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[We interrupt the previously scheduled rant for another rant.]
At some point, if you are so lucky, you will be old. You may already be old. Somebody you love may already be old. Old people, being people, require medical care, and are often treated – because this is basically what primary care in our society consists of – with medications.
Thing is, old bodies handle medicine differently than young ones.
Take the liver. The liver is the catfish organ in the fishtank of your body, responsible for keeping your inner ocean from becoming so choked by the wastes of its metabolic processes that the whole system dies from a surfeit of living. This takes a lot out of a liver, and it should come as no surprise that after the better part of a century, not unlike your knees and lumbar process and eyes and all the other bits of you that start wearing out, your liver's just not quite as up to its job it used to be. Just how not-up-to-its-job it becomes has a lot to do with how hard you used it, meaning what all you poured into your blood supply for it to cope with, and how much and for how long. But don't kid yourself: even straight-edge clean living isn't enough to protect the bottom-feeding organ of your body from handling all your interior toxic waste for six or seven decades. Mortality's a bitch.
All of which is to say, that generally speaking, as you get older, your body becomes less able to break down and get rid of drugs.
Surprisingly perhaps, this post is not a lecture about the perils of demon rum nor of seniors getting high on things other than life. This is about medications.
Hepatic (i.e. liver) function is but one notable aging-related bodily change of many that impact drugs' effects on us. There are a whole variety of ways, as one gets on in years, one's body changes in its response to drugs, and one may become more vulnerable to drugs' side effects. There are particular syndromes and conditions which are nigh-exclusive to late-life stages which can interact with drugs in unfortunate ways.
Unfortunately, there are plenty of prescribers out there practicing who just haven't given this a whole lot of thought. Out of their ignorance, they write prescriptions for elderly patients that are for types or amounts of medications that are various degrees of bad idea.
In particular, it is lamentably common for physicians to simply keep prescribing the same maintenance prescriptions that have "always worked" for a given patient, without re-evaluating those prescriptions' safety and prudence as the patient ages through their 60s and beyond. They rely, perhaps unwittingly, on their patients saying something if they start having noticeable problems.
Well, the first notice a patient of mine had that something was wrong was slumping over at the dinner table on a Sunday evening with family, foaming at the mouth and having a seizure. (Details elided and tweaked for privacy.) He was rushed to the hospital where he fell into a coma; spoiler: he survived, coming out of the coma after almost three weeks. Family told me that at first the doctors thought it was a bacterial infection, but then figured out it was an overdose on one of his psych meds. Of course, we were worried it was a suicide attempt, but it turns out it wasn't: he hadn't deliberately taken more of his medication than prescribed. He hadn't taken more by accident, either, as best as family could tell from checking the pills in his pill case. He hadn't taken any more than prescribed, at all. And it wasn't that his prescription was recently started or increased: he'd been on exactly the same dose for about 20 years.
When all was said and done, as far as his medical team could figure, the only thing he had too much of was birthdays. He had just passed his 67th.
About five years earlier, he'd transferred to our clinic and into the care of our psychiatrist after his previous psychiatrist quit private practice. Our psychiatrist learned what the patient had been on, and since the patient said it mostly worked for him, our psychiatrist just adopted the regimen as it was, under the logic of, hey, it's worked well for over 15 years without causing any problems, let's not mess with success.
And it worked fine, until the day it didn't.
This is a phenomenon many prescribers seem unaware of: aging, alone, is enough to make a safe medication unsafe. A prescription for a medication that has been a perfectly fine maintenance med – "she's been taking it for 30 years!" – well tolerated for years or decades can start – sometimes quite abruptly – being a problem for the patient as they move across their sixties or later decades.
Sometimes it's a lethal problem. Sometimes it's as flagrant as seizure at the dinner table. But sometimes it's subtler; sometimes it's a corrosion of quality of life that's not obviously a side effect of a med that the patient has never previously had side effects with.
