Medications: Sometimes less may be more

Polypharmacy, the practice of taking piles of pills daily, often wastes money and endangers health.

By JUDY SIEGEL-ITZKOVICH
Growing old together on Bat Galim beach, Haifa (photo credit: Esteban Alterman)
Growing old together on Bat Galim beach, Haifa
(photo credit: Esteban Alterman)
Most people think that chronically ill and elderly patients at home, in general hospitals and geriatric institutions should thank their lucky stars that so many types of prescription medication are available to treat their maladies. But perhaps, for some people who gulp down as many as 20 pills or even more per day, the pile of medications is too much of a good thing – and causes them harm.
“Polypharmacy” is the objective term for the use of numerous medications, usually five or more daily. But the term usually refers to excessive or superfluous use of medications and potential harm – a worsening of their condition and even death.
Veteran gerontologist Doron Garfinkel, an associate clinical professor of internal medicine and geriatrics who is now retiring from his post as head of the geriatric palliative department at the Shoham Geriatric Center in Pardess Hanna, has devoted many years to assessing the genuine drug needs of the chronically ill, and gradually getting them to stop swallowing many of these medications with no untoward effects. The 65-year-old physician now works as a consultant for Maccabi Health Fund and as deputy head of the Israel Cancer Association’s Home Care Hospice, which employs a highly experienced interdisciplinary team of professionals who have treated many terminal patients and educated others in palliative care.
Too little is known by physicians and pharmacologists about the drug interactions and efficacy of many medications, which have been tested on younger people but not among very elderly and institutionalized patients. In this population, polypharmacy can result in high copayments, leaving patients with less income for food and other needs, ultimately causing a lower quality of life and decreased mobility and cognition.
“Medications can be great, but sometimes, less is more,” the fourth-generation resident of Rishon Lezion and graduate of Tel Aviv University’s Sackler Faculty of Medicine told The Jerusalem Post. He recalled the typical case of a 72-year-old man on hemodialysis for kidney failure who was diagnosed with Alzheimer’s disease.
“With his family’s consent and declared preferences, six of his 10 prescribed medications were stopped. Dramatic improvement was evident within two weeks, with sharply increased cognitive and functional improvement.”
“On a Mini-Mental cognitive score evaluation given at the beginning, his score was 14/30; following cessation of the medications he attained a score of 30/30 – normal.
He was able to return to active community life and underwent a kidney transplant a year later,” said Garfinkel.
Another case was an 88-year-old woman who had been taking a drug for 17 years after being diagnosed with breast cancer.
But this pill should be taken only for five years, Garfinkel noted. “She also took aspirin, but it caused hemorrhaging and a high dose of diabetes medication, even though her blood sugar level was low. She weighed only 37 kilos and was extremely thin. I told her to stop taking certain drugs, and she gained 15 kilos. She felt great and lived for another two happy years.”
If somebody has a heart attack, it’s absolutely legitimate during the first year to give him aspirin, an ACE inhibitor, a statin, a beta-blocker, paracetamol and an antidepressant. That is not superfluous medication. But if every time a patient goes to the hospital he is given two or three new medications and continues to take others he doesn’t need anymore, that could be polypharmacy, Garfinkel explained.
After assessing a patient’s needs, Garfinkel usually eliminates one medication at a time, and examines the patient and sends him for lab tests, to see if his condition has changed for the worse. If there is a decline, he re-prescribes the medication – but this has occurred in only a minority of cases. Garfinkel’s research in geriatric nursing departments demonstrated that as many as nine out of every 10 medications prescribed for patients hospitalized in long-term nursing departments were unnecessary.
“I am told that the pharmaceutical companies have create a voodoo doll of me and stick pins in it,” Garfinkel joked, referring to the reduction of medication usage in such patients. “Medical students are taught when to start medication, but not when to stop.”
“Doctors must not fear assessing patient’s medications,” he asserted. “With the rise in age, there is more harmful polypharmacy.
We continue to give drugs that were proven effective for a single disease and on people in their 50s, not in patients in their 70s, 80s and 90s.”
“There are drugs taken with others, and the combination can cause damage,” he continued. “Doctors think they are working according to guidelines, but it’s important to understand what we don’t know. I did research on real patients, not theoretical ones, with follow-up.”
He found that after interviewing these patients and their relatives for hours on end, many of them take generic anti-hypertension pills in the morning and the same drug by a commercial brand in the evening. No one has proven that these drugs are necessary or effective at an older age, Garfinkel said. “Very elderly people who get drugs to lower their blood pressure can become weak and confused, and when they get up in the middle of the right to go to the bathroom, they can fall and break a hip. I also recall a 93-year-old’s list of drugs. He was getting statins, allegedly for high cholesterol, even though it hasn’t been proven that taking it over the age of 70 reduces mortality. It actually weakens the muscles and can debilitate the very old even more.”
