GPs are being pressured to prescribe more drugs to their elderly patients, but many are profoundly uneasy about whether they are overmedicalising a whole swathe of the population by default.
A recent study showed that half of primary care patients in Scotland aged over 80 years were taking four to nine medications, and a fifth were taking 10 or more.1
Much of this prescribing can be explained by multimorbidities, but there is rising concern that it is based on limited trial evidence in older populations and some treatments may provide little absolute benefit.
GPs say part of the difficulty stems from NICE guidelines, which are often overcomplicated and concentrate on single conditions, making it difficult to weigh up the relative benefits of different treatments.
For instance, NICE’s recent proposal to lower the threshold for primary prevention for cardiovascular disease will see most men aged over 50 years and half of women aged over 60 years being prescribed a statin on the basis of their age alone.
A debate on the issue at the Pulse Live meeting in London in April found the overwhelming majority of the GPs present felt they were overdiagnosing and overtreating their older patients.
At the meeting, Dr Martin Brunet, a GP in Surrey and programme director of the Guildford GP training scheme, said GPs should be allowed to use their clinical judgment, particularly when it comes to risk factor management where the benefits of treatment are unclear.
He said: ‘NICE guidelines do put us under pressure. You often feel if you act outside the guidelines, you’re in trouble.
‘Choice is written into the guidelines, but it’s in the small print. Could we not have it so patient choice gets not just into the summary of guidance but into the summary of the summary – so that it is clear the priority is to have the discussion rather than to prescribe?’
‘Above five medicines you’re going to start getting emergent interactions that you can’t predict.’
Dr Andrew Davies, chair of NHS Warrington CCG and a GP
Other GPs agree. Dr Andrew Davies, chair of NHS Warrington CCG and a GP in the town, says: ‘I’m not sure we’re making people healthy by giving them all these drugs. We’re trying to eradicate symptoms and signs of disease, but that doesn’t necessarily make somebody healthy.
‘A lot of the evidence for those drugs is based on single diseases. We need to start thinking through really carefully what are we asking people to do? Once you go above five medicines you’re going to start getting emergent interactions that you can’t predict.’
There is some evidence that elderly patients are being given drugs that are ‘inappropriate’. An Italian study earlier this year showed three-quarters of elderly people were being given potentially inappropriate drugs and that this was associated with twice the chance of an adverse drug reaction or decline in functional status.2
Yet a recent analysis of polypharmacy by the King’s Fund suggests that when the baseline risk of an event is very high, the absolute gains from using multiple medications ‘can be considerable’ and exceed any potential harm in the elderly.3 It gives the example of the treatment of hypertension, where the HYpertension in the Very Elderly Trial (HYVET) showed an absolute 12% reduction in deaths from any cause in patients over 80 years as a result of antihypertensive treatment.4
However, the King’s Fund analysis admits that ‘relatively fit’ older people were selected in HYVET and a Cochrane Review of hypertension in older people, which incorporated this study, showed no overall benefit.5
Are GPs overmedicalising the elderly?
It is rare to open the record of someone over 70 and find nothing on their medication page. Some medications are to treat symptoms, because they are ill, but many are to treat surrogate markers – risk factors for dying.
We all recommend statins to our patients at the 20% cardiovascular risk cut-off, with a number needed to treat (NNT) of about 20. But what NNT would we GPs need to convince us to take a statin for 10 years?
We also need to talk about harms. We always talk about benefits but rarely about numbers needed to harm.
We have all these biophysiological markers for assessing risk but the biggest variable of all is missing in these decisions – patient choice. We need to build choice into guidelines.
We should be encouraging informed choice among our patients.
Dr Martin Brunet is a GP in Surrey and programme director of the Guildford GP training scheme.
The assumption is that it is all not worth it. Why diagnose when there is not much you can do about it? The investigations and treatments can be expensive and dangerous – why bother?
These are of course only half-truths and also apply to other sections of society. I recognise that one of the dilemmas is whether to treat when there is little evidence or not to treat and deny possible benefit.
But it is not uncommon now to see older people taking 10 or 12 medications, all with a robust evidence base. The term polypharmacy would be used here and it is usually used in a slightly pejorative way.
I favour the term ‘appropriate prescribing’ based on the Goldilocks and the Three Bears principle. Not too many drugs, not too few drugs but just the right amount of drugs.
Professor Peter Crome is honorary professor at University College London and former professor of geriatric medicine at Keele University.
Speaking at Pulse Live, Professor Peter Crome, former professor of geriatric medicine at Keele University, said his own research had shown flaws in the evidence base for treatment, with one study suggesting the average age of people participating in clinical trials for heart failure was around 10 years younger than the age at which people most frequently suffer from the disease.6
Professor Crome said: ‘One of the major problems facing prescribers is the relative paucity of scientific information on the benefits of treatment in older people, particularly with comorbidity.
‘This in turn arises from the exclusion of older people from clinical trials, which can either be overt with a specific upper age limit or less direct by excluding patients who have other diseases.’
‘I favour the Goldilocks and the Three Bears principle: not too many drugs, not too few drugs but just the right amount of drugs.’
Professor Peter Crome, former professor of geriatric medicine at Keele University
But he argued many elderly patients were missing out on drugs they should be getting, citing a 2010 study showing 23% of elderly patients in primary care who might benefit from drugs of proven efficacy were not receiving them.7
Professor Crome said: ‘These cover treatments that one would think are well known, such as anticoagulation for atrial fibrillation and ACE inhibitors for chronic heart failure.’
