Polypharmacy in geriatrics. Ethical implications

Prof. Dr. Gonzalo Herranz.
Speech delivered at the roundtable.
Medicines and Nutrition in Geriatrics.
School of Pharmacy of the University of Navarra.
Pamplona, 24 June 1988.

Some ethical aspects of the relationship between pharmacy and geriatrics have already been discussed.

I have chosen the implications of polypharmacy and ethics because it seems to me to be a very interesting subject. Bioethics is interesting because it is where science and conscience coincide, where it is very clear that the first ethical obligation is good science, science that knows and is criticised. In geriatrics, polypharmacy is very common. In some studies we are told that elderly patients, being relatively few in number, use a disproportionately high number of drugs expense ; we are told that each of them is prescribed between 3 and 12 drugs, among which tranquillisers, analgesics and cardiovascular preparations are the most common.

This is because as the years go by, illnesses and diagnoses accumulate. Other times, it is the ailments of old age, which are not easy to classify into book entities, but which demand to be alleviated. The elderly person is almost never free of symptoms, real or imaginary: he or she can make a long list of them. And the list of symptoms has to be confronted with a list of medicines.

It is not easy to find a remedy for so many ailments. What one doctor has not given may be given by another. The elderly person may visit different doctors. And instead of maintaining the reasonable 1:1 ratio that is ideal for a good doctor:patient ratio, they see several at the same time or over time. The consequence is an accumulation of prescriptions. Few drugs are definitively abandoned by the elderly person: they keep them, alternate them, combine them, add the new ones that other companions in suffering recommend. The result is an anarchic polypharmacy, in which the problems of incompatibilities and unwanted effects grow in proportion to the possibilities of drug interaction.

I find it interesting to note that the placebo effect is sought - sometimes with the complicity of the pharmacist - as a quick solution to certain difficult problems, with the result end result of a therapeutic muddle that is impossible to untangle.

Anyone who goes to the doctor today has a minimum goal : to come back with a prescription for at least one of the wonder drugs that the TV is talking about.

Every doctor who is worth his salt thinks that every meeting doctor:sick person who is worth a few quid needs a prescription for a drug.

No one is now satisfied with an explanation of self-limiting illnesses. Psychotherapy has become very expensive, because it costs a lot of time and the doctor works with his seconds counted. The expedient is to give a prescription. The enquiry can be closed in a matter of minutes.

Moreover, the gesture of prescribing is always charged with human and magical resonances.

The effects of so many drugs on the elderly are not all good. Pastelaan case. The elderly do not remember the names, they are not able to remember how many times to take what and when. Pills and lozenges that seem so different in shape, colour, inscription, container, etc., to the old man become the little white pills in the little brown bottle, in which the all-important diuretic is mistaken for a bland placebo, or between which it is easier to confuse than to distinguish between the withdrawn and the newly prescribed tranquilliser.

The report fading and the amnesia that comes with age, the diminished visual acuity, the lack of financial aid of relatives at certain long hours of the day and above all the complex medication regimes that result from the passing of the years, in which the ailments grow in number, reduce the ability of the elderly to follow rational and simple treatments that can be satisfactorily obeyed.

The possibility of additive or synergistic effects multiplies and, in the face of such confusion, certain personality types decide to stop all treatment. But others are born collectors: they never throw anything away and are typical candidates for taking diuretics in triplicate or dangerously combining anti-arrhythmics with hypoglycaemics or tranquilisers, with results that not even the most modern computer simulation programmes are capable of calculating.

This must be remedied. This is where professional ethics come in. The doctor, but also the pharmacist, should from time to time give these elderly people confused by the abundance of their medicine cabinet a priceless financial aid : make them bring all, absolutely all, their medicines to enquiry or to the pharmacy, place them in order by families on the table, then discover the risks of interaction, classify them according to clinical priorities: diabetes is more important than constipation, and angina pain hurts much more than osteoarthritic hip pain. And we need to talk to the elderly person and find out what emotional echo the various disorders have on their subjectivity.

The wheat must be separated from the chaff. But this cannot be done by force. The patient's relationship with his or her beloved drugs is much stronger than that with anyone else, doctor and pharmacist included. It is necessary to eliminate the superfluous little by little, but just as important is not to add anything new for banal symptoms that can be overcome with a little asceticism. Do not give non-specific medicines for non-specific symptoms.

The question must be asked from time to time: Are the diagnoses correct? Do they require drug therapy? Is this person not taking more drugs than he or she is able to tolerate and handle? Sometimes a good adjustment of doses, the suppression of a good part of the drugs, produces a spectacular improvement.

If the pharmacist is the expert in medicines, not simply the seller of remedies, he can play a great role in the pharmacological surveillance of the elderly. He will often discover how true Osler's statement is that "The desire to take medicines is perhaps the trait which most strongly distinguishes man from animals". But he will also be able to draw the doctor's attention many other times to the irregularities in people's therapeutic regimen that occur with the biological deterioration of age.

I think this is an interesting topic . Maybe it won't sell more drugs, but it will help health more.