Pills can be vital but in dolling out too many the NHS can harm rather than help… so is it time to STOP the elderly from taking tablets, asks DR JAMES LE FANU
- In Saturday’s Mail, Dr James Le Fanu said doctors are doling out too many pills
- He said that this could be harming us and even shortening our lives
- Today, he explains why the elderly in particular can be adversely affected
In an extract from his disturbing new book in Saturday’s Mail, Dr James Le Fanu argued that doctors are doling out too many pills. He said that ever-greater levels of medication could be harming us and even shortening our lives.
Today, he explains why the elderly in particular can be adversely affected.
Most of us probably think that in terms of our health, there’s never been a better time to be getting older. After all, so many of the tribulations of later life — from angina to cataracts, and arthritis to heart failure — can now be vanquished with a simple medical procedure or a prescription of pills.
So, particularly if you are over 70, there is much to be grateful to modern medicine for. But I’m afraid there is also much to be worried about. Because the shocking truth is that the NHS is guilty of a terrible betrayal of our elderly — people who have trusted their doctors, without question, their entire lives.
As a GP myself, I’m fully aware that caution when it comes to prescribing medication is critical. As the classic medical textbook on pharmacology, that I was required to learn as a student, puts it: ‘Any drug that is worth using can cause harm. Drug therapy in the elderly should be kept to a minimum.’
Over the past few decades, however, this cardinal rule of prescribing has been wilfully ignored in the UK — with deeply worrying consequences.
In an extract from his disturbing new book in Saturday’s Mail, Dr James Le Fanu argued that doctors are doling out too many pills
You have only to consider the following appalling statistics to understand what I mean:
- In just nine years, annual hospital admissions due to adverse drug reactions have increased by an astonishing 76.8 per cent.
- Twice as many older people are suffering from kidney and heart damage than in recent years, due to the drugs they’re taking.
- Adverse drug reactions have been reported in 44 per cent of hospital inpatients and 35 per cent of outpatients. They account for 10 per cent of emergency hospital admissions.
- Studies that examined what people had been prescribed found that two-thirds were on inappropriate medication.
- The risk of side-effects increases from 13 per cent for those taking two drugs to 58 per cent for those taking five, and to 82 per cent for those taking seven or more.
- The proportion of adults prescribed more than five drugs doubled in 15 years to 20 per cent. The proportion given more than ten tripled to 6 per cent. Most of these patients were elderly.
Many of these are victims of what doctors call ‘the prescribing cascade’: a patient experiences bad side-effects from one drug, so his doctor prescribes another to deal with them. Yet another is prescribed to deal with the side-effects of the second drug, and so on.
The following letter, sent to me in my capacity as a GP with an advice column, speaks for itself. It is from a woman whose 71-year-old husband is taking eight pills in the morning and five in the evening.
‘My husband has lost all confidence. He gets up in the morning with no energy and this continues all day long; he is not able to work in the house or the garden. He occasionally washes the dishes but this is too much for him.
‘On inquiring about the necessity for taking so many medications, the GP said that he would not be here if he stopped any of them.’
Her letter takes us to the heart of the problem of over-prescribing in the elderly.
But here’s the most interesting thing: the corollary to that is that the most beneficial ‘treatment’ you can really give to those who are 70 or over is to reduce the number of drugs they are taking.
This will not only alleviate the symptoms they suffer from over-medication, but also reduce their risk of requiring admission to hospital, and prolong their lives.
This was demonstrated unequivocally around a decade ago when a doctor decided to conduct a daring experiment.
Dr Doron Garfinkel simply stopped prescribing 320 drugs that were being taken by around 100 frail residents of an Israeli nursing home. He also roped in a control group of 100 equally frail residents who were still taking their pills. The results were extraordinary.
Over the following year, deaths were halved in the group that had stopped taking the medication, falling from 45 per cent to 21 per cent. There was also a steep drop in those needing emergency hospital admission, from three in ten down to just one in ten.
This is a better result than that achieved by any drug. Ever.
You’d think, therefore, that British doctors would be keen to follow Dr Garfinkel’s example. After all, in a 2014 poll, nine out of ten GPs conceded they were over-treating their older patients.
Yet the over-medicalisation of oldies remains as prevalent as ever in the UK.
The following case shows just how easily it can happen — and what the consequences can be. In his late 70s, Mr Clark was fit and active, playing tennis a couple of times a week. Then, like so many of his age group, he was routinely prescribed a cholesterol-lowering statin by his well-meaning GP.
Two months later, Mr Clark returned to the surgery, complaining of muscular aches and pains. In the absence of any obvious explanation, he was prescribed the anti-inflammatory drug ibuprofen.
A couple of months after that, he was summoned to the surgery for a flu jab. The practice nurse took his blood pressure and found it raised, so he was given a blood pressure-lowering diuretic.
Another three months passed. One night, Mr Clark woke with a swollen and excruciatingly painful big toe, correctly diagnosed as gout. This required yet another drug, allopurinol.
