Older adults take a lot of medications — sometimes they hurt more than help
By Grace Vitaglione
Rachel Baxter moved her mother from Connecticut to Baxter’s home in Fuquay-Varina a little over a year ago. Her mother, 89, has Alzheimer’s disease and needed extra help, but Baxter eventually realized that some of her mother’s issues were because of the prescription drugs she took.
Some of the medications significantly lowered her blood pressure. Another gave her constipation.
“She was in such bad shape when she got here for multiple reasons, and part of those reasons were all drugs that she had been prescribed in maybe her 50s,” Baxter said. “She’s in her late 80s now.”
Baxter learned about the concept of deprescribing, the planned process of reducing/stopping medications that are no longer beneficial or are causing harm, through the Snow Approach Foundation. Led by dementia care expert Teepa Snow, the Hillsborough-based organization provides education and engagement for caregivers.
Baxter started working with DeLon Canterbury, a doctorally-prepared pharmacist who runs GeriatRx, a consulting service that helps families and older adults with medication management, among other things.
Canterbury was able to identify five medications that were impeding her mother’s quality of life and safely taper her off of those medications through working with her provider.
It made a huge difference.
“She’s so much better. Before, she was exhausted. She didn’t want to get out of bed. She was too tired to live any kind of life,” Baxter said. “Now, she’s up and moving and communicating with people.”
Polypharmacy, or the use of five or more medications at a time, is more common in older adults because they often have more chronic conditions and need medications to manage them. If someone starts taking drugs to offset the side effects of other drugs, the pills can quickly start to pile up.
Taking multiple medications isn’t always negative, but it can cause adverse side effects. Taking medications as directed also becomes more difficult with more drugs. Many people don’t know deprescribing is an option, Canterbury said.
No patient should stop taking medications on their own. Yet with large pharmacy chains replacing local businesses, it can be hard for patients to form a relationship with a trusted local pharmacist and ask questions about their medications.
‘Do I need all this?’
More than half of adults 65 and older report taking four or more prescription drugs, compared with one-third of adults 50-64 years old and about one in ten adults ages 30-49, according to KFF, a health policy research and information organization.
Ronald Davis, clinical pharmacy specialist at UNC Hospitals Hillsborough campus, tends to serve an older population with multiple health problems. He evaluates whether any patients’ medications caused what brought them into the hospital, as well as whether any medications could be problematic in the future.
That can be done with the Beers criteria list of potentially inappropriate medications for older adults. Davis said he runs into instances of people taking potentially inappropriate medications at least once a day.
Those include classes of medications that increase the risk of falls in older people, such as sedatives like Xanax and Valium. Others include antihistamines like Benadryl, which can make people sleepy or fuzzy for hours at a time.
Davis used the example of an older adult on medication to lower their blood pressure who has urinary issues and gets up several times at night to use the bathroom. If they also take an anti-anxiety medication before sleeping, the combination could result in grogginess or dizziness when they get up that causes them to fall. Even Tylenol PM, which many people don’t realize contains Benadryl, can result in dizziness for an older adult.
Medications that were appropriate when someone is 50 may not be appropriate when they’re 80, Davis said. Bodies change as they grow older and handle medications differently, often with increased effects and side effects.
“It’s like your garage at your house; you keep getting more and more things, and eventually you have to kind of step back and say, ‘Do I need all these things?’” he said. “You may have a cardiologist that gives you this medication, a kidney doctor that gives you a different medication and a neurologist that gives you another set of medications. You need a good primary care provider to kind of be the ringleader.”
Something else to watch out for is prescribing cascade, in which drugs are prescribed to treat the side effects of other drugs.
“One of my big rules is never treat a side effect with another medication,” Davis said. “Try to find a better medication.”
Canterbury said he also looks at which herbal supplements someone may be taking, because those can have adverse interactions with prescription drugs. Chronic use of over the counter medications like ibuprofen can also have negative effects, he said.
Taking medications as directed
In some cases, patients do need to be on a high number of medications. But Davis said that presents the challenge of taking all of those medications properly and consistently. The patient has to be able to afford all the medications and remember to take them correctly, as well as know what they’re for.
Joe Moose co-owns seven Moose Pharmacy locations across North Carolina with his brother Whit Moose Jr. He said with every medication added, adherence becomes more difficult. The average patient in their program was on around 11 and a half medicines per month, Moose said.
A lack of adherence could drive up how many drugs someone takes, Moose said. For example, a doctor might prescribe medication for a patient’s high blood pressure, then prescribe more if it doesn’t work — when the problem was that the patient wasn’t taking their medication in the first place.
Other factors such as transportation to the pharmacy can play into why someone doesn’t take their medications, Moose said.
His staff compile “MoosePacks” to make medication adherence easier. The medicines are organized and sorted by day, time and dose, in individual MoosePacks.
Moose Pharmacy staff can also coordinate all the person’s pills to be collected on the same day each month. Before the visit, staff reach out to the patient or their prescriber to see if anything has changed and if any medications can be consolidated or discontinued.
