17
Overmedication of the Elderly
After seventy-nine years of dealing with Wisconsin winters, Norman finally met his match in an unusually long and cold one. In the midst of what seemed like interminable snow, he surveyed the icy sidewalks and decided it was probably a good idea for him to discontinue his daily walks around the neighborhood and stay home.
With less physical activity, Norman found it frustratingly difficult to get to sleep. His wife suggested that he try over-the-counter (OTC) diphenhydramine (Benadryl). It seemed to work—he slept for a full eight hours the first time he used it. Norman continued to take the drug nightly, even after the snow and ice melted and he resumed his walks.
In the spring, Norman saw his primary care physician for increasing difficulty urinating. The doctor prescribed terazosin (Hytrin), a medication that can help relieve urinary obstruction due to an enlarged prostate. His symptoms improved a bit.
Two months later, on standing up from a park bench on a warm summer’s evening, Norman became lightheaded and fell, fracturing his hip. After orthopedic surgery, he was given morphine to help manage his pain. To prevent the potentially serious constipation that is often a side effect of opioid drugs, his surgical team started him on Senna-S, a combination stool softener (docusate) and stimulant laxative (senna). His prior medications—diphenhydramine and terazosin—were continued as soon as he was able to swallow pills.
In the ensuing nights in the hospital, Norman became confused and combative and kept trying to get out of bed. To help calm him, the on-call team added lorazepam (Ativan), a benzodiazepine, to the mix of diphenhydramine, terazosin, docusate/senna, and morphine. After his hip fracture had healed enough for him to leave the hospital, Norman was discharged to a rehabilitation facility, still on all the medications.
Within a few days of his transfer, Norman developed redness and warmth at the site of the surgical incision. Suspecting a bacterial infection, the rehab physician gave him a course of an antibiotic, amoxicillin-clavulanate (Augmentin). A few days after starting this, Norman developed diarrhea. The attending physician stopped the Senna-S and started imodium (Loperamide), a drug that slows intestinal movement.
The diarrhea soon resolved, but the stool softener/laxative was not resumed and the imodium continued. A week later, Norman complained of severe abdominal pain and was found to be totally constipated with concerning distension of the bowels (“toxic megacolon”). He was readmitted to the hospital, where he underwent emergency abdominal surgery. Because he could not take oral medicines, he was switched to intravenous morphine and lorazepam, with the addition of IV omeprazole (Prilosec—a proton pump inhibitor, or PPI) to decrease the acid in his stomach and minimize the risk of an ulcer developing. Once his GI tract healed, his diphenhydramine, terazosin, morphine, lorazepam, stool softener/laxative, and omeprazole were all resumed in oral formulations.
When he was deemed stable enough to leave the hospital, Norman was transferred to a skilled nursing facility. (He did not qualify for return to the rehab facility because he was not physically able to participate in the required four hours of physical therapy a day.) His medication list from the hospital went along with him. During his stay in this facility, Norman continued to have pain in his hip and leg, and because he seemed less vibrant and more subdued, the rehab doctor started him on amitriptyline (Elavil), an antidepressant that is also frequently used to help diminish pain. Eventually, Norman was sent home. His wife filled his home-going prescriptions for terazosin, morphine, lorazepam, amitriptyline, and omeprazole. And a bottle of over-the-counter diphenhydramine was dutifully waiting for him on his nightstand.
The following year, Norman’s wife urged him to speak with his primary care physician about new memory problems and an increased tendency to fall. That doctor did document some memory impairment and also noted that Norman was unsteady on his feet, especially just after rising from a seated position. Blood pressure readings both seated and standing confirmed that he was experiencing orthostatic hypotension—a significant drop in blood pressure on standing up that can cause fainting and falling, a potential catastrophe for an older person with brittle bones. The physician explained the side effects associated with each of Norman’s medications, and together they decided to stop all of them: diphenhydramine, terazosin, morphine, lorazepam, omeprazole, and amitriptyline. A few months later, Norman was able to walk outdoors with confidence, albeit with a little limp.
