Juggling multiple medications

 

Taking many drugs at one go may be necessary, especially for less healthy older adults, but we must be aware of the potential dangers.

There are times when it is necessary for a patient to take multiple drugs daily as they suffer from a few chronic medical conditions, but their regime should be regularly reviewed to ensure all the drugs they are on are still necessary. — Pexels

The Malaysian population is rapidly ageing, with over 11% currently aged 60 and above.

This figure is projected to rise to 17.3% by 2040.

The demographic shift has led to increasing healthcare demands, particularly in managing chronic diseases such as diabetes, hypertension (high blood pressure) and heart disease.

These conditions require long-term medicine use.

Alarmingly, studies indicate that nearly half of older Malaysians experience polypharmacy.

Many are also prescribed potentially inappropriate medications or fail to adhere to their treatment regimens.

This issue calls for coordinated care, increased awareness and targeted interventions.

Understanding polypharmacy

Polypharmacy is generally defined as the use of five or more medicines at the same time.

However, the number of medicines alone does not determine the impact.

The necessity and appropriateness of these medicines are equally important.

Polypharmacy can be both beneficial and harmful.

Appropriate polypharmacy occurs when multiple medicines are clinically necessary, carefully monitored and effectively managed.

For example, a person with high blood pressure, diabetes and heart disease may require several medicines to maintain stable health.

Problematic polypharmacy occurs when medicines are prescribed to treat the side effects of other medicines (a situation known as a prescribing cascade), or when the medicines themselves are potentially harmful.

Polypharmacy is common among older adults for several reasons.

Understanding these contributing factors is essential in order to design effective strategies to minimise medicines-related harm and improve overall patient care.

Some of the factors that can be attributed to the high frequency of polypharmacy among older adults are:

• The presence of multiple chronic medical conditions, for which the long-term use of medicines is necessary,
• Prescription of medicines on multiple different occasions by different healthcare practitioners, which increases the risk of duplication or drug interaction.
• Prescribing cascades, where medicines are prescribed to treat the side effects caused by other medicines.
• The absence of regular medicine reviews, which may allow unnecessary or outdated prescriptions to continue without reassessment.
• Poor communication between patients and healthcare providers, which can result in confusion or misuse of medicines.
• Widespread and accessible pharmaceutical promotions, which encourage patients to use traditional or over-the-counter medicines alongside prescribed medicines without medical advice.

Potential dangers

Polypharmacy carries genuine and significant risks, especially for older adults.Community pharmacists are one resource patients can easily access to ensure that their medicine regime is up-to-date and not causing any unnecessary side effects. — Filepic

Due to slower metabolisms and potentially impaired kidney function, the elderly are more vulnerable to the negative effects of multiple medicines.

Some of the most concerning consequences include emergency hospitalisations due to medicine-related complications, drug interactions that lead to undesirable side effects or reduced effectiveness, and adverse side effects such as dizziness, confusion or gastrointestinal issues.

In addition, when medicines impair alertness or physical coordination, they may contribute to falls, fractures and cognitive decline.

Several studies conducted in Malaysia also show that the majority of older adults do not take their medicines as prescribed.

Polypharmacy has a direct impact on medication adherence, which refers to how well patients follow their prescribed treatment plans.

As the number of prescribed medicines increases, the elderly often struggle with complex dosing schedules, leading to missed or incorrect doses.

This not only compromises treatment outcomes, but also increases the risk of hospitalisations and complications.

To address these, it is essential to provide patient education, simplify medicine regimens, and offer support through technology and caregiver involvement.

Reducing the risks

Healthcare systems around the world are adopting more proactive strategies to ensure the safe and effective use of medicines, especially in light of growing concerns about polypharmacy.

One important strategy is regular medicine reviews.

Patients are encouraged to inform their doctors and pharmacists about all the medicines they are taking, including prescriptions, over-the-counter products and supplements.

This open communication allows more regular medicine reviews, which helps healthcare providers identify medicines that may no longer be necessary or could be potentially harmful.

Another key practice is deprescribing, which involves gradually reducing or stopping medicines that are no longer beneficial.

Medicine reconciliation is also essential.

This process ensures that any changes to a patient’s medicine list, such as during hospital admission, discharge or transfer to a nursing home, are accurate and appropriate.

Technology also plays a helpful role.

Electronic health records can alert healthcare providers to potential interactions or duplicate medicines.

Most importantly, a patient-centred approach is needed.

When patients are involved in decisions about their treatment, it builds trust, improves adherence to medicines and leads to better health outcomes.

The most effective strategies to manage polypharmacy involve active participation from both patients and their caregivers.

