A pill for every ill? Make sure your medication is really helping you.

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By Dr. Cara Tannenbaum, Geriatrician and Director, Canadian Deprescribing Network

Click here to download a printable version of this article

Nowadays, it seems there is a choice of pills you can take for every symptom, big or small. Most people only have 10 minutes in their doctor’s office to discuss health issues. A quick fix often comes in the form of a pill – and the number of pills can add up quickly if you count over-the-counter medication.

Two thirds of Canadians over the age of 65 take at least 5 different prescription medications; almost one third take 10 or more. What is important to know is that as we grow older, our bodies become more sensitive to medications, increasing the risk of harmful effects. These risks include drug interactions, falls and fractures, memory problems and even drug-related hospitalizations and death.  

Not only are seniors at risk of harm from taking too many medications, but 40% of Canadians over the age of 65 take a medication considered unnecessary or potentially risky for seniors. Common medications such as sleeping pills, long-term prescriptions of proton-pump inhibitors for acid reflux, and antipsychotics for insomnia and dementia are no longer recommended. Opioids are another dangerous medication used to treat chronic non-cancer pain. As a geriatrician, I now advise patients to try non-drug therapy to treat their symptoms whenever possible. It may take more time and effort, but the benefits pay off down the road in terms of safety and effectiveness.

What can you do?

Check out the brochures and the information on the Canadian Deprescribing Network website (www.deprescribingnetwork.ca) to find out if your medications are safe, and whether you can substitute with safer alternatives. If your doctor suggests you take a new drug, you have the right to ask what the drug is for, what its benefits are and the risks of harm. Ask if there are equally effective lifestyle changes, exercise habits or other therapies you can try instead. Taking medication is, and always has to be, an informed choice. 

Book a special appointment with your doctor, nurse or pharmacist to review your complete medication list on a regular basis. What was good for you then, may not be good for you now.

Do you ever wonder if you still have to take all your medications? Ask about the possibility of “deprescribing”. Deprescribing is stopping or reducing the dose of a drug that may no longer be necessary or may be causing harm. Never stop a medication before speaking to your doctor, nurse or pharmacist.                                               

For more information about medication safety, visit this website: www.deprescribingnetwork.ca.

Are you worried about the medications older family members are taking?

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By Janet Currie and Johanna Trimble

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Often, adult children are the first to notice the effects of prescription medications on their parents or other family members.

Common adverse effects can include problems with memory, over-sedation, confusion, dizziness, balance problems, increased falling or behaviour that is unusual. 

Some facts about medications and older adults:

• Two out of three older Canadians take at least five medications and one out of four take at least ten.

• All drugs have the potential for adverse drug reactions, even those bought over the counter.

• The risk of having adverse drug reactions increases with the number of drugs taken.

• Adverse drug reactions can be mild or serious, temporary or permanent. Problems can begin suddenly with a new drug or take time to develop.

• In general, older adults are more sensitive to prescription medicines because their bodies process drugs differently. Smaller doses may be effective and safer.

• Prescriptions for older adults may increase over the years, even though some may no longer be necessary or safe. This is especially likely if more than one doctor is prescribing.

Are new symptoms caused by medications?

Whenever anyone experiences new or worrisome symptoms, the possibility that it may be due to a prescription drug should be considered, especially if new drugs are being used.

It is important to remember that new symptoms are not necessarily caused by a health condition or due to aging.

Regularly reviewing the list of medications a person takes (especially if they are taking more than five drugs) is recommended for people of any age.

Being sensitive

Be sensitive when talking to an older family member about any changes you see in them or concerns you are having about their medications.

• Your family member may have already noticed new symptoms and be worried that their health is getting worse. They may also fear that reducing some medications will be dangerous.

• Explain that “taking charge” is not your intention but that starting with a review of all their medications by a pharmacist, doctor or nurse is a reasonable thing to do and could improve how they feel.

• Ultimately, most older people are concerned about maintaining their independence and prefer to make their own health decisions.

