Deprescribing Medications for Older Adults
Paring down bloated drug regimens enhances health, safety and quality of life.
According to an article in the Journal of Family Practice, more than one-third of U.S. adults in their early 60s and older take at least five prescription medications.(GETTY IMAGES)
MANY OLDER ADULTS TAKE too many prescription drugs or take them at too-high doses. Prescriptions started long ago to treat temporary medical conditions somehow never get stopped. Other preventive drugs may offer little to no benefit after a certain age and bring unacceptable side effects for older users.
A movement is underway to eliminate excess medications that are more likely to harm than help older patients. Known as deprescribing, it comes down to thoughtfully evaluating and rightsizing individual drug regimens that build up for patients in the course of their lives.
Polypharmacy, or overmedication, is defined in a variety of ways. One commonly used threshold is a medication routine involving five or more different drugs. Patients may accumulate much higher drug totals, according to Cynthia Blevins, a certified registered nurse practitioner at Penn State Health General Internal Medicine of Lancaster. Blevins, a strong proponent of deprescribing, is also an adjunct professor with the nurse practitioner program at Millersville University in Pennsylvania.
It’s not just a matter of counting pills. The larger issue is people taking medication they don’t need.
Blevins describes a patient who came in for admission to a nursing home where she practiced. Earlier in life, he was obese and had high blood pressure. But circumstances changed and he lost a significant amount of weight – yet he still was taking four antihypertensive drugs. As a result, his blood pressure was dangerously low. “Nobody was following up on or carefully tracking him,” she says. Once these medications were cut, his blood pressure became stable.
More than one-third of U.S. adults in their early 60s and beyond take at least five prescription medications, according to a review article in the July 2017 issue of the Journal of Family Practice. The study, led by Dr. Kathryn McGrath, a geriatrician and an assistant professor affiliated with Thomas Jefferson University Hospitals in Philadelphia, gives health care providers a roadmap for deprescribing.
An unintended but vicious cycle can lead to overmedication. “Polypharmacy often occurs when an adverse drug effect is misinterpreted as a new medical problem – leading to the prescribing of more medication to treat the initial drug-induced symptom,” the authors explain.
Death By Prescription
Drug interactions can worsen fluid retention for people with heart failure, increase stroke risk in people with dementia, further damage kidney function in people with kidney disease or worsen urinary problems such as retention or incontinence.
Research on the health benefits of deprescribing is ongoing, but findings so far are promising. After deprescribing, patients have been shown to have fewer falls, improved cognition and greater satisfaction.
Talk to your health care providers and pharmacist about trimming your medication list down to size. Here’s how deprescribing works.
Identify your medication “quarterback.” Your primary care physician or nurse practitioner – your regular health care provider – is likely the best choice for re-evaluating your medication collection. After you’ve been discharged from the hospital or have seen a specialist, your regular provider can sort out new drug orders.
“Often, the cardiologist has not paid attention to what the rheumatologist has prescribed,” says James McCormack, a professor in the faculty of pharmaceutical sciences with the University of British Columbia in Vancouver, Canada. “The rheumatologist has not paid attention to what the psychiatrist has prescribed. That’s where everything goes to hell in a handbasket.”
Talk to your pharmacist. Your community pharmacist can alert you to medication hazards and identify drugs that could be safely tapered and eliminated. Maximizing quality of life for older adults is a primary goal of deprescribing, says Tasha Woodall, the associate director of pharmacotherapy in geriatrics with the Mountain Area Health Education Center in Asheville, North Carolina.
Bring in all your medications for review. A massive collection of medications in their respective containers makes a powerful case for deprescribing. To do so, clinicians use specific deprescribing guidelines and algorithms to evaluate and prioritize your medications.
Re-evaluate dosages. Your body’s ability to break down and eliminate drugs decreases by about half from age 30 to 70, McCormack says. “Probably three-quarters to 80 percent of all side effects are due to doses: giving too much,” he says. Reducing doses as people get older is a major component of proper prescribing and deprescribing.
Consider lifestyle alternatives. Instead of taking a statin, you could realize as much or more benefit by exercising and eating in a healthier way to lower your risk of a heart attack or stroke. Similarly, doing these lifestyle changes will likely reduce borderline high blood pressure without the side effects of antihypertensive drugs.
