In the previous blog, Polypharmacy: Geriatric Health Crisis on the Rise, we looked at factors that are fueling the rise in polypharmacy, defined as the simultaneous use of five or more prescription drugs, over-the-counter (OTC) medications, or dietary supplements. In this blog, we’ll focus on strategies to address the problem, and why this is imperative for improving geriatric health outcomes.
The Lazarus effect
Dr. Nick Schneeman, Lifespark Chief Medical Officer, and Sarah Johnson, APRN, CNP, Lifespark Associate Medical Director, have often witnessed what they call the “Lazarus effect” in elderly adults whose medications are deprescribed or doses reduced. Among the changes they see are cognitive improvement, functional improvement, and extended life with better health. “This is not an uncommon occurrence when clients enroll in hospice,” he said. “In preparing for a peaceful late-life experience, the hospice team will usually deprescribe the client’s chronic medications. And two weeks later, Grandma’s dancing the polka!”
For Dr. Schneeman and Sarah, a big part of geriatric care involves eliminating the medications clients don’t need and keeping them on the ones that improve their quality of life. However, deprescribing alone isn’t the solution. Curtailing the rise in polypharmacy requires a multi-pronged approach which includes:
- A thorough medication review whenever a new medication is prescribed
- Education for clients and family members
- Clinician training
The body’s physiology changes with age, so what was appropriate at 50 may be harmful at 80. “When a geriatric client isn’t feeling well—they’re dizzy, confused, constipated, nauseous—it’s often caused by drug interactions or harmful side effects,” said Sarah. “It takes time to do an expert medication review of 12–18 drugs, but when you take away what’s contributing to poor health, it can really improve a client’s quality of life.”
A medication review should be done every time a new medication is prescribed and at least annually, said Sarah, adding that the med review is one of the most rewarding aspects of her job. “I gain so much insight about the client—not just their medical history and their cognition, but what they understand about the drugs they’re taking and what their goals are,” she said. Often neither the client nor their family member knows why they’re taking a certain drug or what’s it for. “With the client’s permission, we’ll pick up the phone and reach out to the specialist to find out why a certain drug was prescribed and to discuss the risk-benefit of deprescribing,” added Sarah.
Client and family education
A key part of a consultative geriatric visit is educating family members about the potential side effects of certain medications and how ranges differ for the geriatric population. “When we look at blood pressure meds, for example, we’ll explain that blood pressure goals for older clients can be much different than for younger people,” said Sarah. “110 might be a great target for a 25-year-old, but not for an 85-year-old who’s had some falls.” She might recommend a gradual dose reduction of the anti-hypertensive, monitor for changes, and explain that they can always restart the drug.
The same applies to blood sugar levels and the oral hypoglycemic drugs prescribed for diabetes. If a geriatric client is experiencing low blood sugars, it isn’t just unpleasant—it can be life-threatening. At the same time, it doesn’t make sense to maintain tight control in clients with limited life expectancy because it can take years to achieve any health benefit.
Sarah also uses education to dispel the belief that if you can buy it over the counter, it must be safe. “If a client is taking Advil PM to help them sleep, they need to understand that the drug has a Benadryl component which increases the risk of falls and confusion—a dangerous side effect for an older person,” she said.
Dr. Schneeman and his team are currently developing a training module to establish a standard of practice that will be rolled out to all Lifespark clinicians. “For every drug, we look at indication, efficacy, safety, and cost, and then discuss each one with the client to make sure they fully understand what’s behind our recommendation,” he said.
Indication – Does it have an FDA indication and are we using it properly? If we’re using it off-label, is there a body of evidence to support its safety and efficacy?
Efficacy – Is the drug going to work for this individual, given their other comorbidities and life expectancy?
Safety – What are the real risks of taking this medication, considering the other drugs the client is taking and their health history?
Cost – If there’s something cheaper that’s just as effective as the high-priced drug advertised on TV, let’s use that.
“As Lifespark grows, it’s going to be our responsibility to educate our clients and our collaborating partners—health systems, primary care physicians, specialty practices—on the impact of polypharmacy and what they can do to help mitigate the problem,” said Dr. Schneeman. “Together, we can radically improve the life experience for older adults, wherever they are on their life journey.”
To learn how Lifespark’s whole-person approach can help your clients age magnificently, schedule a free consultation.