Much easier to add than to remove - about medication for elderly
Emma Müller-Suur is a medical doctor and works as chief physician at Capio Geriatrics in Sollentuna. Emma struggles daily with the challenges surrounding the elderly and medication management.
The big picture
“Care, above all, in Stockholm, is fragmented,” says Emma. “You sometimes wonder who is in charge of and responsible for the elderly’s medication.”
Emma describes a typical scenario where the GP sees the patient a couple of times a year. In between, there are often several other doctors with different specialties who look after their small part of the patient, and several prescribe different drugs. This happens because the patient often goes to different specialist clinics, each of which is responsible for a specific disease category and, in between, is also treated at an emergency hospital or a geriatric ward.
Sees only a small part
“How should one be able to understand interactions between all drugs, possible potential side effects, and whether the patient is actually overtreated or undertreated when as a healthcare professional, you only get to see a small part of the whole and are not given the opportunity to follow up on the patient continuously? Continuity and the possibility of regular care contact is crucial fo good drug treatment for the elderly. Personal knowledge is the key.”
The organization
The organization is essential to have sensible pharmaceutical handling, says Emma. There must be knowledge, time, and opportunities to work in a structured manner with drug issues, to see the whole, and to provide an individually adapted follow-up to each elderly patient following their needs. Overburdened primary care is today not given the resources needed to cope with this task.
Costs to society
“Society would save much money if the elderly's medication management were put in order. It is, of course, the cost of the drugs, but above all, the extra days of care that both overprescribing and side effects bring. Then we have the patients' suffering and reduced quality of life, which is difficult to measure in money, but we are also talking about large sums there.”
Prescription today
Many medicines are given on a prophylactic basis, i.e. to protect against future diseases, says Emma. For a single drug, that is probably a correct assessment.
“But if we instead see an elderly, multi-sick person who is already taking a lot of medication, the question is whether the risk of side effects from yet another tablet is not greater than the potential risk of disease further down the line that we are trying to treat.”
Scared to remove
Everyone in healthcare is stressed today, and of course, that also applies to doctors. It is, therefore, not surprising that they do not always consider themselves to have time to go through the list of medicines when the patient experiences a symptom, for example, nausea, to see if any of the existing medications specifically have nausea as a potential side effect, says Emma.
“Then, it will be easier to add an anti-nausea medicine instead. If you prescribe a pill, you have, in any case, not made a mistake. Suppose you instead remove a drug, and it turns out to cause symptoms. In that case, there is a risk that you will be questioned, and the doctor who initially inserted the preparation is, in many cases, a specialist in another medical field. Not always easy to motivate yourself or the patient to remove a pill. It is a tricky work situation.”
Fewer may be the solution, not more
Overprescribing is a real problem in healthcare today, says Emma. Everyone in healthcare, and above all doctors who have medical responsibility, must get better at reviewing the medication list before prescribing a new drug to treat a symptom.
“We have to ask ourselves if we might solve the patient's problem by removing a medication instead of adding a new one. A slightly more complicated situation to master, but so much better for the patient and society if we succeed.”
Contributes to polypharmacy
Polypharmacy means that the patient has more than 5 prescribed medicines. Polypharmacy, in many ways, increases the risk of drug problems through increased risk of adverse side effects and increased risk of different drugs influencing each other (interacting) with increased, decreased, or no effect as a result [1]. In addition, it can adversely affect the patient's adherence to take the prescribed medication.
“It is not unusual for a doctor to prescribe a drug that turns out to have adverse side effects in the patient. To counteract the side effect, an additional drug is then prescribed. You quickly get up to 5 drugs in the patient, and we doctors often have contributed to polypharmacy.”
Try things out
There is not so much research on medications and the elderly, says Emma. Most drug studies are not carried out on the elderly, although the number is increasing. This means one has to try out whether a medicine works and in what dose. It takes time to see the outcome and make an accurate evaluation; that time does not exist today.
Evaluate - When has the good effect turned into a bad one
“Without evaluation, how do we know when to stop a medical treatment? When has the good effect disappeared and turned into a bad one? There should be a process that automatically starts every time a new drug is prescribed, which checks that there is an indication and no contraindication and carry out regular follow-ups at regular intervals. And not to forget to include the patient in the decision-making process regarding possible drug treatment; what does the patient want?”
“Of course, primary care is best suited for this task. However, they have far too little time and resources to deal with all multi-sick older people with chronic diseases who need continuous medication follow-up. The district doctors know what to do but are not given the conditions to do it!”
[1] Socialstyrelsen. Indikatorer för god läkemedelsterapi hos äldre. Stockholm: Socialstyrelsen; 2017.
