The biggest health spend in this country is not on any particular disease but on problems caused by drugs – over or under prescribing, wrong doses and adverse drug interactions, according to a prominent Dublin pharmacist.
Karl Hilton, past-president of the Irish Pharmacy Union, encounters potentially dangerous drug interactions on a regular basis and is keenly aware of the complexity of multiple prescribed medicines to patients in hospitals and in their homes.
Polypharmacy is loosely defined as taking five or more prescription medicines a day. Many older people in Ireland now take between seven and 12 medicines a day. “Older people are particularly vulnerable to adverse drug reactions and drug interactions. The risk of an adverse drug reaction increased from 13 per cent for a person taking two medicines to 58 per cent in a person taking five medicines,” says Hilton.
Dr Brendan O’Shea, from the Irish College of General Practitioners, says “the effective use of safe medicines” is contributing to the increased life expectancy of our population. “Polypharmacy is an aspect of evolved medical practice in first and second world economies and, if done well, the advantages significantly outweigh the disadvantages,” he says.
But, as with most things, the devil is in the detail. Doctors and pharmacists are keenly aware that drug interactions are a big cause for concern and some will even admit that sometimes medication is prescribed to deal with social problems in the absence of other solutions.
For many people, the use of multiple daily medicines creeps up on them. “It usually starts when someone is diagnosed with high blood pressure in their late 40s or early 50s. Then, they might be diagnosed with high cholesterol or diabetes. Later, medications are added for conditions such as heart failure, osteoarthritis and possibly dementia,” explains O’Shea.
The importance of medicine reviews is stressed by doctors and pharmacists alike but the question is who should do them. “Medicine reviews can be carried out by GPs, practice nurses or health assistants in GP practices,” he says. But, Hilton believes pharmacists are the best practitioners to carry out medicines reviews. “We don’t do medicine review on a formal structural basis, but we have been campaigning for years for the Government to introduce a system where the pharmacist could sit down with a patient to go through all their medications to see where any duplications could be avoided or if they are taking medications for too long.”
Other key points to consider in such medical reviews are potential drug interactions, incorrect dosage and whether certain medicines should be discontinued. “It’s safe to stop certain types of medicines as a person ages. For example, it’s better not to manage diabetes so tightly when a person is older but it’s a complex decision to take people off or reduce their medicines,” says O’Shea. Studies have also shown that blood pressure medicines should be reduced in older people to reduce the risk of falls.
Prof Brian Lawlor is a consultant in old age psychiatry at St James's Hospital, Dublin. "The risks of polypharmacy are when an older person is attending a number of different specialists who prescribe new medications, increasing the risk of adverse reactions. For example, a patient might leave hospital after a heart attack or stroke with a number of new medications. Then, he/she might develop a pain and go on pain medication and experience dizziness. A GP or specialist might prescribe another tablet for dizziness whereas it could be caused by one of the medications."
Medication for urge incontinence [the need to pee at short notice] is another example of a drug that can have a sometimes unsuspected side effect on the central nervous system, contributing to cognitive decline in older people. “It’s all about improving awareness of possible interactions, justifying the medicines a person is on and looking out for inappropriate prescribing, checking and re-checking. I’ll often call the community pharmacist to clarify the medications the person is on,” says Lawlor.
Karl Hilton says that while the communications between pharmacists and doctors on patients’ medicines has improved, there are still instances where it’s unclear. “Sometimes, on a hospital discharge prescription, we don’t know if the medicines are in addition to the existing prescription or a replacement for the existing prescription or a change in the dose. Sometimes, an intervention by the pharmacist is required and our expertise in pharmacology is now recognised,” says Hilton.
An older person with memory problems can also complicate matters hugely. “A milestone is reached when it becomes unsafe for patients to manage their own medicines and will need help with taking their medicines from a friend, relative or home help,” says O’Shea.
The long-awaited electronic health records will hopefully ease the task of checking patients’ medicines prescribed by GPs and hospital specialists. Currently, GPs and pharmacists hold electronic records of patients’ medicines, but this system is not linked up to hospital patient records systems. In the US, one medical health insurer found that electronic health records reduced medicine errors by more than 50 per cent. Patients will still need to educate themselves on managing their own medicines on a daily basis but the availability of shared electronic records will mean GPs, hospital specialists and pharmacists will have the most accurate and up-to-date records of patients’ medicines in this complex era of polypharmacy.
Tips: Know your medicines
1. Ask whether you really need to take this medicine or if there is something else you can do instead (eg diet and exercise to improve borderline cholesterol levels)
2. Ask what exactly the medicine is treating
3. Ask about the common side effects
4. Ask why this medicine is likely to benefit you in particular
5. Tell the prescriber about any allergies you have
6. Ask how long you will be on the medication
7. Ask if the new medicine will interact with other medications you are on
8. Ask how will you know that the medicine is working for you
9. Ask whether it is or isn’t safe to drink alcohol while taking this medicine
10. Ask if this is the least expensive medicine you can take
