When her mother turned 93 in 2018, American Leslie Hawkins realized something was wrong. Despite health problems such as diabetes, hypertension and anxiety, her mother had always been an active, sociable, church-going lady, as she told The New York Times. But during her birthday celebration, she “couldn’t hold a conversation or even finish a sentence.” By taking her to a geriatrician, along with the 14 medications her mother took regularly, Hawkins discovered the dangers of drug overdose.
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Known as polypharmacy, the multiple consumption of medicines by a person brings together alarming numbers in Brazil and in the world. Brazilian doctor Martha Oliveira, who specializes in aging, earned a doctorate in managing health care systems for the elderly when Europe began to shed light on this topic. “Some countries have prepared a document with data and information on polypharmacy on the continent, what is being done and how to improve. And they put in some commitments for 2030,” she explains.
According to the survey, there are 8.6 million unplanned admissions per year in European hospitals caused by adverse drug events, 50% of which are preventable and 70% in patients over 65 years of age who take five or more medications. . “What scared me the most is that, studying the case of Brazil, I realized that here we have even more worrying numbers.”
Martha Oliveira is the founder of Laços Saúde, a company that offers home care for the elderly, and patients who come to her consume, on average, 16 medications regularly. While abroad there are already some organizations that fight for “deprescribing”, or deprescription, in Portuguese, which consists of re-evaluating and suspending unnecessary doses in a person’s medication routine, Brazil lacks similar initiatives. And in the case of Leslie Hawkins’ mother, it was precisely the interruption of certain medications that made her, ten months later, “be another person, completely different” – the dizziness stopped, she communicated better and had more energy.
But why do seniors receive so many prescriptions, what are the dangers and consequences of polypharmacy, and when is it necessary to try to avoid it? gamma investigate.
a fragmented system
One of the main reasons behind the excessive amount of drugs prescribed to the elderly is specialized medicine. “Throughout our lives, we have been used to looking for health professionals related to a specific symptom”, says geriatrician Carlos Uheara, who is general director of the INTS (National Institute of Technology and Health). “Health care is, for most people, very fragmented. Our medicine looks at the patient as pieces, not as a whole.” That’s why we go to a neurologist when we have a headache; a cardiologist in case of high blood pressure; and an endocrinologist if there is an increase in blood sugar.
However, if an elderly person starts to consume all three drugs – for headache, hypertension and diabetes, for example – attention is needed. One of the effects of the mixture can be drug interactions, that is, a negative reaction of the body to the combination of different drugs. The same can happen when combining medications and certain types of food, and self-medication is another aggravating factor. “Many patients take home-made mixtures, teas, herbal medicines, or even drugs bought at the pharmacy, but without a prescription, and they think there is no interaction.”
Our medicine looks at the patient as pieces, not as a whole.
Another issue, according to Uheara, is what he calls the iatrogenic cascade. “It’s when a patient takes pain medication and becomes constipated”, he exemplifies. “Then I give a new medication for the intestine, which assumes the laxative function and makes the patient lose water, dehydrate. Turn this cascade of symptoms.” He states that he has already received many cases of elderly people who arrive at his office sleepy, not very interactive, and that the cause is often drug interaction, or even inadequate doses of a drug. “When the patient complains about a symptom, it is necessary to reevaluate everything he consumes, and not simply introduce a new one.”
Doctor Martha Oliveira recalls the dangers of excessive medication: “Bradycardia, dizziness and falls are some of the consequences. Directly or indirectly, it can become a cause of death in the elderly.” According to her, there is a lack of integration not only of doctors, but of all health professionals. “Each specialist will look at a system, and they have very important functions. But it takes a geriatrician or general practitioner to carefully review all prescriptionswhat you already take, what you really need, what can interact and cause problems.”
