‘Vanessa was a healthy girl. She didn’t drink or smoke or take drugs – with one exception: over the past year, she had periodically taken cisapride, an acid-reflux drug marketed as Prepulsid. Her doctor, who’d diagnosed her with a minor form of bulimia, prescribed it after she complained of reflux and feeling bloated after meals. Neither their doctor or pharmacist mentioned risks.’ On 19 March 2000, her father watched his 15-year-old daughter collapse on the floor at home. ‘She was rushed to hospital, where she died a day later. The cause: cardiac arrest.’ Five months later, the drug was withdrawn from the market, but it was too late for Vanessa.
Because of the loss of his daughter, her father became active in politics and got elected to the Canadian Parliament, as he wanted to change drug regulation. He expressed incredulity that prescription drugs aren’t regulated as stringently as other public safety threats: ‘The minister of transportation doesn’t “negotiate” with truckers to keep unsafe vehicles off roads,’ he said. By law, doctors must report unfit drivers and are paid to do so. Fast-tracking drugs to market is like ‘air-traffic controllers being told to land planes more quickly’. Eleven years after his daughter’s inquest, none of his major recommendations for reforms had been implemented.
We have thousands of drugs at our disposal, and I wonder why no one ever studied whether the availability of so many drugs does more harm than good. I am sure that’s the case. Otherwise, drugs wouldn’t be the third leading cause of death.
The doctors cannot know about all the dangers, but the patients can. They can read the package insert carefully and stop taking the drug if they think it’s too risky for them. I also hope my book may contribute to making so many citizens angry that they will protest and demonstrate until we force our politicians into introducing some much-needed reforms.
We know very little about polypharmacy
Most patients are in treatment with several drugs, particularly elderly patients. A Swedish study of 762 people living in nursing homes found that 67% were prescribed 10 or more drugs.116 One-third were in treatment with three or more psychoactive drugs; around half received antidepressants or tranquillisers; and anticholinergic drugs (e.g. for urinary incontinence) were used in one-fifth. All these drugs may create cognitive impairment, confusion and falls, which carry a considerable mortality among the elderly. The symptoms are often misinterpreted by the patients and their carers as signs of old age or impending disease, e.g. dementia or Parkinson’s, but when doctors stop the medicines, many of the patients apparently become many years younger, drop the wheeled walking frame, which they got because they couldn’t keep the balance, and become active again. A US study found that almost 18% of Medicare patients took drugs that aren’t safe for older people.85
Just like regulators, doctors see one problem at a time and usually start drug treatment every time. They very often forget about stopping a drug when it’s no longer needed. My most important contribution to internal medicine was to stop drugs in newly admitted patients, only to realise that, quite often, the patients arrived doped with the same drugs by their general practitioner next time they were admitted. It is surely an uphill battle.
We know very little about what happens when patients take many drugs, but we know enough to act. Every one of them may affect many bodily functions, apart from the intended one, and they may interact in unpredictable ways. We also know that old people are much overtreated, with harmful consequences. A randomised trial showed that drug reduction lowered both mortality and admission to hospital, and a subsequent study in 70 patients where number of drugs was reduced from 7.7 to 4.4 per patient showed that 88% reported global improvement in health and most had improvement in cognitive functions.117 Here is a typical story, apart from the fact that few elderly people are that lucky:118
When my father was 88, he was hospitalised for dizziness, which occurred after his medication was increased. In the hospital, he was given more medication which made him confused, frightened, and incoherent. Then his doctor transferred him to a nursing home, where he was dirty, crying, begging people to hold his hand, and listed as DNR (Do Not Resuscitate) – and given still more medication.
I convinced the doctor at the nursing home to discontinue all medication, and I hired a private nurse to give my father an organic diet – rich in fruits, vegetables, grains, beans, nuts, and seeds. In 3 days, my father made such a miraculous recovery that the nurses on the ward didn’t recognise him. When I called to speak to my father, he was back to his old self, and told me that he was bored and looking for a card game. My father was discharged the next day, and died several years later, while relaxing peacefully at home.
Here is another story, of a woman who was also 88. She gets admitted to hospital after a bout of diarrhoea and dizziness.119 Her family was soon shocked by the quick deterioration in her health and the emergence of some strange new symptoms, including delusions, and they couldn’t wake her. They found out that she was taking several new drugs, including a painkiller and an antidepressant, but she wasn’t depressed, she was rightly grieving for the loss of her former life, because she was now stuck inside a hospital room. At the same time, a psychiatrist diagnosed Alzheimer’s and suggested that she take donepezil (Aricept). Her daughter-in-law refused this and took several of the drugs from her, which had dramatic effects. She became herself again. This experience turned her daughter-in-law into a patients’ advocate: ‘I was looking at all the other people in long term care facilities, where family members were either unaware of the problems or didn’t want to rock the boat, and I thought, “Who the hell is going to speak up for these people?”’
Modern medicine doesn’t work well for old people. Every clinician has witnessed the medicalised 80-year-old obsessed with arthritis, Alzheimer’s disease, and serum cholesterol levels. Contrast this patient with someone else in the same physical condition, who admits that her knees are bad and that she has trouble remembering things. Which patient is better off?120
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