Am I taking too much Medicine? How much is too much? Are the Medications I am taking Safe?
This post will discuss information related to medication side effects, which includes prescription medications, over the counter medications (OTCs), vitamins and herbal supplements. I will discuss aging changes that can increase the risk of side effects. How much medicine is too much? At what point should a medication be reduced or discontinued?
Medication Related Side Effects
Up to 35% of emergency department visits are due to medication related causes in older adults
Up to 50% of older adults are at risk for taking 5 or more medications daily, this is called polypharmacy (pol-ee-farm-a-c)
Up to 69% of medication related hospital admissions can be prevented
The annual cost to the united states health care system is up to 31.1 billion dollars yearly
About 42% of older adults use one OTC medication, 49% take at least one dietary supplement, 29% take at least 5 prescription medications.
1 in 25 older adults is at risk for a major medication interaction because of the combination of medications that they are taking.
Up to 46% of older adults take an OTC with prescription medications, and 52% of older adults use a dietary supplement with a prescription medication.
Why are older adults at greater risk for medication related problems!
1. Multiple Medications
2. Multiple medical problems
3. Changes with aging that impact how a body metabolizes and eliminates medications
4. Types of medications prescribed
5. Not taking medications correctly
6. Shortage of Geriatricians to recognize above issues
When Might a Medication Side Effect Occur?
· A new Medication is added
· Dose of a medication is changed
· A medication is discontinued
· A medication is taken with alcohol or other drugs
· Medications are mixed with OTC’s and herbal supplements
· A medication interacts with a food
· Multiple medications cause drowsiness and dizziness
What happens to our body when we age and how does this change effect the way medications are processed?
Body Fat increases
Body Plasma decreases- the yellowish liquid part of blood containing cells, proteins, and water
Total body water decreases– so we get dehydrated
Decrease in body fluid that is outside our cells
Some of these changes may for example lead to elevated concentration of certain medications in the body leading to side effects.
Other changes with aging, specifically Organ system changes like the kidney, and liver can impact the way medications are metabolized and eliminated from the body.
In terms of the liver, certain medications may cause increased metabolism or decreased metabolism of other drugs. This is one big reason polypharmacy can lead to medication side effects and interactions.
As kidney function changes with aging, in addition to decreased body water certain medications may not be eliminated from the body as easily, causing higher concentrations in the body. Patients may experience more side effects with medications that already cause dizziness, drowsiness.
What should you do?
Before starting on any new medication make sure you know what you are taking that medication for.
Ask your health care provider, and the pharmacist if the medication you are being prescribed could potentially interact with another medication, vitamin or herbal supplement. For example, blood thinners may interact with some herbal supplements increasing your chance of bruising or uncontrolled bleeding.
As a Geriatrician, I ask my patients to bring in all their medications including their vitamins and herbal supplements. I treat anything that a patient is taking as a medication. I think about a patient's medication regimen before starting a new medication.
Sometimes if a patient is seeing multiple specialists a doctor may not be aware that the patient was started on a new medication. Ensuring you primary care provider has an accurate medication list can decrease your chance of a medication related side effect.
Call your primary care providers office to let them know if you have been started on a new medication by a specialist.
Try to use one pharmacy to decrease the likelihood of medication errors. The pharmacist can generally pick up on medication interactions if you pick your medications up at the same place.
If you go to the emergency department, hospital or urgent care ensure you have an accurate list of medications with you. You may be started on one or more medications that could cause an interaction with what you normally take.
Now to the concept of Deprescribing (D-pres-Cry-b-ing)-
Reducing the number of medications that a person is on
This is big for geriatricians. We love to deprescribe, the process of stopping, reducing the number of medications that a person takes to try and prevent medication related side effects. As we age, we may see multiple physicians because of various medical problems, over the years if we have a symptom a new medication may be added. Most older patients that I see and have seen over the last several years take somewhere between 5-30 medications a day.
I step back to look at the big picture, I take each medication and think about it.
1. Is the medication still appropriate?
2. Is the medication necessary?
3. What are my patient's goals for treatment and therapy?
4. Could the medication cause more harm?
5. Have I considered other medical conditions, treatments that could interact with the medication?
6. Is there an alternative therapy that does not require a medication?
The process above is not something a primary care provider can do at one visit but may take multiple visits. Once a medication is reviewed, decreased or discontinued a primary care provider will need to ensure the patient has tolerated that change and can move to evaluating another medication.
A primary care provider can refer a patient to a Geriatrician for consultation to perform a comprehensive geriatric assessment. A part of this assessment involves a detailed review of medications. Generally, if a patient is seen for consultation, geriatricians do not change medications, they make recommendations to primary care providers with a focus on improving the quality of life by taking a goal driven holistic approach to care.
The role of a geriatrician as a consultant is to provide support to primary care providers in health care systems.
If you or your loved one has multiple medical problems, taking multiple medications, has had two or more hospitalizations within the last year, you or your loved one may want to consider asking your primary care provider to see a geriatrician for a comprehensive geriatric assessment.
Visit my blog titled Over the counter medications, vitamins and herbal supplements.
Please feel free to contact me with any questions or concerns.
Please see the references related to this blog below
Budnitz DS, et al, Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755–65
Gerety MB, et, al, Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993;41:1326–32
Morin L, et al, The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clin Epidemiol. 2018;10:289–298.
Sultana J, et al, Clinical and economic burden of adverse drug reactions. J pharmacol. 2013; 4:s73-77
Kenya Ie, et al, Physician Factors Associated with Polypharmacy and Potentially Inappropriate Medication Use. JABFM 2017; 30 (4): 528-536.
McGrat K, et al. Deprescribing: A simple method for reducing polypharmacy. J of Family Practice. 2017;66(7):436-445.
Halli-Tierney A, et al. Polypharmacy: Evaluating Risks and Deprescribing. Am Fam Physician. 2019;100(1):32-38.
Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging
Qato DM, Alexander GC, Conti RM et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 2008;300(24):2867-78