Death by medicine

At his 91st birthday two weeks ago Don Ireland was as sharp as a man half his age. He regaled his family with stories from the distant past - his honeymoon at the Coogee Bay Hotel in 1940, and the long train ride across the Nullabor with his bride to start married life in rural Western Australia.
But it was his short-term memory that put us middle-aged folk to shame. His unfaltering recall of people's names, places and dates from recent times showed he was one of the lucky old-old - alert and cheerful.
Nevertheless there is a black hole in his reminiscences. Of the time between his 87th and 89th birthdays, Ireland's memory is blank. It is we, son and daughter-in-law, who remind him of the shell of a man he was then. He could barely talk or walk or feed himself. He nodded off to sleep all the time. And when he roused, it was to complain. He was wrapped in a miasma of gloom, not even mustering enough interest in life to watch his beloved St George rugby league team on television. Perhaps this was what being 87, 88 was like, we thought, a grim vigil in the anteroom of death.
He was in and out of hospital in those years - for falls, minor strokes and suspected heart attacks. The aged-care hostel where he had enjoyed some independence was finding it hard to manage him. He was on the brink of being admitted to a nursing home when he met yet another doctor, Tom Gibian, a geriatrician at Bankstown Hospital. Dr Gibian soon realised the problem: Don Ireland had been poisoned.
Tens of thousands of elderly Australians are at risk of the same fate. They are being poisoned by prescription medicines that are supposed to help them. Between 85,000 and 110,000 people over 65 are admitted to hospital each year because of the adverse effects of their medication - and that is just the tip of the iceberg. Too many doctors working in isolation from one another are prescribing too many drugs to old people, or the wrong medication, say experts contacted by the Herald. And no one is held accountable.
At the heart of the problem is a collision of two forces, says David Le Couteur, professor of geriatric medicine at the University of Sydney, and the director of the Centre for Education and Research on Ageing at Concord Hospital. "We have pharmaceutical companies, and doctors with conflicts of interest, who make a huge amount of money from drugs; and people who expect to live for ever and be well for ever - and they feed off each other."
Because of their medication, many elderly patients suffer unnecessarily. They feel sick, nauseous, confused; their memory deteriorates; they suffer incontinence; they may suffer hemorrhages in the stomach or brain; they fall; they are referred to nursing homes.

How many are killed by their medications is unknown. While Australians are living longer, many in their last years are rendered miserable through poor prescribing and an unco-ordinated health system that fails to pick it up.
Australian studies have shown that up to 30 per cent of hospital admissions of people aged 75 or over are related to their medication, and that almost half are preventable. Dr Tuly Rosenfeld, a senior geriatrician at Prince of Wales Hospital, says: "If we could solve the adverse effects of bad prescribing in older people, most geriatricians would be out of business."
Doctors stress that patients must not come off their drugs without first discussing the matter with their GPs because hasty withdrawal can result in serious consequences. Well-prescribed medicines saved lives.
But as the population ages, and more powerful drugs come on the market, concern is mounting among health specialists that efforts to reduce the problem of polypharmacy - too many medications - and bad or inappropriate prescribing to the elderly, are being overwhelmed.
"I see a lot of elderly people in the wards on crazy combinations of medications," says Dr Peter Hunter, the president of the Australian and New Zealand Society for Geriatric Medicine. "People started on drugs to counteract the effects of another drug; illogical combinations of medications. I tell my medical students the three main causes of acute confusion in older people are drugs, drugs and drugs."
The problem is not new. In recent years the Federal Government has responded with new structures and education programs. The National Prescribing Service tries to counter the billion-dollar marketing budgets of the pharmaceutical companies with GP education programs. Pharmacists and GPs can get federal money to carry out home medication reviews and nursing-home medication reviews, and these have jumped significantly. In recent years medical schools have begun to teach students geriatric medicine.
But the forces are formidable.
"A couple of lectures I give to GPs cannot counterbalance the very effective marketing campaigns of the drug companies," says Professor Le Couter, who warned doctors a year ago about the dangers he saw with the osteo- arthritis drug Prexige, which the Therapeutic Drugs Administration ordered off the market last week after two deaths and two liver transplants.
There are other signs all is not well. A study of almost 4000 elderly Australians published t in the Australian and New Zealand Journal of Public Health this month found that 20 per cent of women aged 65 and over were popping benzodiazepines - depressants used for insomnia and/or anxiety. Nationally an estimated 390,000 elderly men and women have been prescribed enough of the tablets to take one every night for six months, says Alice Windle, a public health researcher, which could put them at greater risk of falls and hip fractures while doing nothing for their insomnia.