Stories like this are all too common among older adults. What started with a simple attempt to improve sleep with an over-the-counter remedy grew into a frightening scenario of overmedication with significant complications and adverse effects. In such cases, the involvement of different prescribers and caretakers, who have little direct communication with one another, often leads to the accumulation of more and more medications to help alleviate symptoms resulting from prior ones. And doctors are unlikely to stop medications prescribed by their peers.
OVERMEDICATING THE ELDERLY
As we age, we have more complaints and symptoms that seem made-to-order for pharmaceutical treatment. Medications like diphenhydramine and combinations of diphenhydramine and acetaminophen (such as Tylenol PM) are designed (or at least marketed) to help us fall asleep faster and stay asleep longer. These OTC remedies are particularly attractive to older people, many of whom find good sleep elusive. Unfortunately, although the sedating antihistamines can be effective, they do not provide the restorative natural sleep that the body and mind need. And they are fraught with potential side effects, which can be particularly dangerous in older people: worsening of urinary obstruction, increased risk of falling, greater likelihood of experiencing delirium, and a greater chance of being diagnosed with dementia*—all conditions that often prompt the administration of even more medications, each with its own potential for adverse effects on aging bodies and minds.
Whether Norman would have developed urinary obstruction if he had not taken the diphenhydramine cannot be determined. It is entirely plausible that his primary care physician was not aware that he was taking OTC diphenhydramine nightly. No one thought to try stopping the sleep aid to see if it was causing his urinary problem.
Terazosin is one of the most common drugs used to treat urinary retention. Although it helps to some extent, it also has an effect on blood vessels that can lead to orthostatic hypotension.
Upon admission to a hospital, there is a tendency among physicians to take the patient’s medication list from home and add new meds to it. Norman’s diphenhydramine and terazosin were continued for sleep and for urinary obstruction, with an opioid added to alleviate pain from the hip fracture. While opioids can be essential for control of severe pain, they have their own attendant side effects to be wary of, such as serious constipation. They can also increase the risk of falling and worsen urinary obstruction.
Studies of older hip fracture patients have shown that 16 to 62 percent develop delirium. Pain appears to be a leading risk factor associated with delirium in this population. Possibly, Norman was not given enough morphine to control his pain (including the significant discomfort caused by a distended bladder and a blocked colon), but it is noteworthy that diphenhydramine on its own can cause delirium in older patients.
Although lorazepam can quickly quell agitation and make a combative patient docile, it is rarely the ideal solution because it does not address the underlying causes of the behavioral change. Moreover, benzodiazepines also increase the risk of falls and can even precipitate delirium by making people groggy and confused. The American Geriatrics Society felt so strongly about avoiding benzodiazepine use in the elderly that it included benzodiazepine prescribing in the “Five Things That Physicians and Patients Should Question” list for the geriatrics section of the Choosing Wisely educational campaign to improve doctor-patient relationships.
As commonly occurs in hospitalized patients today, Norman developed an infection, for which he was given a strong antibiotic. Antibiotic treatment kills not only the offending bacteria, but also the good bacteria in the intestines. Diarrhea is a frequent outcome of this drastic alteration in the normal gut flora. Hospitalized patients on antibiotics are also at risk for serious gut infection with Clostridium difficile (C. diff). In Norman’s case, forgetting to discontinue imodium and restart the bowel stimulant while he was still taking morphine probably led to paralysis of the gut and his toxic megacolon. Then, with his bowels not moving, his hospital team opted to put him on omeprazole to suppress acid production in his stomach. This drug can help prevent or treat a serious bleeding ulcer, but acidity in the stomach serves vital functions, and long-term suppression of it with drugs like omeprazole can have serious consequences (see chapter 3), including increased risk of C. diff infection.