Most perniciously, it can be effects that look like the stereotype of aging. If a medication starts causing you to be unsteady on your feet so you fall down; if it messes with your memory or causes episodes of confusion; if it makes your joints ache; if it blurs your vision or gives you the shakes: oh so sad, you being old. Sucks to be you, growing old stinks, whaddayah wannus-ta doaboudit?
Chillingly, there is actually reason to believe – as US Federal standards in data reporting from nursing homes started revealing certain prescribing patterns among their populations – that some substantial part of the population of people diagnosed with dementia may not actually have dementia – it's that their medications are doing that to them. That is, there may be a population of people who are institutionalized because of "dementia" that, if certain of their medications were discontinued, would partially or wholly remit. Perhaps more about that another time.
Here in the US, there's two things that we can do about this. Ha ha, I lied, no, there's one thing we can do about this, and another thing that would be totally awesome, but we can't do it, because America. In this post, I'll tell you about the thing you can do.
The American Geriatric Society is an organization of physicians, nurses, and other medical professionals that specialize in the care of the elderly. The AGS would really, really like the other prescribers of the US to please stop accidentally poisoning elderly patients.
To that end, the AGS maintains and promulgates a resource you should know about. Its formal name is, as of the most recent edition, The AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Everybody in the biz who knows about it calls it "The Beers Criteria", or just "The Beers List", for short.
It exists in several formats. One of which is a journal article, as published in the Journal of the AGS, which is 20 pages long. One is the extended "evidence" version, available as far as I know exclusively as a PDF file, which includes discussion of the scientific evidence reviewed, and in a few cases, reprints of other articles and papers, and which is over 600 pages. One is a "pocket card", which one can buy in packs of 25. There are occasionally other editions one can find around the internet (though right now most of them seem to be based on the 2012 version.)
What it is, across all formats, is a list of medications that have been identified as "potentially inappropriate" – i.e., potentially dangerous – in the elderly; it describes what the dangers are and in some editions whether there are obvious safer alternatives to prefer; it rates the strength of the evidence for their recommendations to avoid a medication, and how strong their recommendation is. It also has a list of medical conditions common to the elderly that can be exacerbated or complicated by drugs, and which ones.
It's for medical professionals, not lay people. But it's not rocket science, either. Entries in the list look like:
Which means you can use this resource to check up on the prescriptions of someone who is over 60, whether that's your own prescriptions, or those of a loved one.
You can go get your free authoritative copies of either the original journal article or the "Evidence" version from the AGS, at geriatricscareonline.org, which seems to be the AGS' store front:
• AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults - the 10 page research article, with the tables, in PDF. Does not have the evidence column on the table. (Alternative link if that gives you trouble.)
• 2015 AGS Beers Criteria and Evidence Tables – the 600+ page PDF, about 16M. (Alternative link for evidence file if that gives you trouble.)
Additionally, I wanted an edition that was just the tables (and not the discussion, as per the journal article) but which had the evidence column with the convenient hypertext links to the cited works (as in the first pages of the "evidence" version). So I took the two minutes necessary to do that, and I slapped it up at Sendspace for your convenience:
• The AGS 2015 Beers Criteria Tables from the Evidence Version (w/ Citations column, but w/o other 600pp of evidence) – 26 page PDF, about 300kb.
Additionally, you may want to check out:
• How to Use the American Geriatrics Society 2015 Beers Criteria—A Guide for Patients, Clinicians, Health Systems, and Payors - a 7 page PDF, mostly written for a professional audience, the upshot of which is, "Now, just because a medication is on the Beers List doesn't mean it's always inappropriate in the elderly; we're not trying to crimp doctors' styles."
• What to Do and What to Ask: If a Medication You Take is Listed in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Care of Older Adults - this is not available on the open internet, but it's available for free to anyone who signs up for a free account on geriatricscareonline.org; sign up, log in, and then click this link. Two pages, downloadable PDF.
• Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly Quality Measures [sic] - a journal article (for clinicians) discussing alternatives to the medications listed in the Beers Criteria. 11pp, PDF.
• Alternatives for Medications Listed in the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - again, not available on the open internet, but free with a free geriatriscareonline.org account. For patients, 3pp, PDF.