Several steps are encouraged to support safe medication use:

• Maintain an updated medicines list, including over-the-counter products, supplements and herbal remedies.

  Bring this list to every medical appointment.

• Ask your doctor or pharmacist about the purpose, benefits and possible side effects of each medicine.
• Inform your doctor or pharmacist when you experience side effects, especially if they are suspected to be caused by a medicine.
• Get help from pharmacists for medicine reviews, especially after hospital stays or when there is a change in the medicine regimen.
• Use adherence devices or tools to help take medicines correctly, such as pill boxes, mobile apps or mobile alarms.

The role of pharmacists

As the number of elderly individuals taking multiple medications daily continues to rise, the role of pharmacists has become increasingly vital.

While doctors are responsible for diagnosing conditions and prescribing treatments, pharmacists ensure that medications are used safely, correctly and effectively.

With specialised knowledge in pharmacology and drug interactions, pharmacists are often able to detect issues that may be overlooked by others.

These include overlapping therapies, potentially harmful drug combinations, and unnecessary or duplicate prescriptions.

Community pharmacists, in particular, are in a unique position to support patients directly.

As the most accessible healthcare professionals, they can offer personalised counselling, conduct routine medication reviews and help patients understand the purpose and proper use of each medicine.

They can also identify early signs of adverse effects or non-adherence, and refer patients for further medical attention when necessary.

Addressing polypharmacy requires a coordinated approach that centres on the patient.

As the population grows older, providing safe, effective and individualised treatment is crucial.

Balancing illness management with quality of life is key to delivering better and safer care to older adults.

For any inquiries regarding medicines, please call the National Pharmacy Call Centre (NPCC) at the toll-free number 1-800-88-6722 during weekdays from 8am to 5pm, except on public holidays.

By PAYAL CHOUDHURY

Payal Choudhury is a pharmacist at Hospital Tengku Ampuan Najihah in Kuala Pilah, Negri Sembilan. This article is courtesy of the Health Ministry’s Pharmacy Practice and Development Division.

For more information, email starhealth@thestar.com.my.

The information provided is for educational and communication purposes only, and should not be considered as medical advice.

The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The

Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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Juggling Multiple Meds: Doctors and the Ninth Prescription

https://www.linkedin.com/pulse/pills-should-more-than-color-day-alan-pitt-m-d-/

Several years ago, when prescribed a single medication to be taken daily for several months, I found it very difficult to remember to take it every day. I knew it was important and I knew why I was taking it, but even then I forgot. That experience got me thinking about the many people who are asked to take six, seven, ten drugs a day…forever. I have no idea how they remember to take all of these drugs correctly, and the fact is, most people don’t. This was made clear to me as early as my residency, when it was not uncommon for people to bring in garbage bags full of medicines. When asked how they determined which ones to take and when, these patients often seemed to go by the pill color of the day rather than any set schedule or plan. 

In fact, the data on this issue—known as medical compliance—reveal an abysmal record of patients’ taking medications “as prescribed.” Reportedly less than one third of diabetic patients take metformin correctly. And only half the patients with high blood pressure take even 80% of their medications as prescribed. The end result is a multi-billion-dollar expense with unpredictable and often dangerous outcomes. How does this happen? 

Unfortunately, when it comes to prescriptions, providers are required to be compulsive. We are trained not only to address every problem with a solution, but also to do so on an individual basis. If you have asthma, there's a treatment for that. If it’s heart disease, here’s another pill. Diabetes? Take three more. The list grows quickly, adding expense and, more alarmingly, often resulting in untoward drug-drug interactions. It’s gotten so bad you’d be justified in thinking certain providers delusional for even believing the patient could take the list of medications “as prescribed.” Yet, when you talk to physicians about this issue, many simply shrug their shoulders. They’ll tell you they have little choice. The current medical legal climate requires a response to each identified problem.

One solution to this quagmire is personalized medicine, a topic I’ve discussed in prior posts. I should note that personalized medicine means different things to different people, but for many, America's love affair with technology often translates personalized medicine into genomic medicine. Eric Topol wrote extensively about this in his book  Creative Destruction of Medicine, explaining how, through sequencing the genome, doctors will be able to predict how each individual will respond to a particular drug. Equipped with such powerful tools, it’s not hard to imagine a future pharmaceutical industry that could customize medications, rather than simply produce mass quantities that work "well" for the average person. 