The popularity of amitriptyline and related older (tricyclic) antidepressants has waned in psychiatry, but they are still used for the relief of chronic pain, even though their efficacy for this is questionable. Unfortunately for Norman, tricyclic antidepressants, like their antihistamine relatives, can cause urinary obstruction and constipation as well as increase the risk of falls and delirium.
Norman went from home to the hospital, from the hospital to rehab, then back to the hospital, and then to the skilled nursing facility before finally going home. With each change of venue and clinicians, the potential for medication errors increased.
INTEGRATIVE MEDICINE APPROACHES
As you can see from the chapters in this book, there are many ways to manage common complaints other than relying on medications. If Norman had found an indoor exercise routine to take the place of his walks around the neighborhood when the sidewalks were icy, his sleep might not have suffered. An integrative medicine practitioner could have advised him about sleep hygiene and suggested trying valerian or melatonin as natural sleep aids (see chapter 6).
If his primary care physician had asked Norman about any new OTC medicines he was taking, and advised that he try alternatives to diphenhydramine before prescribing terazosin for urinary retention, perhaps the fall and subsequent outcomes might have been different.
After the hip injury, appropriate pain relief and attention to urinary retention and constipation might have averted the episodes of delirium and obviated the need for lorazepam, which, especially in combination with opioids, can dangerously compromise breathing and impact cognitive function.
Had Norman been able to get good nightly sleep, he might have been able to tolerate his pain with less need for medication, and the risk of delirium might have been lower. But prolonged stays in a hospital or rehab facility or nursing home can cause a good night’s sleep to be merely a distant memory and unfulfilled yearning. (See chapters 12 and 6 for suggestions about the non-pharmacological management of pain and insomnia.)
BOTTOM LINE
Too many older people are on too many medications, putting them at risk for serious adverse reactions and drug interactions. When I see the medicines that elderly patients and friends are taking, more often than not I note many drugs prescribed by different physicians, as well as a generous sampling of OTC medications. I wonder if anyone is overseeing all of it. Research suggests that in many instances the answer is no. Among those over the age of sixty-five, the incidence of polypharmacy, defined as being on five or more medications at one time, rose from 30.6 percent to 35.8 percent from 2005 to 2011, putting an estimated 15 percent of older adults at risk for complications from drug interactions. Further complicating matters, nearly two-thirds of older adults also take dietary supplements. Another third regularly uses OTC medication.
Older people grew up in era when medical doctors were more authoritarian and paternalistic; they are used to complying with doctors’ orders and not questioning the need for medications. They may be more reluctant to ask a physician about an OTC product or dietary supplement. If Norman had felt that it was important and permissible to discuss his diphenhydramine use with his primary care physician, perhaps the cascade of untoward events that engulfed him would have been avoided.
If you have an elderly relative or friend on multiple medications, urge that person to consult a pharmacist for a medication therapy management (MTM) review (see chapter 18 for a description of this service).
As a patient or patient’s advocate, you are responsible for keeping an updated list of what medications are prescribed, including the dosage, as well as the dates they were started or stopped or the dosage changed. Be sure to write down the reason for starting or stopping each medication or changing dosage.
It is critically important for each prescriber/caretaker to be thoroughly versed in a patient’s medication history (including OTC products and herbal remedies, as well as use of alcohol and caffeine) and to communicate with all other caretakers and prescribers. Communication must be bidirectional, with open and nonjudgmental discussions encouraged among all concerned parties.
When an elderly patient enters a hospital, rehab, or chronic care facility, the caretaker must be able to advocate for him or her in those settings. It is much easier for an institution to administer a medication than it is to adjust the assault of continuous light and noise that may be disturbing sleep or causing agitation. But firm and reasoned insistence can persuade staff to make modifications. Speak directly with the nurse on duty as well as with the head nurse and the physician or prescriber. Explain your concerns and offer viable suggestions for alternatives. The common paramount goal of everyone should be the health and welfare of the patient.
To learn about safe and effective ways to manage chronic conditions and symptoms, including lifestyle change, natural remedies, and unconventional therapies, consult a health professional trained in integrative medicine.