Older Patients, Wiser Care
The woman had been taking Fosamax for osteoporosis for years. Was this right?
Last updated:March 22, 2010
The case: Suspicions about an old prescription
The elderly woman sat warily, her daughter reassuringly patting her shoulder. "I don't know why I'm here. Everything's fine," she mumbled in response to my greeting. She turned to her daughter. "Why are we here?"
"We're here to get a second opinion about your medicines," her daughter reminded her. It was the first of many times during the visit that she would re-orient Mrs. B, who was 83 and pretty forgetful due to moderate dementia.
"What do you think of these medications she's on?" the daughter asked as she thrust a list into my hands. "In particular, I'm worried about that weekly osteoporosis pill, alendronate [Fosamax], because now on the news they say it might actually increase fractures if you take it for a long time.
"You see," Mrs. B's daughter continued, "our family doctor started my mom on that pill years ago. But I'm not sure he ever did anything to diagnose her with osteoporosis -- or if he just gave it to her because of her age. I hate to pay for something every month she doesn't really need.
"My parents and I have been with this doctor for over 30 years. He knows us all so well! But sometimes I worry that maybe he's not keeping up with the latest information."
The challenge: How can you be sure you're receiving the "right" prescriptions?
Like many people who come to our geriatric clinic for a second opinion, Mrs. B's daughter wanted to check that her mother was being treated appropriately by her primary care doctor.
It's a legitimate concern. Research has shown that doctors often don't prescribe medications in accordance with accepted best practice. Occasionally this is a carefully thought-out decision on the doctor's part. After all, guidelines aren't always a good fit for a particular patient's case; medical care should always take into account an individual's particular situation and preferences.
But too often, when medications aren't prescribed according to best practice, it simply reflects lower quality medical care. Common causes include:
- Oversight -- it's often hard to get everything important done within a 15-minute visit.
- Falling behind on the latest medical knowledge "“ remember when hormone replacement therapy was all the rage, until new research came out on its risks? Keeping up with all the new research and guidelines can require as much time and attention as a second job.
- Undue influence from the pharmaceutical industry "“ even a practice as innocuous-seeming as giving doctors "education" materials and samples has been shown to influence prescribing.
In short, it's easy for even a caring and well-intentioned doctor to either not prescribe something that a thoughtful panel of fellow doctors would agree should have been given, or conversely, to prescribe something that isn't justified by current best practices.
And this is all assuming that the medical issue in question is one for which there is a pretty-well accepted standard of care for older adults. For some medical issues, experts have different opinions, and guidelines can vary depending on which group of experts wrote them.
Given that doctors are imperfect and human, how can patients and caregivers help ensure that the "right" medications are being prescribed?
The solution: Keep track of the purpose of each drug, and double-check with reliable other information sources
Fortunately for Mrs. B, her daughter was willing to invest a little extra time in understanding what meds her mother was taking and why. For instance, not only did she come to the visit with an up-to-date list of all medications, but she'd listed the purpose of each one.
Furthermore, when she noticed her mother's medication, alendronate, in the news, she'd followed up by doing some Internet research. And she'd then been concerned enough to seek the advice of geriatric specialists likely to be current on the matter. (Doctors in an academic medical center, as I am, tend to have more opportunities to keep up with current research.)
Together, Mrs. B's daughter and I reviewed her mother's use of alendronate, part of a class of drugs called bisphoshonates, which are recommended for treatment of osteoporosis. Osteoporosis is very common in elderly women, but current guidelines recommend proof that a person has osteoporosis before starting a bisphosphonate. As Mrs. B had never had a DEXA scan to assess her bone density, or an osteoporosis-related fracture, it did seem that perhaps her regular doctor had started the medication a bit prematurely. Because of [recent links] (http://www.nytimes.com/2010/01/05/health/05brod.html) of bisphosphonates with a paradoxical weakening of bones, some experts now recommend that women not use them for more than five years unless absolutely necessary. (Research studies are currently ongoing to answer this question more definitely.)
Ultimately, I suggested Mrs. B stop alendronate for now, and referred her for a DEXA scan to learn more about her bone density. I also recommended we check her vitamin D level, since low vitamin D is common in adults and has been linked not only to osteoporosis but also to falls and other common problems in frail elders.
"The good thing about our doctor is that he doesn't mind when I get a second opinion," Mrs. B's daughter told me as she left. I told her we'd be happy to see Mrs. B anytime; in our clinic we consider it part of our job to help people get the best care from their regular doctors.
My prescription for caregivers:
- Whenever a medication is prescribed, make sure you understand its purpose, why the doctor decided to prescribe it, and how long your loved one is expected to need the drug.
- Always bring an up-to-date list of all medications (including over-the-counter drugs and supplements) to every doctor visit. Better yet, bring the meds themselves in a bag.
- Write the purpose of each medication on your master list, or on its container. It's also helpful to keep track of when the medication was first started.
- Don't be afraid to get a second opinion about your loved one's prescriptions. Good doctors appreciate patients and caregivers who are engaged in monitoring their care.
- Understand that in some cases there may be uncertainty or even controversy among experts on how to best treat a certain medical problem. A good doctor should be able to briefly explain the main differing viewpoints, and should be able to explain the pros and cons of different approaches.
- Realize that even the best doctors occasionally let something slip. But if you notice a pattern of prescribing medications that don't seem to fit with your background research, or if the doctor otherwise seems "behind the times," consider making a switch. It can be hard for older people to part ways with a longtime physician, but this ultimately might be in their best interest.
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