Until that particular biotech future arrives, I think there is a far simpler and immediate opportunity open to personalized medicine: by identifying a patient's ability to participate in her own care and then matching the medication regimen not only to her needs and preferences, but to subjective criteria such as mental clarity, alertness, daily routines, family support, etc. Two people with exactly the same list of problems may have very different abilities and willingness to take a complex regimen of medications. A 50-year-old executive may have the same problem list as an 80-year-old nursing home patient, but will clearly have different organizational skills, financial resources as well as an understanding of why the regimen matters. For physicians to write prescriptions they know deep down their patients cannot take borders on the absurd and certainly does not constitute good care. 

Although I'd like to think physicians would read this and suddenly change the way they write prescriptions, I am not that naïve. Without a significant change in how we're trained as well as appropriate protections from medical legal risk, it's unlikely doctors will suddenly change the way they practice. However, you as the patient have an opportunity to ask the questions. Are all of these medicines necessary? And if I only take a portion of the drugs, what is the overall increased risk to my health?  If you find yourself simply unable to follow the regimen, have an honest conversation about alternatives. Remind your doctor that you are not a “problem list” but an individual with specific medical requirements and concerns.

Ultimately, treating problem lists instead of people may be “right" but it's not reasonable. 

Breaking the sound barrier: How to stay sociable despite hearing loss

 

The vestibular system, located in the inner ear, is responsible for maintaining balance, stability and spatial orentatation - dpa

So you find it increasingly difficult to follow conversations amid the clattering dishes and loud voices in a restaurant, and then afterwards you feel exhausted? If this sounds familiar, hearing loss could be on the horizon. Christin Klose/dpa© DPA International

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To be a good listener, you've got to be interested in what the speaker is saying. And you need to hear well. If your sense of hearing is weakening, you're likely to first notice it during conversations. Why?

"Because sometimes the speaker will use slight nuances of speech, their tone of voice, or minimally raise or lower their voice, to give what they're saying a particular meaning," says audiologist Eberhard Schmidt.

If you don't pick up these nuances and overtones, you won't know, for example, whether the speaker expects an immediate reaction from you or wants to complete their train of thought first.

Having to concentrate hard when you're listening to someone may be a sign of hearing loss. In some cases, listening can become so strenuous that it tires you out as the day goes on, doctors say. Another possible sign is waning attentiveness during conversations.

Listening is even more strenuous in a noisy environment: music playing, dishes clattering, other conversations nearby. This requires the ability to selectively focus on the conversation you're having, known as the "cocktail party effect." To have it, you need good hearing in both ears.

Your ears work closely together with your brain to filter the voice of your interlocutor out of multiple other sources of sound. "The sound waves that enter both ears are 'translated' into information and classified," Schmidt says.

If you're hard of hearing, your selective attention is impaired. The words of your interlocutor are then largely drowned out by background noise, sentences getting through only in fragments or muffled, explains Schmidt.

There are other signs of possible hearing loss, including constant ringing or buzzing in the ears - known as tinnitus - dizziness, impaired balance and headaches. Another is often being asked to turn down the volume of the TV or radio.

While no one likes to admit trouble hearing - for many a source of embarrassment or shame - a gradual decline in the functioning of the tiny hairs in the inner ear that turn sound waves into electrical signals, and the auditory nerve that transmits them to the brain, is a normal part of ageing.

Reluctant though you may be, you should get a hearing test from an ENT specialist or audiologist if you have hearing problems. Left untreated, hearing loss can lead to social withdrawal and is also linked to increased risk of falling - the vestibular system, responsible for balance, is located in the inner ear.

For mild hearing loss, a hearing aid is often unnecessary. Minor lifestyle adjustments can help to manage it, a very common one being to sit in a front row at speaking events (but not at loud events such as rock concerts!).

"If you sit way in back at church, for instance, you'll experience the reverberations especially strongly, which makes listening and understanding much more difficult," remarks Schmidt, also president of Germany's Federal Guild of Hearing Aid Professionals (biha).

In cases of moderate to severe hearing loss, however, a hearing aid is advisable. "It will detect and suppress disruptive sounds during conversations, enabling you to understand them," Schmidt says. "When it recognizes speech, it automatically turns down background noise."

New hearing aid wearers shouldn't expect things to sound as before though, since your auditory system and brain have to get used to the device. So experts will generally recommend wearing it in fairly quiet environments first, and only later where there's more background noise - say, from a TV or radio - and when you're on the phone.- dpa

In an ENT practice, a simple hearing test will help the doctor determine how well your ears are functioning. Christin Klose/dpa© DPA International

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How to stay sociable despite hearing loss

Figuring out the best time to exercise; Any regular exercise helps maintain the brain

For some people, early morning before getting ready for the day’s duties is the best time to get their daily dose of physical activity in. — Filepic

It's a long-standing discussion for all who want to get into shape: When is the best time to exercise?

