be worse than the cause.
Reactions to medications and combinations of medications can range from minor discomfort such as an upset stomach to serious problems requiring hospitalization. The problems associated with polypharmacy-illness due to taking harmful combinations of drugs or not taking the proper drugs-account for increasing proportions of health problems among the elderly and of dollars spent on health care. Elderly people are more vulnerable to polypharmacy than others, especially when taking medications that have expired or were originally intended for someone else.
Polypharmacy includes a huge range of medical problems related to both prescription and over-the-counter drugs. While the word "polypharmacy" correctly implies that many different medications can be involved, problems also arise from the misuse, overuse, or abuse of single pharmaceuticals. "In elderly people," says Loren G. Lipson, M.D., USC associate professor in the Department of Medicine, and chief of the division of geriatric medicine, "there is a greater chance for drugs to cause severe health problems."
More side effects can mean increased polypharmacy. "Many medications are being taken to combat the side effects produced from taking other medications," says Lipson. "We need to give as few medications as the patient actually needs-try to pare the pill use down to the bare bones."
Although problems related to medication interactions are not specifically related to age, elderly people are far more vulnerable. For one thing, older people tend to take more medications in the first place, in order to deal with greater numbers of medical problems. Individuals with several problems often see several doctors-who may not be aware that their patients are taking medications prescribed by someone else.
Polypharmacy has become a more serious and common problem than most patients and physicians probably imagine. A 1990 Archives of Internal Medicine article estimates that for people over the age of 65, more than 25 percent of hospitalizations in the U.S. are medication-related, and 60 percent of those are due to adverse drug reactions or unsafe combinations of drugs.
While the figures are troubling, doctors and pharmacists can combat widespread polypharmacy with innovative measures. "Everybody says sure, we have a problem," explains Bradley R. Williams, Pharm.D., associate professor of clinical pharmacy at the USC School of Pharmacy, and associate clinical professor of gerontology. "But not a whole lot has been done to solve the problem."
Williams took a step toward a solution last year. He and his colleagues from School of Pharmacy undertook a pilot project sponsored by the Los Angeles County Area Agency on Aging. The project sent pharmacists to senior centers around Los Angeles, where seniors could attend "brown bag sessions"-literally tossing all of their medications in a bag-and bringing them to one of the project's pharmacists for evaluation. At the same time, the researchers trained case workers at the centers to identify potential problems with medication interactions that needed further attention.
Before the project lost financial support a year ago due to county budget cuts, the community-based team counseled dozens of seniors, each of whom was taking an average of eight different medications each day. The counselors identified expired medications, notified physicians of troublesome combinations of drugs, and probably averted some serious and costly health problems among a vulnerable population. Williams hopes to start a similar project in the near future, with funding from a variety of public and private sources.
While some pharmacy-related problems come from elderly patients taking too many drugs, many come from patients not taking their medication at all. Forty percent of medication-related problems, says the Archives of Internal Medicine article, are compliance issues.
The daunting task of taking five, 10, or even 20 different medications each day can be enough to reduce patient compliance and cause plenty of stress and frustration. "Lots of people associate their health status with the number of medications-or the number of doses-they take," says Williams. "More medications and more daily doses equals a lowered self-image with a decreased desire to take their medications." Medications that can be taken once a day instead of four or more times can help ensure that people will take their medicine, and could help them feel better about themselves in the long run.
"It is very difficult to get people to take their medication," Lipson says, "especially when they are not feeling any symptoms. For example, someone who wakes up with stiff hands remembers to take their arthritis medication. But someone with mild hypertension or diabetes might not feel any symptoms, so they do not take an important dose of medication."
It is up to the pharmacists to encourage patients to follow their physician's orders, but the deck is often stacked against them. For instance, says Williams, pharmacists must face the challenge of keeping track of virtually every medication that their clients should be taking, which can be difficult in quick-paced, impersonal work environments that allow little quality time between patients and pharmacists.
Recent legislation may help. Pharmacists in California and all other states are now required to counsel patients on proper medication use and potential harmful interactions each time there is a new prescription or change in the medication that a patient is taking. Additional legislation could encourage even more pharmacist-patient communication, by allowing licensed technicians to take care of tasks like counting pills and formulating particular prescriptions. "The law should help get the pharmacist out from behind the counter," Williams says.
Sufficient patient education is even more difficult when there is no counter to come out from behind. Mail-order prescription services have become increasingly popular and less expensive alternatives to the local pharmacy in recent years. Lipson and Williams estimate that between 10 and 15 percent of their elderly patients purchase their medications through the mail.
While mail-order pharmacies include instructions for taking each medication and attempt to track each medicine that patients receive, some suppliers do better than others.