A further indication of potentially poor prescribing emerges from a smaller study at Royal North Shore Hospital of 220 people aged over 75. They were admitted between May and July for atrial fibrillation, a condition that predisposes people to stroke. A medication review resulted in one-third of those deemed frail being taken off the blood-thinning medication Warfarin (and 10 per cent of those who were not frail being started on the drug). While Warfarin helps prevent strokes, it also increases the risks of gastrointestinal bleeds, and bleeding in the brain among the frail.
"Have we made significant improvement? I don't think we have," said Dr Elizabeth Roughead, of the Sansom Institute at the University of South Australia, whose recent study of prescribing indicates almost 400,000 Australians aged 70 or over are taking at least one drug considered potentially harmful to the elderly, and for which there is a safer alternative.
"We have these structures in place," she said, "but we are not getting enough doctors using them."
The problem seemed to be getting worse when D'Arcy Holman, professor of public health at the University of Western Australia, and his team conducted a survey of hospital admissions because of adverse drug reactions. After examining records of more than 43,000 patients admitted to the state's hospitals, he found the rate of adverse drug-related admissions for people over 60 had more than doubled between 1991 and 2002, and tripled for those aged 80 and over.
But drugs can cause other, more subtle, problems. A study based on more than 3000 well-functioning elderly indicates the total number of drugs taken may be less important than the kind. Dr Sarah Hilmer, head of the department of clinical pharmacology at the Royal North Shore Hospital, who led an international research team, found two particular classes of drugs were associated with poorer cognitive and physical functioning in the elderly. These were drugs with sedative or anticholinergic effects such as benzodiazepines (sleeping tablets), neuroleptics (anti-psychotics), oxybutynin (for incontinence), and antihistamines. The higher the total dosage the worse the elderly performed in tests of mental and physical agility.
When Dr Gibian first met Don Ireland in August 2005 as an inpatient even he thought he was a candidate for the nursing home. When he reviewed Ireland's medications he found he was on 17 different drugs and a further seven to be taken "as needed".

Even if some specialists in geriatric medicine contend that the critical thing is what drugs are taken rather than how many, big numbers can increase the risk of bad reactions and interactions.
Gibian took Ireland off eight of his regular drugs and put another seven under review. And then he waited.
"If elderly patients come into hospital with an acute event I start again with their medication," Gibian says. "I have to decide with each medication whether it is more likely to benefit than to harm them. Potentially every chemical put into an elderly person is a poison unless proven otherwise. If I cannot decide I take it away and see how they go in hospital. It doesn't always work; sometimes I'm wrong."
Gibian has written a pamphlet he gives to young doctors, titled How Not To Poison Elderly Patients. It says: "Every chemical product demands a high index of suspicion in the elderly." But it also cautions against "therapeutic nihilism" - depriving the elderly of medicines for potentially treatable conditions.
By the time Ireland was discharged after a fortnight, Gibian had reduced his medicines dramatically. The revival was little short of miraculous. Within two months Gibian had cut the drugs to three - from 17 - and he could write to another doctor: "He has had no falls, no chest pain and no evidence of depression … This is an outstanding outcome."
It was hard to reconcile the chirpy old man at the Christmas lunch that year with the silent husk of his former self. And two years on, although there are physical problems, he is in many respects better than he has been for years - touch wood. A man who hardly left his chair for two years, he now takes a daily walk round the block with his walking frame, he jokes with the staff, and helps hostel residents less fortunate than him. His case is taught to medical students with a caution to "avoid allocating blame" and a reminder that not all poisoned elderly bounce back quite so spectacularly.
Yet it is one of the joys of geriatric medicine that doctors can often reverse the damage caused by adverse drug reactions by withdrawing some medication.
"It's like turning a switch," one said.
Geriatricians' stories about resurrected patients have remained in the realm of anecdote. Now Dr Shoba Iyer, at the Centre for Education and Research on Ageing at Concord Hospital, and co-researchers have reviewed 31 international studies to ascertain the benefits and risks of withdrawing medication in the elderly.

Preliminary results show adverse effects from stopping medications are "infrequently encountered", and if they are, occur early. "Withdrawal of psychotropic medications was associated with a reduction in falls, improved cognition and a trend towards less aggression. Withdrawal of diuretics was generally well tolerated unless heart failure was present," the review says. But the team says there is a "pressing need" for more evidence.
The problem of bad prescribing has many causes. Older people cannot excrete drugs as effectively as a younger person, and more accumulates in their bloodstream.
Also, drugs are trialled on younger people but are mostly prescribed to those over 70.
"Take beta blockers for heart failure," Professor Le Couteur says. "Most of the trials were done in males aged in their 60s. But 90 per cent of admissions for heart failure are for people aged over 75, the majority women. To me this is as sensible as breast cancer chemotherapy trials being carried out in men."
Australia's specialists too often treat the disease not the person, and while GPs often feel powerless, they are also regarded as "independent professionals" with no official requirement to monitor their patients.
At the same time more preventative drugs are being marketed as essential, and to deny elderly people the possible benefits can seem ageist. Finally, many patients are disappointed if they leave a doctor's rooms empty-handed.
Dr Gibian says it takes a great deal of expertise "not to poison the elderly patient". And for his expertise, Don Ireland is thankful.