When he returned to the surgery a few weeks later, the GP checked his blood sugar level, which had previously been normal.
In just nine years, annual hospital admissions due to adverse drug reactions have increased by an astonishing 76.8 per cent
This time it was raised, so Mr Clark was put on the anti-diabetic drug metformin. Soon afterwards, he began having severe diarrhoea, for which his doctor prescribed a drug called loperamide.
At the next consultation, Mr Clark asked his GP why ‘so many things seem to have gone wrong recently’. The doctor told him: ‘At your age, these things happen.’
But in fact, Mr Clark had become the unwitting victim of a classic prescribing cascade.
It was the statins that had caused the muscular aches and pains. The anti-inflammatories that he was prescribed for those raised his blood pressure.
To treat the raised blood pressure, he was given diuretics. These, in turn, increased the levels of both his blood sugar and uric acid, causing the attack of gout and the diabetes.
His raised blood sugar was dealt with by the drug metformin, and one of its side-effects is diarrhoea. And his gippy tummy was subsequently treated with loperamide.
Thus, Mr Clark’s initial prescription for a statin had led to a cascade of five further drugs — as well as a great many extra health problems.
Obviously, the more drugs you take, the higher the risk of an adverse reaction from any one of them. And when you’re elderly, that can be very dangerous.
Just taking more than five different medications can either exacerbate or cause dementia, recurrent falls, urinary incontinence and a lack of appetite.
Sometimes just a single drug can plunge you into a living nightmare. This was certainly the case for a retired academic who was diagnosed with rapidly progressive Alzheimer’s disease.
He could no longer read a page of text, recall what he’d just said, or recognise people he’d known for decades.
In his case, it was his family’s decision to take him off statins that made all the difference. At his next evaluation, he was told he no longer had Alzheimer’s.
It took another two years for him to recover fully, by which time he was reading three national newspapers a day.
Of course, many people take prescription drugs without developing Alzheimer’s or any other serious diseases. But oldies are more at risk. In fact, they’re three times more likely to have adverse effects caused by their medication than the relatively young. Which means that drugs are more dangerous the older you get.
There are several reasons for this. One is that the functioning of the liver and kidneys declines as you get older. The concentration of a drug in the blood and tissues can therefore reach potentially dangerous levels.
Secondly, elderly bodies are less able to call on glucose for energy when they need it. So an old person on blood pressure medication, for example, may feel dizzy when he stands up, which can lead to a fall.
Thirdly, and very importantly, blood pressure and levels of blood sugar and cholesterol rise naturally with age. A person in his 30s, for instance, may have a 5.5 level of cholesterol. But when he reaches his 60s, it will have risen to 6.5.
This is entirely normal. It’s the same for blood pressure and glucose. A systolic pressure of 160 is high for a 40-year-old, but ‘normal’ for a 70-year-old, and so on.
Over the past 30 years, however, experts have consistently lowered the threshold at which any patient will be diagnosed with elevated blood pressure, diabetes and raised cholesterol.
The result is that the vast majority of oldies — whose levels have gone up with age — now automatically qualify for treatment.
And treated they are, even though a great many of them don’t need the drugs at all. Take, for example, a man in his early 40s, whose cholesterol level of 7 is markedly higher than ‘normal’ for his age group, thus increasing the risk of a heart attack. That can be reduced, if only modestly, by taking statins.
But for someone in his 70s that same cholesterol level is only marginally higher than average for his peer group. So there’s less benefit in taking statins.
Due to his age, his chance of suffering from side-effects is much greater than for a man in his 40s. In other words, he’s almost certainly better off taking nothing.
Why, then, do doctors continue to over-medicate the old?
As I explained on Saturday, it’s partly because it’s the easiest way for GPs to maximise their income. Under the current NHS scheme, every person treated for blood pressure, cholesterol and diabetes earns them extra cash.
But they’re also often reluctant to take elderly patients off any of their multitude of pills.
Let’s look at it from the perspective of a GP faced with a 70-year-old female patient, Mrs Jones, who has slightly raised cholesterol and blood pressure.
She needs statins and/or blood pressure medication, he reasons, because the older you are, the greater your chances of developing heart disease or having a stroke. Indeed, three-quarters of strokes and heart attacks occur in those aged 70 and over. Trouble is, that’s by no means the whole story.
For most people in this age group, the misfortune of having a heart attack or stroke is only marginally related to their blood pressure or cholesterol level, if at all.
The GP may have read the studies about this, but that doesn’t stop him. He lifts his pen and starts writing out a prescription.
Twice as many older people are suffering from kidney and heart damage than in recent years, due to the drugs they’re taking
Why? Because by giving Mrs Jones statins or blood pressure drugs, he ensures that he’s off the hook.
If she has a stroke, he won’t have to justify to her relatives why he failed to prescribe any drugs. On the contrary, he’s done his best —and ticked the boxes on which his remuneration depends. This is literally ‘medicine by numbers’.