Making a medications record

Help your family member put together a record of their prescriptions.

First, with your family member's consent, ask their pharmacist to print out a list of medications. This is also a great opportunity for you and your family member to ask the pharmacist any questions you may have. 

If your family member goes to multiple pharmacies, each pharmacy will usually only have a partial list of prescribed medications. It is very important to double check that the list of medications is complete. 

The information on the printed list can help your family member create their own medication list, which can be entered on a pen and paper grid or on an Excel spreadsheet. Make sure to include over-the-counter drugs and supplements on the list.

 This medications record should include the name of the drug, the dose, what it was prescribed for, how many times a day it is taken, when it was prescribed and who prescribed it. The Canadian Medication Appropriateness and Deprescribing Network provides a sample record form for your use.

If your parent or family member is unable to request a list themselves, you may need to produce official documentation showing you as their healthcare decision-maker. This may mean having a “representation agreement” or a similar document that names you as the person who can make health care decisions on their behalf.

Medication reviews

Ask your parent or family member if they would be willing to have a medication review.

• Explain that medication reviews by a pharmacist, a nurse or a doctor are a normal process and are used to make recommendations about drugs, to check for possible dose problems or drug interactions, whether some drugs are no longer needed and if it is possible to deprescribe*.

• Depending on your province, a pharmacist may be able to provide medication reviews free of charge if a person is taking a certain number of drugs. Check with your local pharmacist to see if this is the case.

• Ask your family member if they would be willing to have you come with them to discuss the results of the medication review with the pharmacist.

• Ask for the medication review to be sent to your family member’s doctor. Make sure the results of the medication review are discussed with the doctor. Be sure a longer consultation appointment is requested to do so.

• Be aware that some older Canadians may not feel comfortable raising new symptoms that may be medication-related with their doctors because they feel this may be seen as impolite indicating a lack of trust.

Medication reactions in the hospital

What do you do if your parent has had a bad reaction to a medication while in the hospital or during a visit to the emergency department?

• Be sure to find out which drug caused the problem and note the information on the medication list you are keeping.

• Make sure this adverse drug reaction is reported in your family member's medical record.

• Many people are taken off a problematic drug at the hospital, only to have the same drug or drug class prescribed again in the community later, due to lack of communication. This may result in another emergency hospital visit. The hospital discharge information does not always reach the right person at the right time.

Looking out for your family

You can be an invaluable help and resource to your loved ones. Respectfully discussing your concerns, and offering practical solutions and a helping hand can prevent serious health issues. Your support can also help your family member maintain their independence and feel empowered about their health. 

*Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life.

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About the authors:

Johanna Trimble is a patient safety advocate and member of the BC Patient Voices Network. She is a member of the geriatrics and palliative care subcommittee of the council on health promotion for doctors of BC. As an honourary lecturer, she co-teaches first year medical students at UBC in community geriatrics as well as pharmacy students on medication issues in long term care. Johanna is an active member of the patient awareness committee of the Canadian Medication Appropriateness and Deprescribing Network.

Janet Currie is a social worker who has been involved with patient and medication safety issues for over 17 years. She is particularly concerned about the safety and efficacy of psychiatric drugs and their impacts on seniors. She was previously a member of the core executive of the Canadian Medication Appropriateness and Deprescribing Network, the past co-chair of the Canadian women’s health network and was a two-term member of health Canada’s expert advisory committee on the vigilance of health products. She owns and manages a website on psychiatric drug safety and has frequently testified to the Canadian senate and the parliamentary standing committee on health on prescription drug surveillance and adverse drug effects.  She completed a PhD on medication safety and off-label prescribing at UBC. At the time of this article’s publication, Janet was chair of the patient awareness committee of the Canadian Medication Appropriateness and Deprescribing Network.

Is your mom on drugs?

