In America, drug addiction is despised as a social scourge, a destructive force for families and communities alike.
Yet when it comes to treating older adults, drugs are hailed as quick salvation — prescription candy — the answer to complex chronic diseases and behavioral “problems” affiliated with dementia.
Older adults consume a shocking number of prescriptions — five or more for 30% of seniors — often without a clear understanding of their success or side effects.
While only 14% of the American population, seniors who are treated for medication reactions and errors constitute about half of all related hospitalizations.
“It’s an out of control roller coaster,” says Dr. Al Power, a national expert on dementia and author of the book “Dementia Without Drugs.”
In fact, Power says that the estimated side effects of a drug are 10% for each prescription, making it almost certain there will be debilitating influence on seniors taking multiple prescriptions — especially those taking 10 or more.
The trend is commonly known as “prescription cascading” — the side effects of one drug actually worsen a disease, or add to overall health risk.
Dr. Michael McCloud says this “drug burden” is a surprisingly common phenomenon among physicians.
“We’re directly harming just though this burden of medications,” says McCloud, co-director of the UC Davis Health System’s Geriatric Clinic. “Their life is now consumed by the volume of medications they’re taking.”
Within the powerful healthcare maw that makes up California’s health systems, only one medical giant and a few scattered programs are addressing this scourge.
“One of the things that makes this clinic very special is we have a psychologist, psychiatrist, licensed clinical social worker, a full nursing and clinic staff trained to take care of seniors,” says Dr. Susan Ehrlich, CEO of San Mateo Medical Center, which houses the Ron Robinson Senior Care Center. “When you take a geriatric approach, it’s very much a holistic approach to medicine, rather than an organ-centered approach.”
The center also employs a nurse practitioner who makes home visits to many of the center’s 3,000 older adult patients.
And targeting only appropriate medications is at the heart of its treatment.
“Every single medication is gone over every visit, and we weigh the pros and cons of those medications,” says Ehrlich, citing side effects like dizziness or internal bleeding.
One essential resource for physicians is the Beers Criteria, a guide to prescription drugs commonly used for older adults. Considered the gold standard for seniors, the list focuses on reducing unnecessary or ineffective drugs to limit adverse reactions and side effects.
Dr. Tim Cutler says that older adults, in particular, must be given a custom treatment plan.
“If you have seen one 75 year-old, you have seen one 75 year-old,” says Cutler, of UC San Francisco’s School of Pharmacy. “The differences (in seniors) are often greater than their younger cohorts.”
One of the biggest problems for physicians: time. In most visits, a doctor has less than 15 minutes per patient.
Yet older adults are complex patients who require more time, attention and patience. For overworked physicians needing quick fixes, prescriptions are often the simplest solution.
Despite California’s severe shortage of geriatricians, as a clinical pharmacist Cutler has a rare opportunity to work with his elder patients — most of whom are covered by Medicare. He spends between 30 to 45 minutes with patients at a clinic operated by Sacramento’s UC Davis Medical Center.
“The opportunity is great,” says Cutler, “but also the cost is high.”
Power says that the prescription problem is compounded by the fact that drugs are typically tested on younger subjects — and the effects can’t be extrapolated to older adults. The metabolic differences between, say, a 20 year-old and 80 year-old are significant.
“Drugs that are safe in younger people can cause confusion in older adults,” says Power.
And these side effects can produce more expensive problems.
Confusion and dizziness can contribute to falls, the number one reason for emergency department visits by seniors.
In fact, McCloud points out that if drug reactions could be classified as a national “cause of death” — like heart disease or cancer — they would come in fifth.
Kaiser Permanente’s medical model is hailed as the best in California for limiting this “polypharmacy” — prescriptions from several doctors — for a simple reason.
Because Kaiser is an integrated system — both insurer and service provider — they have the greatest incentive to reduce costs. Healthier patients mean lower expenses.
Pharmacists play a critical role in Kaiser’s efforts to reduce hospital readmissions by targeting patients with a high number of prescriptions who are at greater risk for readmission. (Under the Affordable Care Act, hospitals now pay the expenses for patients readmitted within 30 days after a discharge.)
“Those highest risk patients are identified at discharge,” says Doug O’Brien, regional director for inpatient pharmacy services for Kaiser’s 21 northern California medical centers. “The vast majority of them are seniors.”
Each month about 5,000 high-risk Kaiser patients meet with these Transitional Care Pharmacists at their bedside before being discharged, spending up to an hour together to clarify side effects and interactions with foods, herbs, and other drugs.
Patients are then contacted by phone once they return home.
“If we can get people on one-a-day medication that’s a huge improvement,” says O’Brien.
Still, Kaiser’s model is rare, and most physicians lack the powerful financial incentive to consult with patients. They don’t get paid more for preventing a hospital admission.
Meanwhile, clinicians stress the importance of patients staying informed about the options available to them: prescription drugs, surgery, nutrition, even alternative measures.
Yet this brings up a huge medical quandary. How can a patient acting as his own advocate discuss all of these complex choices in less than 15 minutes?
“You hit it spot on,” says Cutler.
One of the primary reasons prescription drugs have such a powerful hold on the American psyche is the influence of drug manufacturers.
Since 2010, the ProPublica website has published its comprehensive “Dollars for Doctors” list of income that physicians receive from pharmaceutical manufacturers for speaking fees, promotion and consulting. It illuminates the deep financial connections between physicians and the pharmaceutical industry.
A year ago, the Journal of the American Medical Association reported that of the 50 biggest pharmaceutical manufacturers, 40% included board members from a leading academic medical center.
With a $300 billion American pharmaceutical powerhouse, it’s no surprise that prescriptions flow so freely through physicians and into the hands of older adults seeking a magic pill. In fact, doctors who receive payments from drug manufacturers are twice as likely to prescribe that company’s drugs.
“I think there’s this belief that with technology, life can be perfect,” says Power, “and the drug marketers feed into this: ‘If you have a problem, we can fix it.’”