Intended for healthcare professionals

Observations Reality Check

Is your mum on drugs?

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5184 (Published 24 August 2011) Cite this as: BMJ 2011;343:d5184
  1. Ray Moynihan, author, journalist, and conjoint lecturer, University of Newcastle, Australia
  1. Ray.Moynihan{at}newcastle.edu.au

When “de-prescribing” may be the best medicine

Soon after she went into a small hospital a few years back, Johanna Trimble’s mother in law seemed to enter a rapid physical and cognitive decline.

Fervid Trimble was at the time a woman in her late 80s, living independently in a senior citizens’ home near Seattle in the United States. After a bout of diarrhoea and dizziness she was admitted to the healthcare centre close to the home, but her family was soon shocked by the quick deterioration in her health and the emergence of some strange new symptoms, including delusions. “She wasn’t able to wake up, and we couldn’t wake her,” says Johanna. “It didn’t seem like normal sleep.”

After discussions with the centre’s staff the family discovered that Fervid was taking several new drugs, including a painkiller and an antidepressant. “They said she was depressed,” says Johanna, “but we believed that she was rightly grieving for the loss of her former life, because she was now stuck inside a hospital room. It made sense to us that she was sad.”

At the same time a psychiatrist diagnosed “Alzheimer’s” and suggested that the 88 year old take donepezil (Aricept), which the family declined after learning that there was little evidence that the drug offered clinically meaningful benefits.

After further research the family members began to suspect that their mother was overmedicated and experiencing the harmful effects of a drug interaction, rather than depression or Alzheimer’s disease. In consultation with health centre staff they opted for a partial “drug holiday,” winding back some of Fervid’s treatments.

“She recovered completely,” Johanna told the BMJ last month. “Not only cognitively, but she was also soon doing exercises again. She really came right back.” The family members have compelling before and after photos to back up their views, which are part of a presentation that Johanna now regularly delivers, called “Is your mom on drugs?”1

As a journalist who’s been writing about evidence for many years, I’m acutely aware of the benefits and risks of the powerful anecdote. Used inappropriately, anecdotes can and do distort understanding and mislead readers—a daily reality of the hype based reporting in tabloids and on screens around the world.

In this case, though, hearing what happened to Fervid Trimble helps tell the wider story of the dangerous overdrugging of our elders and the fact that families and loved ones can do something to stop it.

The first thing Fervid’s family did was to tell the doctors that she was not to be given any new drugs without the family’s permission, and they’ve since released a short set of tips urging people to listen closely to their older loved ones, compare any new “symptoms” with drug side effects, and seek out independent, reliable evidence.2

For Johanna Trimble the experience was life changing. “I was looking at all the other people in long term care facilities, where family members were either unaware of the problems or didn’t want to rock the boat, and I thought, ‘Who the hell is going to speak up for these people?’” she told the BMJ. She has since become a patients’ advocate, working with public agencies and communities in Canada where she lives, promoting the idea that discontinuing drugs can sometimes be the best prescription. “I really wanted to do something about this epidemic of overmedication of our elders.”

Last year the Archives of Internal Medicine published a feasibility study of drug discontinuation among elderly people in Israel,3 with extraordinary findings. Using an established tool, researchers were able to cut the average number of medications in half, from roughly eight to fewer than four per person. Just 2% of discontinued drugs were restarted; no adverse effects of discontinuation were reported; and almost 90% of people reported better health.

The study was co-run by Dee Mangin, an academic at Christchurch School of Medicine in New Zealand and a general practitioner who is well schooled in evidence about the harms of unnecessary care. “I look as hard at stopping medications for my patients as I do at starting them,” she says.

Dr Mangin has written previously in the BMJ about the way that quality measures can drive up prescriptions of questionable benefit and why the current approach to “preventive care” for elderly people requires a rethink.4 “Improving the art of ‘not doing’ is what will determine quality care in the next few decades,” argues Dr Mangin, who is part of an informal global network hoping to run a randomised controlled trial of “de-prescribing.”

For Johanna Trimble, reducing numbers of unnecessary drugs and the associated delirium didn’t just improve her mother in law’s health; a returned lucidity in the following years of her life also enabled Fervid to pass on the precious wisdom of those facing death.

“Before she died, she spoke to all of us, touching and inspiring us, pouring out all her wisdom and love,” says Trimble. “Many families are not having these powerful experiences because their elders are too drugged.” Perhaps as northern hemisphere health professionals return from well earned holidays, the idea of a drug holiday for their elderly patients might be something to mull over.

Notes

Cite this as: BMJ 2011;343:d5184

References

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