When It Comes to Medication, Sometimes Less Is More
As an internal medicine physician, medications are my tools. It is my job to carefully choose drugs to treat acute ailments, manage chronic conditions, and prevent life-threatening events such as stroke and heart attack in my patients. While each new pill has a role, over a lifetime, these prescriptions can stack up. It is common for older adults to get to the point they are taking handfuls of pills multiple times per day and wondering if they are really all necessary. Actually, they may not be!
As people age, there is a natural decline in lean muscle mass, as well as kidney and liver function, which slows down the metabolism of medications. At the same time, the brain and central nervous system become more sensitive to drug levels in the blood stream. The longer the medication list, the higher the risk of drug-drug interactions as well.
It can also be difficult for people to stay on top of taking all the right pills at the right times every day. For all of these reasons, it is important to recognize when medications are no longer beneficial, or might even be dangerous for a patient. The concept of “de-prescribing,” or discontinuing medications, is especially important as people age and should be a topic seniors are comfortable discussing with their doctor.
Medication side effects in older adults is such an important issue that The American Geriatric Society has developed a comprehensive list of medications that are potentially inappropriate for seniors. This is called the Beers Criteria, or more commonly, the Beers List. It is a resource commonly known and used by medical providers, and it can also be a powerful tool for patients themselves.
Some examples of common medications found on the Beers List include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are noted to cause increased risk of gastrointestinal bleeding or peptic ulcer disease.
- Diphenhydramine (Benadryl), a sedating antihistamine used to treat allergic reactions and/or insomnia, carries risk of confusion, dry mouth, constipation and urinary retention.
- Benzodiazepines such as lorazepam (Ativan) and clonazepam (Klonopin) increase risk of cognitive impairment, delirium, falls, fractures and motor vehicle crashes.
- Muscle relaxants such as cyclobenzaprine (Flexeril) or methocarbamol (Robaxin) can cause sedation and increased risk of fractures.1
The full Beers Criteria can be found here. This guideline was complied in 2015—but stay tuned, as efforts are underway to publish an updated 2018 version. I strongly advise seniors to take the time to check if any of their current medications can be found on this list. Also check any new medications, including over-the-counter medications, against this list to understand the potential risks associated with taking these drugs before starting them. Finally…
Here are a few tips for discussing de-prescribing with doctor:
- Do not change or stop any medication without talking to your health care team first, even if it is on the Beers List. Some medications may need to be slowly tapered. Others may be very important for your health and unsafe to decrease or discontinue.
- Make sure everyone is on the same page about your medication list. Bring in an updated list of your medications, or the actual pill bottles, to every visit. Ask what each medication is for if you don’t know.
- Be sure to include all over the counter medications and supplements on your medication list. Be open to the fact that these might need to be discontinued too.
- Be patient. Usually only one or two changes should be made at a time. This way if a new symptom or problem arises, you and your doctor will know which change is to blame.
Ana Moreno, MD, internal medicine physician
One Community Health
American Geriatrics Society 2015 Beers Criteria Expert Panel. “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society. 2015;63(11): 2227-2246.