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As part of the Ageing Well Public Talk Series we explore how important it is to maintain well-balanced nutrition and hydration throughout our lives, as well as regular physical and social activity in older age. Within the series we also explore how this knowledge might be used to facilitate self-management and delay the ageing processes for as long as possible.
In an article looking at The Five Pillars for Ageing Well (Nutrition, Hydration, Physical Activity, Social and Cognitive Stimulation) we outline that ageing brings about changes in metabolic rate and muscles, brain, liver, kidneys, and overall mobility. These changes affect our nutrition, hydration, physical social and cognitive stimulation on a daily basis, and vice versa. In particular, the amount of water/liquids we drink every day affects further age-related changes and influences the speed of their impact on the metabolic rate, liver and kidney function, muscle function, nervous system, as well as our overall feeling of wellbeing and mobility.
In addition, we already know that as we grow older, we are at higher risk of having multiple long-term health conditions, which we call multimorbidity, and using multiple medications, which we call polypharmacy. This combination of ageing, multimorbidity and polypharmacy inevitably comes with some risks – these are explored in a previous article in this series, Pharmacotherapy while ageing. You can also access the full talk by Jitka & Sonal here. In this article we look at some of the strategies that can be deployed to offer more person-centred care to older people experiencing multimorbidity and polypharmacy.
The pharmacological effect of a medicine can be beneficial or unwanted; examples of the latter include side effects and drug interactions. Polypharmacy becomes problematic when someone is not getting clinical benefit from a medicine, or the negative effects of treatment outweigh beneficial outcomes. The changes associated with ageing and polypharmacy increase the risk of adverse drug reactions (ADRs) and worsening of chronic conditions.
For example, reflex tachycardia is a mechanism to increase heart rate and blood pressure when changing from a sitting to standing position. This is blunted in older people which means that drugs that lower blood pressure – whether that is their purpose, or a side effect – can lead to dizziness. This can potentially lead to falls, as balance can also be affected.
Certain drugs can affect water balance in the body due to effects on sodium levels, which has implications for some cardiovascular and respiratory conditions. There are also medicines used to manage symptoms associated with ageing (e.g. overactive bladder) which can actually worsen cognitive function. Older people can also struggle to regulate their body temperature, so drugs that act on the brain can lead to unusually low body temperature even in the summer.
The difficulty with identifying ADRs in older people is that they are often vague and non-specific. Issues such as constipation, balance problems, reduced cognition and weight loss can be put down to simple ageing. However, for some older people, this can have serious consequences – it is estimated that ADRs account for 5.8-23.6% of hospital admissions. As a consequence, balancing the risks and benefits of prescribing in the older population can be more of an art than a science.
There are some practical steps that we can take to support an older person to use medication safely and appropriately. The dose and frequency of medication should be reviewed, as changes to body composition and fluid balance can lead to drugs having an enhanced effect. Where appropriate, use medicines only when required, e.g. for pain relief.
‘Older people on multiple medications should have six-monthly consultations to review ongoing need, efficacy and potential harm. Pharmacists are well placed to support patients in these reviews’ Sonal Mehta
Regular blood tests can aid decision-making, by helping to understand how the kidneys and liver are functioning, and what other body systems might be impacted. A range of factors need to be considered – physiology, multimorbidity, polypharmacy – as well as the fact that health status can change quickly.
When treating an older person, we are trying to balance symptom relief, preventing the disease getting worse and keeping a good quality of life. On occasion, in order to understand the effect of a regular medicine, pausing medication might be suggested before a final decision is made about whether to stop or continue a medicine. However, you should NOT stop taking a regular medication without discussing it with your health care professional.
In addition to physiological and pharmacological effects, we also need to consider practical issues when ageing. Problems with dexterity, sight, cognition and swallow function can all affect someone’s ability to use their medication. Broader issues such as being housebound, having a carer, complex medication regimens and people’s values and beliefs around health and medicines, need to be seen holistically, alongside the medicines themselves.
There is now a movement to offer more personalised healthcare as it leads to better health outcomes. Our knowledge of ageing and health behaviours is growing, as is an appreciation of what evidence we should use to guide decisions. The medical model of healthcare, where a problem is diagnosed and a treatment prescribed, has its limits. Clinical trials are generally conducted in a younger population, with one long-term condition. The evidence gathered from these trials cannot always be extrapolated to an older population with multimorbidity.
A biopsychosocial model enables us to consider health in a more holistic way. We can start to consider the evidence for drug treatment alongside individual and social factors. For example, ‘patient activation’ is a term used to describe how involved a person can be in decisions and the extent to which they can self-manage their health. Sharing decision-making between an individual and a professional allows the clinical evidence to be used alongside someone’s lived experience of drug treatment.
It is not unusual to see boxes of unused medication in an older person’s house. Often this will be someone who hasn’t been brought into decision-making. For an older generation that has been brought up with the idea that ‘doctor knows best’, it can be difficult to raise concerns. Professionals also need resources and training to provide care in a different way and support patients through a shared decision-making process.
Quite often, an older person will have support with some of their health and care needs, whether that’s friends and family providing informal care, or a paid service. Professionals must understand the context within which older people use or are supported to use their medicines. Side effects can become troublesome to the point of not wanting to leave the house. This can cut off an older person from activities which support broader wellbeing, such as socialising and being active.
Sometimes, aids are employed to make it easier for some to take their medicines, when in fact we need to question the merits of taking a given medication. Some medicines are given to reduce the risk of disease 10 or 20 years later, but they’re causing problems with quality of life here and now. Risks and benefits will be weighted differently among older people compared to younger people, and this balance needs to be considered on an individual basis. These can be difficult but important conversations in palliative care or end-of-life settings.
To summarise, a combination of ageing, multimorbidity and polypharmacy increases the risks associated with drug therapy, but there are a variety of ways we can mitigate this risk through personalised care.
- Regular review to determine ongoing need, efficacy and potential harm
- Amending dose and frequency; using only when required in some cases
- Appreciating the limits of clinical trials evidence in older people
- Recognising individual barriers, values and beliefs around health and care
- Understanding the broader social context on the impact of medicines use
- Balancing quality of life, symptom relief and prevention of disease in relation to medicines
Of course, the best way to lower the risk is to reduce the need for medicines in the first place. By paying attention to the Five Pillars of Ageing, we can aim to live as healthy and independent a life as possible in older age. If we do develop health concerns later in life, the Five Pillars will still enable us to confidently manage the challenges this can bring.