Based on member data from American fitness company Future, about 41% of workouts take place between 7-9am or 5-7pm.

“The debate is intriguing with proponents of both morning and evening workouts citing various benefits,” says sports medicine research director Dr Andrew Jagim from the Mayo Clinic Health System in Wisconsin, United States.

“From increased energy levels to enhanced performance or greater weight-loss benefits, health experts delve into the science behind exercise timing to shed light on the optimal approach for achieving fitness goals.”

In the morning

For morning exercisers, the allure of starting the day with a workout is undeniable.

“Getting your workout in and completed before you even begin your day can provide a sense of accomplishment and set a positive tone for the day ahead,” explains Dr Jagim.

“The post-workout release of endorphins and the satisfaction of accomplishing something before 9am can serve as a powerful ego boost.”

Perhaps most importantly, morning workouts eliminate the need to worry about finding time for exercise later in the day.

This is as it’s often the only time of the day that hasn’t been previously committed to work, social events or family activities.

“By completing your workout in the morning, you free up your afternoons and evenings for other activities, such as cooking dinner, socialising or simply relaxing,” Dr Jagim notes.

“This sense of freedom and flexibility can alleviate stress and enhance overall well- being.”

For people embarking on morning workouts, strategic pre-exercise nutrition can make a significant difference in energy levels and performance.

“Starting the day with a balanced breakfast containing carbohydrates, protein and healthy fats can provide the necessary energy to power through a morning workout,” he advises.

“Opt for wholegrain cereals, Greek yoghurt with fruit, and allow sufficient time for digestion to prevent discomfort and optimize nutrient absorption.

“Or, if you’re not hungry in the mornings or don’t have time, something simple like an energy bar can suffice.”

In the evening

However, for some people, waking up early to exercise is the last thing they feel like doing, and therefore, the case for evening workouts is more appealing.

“Your body’s ability to perform peaks in the afternoon and early evening, with optimal muscle function, strength and endurance,” states osteopathic medicine practitioner Jake Erickson, who specialises in sports medicine at the Mayo Clinic Health System in Onalaska, Wisconsin.

“During this time, your body has time to wake up a bit by moving around throughout the day, you’ve likely gotten a meal or two in to ensure adequate energy available to use during the workout, and you may be more mentally alert.”

Additionally, oxygen uptake kinetics are more favourable in the evening, allowing for more efficient utilisation of resources during exercise.

“Your body is primed for performance in the late afternoon and early evening, making it an ideal window for high-intensity activities like interval training or speed work,” he explains.

Conversely, people opting for evening workouts face unique considerations in balancing time commitments and mental energy.

“After a long day at work or shuttling around the kids all day, it can be hard to muster the motivation to go to the gym and put forth a lot of physical effort during a workout,” says osteopathic medicine practitioner Alecia Gende, who specialises in sports medicine and emergency medicine at Onalaska’s Mayo Clinic Health System.

“Additionally, intense physical activity in the evening may trigger a stress response and cause difficulty falling asleep or waking in the middle of the night if your cortisol is disrupted and released at an inopportune time.

“If you have to get a workout in before sleep, it would be best to be lower intensity, such as a walk or lighter (weight-)lifting session.

“If that’s the case, moving the workout earlier in the day might be more beneficial for them.”

Lastly, if you choose to work out later in the day, it’s important to ensure that you are getting adequate nutrients throughout the day to make sure you have enough fuel available to support the workout, in addition to eating a well-balanced meal after the workout.

“After a long day, it’s essential to refuel the body with carbohydrates and protein,” Dr Jagim says.

“Consuming a nutrient-rich meal within two hours of your workout can facilitate muscle recovery and enhance adaptation to training.

“Consider options such as grilled chicken with quinoa and vegetables, or a protein-packed stir-fry to refuel and replenish after an evening workout.”

For people engaging in prolonged or intense exercise sessions (more than 90 minutes), mid-workout nutrition can play a pivotal role in sustaining energy levels and preventing fatigue.

He recommends incorporating carbohydrate-rich snacks during extended workouts to maintain endurance and performance.

At midday

Whether working or at home, most people hit the dreaded afternoon slump around 3pm.

A study of more than 90,000 people recently found that working out in the afternoon reduces the risk of heart disease or early death more than physical activity in either the morning or afternoon.

The benefits of afternoon exercise for longevity were most pronounced for men and the elderly.

“Morning workouts may not be ideal for shift workers, or those working late or staying up later in the evening,” says Gende.

“In that case, it may be more prudent to allow more sleep in the morning and perform a mid-day workout or early afternoon workout before your next evening shift or late night.”

