Talking to Patients
Medscape: When you have identified a patient who might be a suitable candidate for prescribing, how do you approach them about it?
Dr. Scott: It takes some time to talk to patients and find out what drugs they are taking and discuss what is most important for them in relation to what we are trying to achieve with whatever healthcare we are providing. Older people are not necessarily interested in prolonging life; they know that their life is only of a certain duration, and what they want to do is to be able to spend it well.
Then we have a good look at what drugs they are taking and the indications for each one. Why did we put them on these drugs in the first place? What was the diagnosis? For example, in older people, we often find that they were put on a nitrate because they had chest pain at some stage, and doctors thought that they probably had ischemic heart disease; but when you drill down, there is little information to confirm this diagnosis. Taking the history again, the chest pain really sounds atypical and probably not ischemic anyway, yet the patient has been on this drug for some years. Nitrate is a vasodilator, so it can lower blood pressure and it can predispose to falls in older people.
So you have to critically review the original indication, whether it was verified, and whether the patient reports that the medication actually had any effect on the original symptoms.. We often find that when you ask the patient whether the drug made any difference to how they felt, they reply, "Not really" -- perhaps a little, but there was no strong effect -- and therefore perhaps this drug may not be having an effect at all other than a placebo effect.
Medscape: What do you do about relatively innocuous compounds, such as vitamins? If you stopped these straightaway, would it help gain the patient's trust in the process before moving to the more potent compounds?
Dr. Scott: We do not worry much about innocuous drugs, such as vitamin pills and so forth. My personal opinion is that many people are spending a lot of their own money on vitamins and health supplements and other things that, in my opinion, don't do them any good, but that is their personal decision.
Medscape: What about over-the-counter nonprescription medicines, such as analgesics or laxatives?
Dr. Scott: Most of these drugs are associated with a relatively low risk for harm, so again our focus is not so much on them. It is more important to try to get patients off drugs that we know from quite a wealth of literature do increase the risk of harm.
Medscape: Such drugs as analgesics and sleep aids are routinely prescribed in older patients, and they often feel a reliance on these drugs. What do you do about these?
Dr. Scott: This is a dilemma. In some cases, patients will have a very strong fixation on certain drugs, and there is no way you are going to get them to stop taking them. That's fair enough; it is all part of shared decision-making. If the patient perceives the drug to be of benefit and if they are prepared to tolerate the side effects or potential harm, then that is their decision, and we go along with that. The important thing is to have the conversation and to ensure that patients are properly informed of the benefits and risks and that they then come to a decision about whether they want to accept the risks.
Medscape: In the United States, some physicians have complained that the pressure on patients of direct-to-consumer advertising of pharmaceuticals may increase the risk for polypharmacy. Do you have this problem in Australia?
Dr. Scott: No, we don't. Australia doesn't have direct-to-consumer advertising of drugs and hopefully never will.
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Cite this: Deprescribing in Clinical Practice: Reducing Polypharmacy in Older Patients - Medscape - Nov 26, 2013.