Patients may feel reluctant to call a toll-free number, wait for assistance, and then talk to an unfamiliar operator about their medication, especially when the questions might not seem worth the effort. "If you get a medication in the mail," Williams says, "and it comes with instructions that say 'take on an empty stomach,' you may not be sure how long you need to refrain from eating, or whether or not you should avoid drinking as well. These are important questions, but elderly patients tend to not make a special phone call to ask them."
For patients with questions about their various medications, Williams says, "The first thing to do is to take all their medications to a pharmacist to have them evaluated-and this includes non-prescription medications." Most keen-eyed pharmacists, he says, will be able to sort medications into different categories, and identify potentially harmful duplications or interactions.
"They should then take that information to their primary care physician," he advises. "And every older adult needs to have a primary care physician." While older people tend to visit a variety of specialists, Williams says, a primary care doctor can handle an individual's entire health care program and spot troublesome combinations of treatments before they become dangerous.
Lipson spends a good deal of his time trying to educate other physicians about polypharmacy in older patients. "The doctor is placed in a difficult situation, because new drugs are coming out all the time-so clinical pharmacology becomes an ongoing educational challenge for physicians."
Aside from keeping up with new drugs, physicians must learn to be sensitive to the different physical needs of older adults. While many drugs tend to get prescribed in standard doses, serious adjustments may be needed for many patients. Side effects could be magnified by a slower metabolism and smaller, more frail individuals: "In some instances a frail 80-year-old who weighs 85-pounds may be given the same dose as a 25-year-old who weighs 150-pounds," Lipson worries.
The best people to help solve educational problems are pharmacists who work closely with physicians and patients. At Rancho Los Amigos Medical Center in Downey, Ca, Williams coordinates a residency program for pharmacy students, medical students and medical residents. He hopes that the interdisciplinary program will increase communication between different health care providers.
"We've seen some long-lasting effects," says Williams. He now gets calls from medical residents who have completed the residency program, asking for technical advice regarding drug interactions and potential problems. "They can provide better patient care if they see that they don't have to know everything," he says.
Williams is quick to point out that polypharmacy is not a problem reserved for individuals taking more medicines than they can count on both hands. "People tend to see the polypharmacy patient as someone with a laundry list of drugs, but the problem exists whenever you have a person who is taking a medication they do not really need," he says, "and I will continue teaching doctors and pharmacists, visiting senior centers and sifting through brown bags full of pills to help remedy this significant problem."
RELATED STORY: PILL ON THE SIDE
Some drug interactions can happen when a prescription drug mixes with other common medications or drugs like alcohol.
Valium is a prime example, says Loren Lipson, M.D., associate professor of medicine, and chief of geriatric medicine at USC.
In older patients, the popular muscle relaxer and anxiety reliever can remain in the bloodstream many times longer than it does in younger adults.
Other medications can exacerbate the effects of Valium and cause it to stay in the bloodstream for even longer amounts of time. The over-the-counter anti-ulcer medicine Tagamet can increase the amount of time that Valium remains in the system, and so can alcohol.
Valium's half-life-the amount of time it takes for half of the drug to be removed from a person's bloodstream-in a young person is typically about 24 hours, says Lipson. In a frail 80-year-old man, that half-life can be extended to 80 hours, and if an overweight person is taking Tagamet and drinking alcohol, the half-life of Valium is extended to a whopping 210 hours.
Since the drug takes longer to leave the system, additional doses over a period of days can lead to accumulated Valium in a person's system, leading to side effects like amnesia, confusion, respiratory depression, and the increased risk of hip fracture due to falls. Other drugs in the Valium family, like Halcion and Dalmane, can be responsible for similar reactions.
Harmful drug interactions can occur when several drugs compete for the same space in a person's body protein. When molecules of a drug attach themselves to a particular area-called a protein binding site-on a body protein, they are effectively removed from the bloodstream and stop acting. Some drugs can displace others from their protein binding sites, launching them into the bloodstream once again.
For instance, the widely used anticoagulant Coumadin can help prevent blood clots in people at risk for stroke or heart attack. Coumadin is gradually removed from a person's system when it binds to a protein called albumin. But another common drug-aspirin-that binds at the same site in albumin can take the place of Coumadin on the binding site, thus causing high amounts of Coumadin to begin circulating once again in the bloodstream. Sudden increased levels of Coumadin, brought about by an innocent aspirin, can cause excessive bleeding and even hemorrhage.
Alcohol can magnify just about all of these harmful drug interactions, often without the knowledge of family members and physicians. Elderly patients often drink secretly, because of depression and other psychological factors. "There are often situations when people are having problems and using alcohol as an escape, but we are not aware of it," says Lipson. "People fall down or have accidents, and it's because they're taking medications whose side effects are being exacerbated by alcohol."
Other symptoms that can be attributed to mild depression, like confusion, can really be the result of interactions of drugs like Valium with frequent alcohol use.
"Sometimes the person isn't mildly demented, but mildly fermented," Lipson says with a smile.
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