On the basis of his clinical experience, the gerontologist developed the Garfinkel Method, which includes his Good Palliative- Geriatric Practice (GP-GP) algorithm and other guidelines that can be adopted by other doctors – not only gerontologists but also general practitioners, other specialists and clinical pharmacists.
“I don’t have any patent on the method, and I don’t profit from it. I really enjoy what I’m doing. The method is not just about stopping drugs. Once they are taking fewer, I also discover some patients suffer from depression, which can be treated. I change drugs and people change for the better; they become more active,” said Garfinkel.
After the consultation, Garfinkel typically writes patients and their physicians a lengthy letter, which includes a review of the evidence for their medications and his suggestions of medications to discontinue or reduce. In some cases, he also proposes starting new medications – most often, antidepressants.
“Sometimes I’m the first one to tell the patient’s family that their loved one is depressed. I enjoy seeing how the method’s use changes the condition of patients,” he said, adding that he has set up a nonprofit website, www.drugstop.co.il, that provides more information.
GARFINKEL SAID he doesn’t understand why some pharmacists fill prescriptions without questioning whether the patient needs all of the medications. “And why don’t all the health funds supervise the drug-taking of their members? Eliminating unnecessary or harmful drugs saves in hospitalization and lowers drug costs,” he said.
“It should be in the insurers’ own interest that they ensure too many pills are not being taken.”
Garfinkel has published articles on his method in the American Archives of Internal Medicine, the Israel Medical Association Journal and others. In recent years, he has become a popular speaker in Turkey, Canada, Germany, Australia, Italy and other countries, where he explains his method to medical administrators who have to cope with growing costs, partly the result of polypharmacy.
He just returned from Istanbul, where internal medicine specialists at the local medical school said they want their country to adopt the Garfinkel Method.
“We would like to thank you very much once more for your distinct academic contribution and your huge effort aiming to increase our awareness on inappropriate drug use,” wrote Prof. Gulistan Bahat-Ozturk of Istanbul Medical School, who is considering the adoption of the Garfinkel Method in his country.
Dr. Laurie Mallery of Dalhousie University’s Center for Health Care of the Elderly in Halifax, Canada, wrote to Garfinkel that her colleagues want to submit a formal proposal for collaborating with him. Garfinkel has also been invited to the World Congress of Gerontology and Geriatrics in Seoul, Korea, to present his method.
“It’s frustrating to be ignored here,” said the Israeli doctor. “Why is Turkey excited while the Health Ministry in Jerusalem and health funds that pay for superfluous medications are not adopting it here?” People in the medical establishment have “stratified views. Maybe they are involved in defensive medicine and afraid that if a patient whose medications have been reduced suddenly dies, they will be blamed,” he explained. Estimating patients’ life expectancy may make doctors feel uncomfortable, but it can bring focus to the issue of what drugs are actually needed, he said.
Family doctors may not dare to stop a certain medication because they know a hospital professor gave it to the patient, he said, adding that “one general practitioner scared his very elderly woman patient out of her mind, when he told her that if she stops taking a statin against cholesterol, ‘tomorrow your arteries will clog up and you’ll die.’” Garfinkel notes that he has never been sued by a family for reducing the number of medications. “I recall a very wealthy, elderly lawyer brought in by his wife. I stopped his high blood pressure drugs because he didn’t need them, even though he was taking five different pills daily. He had been diagnosed for allegedly having Parkinson’s disease, but it turns out he had only Essential tremor and not Parkinson’s. I stopped his drugs, which caused severe side effects, and he felt much better without it.”
“Every patient needs a case manager,” the gerontologist suggested. “Non-prescription medications, vitamins and other supplements must also be assessed, because they have an effect. Israelis enjoy longevity, but what about quality of life? Patients tell me I’ve changed their lives. And the economic impact is huge.”
THE HEALTH Ministry told the Post that it is aware of polypharmacy and has issued statements about it and trained more clinical pharmacists, but officials conceded that not enough has been done. Dr. Eyal Schwartzberg, the ministry’s new head of the pharmacology division and an experienced clinical pharmacist himself, commented that “awareness of the problem has increased. As people live longer, they collect more chronic diseases and are given more drugs. Patients also are examined and treated by a larger number of specialists who may not know what the other has done.
There are new indications for existing drugs. This doesn’t mean that everybody who get a lot of pills don’t really need them. But order has to be made out of all this.”
“There are clinical pharmacists at Clalit Health Services and the Maccabi Health Fund who deal with polypharmacy, but the subject must become more developed. I don’t claim that the current situation is ideal. I started to deal with it when I joined the division. My vision is that every pharmacy will have a specialist who can give customers pharmaceutical counselling.
There are a variety of ways to deal with the problem. But I would like to hear more from Garfinkel,” Schwartzberg said.
He offered this suggestion: “There is a National Council for Geriatric Medicine. It would be helpful to invite him to speak at a session.”