Ask whether benefits are meaningful. Among people who’ve never had a heart attack or stroke, only about one to three of 100 will benefit over five to 10 years from taking a statin or blood-pressure drug, McCormack says. Whether that preventive boost is worth it depends on the individual, he says: “There’s only one person who can decide that – and that’s you.”
Take a hard look at risks. Older adults with an irregular heartbeat called atrial fibrillation are often prescribed blood-thinning, or anticoagulant, drugs to reduce their risk for stroke. However, warfarin and other anti-clotting pills carry bleeding risks. Doctors and patients should weigh these risks together.
Be cautious with sedatives. Cutting back on insomnia or anxiety drugs like Xanax and Ativan is a good starting point for deprescribing, Woodall says. Any medication that affects the central nervous system – including sedatives, antipsychotics and antidepressants – should be carefully reconsidered.
“A lot of those medications continue to be appropriate for somebody’s entire life,” Woodall says. “But the cumulative effect of having someone on three, four or five of these psychotropic medications that impact their brain can spell out a recipe for disaster in terms of falling and cognitive decline.”
Pay attention to antacids. Antacid drugs known as “proton pump inhibitors,” such as Nexium, Prilosec or generic omeprazole provide short-term relief for gastrointestinal issues like acid reflux or heartburn. However, long-term use tends to accelerate bone loss, Woodall says.
Long-term use of PPI drugs also puts older adults at risk for infection with Clostridium difficile bacteria, Blevins notes, which can cause severe gastric problems. Pneumonia is another potential C. difficile side effect.
Don’t overlook OTC drugs. It’s also important to sift through any over-the-counter drugs and products. For instance, using Benadryl as a sleep aid, which many seniors do, is discouraged. Vitamins, dietary supplements, herbal remedies and even topical creams and gels should be scrutinized, too.
Think about cost. Reducing costs is another benefit of eliminating unneeded medication. For drugs that do help, switching to generic versions is another way to cut costs.
Eliminate medications with care. By discontinuing only one medication at a time, you and your health care team can keep a close eye on how that affects you. In many cases, gradually reducing the dose on a tapering schedule is safer than abruptly discontinuing the medication.
Deprescribing isn’t a one-time measure, but a process, Woodall says: “We continue circling back with the patient. Sometimes we have to add things back that we tried to get rid of. Other times it’s very successful and we keep going and peeling things away the best that we can.”
Older Adults Don’t Get Enough of This Important Nutrient
According to a new study, more than one-third of adults lack a key source of nourishment.
Are You Getting Enough of This Nutrient?
Experts recommend spacing out proteins evenly during the day, but there is no definitive answer on the right amount of protein needed for optimal health.(GETTY IMAGES)
LATELY, IT SEEMS LIKE every diet is a high-protein one. But according to new research, more than one-third of older adults still aren’t getting enough protein to maintain muscle health, combat age-related weight gain, prevent the development of Type 2 diabetes and heart disease and live longer, healthier lives.
Presented at the American Society for Parenteral and Enteral Nutrition 2018 Nutrition Science & Practice Conference, the study evaluated the dietary patterns of 11,728 men and women age 51 and older. The study’s researchers from Ohio State University and the Abbott health care company found that roughly 40 percent of the participants didn’t meet current daily protein recommendations.
The older the subjects were, the less likely they were to get enough protein, according to the study’s findings. Approximately 37.7 percent of those ages 51 to 60 years old did not meet requirements, while 46.2 percent of adults over age 70 got less than the recommended daily allowance. What’s more, up to 10.7 percent of adults were at least 30 grams shy of their nutrition goals, explains Suzette Pereira, research scientist and muscle health expert at Abbott, who was not involved in the study.
While the results are pretty shocking to everyday dieters, they aren’t surprising to researchers. “Both American and European cohort studies demonstrate that older adults are at risk of not meeting dietary protein recommendations,” says Oliver Witard, a protein metabolism researcher and senior lecturer at the University of Stirling in Scotland.
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For example, in one 2012 study published in the European Journal of Nutrition, researchers found that up to 10 percent of older Dutch adults living independently and 35 percent of those in institutional care fail to meet their daily protein targets.
