I must admit that I am not sure what to make of Dr Gallagher’s article, “Real doctors treat more than one species,” in the January/February issue [BCMJ 2016;58:44-45].
The analogy of the appropriateness of using different medications in different species in veterinary practice combined with a simple classification of groups of human patients based on age suggests the use of a simple, one-size-fits-all system of medicating frail geriatric patients. In medical practice, however, I have found that treatment decisions tend to be complex and prevent the use of simple treatment protocols. While special care must be used in prescribing medications to geriatric patients, polypharmacy or the simultaneous use of multiple medications should not be described pejoratively because in many cases it is entirely appropriate. Interestingly, Dr Gallagher notes that a few medications account for a significant percentage of adverse drug reactions in the elderly but, not surprisingly, these same medications largely overlap with a list of four high-alert medications accounting for the most frequent and severe adverse drug reactions in hospital patients at any age. In contrast, drugs on the ubiquitous Beers list account for less than 9% of adverse drug reactions in elderly patients presenting to the ER. In addition, there are concerns that using a broad stroke to vilify the use of multiple medications in geriatric patients can result in underuse of beneficial medication in the elderly.[3,4]
In closing, the foregoing suggests to me that older, frail patients need a detailed, individualized review of their medications in all situations to optimize their outcome, and that a cookie-cutter approach is ill advised. Perhaps rather than looking to veterinary science we should look to physics for advice on how to approach complex medical issues. Dr Einstein’s recommendation that we should simplify everything as much as possible, but no more, is appropriate in all situations.
—Aidan Byrne MD, FCFP
1. Institute for Healthcare Improvement. How-to guide: Prevent harm from high-alert medications. Accessed 24 February 2016. www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedi....
2. Hitzeman N, Belsky K. Appropriate use of polypharmacy for older patients. Am Fam Physician 2013; 87:483-484.
3. Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med 2004;140:714-720.
4. Gotto Am Jr. Statin therapy and the elderly: SAGE advice? Circulation 2007;115:681-683.
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