Now, so armed, and with the search engine of your choice to look up terms you don't know, you're in a position to check the med list of an elder.
If you find something being prescribed that's on the Beers List, first thing is not to panic. Like the "How to Use" and "What to Do" documents say, the right answer is not just cold-turkey quitting the medication. For one thing, there's medications on that list that are actually dangerous to abruptly discontinue; one of the psych meds on the list is notorious for causing dangerous seizures if abruptly stopped. There's conditions that may be being managed by such a medication that you don't want to abruptly stop treating, even if the medication being used is causing other harms.
And, like those documents stress, sometimes there's a good reason to prescribe an elder a medication on the Beers List. Pharmacology in the elderly is often about making difficult trade-offs. For example, just about all the standard medications for insomnia greatly increase the risk of developing senile dementia – but leaving insomnia untreated can lead to severe mental health problems. For another example, one of the medications on the Beers List is a heart medication which they strongly suggest not using to treat heart conditions – but it's the one medication demonstrated effective against PTSD nightmares.
If a Beers List medication shows up on the med list of an elderly patient, the doctor should have a good reason for it. They might not – they might have prescribed the medication without thinking about it, they might not be aware of the research showing it's got the risks it does in the elderly. So the thing you do when you find a Beers List medication on the med list of an elderly patient is ask. You start the conversation. You say to the doctor, "Hey, I noticed that this medication is on the Beers List. What's up with that?" Or "I saw that this medication is on the Beers Criteria, and I'm concerned. Should we be rethinking this?"
What you should not do is just trust that your doctor is on top of it because they are a doctor, and doesn't need to be asked. For three reasons.
First of all, while the AGS calls this "Potentially Inappropriate Medication Use", that's somewhat euphemistic in its exquisite accuracy. I see why the AGS has to pull its punches for reasons of diplomacy. But I don't. These are medications – and usages of medications – which are dangerous in the elderly. To say they're "potentially inappropriate" because they have elevated risk of adverse events in the elderly: that's what the word "dangerous" means. To say they are dangerous is not to say they're inevitably harmful or fatal, but to say they have a likelihood of having unacceptable risks for the potential benefits.
And further, to say they're dangerous stresses important true things: that if they are to be used,
• They must have a case-specific medical justification (documented in the chart),
• They must be used with informed consent of the patient (and/or their guardians), and
• Their use must be carefully monitored by medical professionals.
Especially given that some of these medications have deleterious effects on cognition, and that the population of concern is one which experiences a high rate of cognitive decline, it's wildly inappropriate for prescribers to rely on patients to identify problematic side effects and bring them up to the prescriber. The prescriber, or a medical professional delegated by the prescriber, needs to know what to look out for, and they need to take the initiative in checking for it, whether that means asking the patient and/or their caregivers specific questions, or running the appropriate physical tests.
The stakes of getting this wrong can be enormously high. And as medical screwups go, this sort is unfortunately common. That's why the Beers Criteria is even a thing. That's why you should take it upon yourself to check, and if you find such a medication is being prescribed, discuss it with the physician.
Second, doctors make mistakes. Even the best intentioned, even the best informed. Physicians are human; they get tired, overworked, distracted. And, alas, not all doctors are the best intentioned, or the best informed.
It is precisely because the physicians are humans, because it an easy mistake to make, that you should speak up. As they say in open source, "Many eyes make bugs shallow". "See something, say something." Don't just be a bystander in your own medical care or the medical care of your loved ones.
One of the classic problems in the medical care of the elderly is that there can be so many prescribers. In any complicated work system, where there's division of labor, it's a classic fault for something to fall between the cracks. In the medical care of the elderly, it can be that everybody thought somebody else was making sure the medications were safe. The PCP might think, "Well, if the cardiologist prescribed it, surely they knew what they were doing and must have a good reason to. Surely they already discussed it with the patient." The oncologist might think, "Well, I don't know for cardiology, so I presume the cardiologist knows what they were doing, and, well, it's the PCP's job to check up on things like that."
