Too Many Medications
When polypharmacy becomes the real problem
I shook my head as the elderly woman was wheeled into the exam room, holding a large brown paper bag in her lap. I was the only doctor in the urgent care department of an HMO, assisted only by two nurse practitioners. The sore throats and other minor cases went to the nurse practitioners, while I got all the complex medical problems. Since I was the supervising doctor, this scenario made sense. But at the time I resented that I had a mere 15 minutes per patient, during which I was supposed to take a history, do a physical exam, make a diagnosis, prescribe a treatment, explain it all to the patient, and then dictate the chart. In addition, because I was supervising, I needed to discuss the nurse practitioners' cases with them as well.
When treating elderly patients who are unaccompanied by someone knowledgeable about their medical history, just figuring out what medications they take and why they take them can last more than 15 minutes. This particular lady, who I'll call Helen, refused to get out of her wheelchair. "Why should I if you're only going to spend thirty seconds with me," she barked. I took the grocery bag out of her lap and dumped it onto the exam table. "Twenty!" I blurted out, after which Sandra, the nurse helping me that day, quickly added, "No, sixteen!" We had a standing bet that whoever guessed the number of medication vials correctly got treated to lunch. "Both wrong," Helen said as she stared at the wall, "The correct answer is eighteen."
Sandra and I looked at each other. Helen had an orange sticker on her chart that said, "Blind," under which somebody had scribbled "Demented" and "Combative" in red ink. But she knew exactly what was going on. I felt embarrassed that she actually understood our game.
"Helen," interrupted Sandra, "it says here that your chief complaint is 'not feeling good.' Don't you think this could have waited for your primary doctor?" "Primary shrimary," mocked Helen, "I feel like shit and nobody can figure it out." I asked Sandra to excuse us and sat down with Helen to try to get to the bottom of things by taking an accurate history. I emerged a half-hour later realizing Helen would probably be spending the entire afternoon with us; I still hadn't gotten past the death of her husband, which had occurred 10 years previously. I darted in and out of exam rooms, leaving charts to dictate for the evening, and joined Helen in her exam room whenever I could to continue with her assessment. Sandra made her tea and gave her crackers from the vending machine.
Helen's story could be recounted through a string of prescription medications. Two years previously, she had gone to her eye doctor, who diagnosed her with glaucoma. He prescribed an oral medication called acetazolamide, which causes nausea and a severe loss of appetite. Helen's weight dropped from 111 pounds to 88 pounds during an eight-month period. She then consulted her primary doctor, who diagnosed her with "anorexia due to depression" -- even if her doctor was aware that she was taking the glaucoma medication, he probably wasn't familiar with its systemic side effects. He prescribed the antidepressant desipramine. A possible side effect of desipramine is constipation, and Helen's constipation proved to be severe. After two visits to the emergency room for treatment of fecal impaction, Helen went to a gastroenterologist who prescribed the laxative lactulose. He apparently did not know that Helen had diet-controlled diabetes; lactulose is actually a sugar. Helen's diabetes worsened and could no longer be controlled by diet alone, so her primary doctor put her on glyburide, an oral diabetes medication.
Part of a generation that didn't dare question a doctor's orders, Helen continued to take all the medications her doctors had prescribed to date, including the diabetes medication. At one point, because she was still not eating well and remained on the diabetes medication, she had a severe hypoglycemic episode (low blood sugar) that led to a generalized seizure. Believe it or not, Helen was then put on an antiseizure medication called phenytoin, which caused a profound change in her personality, including moodiness and agitation, as well as slurred speech and an unsteady gait. Incredibly, her doctor kept her on the phenytoin, as well as on all the other medications, and put her in a wheelchair.
Helen's case is actually not an unusual one. She was a victim of polypharmacy, the overprescription of medication. What she needed was simple: a doctor who had the time to listen instead of addressing each new symptom with yet another drug. The emotional and financial costs of her care were exorbitant, as was the cost to her health -- Helen nearly died. And this happened in a country that is considered to have the best-quality health care in the world. Helen's case was appalling; every doctor I know would agree. But I wonder how many patients like Helen we have let slip through the cracks.
Helen now lives alone and is no longer in a wheelchair. She still sends me a Christmas card every year. She can even see again because she had surgery to correct her severe cataracts. The only medication she takes now is drops for her eyes. And maybe an aspirin or two.