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Medicine and the elderly: Age shall not weary them-but drugs might

MagazineDecember 2010 (Vol. 21 Issue 9)Medicine and the elderly: Age shall not weary them-but drugs might

The over-65s take one-third of all pharmaceuticals that are prescribed by doctors every year, despite the fact that they represent just 13 per cent of the total population

The over-65s take one-third of all pharmaceuticals that are prescribed by doctors every year, despite the fact that they represent just 13 per cent of the total population. On average, an elderly person is taking around six drugs at any given time (Johnston CB. UCSF Division of Geriatrics Primary Care Lecture Series May 2001. Geriatric Assessment in a Time Dependent Practice: Practical Approaches for Primary Care Practitioners).

Polypharmacy-when more than one drug is prescribed at a time-is an even bigger problem in hospitals and care homes, where the average patient is given at least seven different drugs every day. In addition, powerful dementia drugs are being prescribed for most patients as a 'chemical cosh' to keep them quiet, evidently mainly for the convenience of the medical staff. An official UK government review has revealed that the drugs are being inappropriately prescribed in around 80 per cent of cases. In the UK alone, this works out to around 150,000 people who are being given anti-psychotic drugs just to keep them pacified. Worse, the drugs are directly responsible for about 1800 deaths every year (http://news.bbc.co.uk/2/hi/8356423.stm).
This may perhaps explain why 11 per cent of elderly patients, admitted to hospital for other medical conditions, will suffer a heart attack while they are there. In addition, they are also twice as likely as a younger patient to die within 30 days from such an attack. Researchers made the discovery when they examined the health records of 7054 patients who were admitted to hospital as part of the US Veterans' Health Administration between 2003 and 2004. Of those patients, 792-or 11.2 per cent-suffered a heart attack while under hospital care (Arch Intern Med, 2006; 166: 1410-6).

Tick-box medicine

Most patients are over 65 and, yet, they rarely see a doctor who specializes in geriatric medicine. This might be because, in almost every country except the UK, there is a serious shortage of geriatricians. In Canada, for example, there are fewer than 200 qualified geriatricians serving the entire country. In an attempt to attract more medical graduates into geriatric medicine, Dr Laura Diachum, at the University of Western Ontario, has gone as far as to describe the speciality as "totally sexy" (J Am Geriatr Soc, 2006; 54: 1453-62).

As a result of the lack of geriatric specialists, an elderly patient is invariably seen by a general practi-tioner, whose almost instinctive tendency will be to start reaching for the prescription pad. Sadly, as discover-ed by a doctoral thesis defended by Sandra Pennbrant, at the Sahlgrenska Academy in Sweden, elderly patients tend to become passive when faced by the doctor and feel intimidated by the practitioner's power and, so, fail to participate in the consultation by almost never challenging the decision to start taking a drug or even asking any questions (http://gupea.ub.gu.se/dspace/ handle/2077/21198).

Doctors routinely hand out prescription drugs simply because the patient is old, not because he or she needs them, says Michael Oliver, an emeritus professor of cardiology at Edinburgh University. This 'tick-box medicine', as he calls it, means that elderly people are not only taking
drugs they don't need, but they are also being exposed to side-effects that can seriously endanger their health. "Nowadays, few elderly people are allowed to enjoy being healthy," he says (BMJ, 2009; 338: b873).

One example of this so-called tick-box medicine is bringing down levels of blood cholesterol, especially in the elderly. But this is, in fact, a failure to understand the changing metabolism of older patients, who appear to need higher levels of cholesterol for their general wellbeing and, especially, to support mental acuity. One study that involved 3572 men, aged 71-93 years, discovered that those who had the lowest cholesterol levels-from 2.09 to 4.32 mmol/L (80.0 to 167.0 mg/dL)-were up to 40 per cent more likely to die than those whose cholesterol levels were higher. Indeed, this study, which monitored the health of the partici-pants for 20 years, questioned whether there was any "scientific justification for lowering cholesterol to very low concentrations (below 4.65 mmol/L [179.8 mg/dL]) in elderly people" (Lancet, 2001; 358: 351-5).

Not only may higher cholesterol levels be health-giving in the elderly, but the cholesterol-lowering drugs themselves may also be doing more harm than good, according to a study from the Yale University School of Medicine. There, the researchers found that, while there was a marginal benefit from the drugs in reducing heart fatalities, they also found that the patients were dying of other causes as
a result of taking the drugs (JAMA, 1994; 272: 1335-40).

Worse, most general practitioners are unaware of the dangers of the drugs they are prescribing to their elderly patients, despite the frequent drug alerts and warnings they are sent by drug-monitoring agencies.