According to a OnePoll survey, the most effective activity for people during an afternoon workout is getting up and going for a walk, which is a great way to perk up both your mind and body.

Find your right time

So, what is the best time to exercise?

For those who just say I don’t have any time available, there’s always time.

“I suggest scheduling a ‘snack competing’ activity,” says Erickson.

“This can be a good excuse to flip the script, and for people who know they may choose to sit on the couch and snack in the evenings.

“They can use that time to grab a workout of some kind instead.

“This can lead to a big swing in people’s fitness as they consume less calories by avoiding the typical snacking time and burn more calories by the workout.”

There are even benefits to splitting up a workout into short 10-minute mini-sessions throughout the day if you don’t have time to get a full 60-minute session in.

ALSO READ: Always busy? Try stacking short workouts throughout your day

One thing is clear; even though science may seem contradictory, the importance of regular physical activity cannot be overstated.

“Ultimately, the best time to exercise is the time that fits into your schedule and aligns with your energy levels and preferences,” says Dr Jagim.

“Consistency and adherence to a regular exercise routine are key, and far more important, regardless of the time of day you choose to work out.

“Any time of day is better than no exercise in reducing the risk of death from any cause, including from heart disease and cancer specifically.

“Experimentation and self-awareness are essential in determining the ideal timing toward optimising exercise performance, recovery and overall well-being.” – By Rick Thiesse/Mayo Clinic News Network/Tribune News Service

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Any regular exercise helps maintain the brain

Exercising even once a month at any time during middle age helps preserve brain function in older age; although the best results are gained by those who consistently exercise five or more times a month throughout their adulthood. — Filepic

Any regular leisure-time physical activity at any age is linked to better brain function in later life, suggests a study published online in the Journal of Neurology, Neurosurgery & Psychiatry.

The findings also suggested that maintaining an exercise routine throughout adulthood seems to be best for preserving mental acuity and memory.

Even though factoring in childhood cognitive ability, household income and education weakened the observed associations, the findings remained statistically significant.

Physical activity is modestly associated with a lower risk of dementia, cognitive decline and loss of later life mental acuity. 

But it’s not known whether the timing, frequency or maintenance of leisure-time physical activity across the life course might be key to later life cognitive abilities.

The researchers were particularly keen to know if physical activity might be most beneficial in specific “sensitive” periods across the life course, or across multiple time periods.

To try and find out, they looked at the strength of associations between a range of cognitive tests at age 69 and reported leisure-time physical activity at the ages of 36, 43, 53, 60-64, and 69 in 1,417 people (53% women) taking part in the 1946 British birth cohort study. 

Physical activity levels were categorised as: inactive; moderately active (one to four times per month); most active (five or more times per month).

These levels were added together across all five age assessments to create a total score ranging from zero (inactive at all ages) to five (active at all ages).

Some 11% of participants were physically inactive at all five time points, 17% were active at one, 20% were active at two and three, 17% were active at four, and 15% at all five.

Cognitive performance at age 69 was assessed using the validated ACE-111, which tests attention and orientation, verbal fluency, memory, language, and visuospatial function.

The 69-year-olds were also given tests of verbal memory (word learning test) and processing speed (visual search speed).

Factors associated with a heightened risk of cognitive decline – cardiovascular (heart) and mental health, and carriage of the APOE-4 gene – were also assessed to see if these modified any observed associations.

Analysis of the results showed that being physically active at all five time points was associated with higher cognitive performance, verbal memory and processing speed at the age of 69.

The effect sizes were similar across all adult ages and for those who were moderately and most physically active, “suggesting that being physically active at any time in adulthood, even if participating as little as once per month, is linked with higher cognition,” write the researchers.

But the strongest association was observed for sustained cumulative physical activity and later life cognition, and for those who were most physically active at all ages.

The positive association between cumulative physical activity and later life cognitive performance was partly explained by childhood cognition, socioeconomic position and education.

But the effect remained significant when these were factored in, and the associations weren’t explained by differences in later life cardiovascular or mental health.

“Together, these results suggest that the initiation and maintenance of physical activity across adulthood may be more important than the timing... or the frequency of physical activity at a specific period,” say the researchers.

This is an observational study, and as such, can’t establish cause, and the researchers acknowledge various limitations to their findings.

The study included only White participants and had a disproportionately high attrition rate among those who were socially disadvantaged.

No information was available on exercise intensity, duration or adherence either.

But the researchers nevertheless conclude: “Our findings support guidelines to recommend participation in any physical activity across adulthood and provide evidence that encouraging inactive adults to be more active at any time and encouraging already active adults to maintain activity, could confer benefits on later life cognition.”

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