An elderly man with dementia once hurled a heavy vase at Dr. Tom Perry, who said it could have killed him had he not seen it coming out of the corner of his eye and ducked.
So the expert in inappropriate drug use agrees that aggressive and demented seniors sometimes need anti-psychotic drugs to calm them down. But they should not be kept on them for days or weeks without a drug review justifying why potentially harmful drugs should continue, said Perry, an MD and professor of pharmacology who teaches workshops on medication reviews to doctors and pharmacists around B.C.
Perry said he is disturbed but not surprised at more reports about widespread overprescribing to frail elderly people living in B.C.’s public care homes, including 26 facilities in the capital region.
He estimated that it wastes “tens of millions of dollars” annually, harms health and diverts money from human services that benefit people with dementia — companionship, music and recreational outings, for example. Health experts can almost always reduce the number of drugs and the patient is almost always better. “That’s a rule of thumb,” Perry said. B.C. spent $43.7 million on drugs for 29,000 seniors in public care homes in 2013-14.
About half of seniors in care homes are prescribed nine drugs at any one time and powerful antipsychotics meant to treat schizophrenia are prescribed to 34 per cent of residents when only four per cent have a diagnosis that supports such a drug, the B.C. seniors’ advocate found in a report released April 8.
The widespread use of anti-psychotics in care homes is “probably the biggest scandal in prescribing in the elderly,” said Victoria drug-policy researcher Alan Cassels. “Those drugs are contra-indicated in people with dementia,” he said, venturing to guess half or more of the seniors given anti-psychotics have dementia.
“If you give them to someone with dementia, they are more likely to die, by whatever means,” Cassels said.
Both Health Canada and the U.S. Food and Drug Administration have warnings saying they should not be used in the elderly with dementia, Cassels added.
A Victoria family once hired Perry privately to assess the drugs their mother in care was prescribed. He discovered the woman was suffering from drug-induced symptoms similar to Parkinson’s Disease — absence of facial expressions, extremely slow gait and a zombie-like look. They had developed over two years since a single episode of paranoia, likely induced by a bladder infection, was treated with anti-psychotic drugs, he said.
Anti-psychotic drugs are promoted “very aggressively, if not illegally,” for so-called off-label uses, he said. Drugmaker AstraZeneca paid $520 million US to settle a suit with the U.S. government for its promotion of the anti-psychotic Seroquel in 2010.
Twice-yearly medication reviews should be mandatory in care to counter over-prescription, Perry said. But what is really needed is a multi-pronged attack on irrational or harmful use of prescription medicine.
“Most doctors learn as they get older that we have been socialized to believe that drugs are much more powerful and much more beneficial than they are,” Perry said. “The first step is for everyone — doctor, nurse, nurse’s aide or pharmacist, family or patient — is to ask what are we trying to accomplish and how do we know it’s necessary. And if we’re not absolutely sure it’s necessary, ditch it.”
Cassels is working to develop an app or decision aid for MDs who need to help making sequencing decisions about which drugs to taper and stop and in which order. He has interviewed physicians who work in care homes and are faced with patients transferred from hospital taking up to 15 drugs at a time.
“My sense is that it is very much on their radar,” he said. “I think they would all admit that they need to do a better job — that they need to be more aggressive.” The project is funded by the Canadian Institutes of Health Research.
Drugs for high blood pressure, high cholesterol, osteoporosis and Alzeihemer’s are also problematic in elderly people, the experts said.
When such drugs are removed, patients almost always feel better “and in that age group, feeling better is all they really want,” Cassels said.
Statins prescribed to lower cholesterol and fend off heart disease and stroke have “never been tested in the elderly,” yet are routinely used to prevent future events while making recipients feel ill, Cassels said. Some frail elderly people get two or three different high blood pressure drugs from doctors “obsessed” with returning their blood pressure to what it was at age 25 or 30. “I think it’s very dangerous,” Cassels said, as it results in low blood pressure, dizziness and falls.
Aricept, marketed to fight Alzheimer’s, “shouldn’t be used at all for the frail elderly,” Cassels said. “It has no benefit and it causes harm. It actually doesn’t do what the manufacturers claim, which is to prevent the decline of cognition.” Instead, it causes vomiting and gastro-intestinal upsets.
There is no point in giving osteoporosis drugs past four years, added Perry.
“If your mother at age 90 is still getting a drug to strengthen her bones, it’s certainly ridiculous and probably harmful,” Perry said.