The heart throws a tantrum. The ways of breathing are narrowed. The joints feel the signs of aging. The stomach sends signals of pain, the intestine does not remember to be regular, the mood is not that of the best days. Add all of these elements, or even just some of them, and you will understand how it is increasingly important to doctors keep many pathological conditions under control in a single elderly person. The result? According to OsMed data in Italy 30% of over 65s take 10 or more drugs (in 2018 they were 22% and in 2016 11%). And one in two people takes between 5 and 9 or takes medicine for longer than necessary. This was reported by the experts in geriatrics, who propose, when obviously possible and only on the advice of the doctor, a drastic solution: check the treatments indicated every year. This sort of “coupon” by the doctor could reduce the risk of adverse events by at least 20% and eliminate at least one inappropriate drug, sometimes a therapeutic duplicate.
The value of prescribing less
Limiting prescriptions and reviewing them regularly to stay close to the elderly person with various pathologies is one of the cornerstones of the new intercompany guidelines for the management of multimorbidity and polypharmacotherapy, presented at the National Congress of the Italian Society of Gerontology and Geriatrics (SIGG) and developed by the SIGG in collaboration with the Italian Society of General Medicine and Primary Care (SIMG), the Italian Society of Internal Medicine (SIMI), the Italian Society of Hospital and Territory Geriatrics (SIGOT), the Italian Society of Pharmacology (SIF) and the Federation of Associations of Hospital Managers Internists Internal Medicine (FADOI). Many examples are cited by elderly care experts.
“Polytherapy, that is the taking of 5 or more drugs, which in our country affects 75% of over 60s or prolonged therapies over time without indication, can involve dangers and a serious waste of resources – reports the President of the SIGG Francesco Landi. It is estimated that at least 2 million older people experience the risk of serious adverse events due to interactions between prescribed drugs. But a drug isn’t forever and it is not always the same medicine is needed in all age groups. Often, however, these prescriptions remain as a ritual obligation, for which a drug continues to be taken for years, well beyond what is necessary for a sort of ‘therapeutic inertia’. Furthermore, in many cases, each specialist adds their own therapy without verifying any interactions with the others or prescribing unnecessary drugs “. Examples on the topic? Here are some cited by the experts. “In many cases, for example, people over 65 take proton pump inhibitors that they shouldn’t and in those who don’t have a clear indication of their use, it would be advisable to stop them, because in the long term they can increase the risk of fractures. Just as it would be good to eliminate statins in the elderly with a limited life expectancy and give vitamin D only to patients with osteoporosis or high risk of falls – underlines Alessandra Marengoni, participant in the Guidelines panel and Associate Professor of Geriatrics at the University of Brescia. Equally counterproductive could be aiming for ‘normal’ blood pressure values in the over 80s, in the case of fragile patients who may not be able to tolerate hypotensive therapy “.
Focus on controls
“The first recommendation of the new Guidelines involves defining a treatment plan with the aim of prescribing only compatible, necessary and truly effective drugs in the control of symptoms and complications – recalls Graziano Onder, Scientific Director of the Guidelines and Director of the Department Cardiovascular, Endocrinometabolic and Aging Diseases of the Istituto Superiore di Sanità. The document focuses on the need for a periodic review of the therapy, with possible reduction or suspension of drugs, some very widespread and abused such as gastroprotectors and statins, weighing the risks and benefits of each individual drug, taking into account the priorities and preferences of the patient. At least once a year, and whenever there are changes in clinical conditions, the pharmacological regimen should be re-evaluated as a whole, aiming at deprescription, sharing the new therapeutic scheme with the patient, and trying to simplify and optimize the therapy as much as possible “.
The numerous clinical experiences conducted in recent years confirm that it is possible to reduce the load of drugs by eliminating at least one, without consequences on the health of patients: a study conducted in particularly fragile patients in RSA for example has shown that it is possible to remove psychotropic drugs such as benzodiazepines. o antidepressants by reducing the number of patients exposed to serious interactions by 21%, a survey of patients treated by the general practitioner showed that revision of therapies can reduce the misuse of proton pump inhibitors and others by up to 17% drugs, decreasing the risk of interactions by 10% and at the same time increasing adherence to necessary treatments by up to 30% “.
The personalization of care
“The personalization of treatments must be agreed between the individual patient and the doctor, identifying priorities and trying to synthesize the different therapies – the experts observe – It is necessary, however, that patients also play an active role to reduce the risks related to drug abuse. For this reason we have also drawn up a vademecum of 6 rules for patients and their caregivers – continue the geriatricians – For example, it is good to always have a precise scheme of the therapies taken, including supplements and herbal products that can interfere with the correct functioning of some medications, making sure your doctor is always aware of all the therapy you are taking. It may be useful to involve a family member or a caregiver in the management of polytherapy, especially for those patients who have memory difficulties and risk administration errors, also with the help of the daily and weekly dispensers so as not to repeat the intake several times or, conversely, forget the pills. In some cases, then, appropriate advice to change one’s lifestyles (correct diet, constant physical activity, smoking ban) can at least partially make the intake of a certain medicine superfluous “.
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