Asking, "Hey, what's going on with this? Why is it this way?" can catalyze the system to noticing something is wrong, and beginning to deal with it.
That said, systems push back, and you may have to be insistent. "Why is it that way?" "Dr. Cardiologist prescribed it." "So we need to talk to Dr. Cardiologist? Could you confer with Dr. Cardiologist about it?" You may wind up having to talk to Dr. Cardiologist, yourself, too.
Third, like I just mentioned, the justified use of Beers Criteria medications is often a matter of difficult tradeoffs and informed consent. If you see a Beers Criteria medication among the prescriptions of an elderly patient, and the patient and their caregivers or guardians don't know what it's doing there, and don't know why it's being prescribed over alternatives not on the list, then there's no informed consent and the patient is not being given a say in making those tradeoffs.
In the ethical practice of medicine with elderly patients – I hope to write more about this later – because such tradeoffs are so core to the practice of medicine with the elderly, it's absolutely crucial that the patient and those the patient has chosen to advocate for them are the decision-makers of such tradeoffs. Among specialists in elder care, this is widely understood to be the precise decision point where medical practice goes haywire: when decisions are made for the elder that do not reflect the elder's own values and preferences.
So much discussion about "end of life care" focuses on things like advanced directives and DNRs and so forth, and I am coming to the considered position that those issues take up so much of the oxygen in the room of discussing ethical eldercare that they've become a kind of bullshit. While such things are important, a DNR aint going help you much if your loved one lives for 20 years with Alzheimer's. In reality, a lot of medical practice with the elderly is not treating someone with one foot in the grave, and the ethics of doing so are not just about when it is more humane to withhold care.
They're about things like, "would you rather have an increased risk of a heart attack, or nightly PTSD nightmares". At the end of the day, decisions like that have to be made by the patient, or with the patient's own preferences in mind. Our society has historically said that life is more important than wellbeing, and deprecated peace of mind, and that consequently there is no question: prevent the heart attack at the cost of any misery to the patient. But there are people in the world for whom putting their unmedicated head on a pillow means being back in 'Nam, or Auschwitz, who will chose the heart attack over that, every time. And they should get to. That choice should be theirs.
If there's a Beers Criteria medication on an elderly patient's med list and they and their caregivers don't know what it's doing there, then they and their caregivers are not being involved in the discussion of the tradeoff they are, unwittingly, making. And they damn well should be.
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[We interrupt the previously scheduled rant for another rant.]
At some point, if you are so lucky, you will be old. You may already be old. Somebody you love may already be old. Old people, being people, require medical care, and are often treated – because this is basically what primary care in our society consists of – with medications.
Thing is, old bodies handle medicine differently than young ones.
Take the liver. The liver is the catfish organ in the fishtank of your body, responsible for keeping your inner ocean from becoming so choked by the wastes of its metabolic processes that the whole system dies from a surfeit of living. This takes a lot out of a liver, and it should come as no surprise that after the better part of a century, not unlike your knees and lumbar process and eyes and all the other bits of you that start wearing out, your liver's just not quite as up to its job it used to be. Just how not-up-to-its-job it becomes has a lot to do with how hard you used it, meaning what all you poured into your blood supply for it to cope with, and how much and for how long. But don't kid yourself: even straight-edge clean living isn't enough to protect the bottom-feeding organ of your body from handling all your interior toxic waste for six or seven decades. Mortality's a bitch.
All of which is to say, that generally speaking, as you get older, your body becomes less able to break down and get rid of drugs.
Surprisingly perhaps, this post is not a lecture about the perils of demon rum nor of seniors getting high on things other than life. This is about medications.
Hepatic (i.e. liver) function is but one notable aging-related bodily change of many that impact drugs' effects on us. There are a whole variety of ways, as one gets on in years, one's body changes in its response to drugs, and one may become more vulnerable to drugs' side effects. There are particular syndromes and conditions which are nigh-exclusive to late-life stages which can interact with drugs in unfortunate ways.
