Medicine

A crutch that cripples at an age when it hurts

Brenda Rabkin March 19 1979
Medicine

A crutch that cripples at an age when it hurts

Brenda Rabkin March 19 1979

A crutch that cripples at an age when it hurts

Medicine

"Gace” is an attractive, wellgroomed 67-year-old Winnipeg resident who feels she has outlived her usefulness. Her children are grown and live far away. Her husband is retired, and spends most of his day at home “getting underfoot.” She has been on anti-depressants, tranquillizers and sleeping pills for the past five years. Recently “Grace” discovered she was getting forgetful and unsteady on her feet. She fell and broke an ankle. Despite all the mood medicine she was taking, “Grace” became even more depressed. Finally, her doctor advised her to throw away all her pills. She followed the advice for a week, then resumed her pill taking. “I just couldn’t manage,” she recalls. “I was nervous, depressed and I couldn’t sleep a wink.”

“Grace” is one of hundreds of thousands of elderly Canadians who face increased risks from drug complications—and their numbers are growing. The over-65 group represents eight per cent of the population, according to Statistics Canada, but accounts for 25 per cent of drug consumption. By the year 2000, the over-65s will make up 12 per cent of the population—and researchers

fear their drug use will rise accordingly.

“Grace,” however, is far more than a statistic. Her case is a living example of what Dr. Jack MacDonell, head of geriatric services of Winnipeg’s Deer Lodge Hospital, calls the “potential dangers of casual and uninformed drug taking. Old people are particularly at risk,” says MacDonell, flinging down 18 different medical preparations confiscated from an elderly patient, “because they have so much of the stuff lying around that they’ve accumulated over a period of time.”

MacDonell and other Canadian geriatric researchers can only guess at the real extent of the problem: statistics only indicate old people’s use of drugs is increasing and there is no accurate tally kept on the number of users who abuse their prescriptions. Moreover, little pertinent research has been done in Canada, where geriatric medicine is not recognized as a specialty; most studies relevant to Canada’s geriatric problems originate in Britain and the U.S.

Research that is available has defined three major factors contributing to the abuse problem: drugs can have a substantially different effect on the

body of an older person than on a young person; the poor quality of life enjoyed by older people, which often aggravates the variety and extent of physical ailments; and the often casual way that drugs are prescribed and administered.

Because the rates of metabolism, absorption and excretion may be slower in the body systems of an older person, says MacDonell, the way in which he will respond to a drug may be different. The instructions may say, “Take four times a day,” but these may have been derived from trials done on much younger people. The longer a person lives, the more diseases he is inclined to accumulate and the greater variety of drugs that are used to combat them. The consequences of this “geriatric confectionery,” as it is called in a British study, worries researchers. Dr. Paul Mitenko, head of clinical pharmacology at the University of Manitoba, cites the case of a patient indefinitely on a fixed dosage of the heart stimulant digitalis, one of the most commonly prescribed drugs for the elderly in Canada. The physician didn’t take into account that the patient’s kidney function declined with age, so the originally effective dose became unsafe. Says Dr. MacDonell: “The physician is going to have to be educated that the body of an older person just works differently.”

But researchers say the problems of taking drugs accurately are even more significant. As long ago as 1968, a British study showed that when geriatricians assessed their patients and compared the drugs they were originally prescribed with what they were actually taking, more than half had deviated from the dosage. The study indi-

cated the elderly can effectively take an average of only three preparations simultaneously. Yet a 1977 British study showed that 24 per cent of elderly patients were on more than three drugs regularly. To make matters worse, a 1968 study by Dr. Norman Hurwitz of New York City Hospital showed the rate of adverse drug reaction is more than twice as great among the over-60s as those under 60.

According to Canadian researchers, older people don’t get much help from the medical profession or the community to facilitate accurate drug taking. The U.S. journal Clinical Pharmacology and Therapeutics notes: “In our society, better instructions are provided when purchasing a new camera or automobile than when the patient receives a lifesaving antibiotic or cardiac drug.”

The way in which drugs are labelled and packaged doesn’t help either. “Take as directed” isn’t of much use to an older person with a failing memory, says Mitenko, and “Take before meals” implies that meals are eaten regularly, whereas in fact many older people eat erratically. Far too often, he says, the directions are typed in small print which many elderly people cannot read. More than half of Canada’s blind population of over 32,000 are over 65, and an even greater number in that age group have failing eyesight. It is no simple task for people with arthritis or rheumatism to open child-proof bottles or bubble packs. A 1977 British study indicates that the most satisfactory container is palm-sized, of transparent material, with a screw or snap top. “The way in which drugs are made available to elderly people,” says Dr. Mitenko, “is

just another indication that, in general, we do not anticipate their needs.”

But researchers say perhaps the key issue underlying the problem is one of poor lifestyle and unrealistic expectations. They say that because of the social and psychological stresses that old people are subject to, they come to their doctors with poorly defined but persistent symptoms that are often a manifestation of their feelings of loneliness and rejection. Says MacDonell: “For an elderly person, a pill is often a substitute for companionship.” The public commonly expects drugs not only for every disease, but for every symptom, maintains Mitenko, “and doctors rein-

force this by widely prescribing drugs.”

In Manitoba alone, for example, over 56 per cent of women and 42 per cent of men over the age of 65 in a study of heavy drug users—defined as those who use more than $50 worth of drugs a year—take tranquillizers regularly.

“Sure I know that it’s a quality-of-life issue,” says Mitenko. “But when an older patient comes to me because he’s alone, he has nothing to look forward to, and he’s depressed, I have two choices: I can give him a mood-altering drug so that will lessen his depression, or I can do nothing. But I don’t have the power to bring about a change in his life’s circumstances.” Brenda Rabkin