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Pathy's Principles and Practice of Geriatric Medicine. Группа авторов
Читать онлайн.Название Pathy's Principles and Practice of Geriatric Medicine
Год выпуска 0
isbn 9781119484295
Автор произведения Группа авторов
Жанр Медицина
Издательство John Wiley & Sons Limited
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CHAPTER 10 Polypharmacy and deprescribing in older adults
Fernanda Heitor1 and Milta Little2
1 Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
2 Division of Geriatric Medicine, Department of Internal Medicine, Duke University School of Medicine, Durham, North, Carolina, USA
Introduction
The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.
—Hippocrates
L.H. is an 88‐year‐old female with a diagnosis of hypertension, type 2 diabetes mellitus, chronic venous insufficiency, chronic depression, osteoporosis, osteoarthritis of the knees, recurrent dizziness, and mild Alzheimer’s dementia. Two weeks ago, she experienced one fall, without loss of consciousness, when she felt weak while standing in line at her local pharmacy. Subsequently, she was in hospital observation for two days and had a negative workup for acute vascular or infectious etiologies. While her sitting blood pressure was 168/90, her standing blood pressure was 132/72 and her pulse was 58. Her medications are (all taken orally) nadolol 40 mg daily, lisinopril 5 mg daily, furosemide 20 mg twice a day, spironolactone 25 mg daily, nifedipine 10 mg three times a day, metformin 1000 mg three times a day, glimepiride 4 mg twice a day, aspirin 325 mg daily, simvastatin 40 mg at bedtime, cilostazol 100 mg twice a day, omeprazole 40 mg once a day, famotidine 20 mg twice a day, sertraline 150 mg daily, trazodone 100 mg at bedtime, tramadol 50 mg three times a day, meclizine 12.5 mg every morning, oxybutynin 5 mg twice a day, donepezil 10 mg at bedtime, a multivitamin daily, ferrous sulfate 325 mg twice a day, and calcium carbonate 1000 mg three times a day. Her daughter, who is her healthcare durable power of attorney, is concerned that a medication side effect might have played a role in the fall.
Mythology introduced us to the memorable symbol of abundance known as the cornucopia, which is ubiquitously pictured as an overflowing horn‐shaped basin, typically filled with fruits and vegetables and with a positive connotation toward plenitude. On the other hand, the same idea of a cornucopia filled beyond capacity with capsules and tablets is rather ominous. Abundance, in this regard, is not necessarily a good thing. The Hippocratic maxim ‘Do no harm’ is sometimes a trying goal when it pertains to medication prescribing, and harm related to pharmacotherapy is common, pervasive, and costly. It is well known that one of the most common causes of avoidable hospital admissions in the elderly is adverse drug reactions, which, in turn, are directly correlated to the number of medications being taken.1,2
The concepts of polypharmacy and deprescribing are relatively new, gaining traction in the mid‐1990s and becoming a more prominent and complex problem over the past two decades, as indicated by an increasing body of literature. A study in Scotland demonstrated that from 1995 to 2010, the use of five or more medications in the elderly increased from about 11% to 20%, while for 10 or more medications, it rose from