The method has “a lot of human touch,” Moose said.
One aspect of adherence is being able to afford the medications. NC MedAssist, a statewide nonprofit pharmacy, provides free prescription medication to uninsured and low-income North Carolina residents. The free pharmacy program served 16,000 patients in the past year, according to Dustin Allen, chief operating officer and director of pharmacy operations.
‘Trying to swallow all of these pills’
People with dementia who live in nursing homes are more likely to be affected by polypharmacy, said Joshua Niznik, an assistant professor in the Division of Pharmaceutical Outcomes and Policy at the UNC Eshelman School of Pharmacy, as well as in the Division of Geriatric Medicine at the UNC School of Medicine.
Part of his research focuses on evaluating the impact of deprescribing or discontinuing medications that may no longer have value in nursing home residents with severe dementia.
Some people with dementia are physically healthy, but the majority have medical complexities that contribute to polypharmacy, he said.
At least half of people with dementia are on at least one inappropriate medication, Niznik said. Medications to look out for tend to be ones that increase dizziness or affect cognition, he said. Diabetes medications can also cause low blood sugar, which increases fall risk.
For him, the issue is personal.
“My grandmother was living with dementia…and I was always struck by how many medications she continued to take despite the poor quality of life that she had,” Niznik said. “It made me really question, is any of this actually helping you? I’m watching you basically choke trying to swallow all of these pills every day.”
Helping older adults deprescribe
Canterbury became interested in polypharmacy when he watched his grandmother, who had dementia, be prescribed the wrong medication — which worsened her condition.
He worked as a pharmacist at Walgreens, where he saw many people dealing with the same problems his family had. But he didn’t have the time in that role to help them.
Canterbury volunteered at Senior PharmAssist, a nonprofit that helps Durham seniors get access to and learn about their medications. He was inspired to start GeriatRx in 2020. The services are conducted through telehealth throughout the country.
The organization’s first client was able to go from taking 36 medications in 2020 to three currently, he said. That kept her out of a nursing home, as well, because her family thought she had dementia. It turned out the medications were the problem.
Canterbury said he works with patients to come up with a plan based on their symptoms, side effects and personal goals. He also aims to help patients advocate for themselves when they talk with their health care providers.
Health care providers are generally receptive and positive to suggestions, he said. Pharmacists don’t usually get to weigh in this way, so it’s a “win-win” to coordinate care, he said.
Communicating with providers
The pharmacist is a vital part of a patient’s care team, Moose said. Most patients with two or more chronic conditions see their primary care provider a few times a year, but they see their community-based pharmacist far more often, he said.
People with chronic conditions and/or who take six or more medications would likely benefit from having a provider look at their medication list on a routine basis and reevaluate whether those are the best options, he said.
“The best thing a patient can do is get with one pharmacy and stay with one,” Moose said. “So somebody is there to be the gatekeeper. And to make sure they’re with a pharmacy that is looking and actively working with them.”
For family members who help oversee care, he also recommended working with their pharmacy to make sure there are no problems with the patient taking their medication properly and to let them know if something isn’t working.
Moose advised patients to pick a pharmacist the way they would pick a primary care doctor — does the pharmacist listen to their concerns and answer their questions? If they’re always too busy to address concerns, maybe it’s time to switch, he said.
Losing community pharmacists
Many prescribers recognize polypharmacy is an issue, but it’s a time-consuming problem to fix — and there aren’t good ways to pay for the kind of time that attention requires, Moose said. On top of that, discontinuing a medication for a patient means places like Moose Pharmacy lose the money they may have made off that drug.
But that’s not the kind of business Moose wants to run, he said. They focus on the patient as a whole.
“If you get paid to fill prescriptions, your goal is to fill as many as you can,” he said. “So it’s an inverse incentive on the pharmacy end to discontinue [a medication], but that’s what we do.”
Moose said he doesn’t charge his customers extra for services like MoosePacks, but he doesn’t know how much longer they can do so for free. Prescription reimbursement has gotten increasingly worse over the years, he said.
Moose said that’s in part due to pharmacy benefit managers, which manage prescription drug benefits on behalf of payers and negotiate with pharmacies and drug manufacturers. The organizations face increasing national criticism about their role in rising prescription drug costs and spending, according to the nonprofit research institute The Commonwealth Fund.
There were over 300 independent pharmacy net closures — almost one less pharmacy open for patients a day — in 2023, according to the National Community Pharmacists Association.
Big chains emphasize convenience in their marketing, but that’s not what everyone needs, Moose said.
“The population that drives the most health care costs doesn’t need convenience,” he said. ”They need true care and intervention, coaching, accountability and all those things we think the independents provide,” he said.
Baxter said while she’s grateful for her own mother’s improvement, deprescribing should be part of the wider health care system and available to everyone.
“I know in my heart there’s so many people who are probably suffering unnecessarily because of that situation, and not knowing what to do,” she said.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.
Photo by Myriam Zilles on Unsplash
