Dr John Garner: Prescribing a cure for elderly patients'pill-popping culture

Published on Monday 11 May 2009 18:56

MY PRACTICE is privileged to look after the medical needs of 300 patients who are resident in care or nursing homes. One of the more time-consuming tasks is the checking, writing and signing of several thousand prescriptions each month.

Each of these 300 patients is on at least one prescribed medication and many are on ten, 12 and up to 17 prescribed products. Most of our patients are admitted to the nursing or care home following a period in hospital so all the long lists of medications patients are on are sanctioned by an appropriate specialist.

There has been a significant shift of opinion here. I recall that 20 years ago, there was major concern about "polypharmacy". This described the situation when an individual was on multiple pharmaceutical products and there was concern that these drugs would "fight" each other, causing unknown side-effects or else nullify the intended action.

Statistics were produced showing that a significant percentage of admissions to hospital were iatrogenic, that is, caused by the side-effects of prescribed medicines. In addition to this, patients coming into the surgery would ask which medication was the least important as they could only afford the prescription charge for two rather than three.

Doctors responded to this polypharmacy phenomenon by trying to get patients on as few medicines as possible. This was to ensure that interaction between drugs was minimised and that patients could understand and be able and willing to take the necessary pills.

This concern about "polypharmacy" has subsided, though a significant proportion of admissions to hospital are still related to the effects of prescribed drugs.

One of the reasons for the increase in prescribing for the elderly is that as well as having "a pill for every ill", we have pills for risk reduction.

Let's look at some of the medicines our senior citizens are on. A common one is folic acid. This is a vitamin, and important; however, a glass of orange juice or a portion of green vegetables would be an appropriate substitute. But in hospitals and care homes it is not always possible to persuade elderly patients to "eat their greens".

Similarly, calcium and vitamin D tablets are almost universal, often taken with a tablet to reduce the risk of fractures. Our elderly patients often have pain and may require several types of painkiller to ease their suffering. Patients who need to be in a nursing home may also have heart problems and the current recommendations suggest at least four separate products to treat this, sometimes more.

Add to these treatments for raised blood pressure, chronic chest problems, diabetes and too much cholesterol in the blood; a tablet to protect the stomach from all the other tablets and a couple of laxatives to counter the constipating effect of this "pill diet" and it's relatively easy to see that as having to take as many as 17 products and 30 doses a day is not too unusual.

One pill I haven't mentioned is the almost universal antidepressant. Now, I can understand that after languishing in hospital for several months and then finding you are not able to return to your own home, even with an extensive care package, would depress the most stoical of patients; hence the prescribing of antidepressants.

They do help, but, we hope are not be required long term as patients settle into their new home and discover it can be a pleasant and rewarding experience.

One of the great difficulties, though, with polypharmacy is that almost three-quarters of the patients in care and nursing homes have some degree of cognitive impairment (a nice way of saying dementia).

This makes it difficult for patients to make decisions about their medicines. Some do make it plain that they don't want tablets by spitting them out or secreting them in pockets, only for staff to discover them days later. We need to try to explore how better to understand and respect the wishes of such patients.

It's right that all patients should be offered treatments that can help make a difference to their lives. However, doctors, carers and families need to work with our elderly and vulnerable patients to ensure that their final months aren't blighted by a pill-swallowing bonanza. It's important to get that balance right.

&#149 Dr John Garner is a member of the British Medical Association's Scottish Council and a practising GP.