Later, if Mrs Jones complains of side-effects, her GP may still be reluctant to take her off the pills.
He may not recognise whether a symptom — say, fatigue or dizziness — is due to a drug reaction or another illness.
It gets even more confusing if Mrs Jones has been on the medication for a long time. In some cases, a drug that’s been well-tolerated for many years can later trigger harmful side-effects.
What, then, can you do if you suspect that you, or an elderly relative, are taking too many drugs or suffering from side-effects?
My advice would be first to arm yourself with research, and then have a discussion with your GP.
Most doctors, one hopes, would welcome the opportunity to improve the quality of their patients’ lives. But you need to ask.
Your doctor may tell you that taking statins or other drugs will help you avoid heart disease and other life-threatening conditions. It therefore takes some courage to say you don’t want them.
Before deciding, the best thing you can do is to weigh up the benefits and risks of various treatments for oldies. And always bear in mind that drugs should be kept to a minimum:
It’s almost impossible for those in their 70s and beyond to escape being prescribed a cholesterol-lowering statin.
But, as a recent review observes: ‘Despite their widespread use, evidence for the effectiveness of statins in the elderly remains unclear.’
So far the only clinical trial in Britain that has specifically examined the drug’s effects in the elderly found that men were just 1 per cent less likely to have a fatal heart attack. There was no advantage for older women at all.
The situation for those known to have heart disease is slightly better, as statins reduce the risk of a fatal episode by 1.9 per cent.
Harms: Statins can significantly compromise an older person’s quality of life. Side-effects range from crippling muscular aches and pains to a dementia-type syndrome.
Verdict: There’s no justification for the current near-universal prescribing of statins for oldies.
Their very modest benefits must be offset against the likelihood of suffering adverse effects.
HIGH BLOOD PRESSURE
Treating raised blood pressure can be critical if it’s very high. But otherwise, there are various factors to consider.
The threshold for drug treatment at the moment is 150/80.
Let’s say your systolic pressure is 170. Drug treatment that brings it down to just over 140 has been found to reduce the likelihood of a stroke — but only by 2.2 per cent, and even less for a heart attack. So if your systolic pressure is 170 or less, you do at least have a choice.
Harms: Adverse effects caused by blood-pressure medication are common. Thiazide diuretics deplete the body’s salts (sodium and potassium) while beta blockers slow the heart. Both drugs can lead to serious disturbances of heart rhythm.
And there’s a further problem with the mass-prescribing of such medication for oldies: too much of a good thing can be bad for you.
While it might be desirable to reduce your systolic pressure to 150, if it goes much lower you start to run into trouble. The blood pressure may be insufficient to propel blood from the heart through narrowed arteries to the brain.
Indeed, people whose systolic pressure is running at about 120 may experience fatigue, weakness, unsteadiness and confusion, all of which may improve dramatically upon reducing the dose or stopping the medication.
Another sign of over-treatment is the sudden precipitous fall in blood pressure on standing up, which is more common in the elderly. Falls are clearly bad news for oldies, and low blood pressure makes them more likely.
Verdict: The rise of the systolic pressure with age is not necessarily benign. Still, caution is necessary when seeking to reduce it to that threshold of 150
Verdict: The rise of the systolic pressure with age is not necessarily benign. Still, caution is necessary when seeking to reduce it to that threshold of 150.
What you don’t want is to experience a precipitous drop. To that end, blood pressure should be measured not only when sitting but also when standing, and preferably after mild exertion.
The rising prevalence of diabetes with age is closely related to the tendency to put on weight as the years tick by, due to eating and drinking more and exercising less.
As Daily Mail readers will know, the disease is reversible for many through losing weight and cutting back on carbohydrates in favour of meat and dairy products.
Most people learn they have the condition after a blood test gives them a score of 7.5 or higher. The main goal of drug treatment is to try to prevent serious complications, including heart disease, stroke, and impaired functioning of the kidneys, eyes and nerves.
Harms: Oldies on these drugs are particularly vulnerable to hypoglycaemia (or excessively low blood sugar), which can result in anything from confusion to going into a coma. Even a spell of confusion can be fatal, as it may lead to falls and serious injuries sustained in road traffic accidents.
Verdict: There’s been an alarming increase in hospital admissions of the elderly for drug-induced hypoglycaemic confusion or coma, ever since GPs were given financial incentives to test for diabetes in 2004. This strongly suggests over-treatment.
Anyone diagnosed with diabetes should try to achieve remission by changing their diet. The elderly would also benefit if targets for treatment were revised upwards from 7.5 to 8 or 9.
Adapted from Too Many Pills: How Too Much Medicine Is Endangering Our Health And What We Can Do About It by James Le Fanu, published by Little, Brown on May 24 at £13.99. To order a copy for £10.49 (valid to May 19) visit mailshop.co.uk/books or call 0844 571 0640. P&P is free on orders over £15.
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