Unfortunately, there are plenty of prescribers out there practicing who just haven't given this a whole lot of thought. Out of their ignorance, they write prescriptions for elderly patients that are for types or amounts of medications that are various degrees of bad idea.
In particular, it is lamentably common for physicians to simply keep prescribing the same maintenance prescriptions that have "always worked" for a given patient, without re-evaluating those prescriptions' safety and prudence as the patient ages through their 60s and beyond. They rely, perhaps unwittingly, on their patients saying something if they start having noticeable problems.
Well, the first notice a patient of mine had that something was wrong was slumping over at the dinner table on a Sunday evening with family, foaming at the mouth and having a seizure. (Details elided and tweaked for privacy.) He was rushed to the hospital where he fell into a coma; spoiler: he survived, coming out of the coma after almost three weeks. Family told me that at first the doctors thought it was a bacterial infection, but then figured out it was an overdose on one of his psych meds. Of course, we were worried it was a suicide attempt, but it turns out it wasn't: he hadn't deliberately taken more of his medication than prescribed. He hadn't taken more by accident, either, as best as family could tell from checking the pills in his pill case. He hadn't taken any more than prescribed, at all. And it wasn't that his prescription was recently started or increased: he'd been on exactly the same dose for about 20 years.
When all was said and done, as far as his medical team could figure, the only thing he had too much of was birthdays. He had just passed his 67th.
About five years earlier, he'd transferred to our clinic and into the care of our psychiatrist after his previous psychiatrist quit private practice. Our psychiatrist learned what the patient had been on, and since the patient said it mostly worked for him, our psychiatrist just adopted the regimen as it was, under the logic of, hey, it's worked well for over 15 years without causing any problems, let's not mess with success.
And it worked fine, until the day it didn't.
This is a phenomenon many prescribers seem unaware of: aging, alone, is enough to make a safe medication unsafe. A prescription for a medication that has been a perfectly fine maintenance med – "she's been taking it for 30 years!" – well tolerated for years or decades can start – sometimes quite abruptly – being a problem for the patient as they move across their sixties or later decades.
Sometimes it's a lethal problem. Sometimes it's as flagrant as seizure at the dinner table. But sometimes it's subtler; sometimes it's a corrosion of quality of life that's not obviously a side effect of a med that the patient has never previously had side effects with.
Most perniciously, it can be effects that look like the stereotype of aging. If a medication starts causing you to be unsteady on your feet so you fall down; if it messes with your memory or causes episodes of confusion; if it makes your joints ache; if it blurs your vision or gives you the shakes: oh so sad, you being old. Sucks to be you, growing old stinks, whaddayah wannus-ta doaboudit?
Chillingly, there is actually reason to believe – as US Federal standards in data reporting from nursing homes started revealing certain prescribing patterns among their populations – that some substantial part of the population of people diagnosed with dementia may not actually have dementia – it's that their medications are doing that to them. That is, there may be a population of people who are institutionalized because of "dementia" that, if certain of their medications were discontinued, would partially or wholly remit. Perhaps more about that another time.
Here in the US, there's two things that we can do about this. Ha ha, I lied, no, there's one thing we can do about this, and another thing that would be totally awesome, but we can't do it, because America. In this post, I'll tell you about the thing you can do.
The American Geriatric Society is an organization of physicians, nurses, and other medical professionals that specialize in the care of the elderly. The AGS would really, really like the other prescribers of the US to please stop accidentally poisoning elderly patients.
To that end, the AGS maintains and promulgates a resource you should know about. Its formal name is, as of the most recent edition, The AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Everybody in the biz who knows about it calls it "The Beers Criteria", or just "The Beers List", for short.
It exists in several formats. One of which is a journal article, as published in the Journal of the AGS, which is 20 pages long. One is the extended "evidence" version, available as far as I know exclusively as a PDF file, which includes discussion of the scientific evidence reviewed, and in a few cases, reprints of other articles and papers, and which is over 600 pages. One is a "pocket card", which one can buy in packs of 25. There are occasionally other editions one can find around the internet (though right now most of them seem to be based on the 2012 version.)
