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By Miriam E. Tucker
In 1999, an 83-year-old Maryland woman wound up
in the hospital after a particularly bad asthma attack. She'd quit using
her inhaler, since it made her nauseated. While in the hospital she was
given powerful steroids to treat her asthma. These raised her blood pressure.
So she was given an antihypertensive drug. It made her dizzy.
When her ankles swelled, she was prescribed a diuretic
to reduce water retention. But that dropped her potassium level. Naturally,
potassium supplements were added. She was also given an osteoporosis drug.
This made her stomach bleed.
"I
came out sicker than I went in," says the grandmother,
who was willing to tell her story but asked her name not be published.
She was so sick,
in fact, that she couldn't care for herself
after getting out of the hospital and had to stay with her daughter. When
she became depressed, an antidepressant was added to her regimen. Then
came another drug for stomach acid.
Medicines save lives, but few are completely free
of risks or side effects.
The more drugs
that are taken together, the greater the risk for side effects and interactions.
The Maryland grandmother's troubled relationship
with her medications is far from unique. In fact, it's common enough that
experts have even given the phenomenon the requisite Latinate label that
confers official status in the medical world: polypharmacy.
The term describes cases in which patients are prescribed
many different medications, often by different doctors, for a succession
of conditions or for side effects created by other medications. Polypharmacy
has been committed when the conditions can be effectively treated with
fewer medications.
Seniors and the Chronically
Ill
Polypharmacy is more commonly seen in older people,
who tend to have more chronic conditions that call for drug treatment.
At the same time, aging changes the body's ability to tolerate and process
medications: Muscle tissue and fluid levels decrease, fat tissue increases,
liver mass diminishes and kidney function declines.
Persons aged 65 and
older constitute approximately 13 percent of the U.S. population, but
they take about one-third of all prescribed drugs.
The
typical senior citizen regularly
takes four to six prescription drugs,
plus a couple of over-the-counter preparations. Nursing home residents
typically take more.
"Statistically, if you take
six different
drugs, you have an 80 percent
chance of at least one drug-drug interaction.
With eight drugs,
the chance is 100
percent," according to Wayne K. Anderson, dean of the
School of Pharmacy and Pharmaceutical Sciences at the State University
of New York at Buffalo.
No advocates of reducing medications suggest that
people just stop taking their prescribed medications or attempt to adjust
their regimens themselves. Proper adjustments require the efforts of a
physician and pharmacist working together.
Polypharmacy often happens when a patient sees more
than one physician, each of whom prescribes medications that interact
or overlap with those another physician has prescribed. Often there's
no one person charged with the responsibility of overseeing the patient's
total drug therapy regimen.
People
often assume that over-the-counter drugs are safe.
Some of the most dangerous drug-drug interactions
occur when patients take over-the-counter medicines along with their prescription
drugs. For instance, nonsteroidal anti-inflammatory agents like ibuprofen
can cause bleeding ulcers when taken with more powerful prescription painkillers.
Combining ginkgo biloba, an herbal product promoted
to improve memory, with blood-thinning drugs like aspirin or warfarin
also can lead to severe bleeding.
Of course, prescription drugs also interact with
each other. The antibiotic erythromycin, for example, can lead to a toxic
reaction when combined with certain cholesterol-lowering drugs, potentially
leading to kidney failure.
Pharmacy computers will flag many potential prescription
drug interactions, but not if the patient fills prescriptions at different
drugstores or has an unusual reaction. Moreover, computers
can't address the complexity of interactions among six
or eight different drugs.
And older people may not complain, assuming that
feeling bad is an inevitable part of aging, or a symptom of the condition
for which they are being medicated. The Maryland grandmother didn't mention
her medication concerns to her physician because "I didn't want to
noodge him."
The Role of the Pharmacist
According to some estimates, as many as one-fourth
of all nursing home admissions and an even
higher percentage of hospitalizations among the elderly may be due to
"preventable drug therapy failures,"
resulting from adverse reactions or interactions, noncompliance or use
of medications inappropriate to the patient's condition.
Pharmacists will not tell patients to stop taking
their medicine. But they can alert the physician about potential problems
and make recommendations. Think of your pharmacist as your drug advocate.
The problem is, with a few exceptions, pharmacists
don't get paid anything extra for such services. Insurance companies typically
reimburse pharmacies for dispensing, but not for clinical or administrative
services.
Although pharmacists routinely answer customers'
questions about medications as part of their jobs, in-depth consultations
may be difficult to schedule in busy drugstores where the dispensing volume
is high. It's best to call ahead for an appointment.
The
Washington Post February
6, 2001; Page HE09
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