By the time Janet Johnson’s father reached his mid-80s, he was on so many medications their names are now impossible to recall. There were pills for managing his cholesterol, blood pressure, and asthma, says Johnson, an administrative assistant who lives near Minneapolis. Other drugs helped with his sleep problems and treated his type 2 diabetes. There were more, too, but who can remember? One thing was certain though: As the number of prescriptions increased, his health seemed to get worse.
“As he aged, he fell often and was confused. It was awful,” Johnson remembers. It turns out her father’s symptoms weren’t a sign of age-related decline, as she’d suspected. Instead, he was over-medicated, and it was taking a toll. “Finally, he was seen by a new doctor who took him off most of his medications, keeping only those that were critical,” Johnson says. Now, at age 88, he’s doing far better—a direct result of reducing the number of prescriptions he’s on.
Johnson’s story about her father is not unusual. When older adults take multiple drugs with varying side effects without proper management, they can find themselves dealing with everything from falls with hip fractures, to confusion and delirium. In some cases, drug interactions are lethal.
It’s often true that the older we get, the more prescriptions we add to our medicine cabinets. And if you’re caring for a loved one who has trouble keeping track of these meds on their own, keeping them safe from the dangers of over-prescription can be bewildering.
We asked for some guidance from geriatrician Leslie Kernisan, M.D., who specializes in handling the unique healthcare needs and treatment preferences of older people. Dr. Kernisan is a clinical instructor in the University of California–San Francisco division of geriatrics with research experience in improving the health of older adults. Her website Better Health While Aging is one of the few resources focusing on older adults that is geriatrician-sourced. Here’s our conversation with her:
The Candid Caregiver: Why is it especially important for aging adults to limit the number and types of drugs they take whenever it’s possible?
Dr. Kernisan: The main reason is because as people get older, their bodies become more vulnerable to the side effects. For instance, many medications cause drowsiness or poor balance. Even though the drowsiness may actually feel desirable to an older person who may be hoping to get help with sleep problems, nobody takes a drug hoping that their balance will be impaired. Furthermore, drowsiness generally corresponds to brain function slowing down, and that can persist into the next day, even when an older person is no longer feeling drowsy. These symptoms are all amplified when people take multiple prescriptions with these same effects.
Some medications are known to be particularly risky for older adults, and they're listed in the American Geriatrics Society Beers Criteria. It's not necessarily "wrong" for an older person to take a medication on the Beers list, but it should only be used when it's truly necessary and the likely risks and benefits have been discussed.
TCC: What does it mean to ‘de-prescribe’ medications and how do you do it?
Dr. K: We've always emphasized the importance of regularly reviewing medications (at least annually, if not more often) with your health provider. But deprescribing takes things a step further and is really about thinking about each medication and asking ourselves:
- Is this medication still needed?
- Does the likely benefit of this medication outweigh any risks or harm that it might cause?
- Could we manage without this drug, or could we make do with a lower dose of it?
There tends to be a lot of "inertia" when it comes to medications, so once a drug is started, it can easily remain on a person's Rx list for years unless you're proactive about reassessing and considering deprescribing.
TCC: Let’s talk about what meds should be deprescribed. Which categories of drugs present the biggest risks for older adults?
Dr. K: In general, the drugs that cause drowsiness or relaxation are especially risky, as we said before. Another major category to watch is anti-inflammatory painkillers, which are available over-the-counter and also come in prescription strengths. Many older adults take these for arthritis pain, but in fact they're on the Beers list because they can increase the risk of gastroinstestinal bleeding; daily use should be a last resort.
TCC: This could be a tricky conversation with your doctor. Give us some tips for asking to eliminate a prescription that the doctor has—at some point—said is necessary?
Dr. K: I think it's always helpful to start by articulating a goal that most health providers want to support, such as being proactive about understanding one's medications, wanting to only take the medications that are really necessary and don't put one at unnecessary risk. People can also share that they read that it's common for older adults to be on more medications than is needed and/or risky medications, because our health system often isn't set up to give providers the time they need to address everything.
Judicious use of medications is a good policy at any age but it’s even more important for older adults who don’t metabolize the drugs well. When you're gut tells you: the fewer the better, it's a good idea to follow it.