In fact, researchers have discovered that around one in five elderly patients is being given drugs that are dangerous, and could be the cause of debilitating side-effects. In a study of 760,000 elderly people taking a prescription drug, it was revealed that 21 per cent were taking one or more drugs that were on the Beers list, a compilation of all the prescription drugs that geriatric patients, in particular, should avoid (Arch Intern Med, 2004; 164: 1621-5).
In another study, researchers found that 20 drugs had been identified as being too dangerous for use by the elderly and, yet, most of these patients (79.6 per cent) were being prescribed one of these drugs and 20.4 per cent were taking two or more, including the beta-blocker propranolol, the anti-hypertensive agents methyldopa and reserpine, the painkiller dextropropoxy-phene and the anticoagulant dipyrid-amole (JAMA, 1994; 272: 292-6).
Many elderly people regularly take a common NSAID (non-steroidal anti-inflammatory drug) such as aspirin and ibuprofen to help ease their aches and pains. Yet, according to a survey of 4099 people aged 70 years and over, these drugs increase the risk of kidney dysfunction. Those who took an NSAID at least once a day had the highest levels of blood urea nitrogen and serum creatinine, both of which are markers of kidney problems (J Am Geriatr Soc, 1999; 47: 507-11).

Prescribed drugs may also be responsible for dry eyes and dry mouth, assumed to be a natural consequence of growing old. However, common pain-killers such as aspirin could be respon-sible, according to a study of 2481 patients aged 65-84 years. Antidepress-ants and antipsychotics may also be the cause of similar side-effects (Arch Intern Med, 1999; 159: 1359-63).

What's more, doctors are more than ready to prescribe 'off-label'-handing out drugs for health problems for which they have been neither tested nor licensed to treat. The problem has become so prevalent, and dangerous, that America's drugs watchdog, the Food and Drug Administration (FDA), has warned doctors to stop using atypical antipsychotic drugs to treat general behavioural problems in elderly patients. Indeed, agents such as olanza-pine, aripiprazole, risperidone and quetiapine are so dangerous that they double the risk of death-and they are supposed to be prescribed only to those with schizophrenia (www.fda.gov/cder/drug/ advisory/antipsychotics.htm).

The four giants

In 1965, when geriatric medicine was still in its infancy, Bernard Isaacs, a professor of geriatric medicine at Birmingham University in the UK, said the elderly were faced with four 'giants' that would determine their health: immobility; instability; incontinence; and impaired intellect (Isaacs B. An Introduction to Geriatrics. London: Balli`ere, Tindall and Cassell, 1965). Every health concern in the elderly could be traced back to one of those four conditions, he said. However, neither Isaacs nor the other pioneers of geriatric medicine could have foreseen that, in many older patients, these 'giants' would be caused by the very medicines that were supposed to help them, and not by the ageing process itself.

o Immobility and instability. Around 30 per cent of all over-65s fall each year, and this proportion rises to half of all those in hospital or in nursing care, where multiple drugs are an essential part of their daily regimen. Also, 25 per cent of these patients die within six months of falling. While there may be a number of reasons why an elderly person falls, prescription drugs are among the biggest causes, responsible for around 18 per cent of all cases (Johnston CB. UCSF Division of Geriatrics Primary Care Lecture Series May 2001. Geriatric Assessment in a Time Dependent Practice: Practical Approaches for Primary Care Practitioners).

Tranquillizers and sedatives, such as benzodiazepine, can increase the risk of a fall in an elderly patient by nearly threefold. Flurazepam and triazolam (both of which are benzo-diazepines) are the most dangerous, according to Canadian researchers, and the elderly patient was most likely to suffer a fall within the first two weeks of starting such drug therapy (Age Ageing, 1996; 25: 273-8).

In a separate small US study a year later, the geriatric researchers in Durham, NC, found that benzo-diazepines acted directly on the central nervous system, and affect neuromuscular processing and balance control, thereby causing falls, disorientation and slower responses in the elderly (J Am Geriatr Soc, 1997; 45: 435-40).

Powerful antidepressants of the class known as 'SSRIs' (selective serotonin-reuptake inhibitors) as well as the older tricyclic drugs, can also significantly increase the risk of falls in the elderly (N Engl J Med, 1998; 339: 875-82). As a consequence, elderly people taking an SSRI are 2.4 times more likely to suffer hip fractures compared with those not taking these drugs, researchers from the University of Toronto, Ontario, have found. However, the earlier types of antidepressant are not much safer for elderly patients. In this study, which involved 8239 patients, aged 66 years and over, who had been treated in hospital for hip fractures, it was found that those taking a tricyclic antidepressant such as desipramine or nortriptyline were 2.2 times more likely to suffer from hip fractures as a result of falls (Lancet, 1998; 351: 1303-7).

Insulin can also cause falls, and is among the three drugs that are also most likely to cause an adverse reaction in the elderly; the other two are warfarin, a blood thinner, and digoxin, a heart drug. The three drugs alone accounted for 59,108 of the 177,504 cases of adverse drug reactions reported by US emergency services in 2004-2005. Insulin can cause sudden hypoglycaemia (low blood sugar), which may result in a seizures or unconsciousness (Ann Intern Med, 2007; 147: 755-65).

In fact, most prescription and over-the-counter drugs appear to increase the risk of falling. In a meta-analysis of studies published from 1996 to 2007, involving more than 79,000 participants, aged over 60, who were taking some sort of pharmaceutical, it was found that many drugs "significantly" raised the risk of falls. The biggest culprits included sedatives, SSRIs, antihyper-tensives, diuretics, beta-blockers, and even NSAID painkillers such as aspirin and ibuprofen.