What it is, across all formats, is a list of medications that have been identified as "potentially inappropriate" – i.e., potentially dangerous – in the elderly; it describes what the dangers are and in some editions whether there are obvious safer alternatives to prefer; it rates the strength of the evidence for their recommendations to avoid a medication, and how strong their recommendation is. It also has a list of medical conditions common to the elderly that can be exacerbated or complicated by drugs, and which ones.
It's for medical professionals, not lay people. But it's not rocket science, either. Entries in the list look like:
Drug(s): Megestroland
Rationale: Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults.
Recommendation: Avoid
Strength of Recommendation: Moderate
Quality of Evidence: Strong
Cites: Bodenner 2007; Reuben 2005; Simmons 2005; Yeh 2000
Disease or Syndrome: Heart failureIf you're a regular reader of my journal, you're probably up to this.
Drug(s): NSAIDs and COX-2 inhibitors; Nondihydropyridine CCBs (avoid only for systolic heart failure): Diltiazem, Verapamil; Pioglitazone, rosiglitazone; Cilostazol, Dronedarone
Rationale: Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation: Avoid
Quality of Evidence: NSAIDs: moderate; CCBs: moderate; Thiazolidinediones (glitazones): high; Cilostazol: low; Dronedarone: moderate
Strength of Recommendation: Strong
References: Cilostazol Package Insert; Connolly 2011; Dronedarone Package Insert – revised Dec2011; Heerdink 1998; Goldstein 1991; Jessup 2009; Korber 2009; Loke 2011; Pioglitazone Package Insert; Rosiglitazone Package Insert
Which means you can use this resource to check up on the prescriptions of someone who is over 60, whether that's your own prescriptions, or those of a loved one.
You can go get your free authoritative copies of either the original journal article or the "Evidence" version from the AGS, at geriatricscareonline.org, which seems to be the AGS' store front:
• AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults - the 10 page research article, with the tables, in PDF. Does not have the evidence column on the table. (Alternative link if that gives you trouble.)
• 2015 AGS Beers Criteria and Evidence Tables – the 600+ page PDF, about 16M. (Alternative link for evidence file if that gives you trouble.)
Additionally, I wanted an edition that was just the tables (and not the discussion, as per the journal article) but which had the evidence column with the convenient hypertext links to the cited works (as in the first pages of the "evidence" version). So I took the two minutes necessary to do that, and I slapped it up at Sendspace for your convenience:
• The AGS 2015 Beers Criteria Tables from the Evidence Version (w/ Citations column, but w/o other 600pp of evidence) – 26 page PDF, about 300kb.
Additionally, you may want to check out:
• How to Use the American Geriatrics Society 2015 Beers Criteria—A Guide for Patients, Clinicians, Health Systems, and Payors - a 7 page PDF, mostly written for a professional audience, the upshot of which is, "Now, just because a medication is on the Beers List doesn't mean it's always inappropriate in the elderly; we're not trying to crimp doctors' styles."
• What to Do and What to Ask: If a Medication You Take is Listed in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Care of Older Adults - this is not available on the open internet, but it's available for free to anyone who signs up for a free account on geriatricscareonline.org; sign up, log in, and then click this link. Two pages, downloadable PDF.
• Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly Quality Measures [sic] - a journal article (for clinicians) discussing alternatives to the medications listed in the Beers Criteria. 11pp, PDF.
• Alternatives for Medications Listed in the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - again, not available on the open internet, but free with a free geriatriscareonline.org account. For patients, 3pp, PDF.
Now, so armed, and with the search engine of your choice to look up terms you don't know, you're in a position to check the med list of an elder.
If you find something being prescribed that's on the Beers List, first thing is not to panic. Like the "How to Use" and "What to Do" documents say, the right answer is not just cold-turkey quitting the medication. For one thing, there's medications on that list that are actually dangerous to abruptly discontinue; one of the psych meds on the list is notorious for causing dangerous seizures if abruptly stopped. There's conditions that may be being managed by such a medication that you don't want to abruptly stop treating, even if the medication being used is causing other harms.