Old age is not a disease
See the admirable generation of old young people, as shown in a report by gamma about a group of people who reach the age of 70 with more health and energy. But the fact is: for aging, there is no alternative route – only Benjamin Button, even though he gets younger every day. The rest of the planet just adds more candles to the birthday cake each year. And yet, society insists on putting old age as a disease. “If getting old is synonymous with getting sick, this means that medicines are prescribed for the elderly naturally”, says Oliveira. “There is this culture of medicalizing the elderly, and the patient himself thinks it is correct. He goes to appointments waiting for the prescription of a medication. Our healthcare system doesn’t know how to take care of the older person.”
The professor, doctor in public health from USP and columnist for Uol on longevity Alexandre da Silva also points to the lack of structure and service options for the elderly. “An infection, for example – we treat it more easily than a chronic disease, which demands more time, assistance and generates emotional wear on the patient.” According to him, the great difficulty of polypharmacy today is the increase in life expectancy, the problems that come with old age and the little stimulus and access to means that prevent chronic diseases. “People were not taught to have wholesome habits, but they were well instructed to take pills.”
He recalls the importance of also understanding the healing process, which is not as quick, most of the time, as taking a pill that promises to end the pain. “In the example of chronic diseases, they take time to appear. Healing and pain management is as slow as getting sick,” he says. “A medication that takes away a pain in the spine helps with the symptom, but not the cause, which could be a weak muscle, loose ligament, etc.”
When it’s time to unsubscribe
In the case of the mother of American Leslie Hawkins, stopping the use of medication – with professional guidance, of course – was the path to a better quality of life, even over 90 years old. Of the 14 medications she was taking before discovering the benefits of deprescription, Hawkings’ mother, at the time of the NYT report’s publication, was taking only four.
Re-evaluating prescriptions, discontinuing unnecessary medications, changing doses or switching medications – it’s all part of the deprescription, which aims to keep only essential medication for each patient. “As important as introducing a drug is knowing when to discontinue it”, says Carlos Uheara.
We have to unlearn that it is only with medicines that we will solve certain problems
There are elderly people who, however, really cannot escape the box full of medicines to maintain their health. That is why, the practice of deprescription, it is important to say, preaches the singular look at each person, their needs and symptoms, and withdraws or exchanges medications that have been prescribed unnecessarily. “Aging is very heterogeneous. A group of children of the same age has very similar characteristics, while a group of seniors is completely different. There will be the active ones, who even do extreme sports, and the more sedentary ones”, says Uheara. “In geriatrics, care is also heterogeneous, and takes into account the various factors, over a lifetime, that impact aging.”
Alexandre da Silva adds: “How does society see a health professional who does not prescribe? It is the opposite of what is expected. We have to unlearn that it is only with medicines that we will solve certain problems”. He points to a more adequate supply of non-drug means of treatment, which should be thought of on a case-by-case basis, according to the needs and possibilities of each elderly person.
The exercise of deprescription is not a distant reality. Silva indicates some paths. First, honest and open dialogue between doctor and patient. “Every treatment is a pact. Often the professional can prescribe a medicine thinking it is what the person wants, when in fact it is not.”
The second point, more in the long term and which involves public power and the implementation of infrastructure and assistance policies, is offer services and encourage the practice of healthy habits. “The pharmaceutical industry will always create and prescribe pills for symptoms. A gastritis caused by anxiety, sexual impotence that is the effect of emotional issues and social pressures. The medicine will treat the symptom, but the cause is much broader”, he concludes.
What else can an elderly person do to reduce the amount of medication
The first step is to choose a geriatrician or general practitioner who can follow the patient as a whole. Specialists are important, but the role of the general practitioner is to review all prescriptions and prevent dangerous combinations, notice side effects that can be avoided, and adjust medications. If the elderly person does not have full autonomy to go to an appointment alone, it is important that they are always accompanied by a caregiver or family member, who is able to talk to the doctor, understand the medication routine, explain the symptoms and ask questions. The geriatrician Carlos Uheara suggests taking the entire box of medicines that the elderly person consumes for the consultation with the general practitioner – including those that seem totally harmless. It is also possible to help the elderly person to read the leaflet – a report by Uol indicates six simple steps.