Why Older Adults Still Aren’t Getting Enough Protein
“Meal skipping may be part of the problem,” Pereira says. In the recent study, 75 percent of the adults who met their daily protein goals ate three meals per day, while roughly 60 percent of adults who weren’t getting enough protein regularly skipped at least one meal, she explains.
Witard notes that hunger levels naturally decline with age. “To compound this issue, protein-rich foods exhibit greater satiety value than carbohydrate- or fat-rich food sources,” he says. In the study, older adults who did not meet their protein needs ate fewer greens, beans and dairy, but incorporated more refined and added sugars into their diet.
Appetite and fullness aside, “several other factors, including physical and mental disabilities that limit shopping, food preparation and food insecurity due to financial and social limitations may also make it difficult for older adults to consume sufficient protein,” he says. Preparing protein-rich foods is often a time- and energy-intensive process, while most pre-prepared and packaged foods – a mainstay of the average American’s diet – tend to be low in protein and high in refined carbohydrates, Pereira adds.
How Much Protein Is Enough?
Most people don’t have a clear-cut answer on the right amount of protein needed for optimal health. “In a 2016 AARP-Abbott survey, 62 percent of adults thought they were getting enough protein, but only 17 percent knew that actual amount,” Pereira says. Current federal recommendations include eating a minimum of 0.8 grams of daily protein per kilogram of a person’s body mass per day. That equals about 0.36 grams of daily protein per pound of body weight or, for a 150-pound person, 54 grams of daily protein.
However, both Pereira and Witard emphasize that mounting research shows those recommendations are far from sufficient. “Your protein needs change based on things like age, gender, activity level or illness – and our current recommendations don’t take that into consideration right now,” she says. In a 2015 study of older adults published in the American Journal of Physiology–Endocrinology and Metabolism, those who ate double their recommended daily allowance of protein improved both their muscle protein synthesis (the process in which cells use protein to build muscle) and net protein balance, the difference between muscle protein synthesis and your muscle protein breakdown.
That’s important since the average person begins breaking down more muscle than they build by age 40, according to Witard. “Thereafter, the average rate of muscle mass loss is estimated at 8 percent per decade until the age of 70 years, increasing to 15 percent per decade in octogenarians and beyond,” he says. According to 2013 research review published in Muscle, Ligaments and Tendons Journal, after age 50, leg lean body mass declines by 1 to 2 percent per year, with leg strength declining 1.5 to 5 percent per year. “Hence, most individuals 70 to 80 years old possess only 60 to 80 percent of the muscle mass they had at 30 years old, declining to 50 percent in octogenarians,” Witard adds.
For that reason, Witard says that older adults get 1.2 to 1.5 grams of daily protein per kilogram of their body mass. That works out to about 0.54 to 0.68 grams per pound of body weight or, for that same 150-pound person, 82 to 102 daily grams.
He also recommends spacing out proteins evenly through the day, with 2017 research published in The American Journal of Clinical Nutrition showing that adults ages 67 to 84 who spread out their protein intake throughout the day tend to have stronger, healthier muscles than those who get the bulk of their protein in one meal. A 2016 Biogerontology study co-authored by Witard found that older adults should consume 0.4 to 0.5 grams of protein per kilogram of body mass (or 0.18 to 0.23 grams of protein per pound of body weight) at each of their three daily meals. That’s the equivalent of 27 to 34 grams of protein three times per day.
A person’s levels of muscle mass impacts more than strength. “Skeletal muscle is the largest organ in the body and provides the main reservoir for glucose disposal,” Witard says. By helping to manage glucose, or blood sugar, muscle plays a major role in the prevention of insulin resistance and Type 2 diabetes.
“The amount of muscle you have also has an impact on health outcomes,” Pereira says. “Your muscle health can impact your immunity as well as your risk of hospitalization or recovery. When you look at chronic diseases, there’s a lot of emerging research in the oncology space. For example, research shows patients with cancer who have high amounts of muscle live longer because they can tolerate their chemotherapy drugs better than those with lower muscle mass.” Strong muscles also help older adults maintain their mobility, independence and reduce their risk of falls and bone breaks, she adds.