He added: ‘I favour the Goldilocks and the Three Bears principle: not too many drugs, not too few drugs but just the right amount of drugs.’
Professor Crome’s view chimes with a recent study showing polypharmacy is not always dangerous, especially in patients with multiple conditions. The UK retrospective analysis showed patients with six or more long-term conditions were no more likely to end up in hospital if they were taking four to six medications, than if they were taking up to three drugs.8
Lead author Dr Rupert Payne, clinical lecturer at the University of Cambridge and a GP in the city, says the study showed that simply counting the number of medications was a ‘crude measure’ for predicting outcomes. He tells Pulse: ‘We need a more nuanced way of looking at risks from inappropriate prescribing.’
There are moves to improve the situation, with NICE planning to develop GP-relevant recommendations on the management of patients with multimorbidities.
NICE chair Professor David Haslam says the institute does recognise that the treatment of multiple conditions in older people is an area where GPs require some help.
He says: ‘It’s clear we have to find a way of addressing the whole complex issue of multimorbidity and that’s something NICE is absolutely up for.
‘What we don’t believe in is massive polypharmacy, with a person taking more and more pills and needing a blood test every third day and having no quality of life – that is not the point of all this. Finding a way to determine what looks good for a patient [with multiple conditions] is extraordinarily important.’
Dr Julian Treadwell, a GP in Frome, Somerset, who is working with NICE on a guideline that will seek to address the problem of comorbidity, says he finds the absolute benefits of commonly prescribed, NICE-recommended treatments are often surprisingly small.
He says: ‘One of the big drivers [of overtreatment] is how guidelines have evolved over recent years, albeit with good intentions, serving to maximise the uptake of treatments so that even those with really very small benefits end up in the guidelines.’
Dr Treadwell adds: ‘If GPs want to find this out it takes them hours and even days to find the information, and then you come up with all sorts of data that is at odds with the guidelines. So you have a dual problem of time constraints and having the confidence to deviate from guidelines that appear to be giving you very robust instructions.’
‘Evidence-based medicine can be a starting point but it is not the endpoint’
Dr Linda Patterson
Dr Treadwell’s work with NICE aims to come up with more practical recommendations for the new multimorbidity guidance, but it is at an early stage. The guidance is unlikely to be available for another two years, and some argue a focus solely on medicines is too narrow.
Dr Linda Patterson, consultant physician in general medicine and geriatrics and former vice-chair of the Royal College of Physicians, says wider factors must be considered as well as the drugs that older patients are taking.
Dr Patterson told Pulse Live: ‘Their diseases interact, they’re interested in symptom control and maximising function. They may be living in poverty and social isolation and unable to carry out the basic activities of daily living.
‘Evidence-based medicine can be a starting point but it is not the endpoint. Older people need a more comprehensive assessment, rather than a pill for each disease, and may have trade-offs in their own lives about the risks and benefits of treatment.’
Five steps on managing medication in the frail elderly
1. Treat the person The principle for effective care planning should be to assess the person first and disease(s) second, particularly in older people, who often have multimorbidity.
2. Assess for frailty If the person is fit (not frail), single-disease guidelines can be discussed and sensibly applied. But in the case of advanced frailty, the risk-to-benefit assessment for any medication will move towards higher risk, and many drugs can be reviewed with a view to dose reduction or cessation.
3. Use the walking test Frailty is a graded health state and a simple, evidenced-based test GPs can use to detect it is the walking speed test. If a person takes longer than five seconds to walk four metres, they are highly likely to have frailty (where there is no other explanation, such as intrusive hip arthritis). The slower the walk, the more frail the person is.
4. Adjust medication For people with moderate frailty – typically someone who is largely housebound – bear in mind that certain medications, such as benzodiazepines or opiate analgesics, are associated with increased risk of the adverse events of falls and delirium. Such drugs should be avoided, or doses reduced, where possible.
5. Discuss meaningful goals An older person with moderate to severe frailty who also has hypertension, heart failure and diabetes, for example, may not see the relevance of the traditional outcomes of blood pressure or glycated haemoglobin control. Instead, a more meaningful, goal-oriented outcome could be set, such as the ability to get up out of a chair and walk to the toilet independently, without fear of dizziness or falling.
Professor John Young is a geriatrician and national clinical director for the frail elderly and integration at NHS England.
1. Payne R, Avery A, Duerden M et al. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol 2014; 70:575-581
2. Tosato M, Landi F, Martone A et al. Potentially inappropriate drug use among hospitalised older adults: results from the CRIME study. Age Ageing 2014. Published online 17 March
3. Duerden M, Avery T and Payne R. Polypharmacy and medicines optimisation. Making it safe and sound. London: King’s Fund; 2013. Published online 28 November
4. Beckett N, Peters R, Fletcher A et al. Treatment of hypertension in patients 80 years of age and older. N Engl J Med 2008; 358:1887-1898
5. Musini V, Tejani A, Bassett K and Wright J. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev 2009 Oct 7;(4):CD000028
6. Cherubini A, Oristrell J, Pla X et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. Arch Intern Med 2011; 171:550-556
7. O’Mahony D, Gallagher P, Ryan C et al. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. Eur Geriatr Med 2010; 1:45-51
8. Payne R, Avery A, Abel G et al. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharm 2014. Published online 14 January http://onlinelibrary.wiley.com/doi/10.1111/bcp.12292/pdf