And, like those documents stress, sometimes there's a good reason to prescribe an elder a medication on the Beers List. Pharmacology in the elderly is often about making difficult trade-offs. For example, just about all the standard medications for insomnia greatly increase the risk of developing senile dementia – but leaving insomnia untreated can lead to severe mental health problems. For another example, one of the medications on the Beers List is a heart medication which they strongly suggest not using to treat heart conditions – but it's the one medication demonstrated effective against PTSD nightmares.
If a Beers List medication shows up on the med list of an elderly patient, the doctor should have a good reason for it. They might not – they might have prescribed the medication without thinking about it, they might not be aware of the research showing it's got the risks it does in the elderly. So the thing you do when you find a Beers List medication on the med list of an elderly patient is ask. You start the conversation. You say to the doctor, "Hey, I noticed that this medication is on the Beers List. What's up with that?" Or "I saw that this medication is on the Beers Criteria, and I'm concerned. Should we be rethinking this?"
What you should not do is just trust that your doctor is on top of it because they are a doctor, and doesn't need to be asked. For three reasons.
First of all, while the AGS calls this "Potentially Inappropriate Medication Use", that's somewhat euphemistic in its exquisite accuracy. I see why the AGS has to pull its punches for reasons of diplomacy. But I don't. These are medications – and usages of medications – which are dangerous in the elderly. To say they're "potentially inappropriate" because they have elevated risk of adverse events in the elderly: that's what the word "dangerous" means. To say they are dangerous is not to say they're inevitably harmful or fatal, but to say they have a likelihood of having unacceptable risks for the potential benefits.
And further, to say they're dangerous stresses important true things: that if they are to be used,
• They must have a case-specific medical justification (documented in the chart),
• They must be used with informed consent of the patient (and/or their guardians), and
• Their use must be carefully monitored by medical professionals.
Especially given that some of these medications have deleterious effects on cognition, and that the population of concern is one which experiences a high rate of cognitive decline, it's wildly inappropriate for prescribers to rely on patients to identify problematic side effects and bring them up to the prescriber. The prescriber, or a medical professional delegated by the prescriber, needs to know what to look out for, and they need to take the initiative in checking for it, whether that means asking the patient and/or their caregivers specific questions, or running the appropriate physical tests.
The stakes of getting this wrong can be enormously high. And as medical screwups go, this sort is unfortunately common. That's why the Beers Criteria is even a thing. That's why you should take it upon yourself to check, and if you find such a medication is being prescribed, discuss it with the physician.
Second, doctors make mistakes. Even the best intentioned, even the best informed. Physicians are human; they get tired, overworked, distracted. And, alas, not all doctors are the best intentioned, or the best informed.
It is precisely because the physicians are humans, because it an easy mistake to make, that you should speak up. As they say in open source, "Many eyes make bugs shallow". "See something, say something." Don't just be a bystander in your own medical care or the medical care of your loved ones.
One of the classic problems in the medical care of the elderly is that there can be so many prescribers. In any complicated work system, where there's division of labor, it's a classic fault for something to fall between the cracks. In the medical care of the elderly, it can be that everybody thought somebody else was making sure the medications were safe. The PCP might think, "Well, if the cardiologist prescribed it, surely they knew what they were doing and must have a good reason to. Surely they already discussed it with the patient." The oncologist might think, "Well, I don't know for cardiology, so I presume the cardiologist knows what they were doing, and, well, it's the PCP's job to check up on things like that."
Asking, "Hey, what's going on with this? Why is it this way?" can catalyze the system to noticing something is wrong, and beginning to deal with it.
That said, systems push back, and you may have to be insistent. "Why is it that way?" "Dr. Cardiologist prescribed it." "So we need to talk to Dr. Cardiologist? Could you confer with Dr. Cardiologist about it?" You may wind up having to talk to Dr. Cardiologist, yourself, too.
