Grandmother's little helpers

Julie Robotham - 21 January  2012

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Dr Timothy Steel FRACSwww.drtimothysteel.com.au

Extra medication can create bigger problems than those it solves for older people, writes Julie Robotham.

Professor Paul Zimmet's diabetes clinic is an epicentre of human misery.  Living with the disease requires hard, dispiriting labour, endless appointments that may include dressings for leg ulcers that will not heal, and frequent eye examinations to check for vision loss from malfunctioning blood vessels. Patients may feel thirsty, tired, weak and itchy, and succumb easily to infection.

Then there is the medication.

''Nearly every person I see is on something for cholesterol, and up to three drugs for blood pressure,'' Zimmet, the director emeritus of Melbourne's Baker IDI Heart and Diabetes Institute, says. ''They can be on three different agents for their diabetes, and sometimes insulin.''

The therapy, as much as the disease, is a huge psychological burden, Zimmet says. ''It's very difficult for people to be compliant with all those medicines, and to afford them,'' he says. ''They also have the demands of affording the diet and following the diet. The rates of depression and anxiety in this group are 40 to 50 per cent, at least. We're now recognising depression is a serious comorbidity.''

Zimmet's patients are at the sharp end of an escalating trend for people in middle age and beyond to take multiple medications as they manage overlapping chronic conditions.

The National Prescribing Service this week reported 40 per cent of people in their 50s and early 60s took five or more medications a day while, by their mid-70s, about a quarter were popping at least 10 different types of pill. Almost all were using complementary medicines with prescription drugs, and the proportion of people taking six or more prescription medicines had trebled to 40 per cent since the last major survey in 1995.

Medicines, especially those that prevent heart attacks and strokes, along with reduced tobacco use, have helped bring a generation to healthier old age.

But every additional drug confers a chance of new side-effects, and interactions with other medicines grow likelier and less predictable the more therapies are used.

Specialist doctors were broadly aware of the pattern but have been shocked by its magnitude. The figures, they say, should prompt urgent soul-searching about how much is too much, and where to draw the line with older people, given many of the drugs are taken to prevent rather than treat disease.

Cholesterol-reducing medicines, the research shows, are taken by one in five people in their 50s and early 60s, and close to half of the over 75s.

But it is not good enough, professor Andrew Tonkin says, for doctors to prescribe them based on a blood test. ''You really have to take into account, not only their cholesterol level, but the sex of the individual, whether they smoke, do they also have diabetes, their family history,'' Tonkin, the head of the Cardiovascular Research Unit at Monash University's Department of Epidemiology and Preventive Medicine, says.

It is also too easy, he says, to prescribe drugs based on a person's age. Cardiovascular disease, which cholesterol and blood-pressure drugs are intended to prevent, increases with age; but that, Tonkin says, is because older people are more likely to have been exposed longer to the precursors of disease, rather than a direct effect of age.

''We're going to have to reassess the way we see risk in the elderly,'' he says. ''The elderly experience more [medication] side-effects and we need to become cleverer at saying who is clearly at risk.''

This week's figures show one in 10 of over 50s takes an antidepressant - three times as many as in 1995 - and Sydney GP Liz Marles says much of this can be attributed to improvements in medications.

Marles, a vice president of the Royal Australian College of General Practitioners, says antidepressants have become easier to take, have fewer side-effects, ''and a lot of people respond quickly to them''.

Depression is widespread among older people, she says, and there are good reasons for robust, pharmacological treatment. "An older person who gets depression may just sit at home and do almost nothing else,'' Marles says. ''They'll physically decondition really quickly, and they'll probably suffer malnutrition.''

Where the treatment is working well, she says, and the person, ''engages more, and gets back into their daily routine, I don't think there's a reason to take them off.''

But the key is close monitoring of their response and a willingness to change direction. If someone is allowed to drift along on antidepressants, Marles says, ''then it's just another piece of polypharmacy.''

A Sydney geriatrician, associate professor Peter Gonski, says too little regard is taken to -

(i)         the physical differences of very elderly people, and

(ii)        their vulnerabilities to side-effects and interactions between medicines.

Gonski, the NSW division president of the Australian & New Zealand Society For Geriatric Medicine, says people in their 80s could appear in good health. "But inside them their blood vessels are getting smaller or harder, the kidney function is no longer what it used to be.''

To avoid further stresses on already fragile bodies, Gonski says doctors ''need to look at the whole person, and maybe do a hierarchy of what's affecting them''. Dementia drugs, for example, may exacerbate urinary incontinence; good prescribing is about learning which condition is more troubling to the patient, and concentrating treatment on that.

Dispensing multiple pills to older people does not signify regard for them, professor Hal Kendig, a sociologist and head of the University of Sydney's Ageing, Work and Health Research Unit, says. Instead, he says, it represents a reluctance to engage with them more thoughtfully.

Government-sponsored physical activity and diet campaigns are heavily skewed towards younger people, Kendig says. ''The message is that older people are not worth investing in,'' he says.