By Terry Fulmer, PhD, RN, FAAN, the President of The John A. Hartford Foundation. August 20, 2019.
An Interview with the Institue for Healthcare Improvement.
In a recent Health Affairs article, you and Shannon Brownlee of the Lown Institute refer to the problem of “medication overload.” What is medication overload?
Medication overload is when people use multiple medications and the harm, or potential harm, of taking those medications outweighs the benefits. While there isn’t a strict cutoff or a specific number of medications that are a problem, we know that the risk for harm increases with the number of medications a person is taking.
In our work with IHI, we focus on elements that we call the 4Ms — what matters to the older person, medication, mentation, and mobility — because they’re critical to creating Age-Friendly Health Systems. Getting medications right is essential because when your medication is wrong, your mentation can be off, your mobility can be compromised, and what matters to you will not be front and center.
Why does medication overload pose a problem for older adults?
Medication overload is problematic for older adults because normal aging leads to a decline in some vital organ functions. Lung function, kidney function, and liver function all weaken over time. This means that you clear medication less well, less quickly, and less readily. This puts an older person at greater risk [for side effects]. You may have an upset stomach or a serious problem with your gastrointestinal tract. You can have constipation or diarrhea. Acute or chronic disease can make the situation even worse.
Medication overload also puts older people at greater risk because they experience a higher proportion of cognitive impairment and osteoporosis. I’m a practicing nurse and I see how taking multiple medications can cloud a patient’s cognition. If they fall, they’re more likely to suffer a hip fracture than a younger person.
What are some keys to addressing medication overload?
There are some simple, straightforward things we can do. [Clinicians] can consider deprescribing. This means taking a thoughtful look at prescribed medications and deciding which ones are no longer needed or warranted. It’s very sensitive work because — especially if we’ve been taking a medication for a long time — many of us would worry that something bad will happen if we stop.
Another tricky situation is deprescribing for a different prescriber. Clinicians often hesitate to stop a medication that someone else prescribed. Clinicians need to talk with one another about what’s in the best interest of the older adult and be less sensitive about how their fellow clinicians might react. It’s a good practice.
When deprescribing, you’re literally taking something away from a patient. How do you address an older adult’s perception that this is a loss, especially if they’re concerned that deprescribing is to save money?
That is absolutely something that is in the minds of people these days. Clinicians need to explain carefully and sensitively about why they want to deprescribe a medication. Communication is so important. If a patient is concerned about being taken off a medication, clinicians should learn the reason for their concern.
Sometimes older adults share medications, for example. They might initially tell me that they’re taking their medications as prescribed, but they may be embarrassed to say that they’re sharing medications with a sibling or a neighbor. Unless we build a trusting relationship and unless I ask, I won’t necessarily know what’s going on.
You’ve said that medication overload is largely invisible in this country. What are other countries doing to address the problem?
Canada and Australia have established deprescribing networks. This means researchers, clinicians, pharmacists, and patient advocates come together to share information and develop strategies. We can learn a lot from them. In the European Union (EU), they have a health program they call the SIMPATHY (Stimulate Innovation in the Management of Polypharmacy and Adherence in The elderly) project. It conducts systematic reviews of EU polypharmacy policies.