Looking to Tackle Prescription Overload

June 7, 2021

By Paula Span

June 7, 2021, 10:00 a.m. ET

The last straw, for Leslie Hawkins, was her mother’s 93rd-birthday gathering in 2018.

Her mother, Mary E. Harrison, had long contended with multiple health problems, including diabetes and the nerve pain it can cause; hypertension; anxiety; and some cognitive decline. She was prone to falling.

Still, she had been a sociable, churchgoing nonagenarian until Ms. Hawkins, who cared for her in their shared home in Takoma Park, Md., began seeing disturbing changes.

“She was out of it,” recalled Ms. Hawkins, 57. “She couldn’t hold a conversation or even finish a sentence.” On her mother’s birthday, she said, “A bunch of us went to Olive Garden, and Mommy sat there asleep, slumped over in her wheelchair. I decided, nope.”

Ms. Hawkins and one of her brothers took their mother to see a geriatrician at Johns Hopkins Hospital, where she could supply only three correct answers on the 30-question test commonly used to assess dementia. “She didn’t really participate,” said the geriatrician, Dr. Stephanie Nothelle.

Fortunately, Ms. Hawkins had brought a list of the 14 medications Ms. Harrison was taking, several of which alarmed her new doctor. “I started chipping away at them,” Dr. Nothelle said.

She recommended stopping oxybutynin, prescribed to treat an overactive bladder, because “it’s notorious for precipitating delirium and causing confusion in older adults,” she said. She also suggested eliminating the pain medication Tramadol, which has similar effects and contributes to unsteadiness and falls.

At their next visit in three months, Dr. Nothelle told the family, they would discuss stopping several more drugs, including gabapentin for neuropathy; a diabetes medication that lowered Ms. Harrison’s blood sugar to unnecessary levels; and a reflux drug that nobody could remember her needing.

The follow-up visit did not happen as scheduled. Ms. Harrison fell and broke her hip, requiring surgery and six weeks in rehab.

Still, her daughter had gotten the message: Her mother’s many drugs might be harming her. “I went online and looked everything up and I started questioning her doctors,” Ms. Hawkins said.

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Fourteen prescriptions? “Unfortunately, that’s pretty common” for older patients, Dr. Nothelle said. The phenomenon is called polypharmacy, sometimes defined as taking five or more medications, as two-thirds of older people do.

More broadly, polypharmacy refers to an increasing overload of drugs that may not benefit the patient or interact well with one another, and that may cause harm including falls, cognitive impairment, hospitalization and death. It has sparked interest in “deprescribing”: the practice in which doctors and patients regularly review medication regimens to prune away risky or unnecessary drugs.

For older patients, the most commonly prescribed inappropriate medicines include proton pump inhibitors like Nexium and Prilosec, benzodiazepines like Xanax and Ativan, and tricyclic antidepressants, according to an analysis of Medicare data published last year. Over-the-counter products and supplements can also prove problematic.

“We spend hundreds of millions every year to bring meds to market and figure out when to start using them, and next to nothing trying to figure out when to stop them,” said Dr. Caleb Alexander, an internist and epidemiologist at the Johns Hopkins University School of Medicine. Yet among older people, adverse drug reactions account for one in 11 hospital admissions.