Studies suggest that the cumulative effect is an overall longer, healthier life. According to 2017 research published in the peer-reviewed journal PLOS One, in men ages 40 to 90, larger mid-arm muscles (think: biceps and triceps) were significantly less likely to die from any cause within the study’s 14.3-year follow-up. And, according to a 2014 the American Journal of Medicine study of 3,659 older adults, lean muscle mass was a strong predictor of longevity.
Track Your Protein Intake for Better Health
Knowing how much protein you need is not enough for good health. You also need to know how much you are getting.
To do so, try keeping a food journal. Record what you eat for each meal, adding up your grams of protein per day to see what your current average daily protein intake is and how it might need to change, Pereira says.
She explains that the protein content of packaged foods appears on their back label. When eating whole foods, which should make up the majority of your diet, you can easily find the protein content by typing your food’s name and “nutrition” into a search engine such as Google. Generally, the first result will be a full nutrition panel from the U.S. Department of Agriculture. Online food trackers and apps, such as MyFitnessPal or Fooducate (available in the Apple App Store and Google Play Store), can also help.
It can be time-consuming, but ideally keeping a food journal isn’t something you have to do over the long term. Tracking for even a few weeks can drastically improve nutritional awareness and understanding, so that you’ll be able to more intuitively get the protein you need for decades to come.
High-Protein Breakfast Ideas
Americans once wanted to live to an old age. Now, as people are living longer than ever, they want to age well.
Each day, more than 10,000 adults are turning 65, and by 2060, nearly one in four Americans – 98.2 million people – will be 65 or older. (Florida and Maine are nearly there.) And a sizable chunk of those older U.S. residents across the country – almost 20 million – will be at least 85 in 2060, according to U.S. Census projections.
With that shift has come an increasing focus among researchers, health care professionals and commercial brands alike on how to help older Americans age healthily and comfortably in their own homes.
At the forefront of that movement have been high-tech companies with innovations designed to look after older adults and improve their quality of life, with inventions ranging from a smart refrigerator that orders food from the grocery store after sensing there is not enough, to remote monitoring devices and apps that allow people to check in on their older family members.
At the same time America is graying, older generations are using technology in increasing numbers. Forty-two percent of the nearly 50 million adults 65 and over today own smartphones, a sharp jump from the 18 percent who had smartphones in 2013, a survey from Pew Research Center found. And 79 percent of older adults say the lack of internet access is a serious disadvantage.
“Older adults don’t adopt new technologies quite as quickly as younger people,” says Elizabeth Zelinski, a technology and aging expert at the University of Southern California. “But one of the ideas we have with technology adoption is that if people find it useful, and it’s accessible – meaning it’s cheap enough, it’s easy enough, it’s ubiquitous enough – people will adopt it.”
Over the next two decades, overall spending by people 50 and older is expected to increase 58 percent, while spending by Americans 25 to 50 will grow by only 24 percent, according to a 2013 investment report from the AARP. And because baby boomers – Americans born between 1946 and 1964 – spend the most across all categories, particularly health care, “this market is too big to ignore,” the report said.
Within the burgeoning movement to create high-tech products geared toward older Americans, there’s an emphasis on health, social well-being and safety. And the nation’s $3 trillion-per-year health care industry is closely monitoring tech innovations that could prevent falls or other accidents and alleviate health risks, particularly as the number of health care workers has dwindled in recent years.
Falls are the leading cause of injury and death among older Americans, according to the Centers for Disease Control and Prevention, contributing to about 27,000 deaths annually. In 2014 alone, older Americans’ 29 million falls resulted in 7 million injuries and cost about $31 billion in annual Medicare costs.
Fall-detection wearables that can call for help are nothing new – think Life Alert’s“Help, I’ve fallen” pendants that have been around since the late 1980s – but implementing the same technology into sleeker, more attractive devices may entice older Americans who find the pendants stigmatizing and unattractive, says Laurie Orlov, who has been analyzing industry trends since 2009 for her blog, Aging in Place Technology Watch.
Sensosafe, for example, recently released a smartwatch that monitors the wearer’s heart rate, step count and can even call a designated family member if he or she falls. The watch allows family members to monitor an older person’s safety while maintaining their privacy and independence. While only a small share of adults 65 and older owned wearables in 2016, according to an AARP survey, those rates will likely increase as the devices become more commonplace.