Third, like I just mentioned, the justified use of Beers Criteria medications is often a matter of difficult tradeoffs and informed consent. If you see a Beers Criteria medication among the prescriptions of an elderly patient, and the patient and their caregivers or guardians don't know what it's doing there, and don't know why it's being prescribed over alternatives not on the list, then there's no informed consent and the patient is not being given a say in making those tradeoffs.
In the ethical practice of medicine with elderly patients – I hope to write more about this later – because such tradeoffs are so core to the practice of medicine with the elderly, it's absolutely crucial that the patient and those the patient has chosen to advocate for them are the decision-makers of such tradeoffs. Among specialists in elder care, this is widely understood to be the precise decision point where medical practice goes haywire: when decisions are made for the elder that do not reflect the elder's own values and preferences.
So much discussion about "end of life care" focuses on things like advanced directives and DNRs and so forth, and I am coming to the considered position that those issues take up so much of the oxygen in the room of discussing ethical eldercare that they've become a kind of bullshit. While such things are important, a DNR aint going help you much if your loved one lives for 20 years with Alzheimer's. In reality, a lot of medical practice with the elderly is not treating someone with one foot in the grave, and the ethics of doing so are not just about when it is more humane to withhold care.
They're about things like, "would you rather have an increased risk of a heart attack, or nightly PTSD nightmares". At the end of the day, decisions like that have to be made by the patient, or with the patient's own preferences in mind. Our society has historically said that life is more important than wellbeing, and deprecated peace of mind, and that consequently there is no question: prevent the heart attack at the cost of any misery to the patient. But there are people in the world for whom putting their unmedicated head on a pillow means being back in 'Nam, or Auschwitz, who will chose the heart attack over that, every time. And they should get to. That choice should be theirs.
If there's a Beers Criteria medication on an elderly patient's med list and they and their caregivers don't know what it's doing there, then they and their caregivers are not being involved in the discussion of the tradeoff they are, unwittingly, making. And they damn well should be.
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Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-23 10:56 pm (UTC)Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-23 11:47 pm (UTC)Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-24 12:57 pm (UTC)When I learned about it, I went looking, and found these:
"a dangerous interaction is that of erythromycin, an antibiotic and certain antipsychotics. When both are taken at the same time, the erythromycin will cause the concentration of the antipsychotic in the bloodstream to increase up to 70%. The result of this can be agitation, palpitations, and even an overdose." ... has a cite in French to the presumed source: http://www.asmfmh.org/resources/publications/interactions-between-medications/
and
Pharmacologic interactions of antibiotics and psychotropic drugs 1998
https://www.ncbi.nlm.nih.gov/m/pubmed/9577846/
"macrolide antibiotics, isoniazid, ciprofloxacin and ampicillin can lead to toxic concentrations of psychotropic drugs, while rifampicin causes subtherapeutic levels."
Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-24 03:30 am (UTC)"that after the better part of a century that"
I think the secomd "that" is redundant.
"To say they're "potentially inappropriate" because they"
Missing "is" before "because"?
"I am coming to considered position"
Missing "the" before "considered"?
Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-24 04:57 am (UTC)Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-24 07:55 pm (UTC)Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-25 08:08 am (UTC)Re: Comment Catcher: Medications Dangerous to the Elderly
Date: 2017-09-25 02:20 pm (UTC)You remember when I cracked my ribs coughing several years back? My doctors put me on both a codeine cough syrup and one of the pain relievers with codeine in it which nearly wiped me out. After that was straightened out, it took me six weeks to recover from the ribs and another two weeks to recover from the medication.
Fast forward a year and a 90 year old great aunt falls. She's put on a pain medication. A week later, her kids are talking about putting her into an intensive care home because she has symptoms of a fast onset dementia. I recognize the name of the pain medication and say, "It nearly wiped out a 40 year old. Have them check before upending her life and theirs."
Sure enough, a change in medication as well as a strength reduction (she weighed barely 100 lbs and was on the same dosage I'd been at nearly 200 lbs), eliminated her "dementia."
(no subject)
Date: 2017-09-24 03:10 am (UTC)