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by Johanna Trimble

Our Mom was happy in her independent living apartment and involved in her community. But in 2003, at the age of 86, she was admitted to the Health Centre. The day before she’d asked her daughter to take her to the ER: “I was weak and dizzy and I knew I couldn’t stand without passing out”. She had been suffering from the flu but did not have pneumonia. She was dehydrated, had low sodium, received intravenous fluids and was released. Still not feeling well, her doctor suggested a few days recuperation in the attached Health Centre then a return to her apartment.

The prescribing cascade

However, after admission to the Health Centre, surprisingly her cognitive status declined precipitously and she was not released back to her apartment. Two different SSRI antidepressants had been given without family consultation. The first one gave her hallucinations. Instead of depression, we believed she was rightfully mourning her loss: her apartment, independence, privacy and friends – her life.

She began experiencing agitation, delusions, and inability to tell dreams from reality. She was “sleeping” and difficult to rouse even during the day. It didn’t seem like a normal nap. She developed unexplainable, repetitive movements of her arm, sudden sweating, episodes of rapid heartbeat and lack of coordination. This was not our Mom!

Now on nine drugs, the staff said, “that’s not very many”! We suspected, after watching and listening carefully to her symptoms when she was lucid and able to talk with us, that drugs could be the problem. We discovered that she likely was experiencing “serotonin syndrome” caused by drug interactions.

Deprescribing

Our family met to coordinate our approach. Research in hand, we met with medical staff with the goal of a directed “drug holiday”. We were successful. The psychiatrist for the Centre had recently visited and prescribed donepezil for “vascular dementia”. We declined the drug, which had possible adverse effects and only a small, statistical benefit and no guarantee of clinical effect. By this time, we had asked the medical staff not to prescribe anything we had not approved.

The “drug holiday” soon brought our Mom back cognitively! Completely! Her mental status returned to normal, she improved physically and could get up. She improved to the point where we would take her in a fold‐up wheelchair and drive to her favourite restaurant for oysters and white wine. This gave great joy to all of us. She had 3 years more of a good life though to our sorrow was never able to return to her apartment – or even to the assisted living floor. She had been bedridden too long and lost function to the point that she could not leave. This is a great danger for elders and why drug interactions and adverse events have to be dealt with quickly. It can impact on how they live the rest of their lives.

Four years later, our Mom died (October 2008). She passed on her down‐to earth‐philosophy of life: “religion is really about how you treat other people”. Her last weeks were remarkable and moving; she was intent on passing on to her family what she’d learned about life and how much she loved us. We would never have received this last gift from her if she had died in her earlier drug-induced, delusional state. She would have died not even recognizing us.

Spending long hours with our Mom allowed us to observe, ask questions and listen. We compared her symptoms with adverse effects of drugs she was on. Doctors often see adverse effects of drugs as another “condition” and more drugs ensue -- the “prescribing cascade”. Our love and respect meant we left no stone unturned. Medical professionals don’t have time for that and they may not know their patient’s baseline, especially when first admitted, so they don’t notice changes due to new drugs. The family’s feedback is essential to keep patients safe and well. Doctors – please seek it out instead of ignoring, disdaining, or even resenting it. Actively invite feedback from the family!

We saw the isolation and loneliness of so many residents. There is not a lot to remain sane for. Tiny ladies in wheelchairs approach you in the hallway and whisper, “help me, help me!” Hallways resound with TV noise. Many sleep or stare blankly into space. Isolation and boredom blur the boundaries between sleeping, dreaming and waking. Strange how apparent opposites coexist here and create the worst of both worlds: isolation and lack of privacy — anxiety and boredom.

Talk to your children and your family doctor; tell them how you want your life as an elder to go. Could the so‐called “epidemic” of Alzheimer’s and dementia be, to some degree, a reflection of widespread and increasing overmedication? Recent studies reveal a link to increased risk of dementia from common anti-cholinergic drugs. Become more knowledgeable about what you take and why and advocate for those elders who can’t advocate for themselves.

Johanna Trimble is an active patient/family advocate based in Vancouver, BC. See her website here.