"Elderly people may be more sensitive to drugs' effects and less effective at metabolizing medica-tions, leading to adverse events which, in turn, lead to falls," said researcher Carlo Marra, at the University of British Columbia in Vancouver, Canada (Arch Intern Med, 2009; 169: 1952-60).

o Incontinence. This is often viewed as an unfortunate consequence of ageing, but this is not so. The US Agency for Health Care Policy and Research reports that eight out of 10 cases of incontinence can be either resolved or greatly improved by medical interventions (Agency for Health Care Policy and Research. Overview: Urinary Incontinence in Adults, Clinical Practice Guideline Update. Rockville, MD. March 1996; www.ahrq.gov/clinic/uiovervw. htm). The one exception is age-related prostate enlargement, which can cause urinary incontinence.

In fact, incontinence can arise for many reasons and in people of all ages, although one in 10 of those aged over 65, and three in 10 aged over 80, have some loss of bladder control, and half of all elderly patients in nursing homes have incontinence. Many prescription drugs cause temporary incontin-ence and, as the elderly take one-third of all drugs prescribed, it's not unreasonable to conclude that they are a primary cause of the condition in the over-65s. Anticholinergic agents, which block the passage of neural impulses, include drugs such as antihistamines, antidepressants, opiates, antispasmodics and Parkin-son's drugs, and can all lead to incontinence (Cochrane Database Syst Rev, 2006; 4: CD003781), as can heart drugs such as the calcium-channel blockers.

Diuretics, or 'water pills', increase the body's loss of fluid by promoting the production of urine and, as a result, can frequently cause acute incontinence. They are among the most regularly prescribed drugs among the elderly-and often unnecessarily so, as one study has identified (BMJ, 1994; 308: 511-3).

Alpha-adrenergic blockers, which include drugs for hypertension (high blood pressure) such as doxazosin (Cardura), prazosin (Minipress) and terazosin (Hytrin), can also cause incontinence (Drug Saf, 1994; 11: 12-20), as can the angiotensin-converting enzyme (ACE) inhibitors such as benazepril (Merck Manuals; www.merck. com/mmhe/sec11/ch147/ch147a.html).

o Impaired intellect. Around 22 per cent of those aged 71 years and over have some degree of cognitive impairment, which is often seen as
a forerunner of dementia and Alzheimer's disease (Ann Intern Med, 2008; 148: 427-34). However, research-ers at the Mayo Clinic reckon that this figure could be lower, with only 12 per cent of individuals aged between 70 and 89 years displaying such symptoms, according to a study funded by the National Institute on Aging (www.mayoclinic.org/news2006-rst/ 3306.html).

The Mayo researchers define cognitive impairment as having problems with remembering words, or placing things in time and space, or finding it more difficult to make decisions, or suffering from short-term memory loss. The problem doubles in those aged between 80 and 89, and it also appears to affect more people who have received only basic levels of education.

However, although ageing is a genuine factor in cognitive decline, pharmaceuticals also play a role in accelerating the problem. Scientists from the University of Florida have demonstrated that any drug that has anticholinergic (nerve-blocking) qualities can speed cognitive decline in the elderly patient. Although this includes drugs known to have anticholinergic actions, such as those used to treat an overactive bladder, many other drugs have similar effects, but have not been listed as such in the literature (Presentation at the American Academy of Neurology 60th Annual Meeting, Chicago, IL, Abstract S51.001, 17 April 2008).

Indeed, it appears that almost every commonly prescribed or over-the-counter drug can produce symptoms that resemble dementia in the elderly. A pair of researchers from the Medical University of South Carolina have reported that many drugs cause side-effects that include confusion and memory loss, two signs of cognitive impairment. In addition, the problem can be magnified when the patient is taking more than one drug at the same time (J R Soc Med, 2000; 93: 457-62).

Polypharmacy

It's evident that the dangers to the elderly of taking any one drug are bad enough, but it's almost impossible to measure the negative impact of taking many drugs at the same time, as most elderly patients are doing.

Even young Hollywood celebrities, such as Heath Ledger and Brittany Murphy, may have died as a result of taking several pharmaceuticals at the same time. As Dr Bruce Goldberger, a professor of toxicology at the University of Florida's College of Medicine, said of the latter's death, "Mixing a number of these drugs could have resulted in her death".

Every drug is tested for its safety and efficacy on its own, but no one is testing the lethal cocktails that can result from taking several powerful chemical compounds in combination.

Nevertheless, what is clear, as pharmacologists at the University of Wales College of Medicine, Cardiff, have pointed out, is that drugs-and especially polypharmacy-may be responsible for many of the common health problems seen among the elderly, such as confusion, weakness, incontinence, depression and falls, all of which have been blamed on growing old (Drugs Aging, 1998; 12: 485-94).

Without drugs and medicine, perhaps getting older wouldn't be such an unhealthy rite of passage.

Bryan Hubbard

WDDTY VOL 20 NO 11


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