“A lot of older people feel that their children are worrying about them too much, and the younger people are saying, ‘Well, I want to make sure Mom’s OK,’ but the difficulty is getting to the right balance between privacy and security,” Zelinski says.
As older Americans increasingly live alone, concerns arise regarding their security and health. About one-third of Americans 65 or older live alone, according to the Institute on Aging. Women are twice as likely as men to live on their own – nearly half live alone by the time they hit 75. Social isolation and loneliness contribute to poor health outcomes, including depression and declining mobility, according to a report published by the National Center for Biotechnology Information.
Branding its product ElliQ as the “active aging companion,” Intuition Robotics hopes to alleviate some of those social and health problems. ElliQ, a tabletop robot that uses artificial intelligence and speaks with a female voice, is designed to simplify communication and other social interactions for older Americans.
Rather than waiting for the user to start the interaction, ElliQ suggests activities to keep older Americans engaged and active. If Grandma has a game of bridge on the calendar, for example, ElliQ will offer to practice with her, or if the weather is nice, ElliQ will suggest going for a walk. Intuition Robotics plans to commercially release the robotic companion in 2018.
“If you look at [Apple’s] Siri or something like that, the goal for us as users is A) for us to initiative the conversation, and B) for it to be completed as quickly and efficiently as possible,” Intuition Robotics CEO Dor Skuler says. “ElliQ has much more of a persona attributed to her, whether it’s her ability to show body language to communicate … or her ability to personalize her approach to different people based on what she learns about them.”
Skuler says ElliQ’s use of emotional intelligence and body language make the device feel more natural for older Americans who may be tech-averse. ElliQ’s proactiveness is what makes the device an asset for older users, Skuler says, because older people often fall into routines of passivity and inactivity. Research suggests that remaining physically active and social can help older Americans fend off health issues such as Alzheimer’s disease and high blood pressure, and can even increase longevity.
But Orlov says ElliQ and other tabletop robotic assistants designed specifically for the elderly may be missing the mark. Older people just need popular devices to allow for more personalization and easier-to-use interfaces, such as the “easy mode” on Samsung Galaxy phones that enlarges icons and simplifies the home screen, she says.
“Having standardized hardware and configurable software is what would make these devices simpler to use. There doesn’t need to be an entirely separate product,” Orlov says, citing controls that parents of young children can enable on their smartphones.
“Alexa,” the digital assistant built into the Amazon Echo, is an example of how a universal device can be tailored to meet the needs of its user. Older Americans can ask Alexa to remind them to take their medicine and adjust lights and temperature, for example, and their adult children can use the accompanying app to check in. The newest version of the device, the Echo Show, also includes a screen, allowing people to check their home security cameras and make video calls.
Orlov says that for older Americans to adopt new tech devices en masse, they must be affordable and unobtrusive, so another major draw for existing digital assistants is the price: The Amazon Echo starts at around $180, while the Google Home is even cheaper. There is no set price for ElliQ yet, but Skuler says his team is “targeting the product to be as affordable as other sophisticated consumer electronics products.”
American workers’ top retirement fear is outliving their money – not declining health or loneliness – according to a 2015 survey by the Transamerica Center for Retirement Studies, which may make older Americans wary of new products with high price tags. Still, Americans may find that the higher price tags of some tech devices are worth the splurge if they seem to make Grandma’s life easier – and their own by default.
“I think there’s a lot out there that can be very helpful,” Zelinski says. “And the older people who are most responsive to that have money.”
Editor’s Note: Growing old in America today looks far different than it did 10 years ago. Older people are working throughout their golden years, are living longer, and many are choosing to age in place. As baby boomers hit the 65 and older mark, the share of seniors in the U.S. is rising drastically. This series explores what it’s like to age in 21st century America, and the issues officials must address to keep up with the nation’s changing demographics and culture. U.S. News determined which states are best serving their growing senior populations in a new Best States for Aging ranking.
Corrected on Oct. 11, 2017: This article has been updated to correct the spelling of Intuition Robotics CEO Dor Skuler’s name.