Kenneth Hubbard,1 an eighty-year-old retiree, was physically active and mentally alert. One day while shopping at a local mall, his wife urged him to get a cholesterol test. It came in high, so he decided to visit his physician.
Hubbard’s doctor looked at the results and without any further tests prescribed atorvastatin (Lipitor), a statin drug, which Hubbard began taking dutifully. About a month later, he was back in his doctor’s office, with complaints of joint and muscle pain and problems with his legs twitching at night, making it difficult for him to sleep. (These, in fact, were caused by the drug that Hubbard was taking.) “Well,” the physician said, “you’re getting on up there and probably have a little arthritis and restless leg syndrome.” Hubbard left with prescriptions for naproxen, a nonsteroidal anti-inflammatory drug, or NSAID, that he began taking twice daily for arthritis, and pramipexole (Mirapex), a dopamine agonist that he began taking at bedtime for restless leg syndrome.
Soon Hubbard’s stomach began to bother him—he was now buying Tums in 160-count containers—and his wife noticed some worrisome changes in his mental state. (Both problems, in fact, were caused by the new drugs.) Hubbard was soon back in his doctor’s office, accompanied by his wife, mostly to talk about his newfound confusion, hallucinations, and memory problems. “Well,” the internist said, “it isn’t unusual for someone of your age to have problems like this”—he walked them through the typical profile of Alzheimer’s disease—“so we’ll start you on a cholinesterase inhibitor to help slow down the process.” They left with a prescription for donepezil (Aricept), which Hubbard began taking the same day.
A month or so later, he was back in his physician’s office once again, this time complaining of not being able to play golf, drive his car, or lift his arms above his head, along with constant heartburn and stomach pains and general weakness and dizziness. (These too were all drug effects.) He feared that something was seriously wrong, but the doctor said reassuringly, “All old people have reflux and GI problems. We can stop the stomach discomfort with a proton pump inhibitor.” Hubbard left with a prescription for pantoprazole (Protonix).
By now Hubbard was a changed man. He complained of weakness, dizziness (especially when he stood after sitting or lying down), and lethargy. He stopped playing golf and mostly just sat around the house. Hubbard was reluctant to see his physician again, but his wife persuaded him to do so. During the visit, the doctor drew blood to check Hubbard’s hemoglobin, the iron-rich protein that carries oxygen from the lungs to the rest of the body. Seeing that the level was low, he started him on ferrous sulfate to build up his iron stores and improve the hemoglobin values. The doctor didn’t realize that because ferrous sulfate is acid sensitive, it can’t be absorbed in the stomach—and therefore useless—when given with the proton pump inhibitor, and, further, that his patient’s problems stemmed from malnutrition and blood loss.
A month later, during a follow-up visit, Hubbard’s physician found lower hemoglobin values, assumed that his patient had a twenty-four-hour virus, and upped the ferrous sulfate to three times a day. He didn’t think to check for Clostridium difficile diarrhea (C. difficile is a bacterium that can cause difficult-to-treat, life-threatening infections.) That, in fact, was Hubbard’s biggest problem, and it was brought on by the pantoprazole. That’s also why he was losing blood values and the essential vitamins and nutrients that are needed to sustain life.
Hubbard didn’t live to see his physician again. The death certificate showed that he died in his sleep, at eighty, from old age, with Alzheimer’s disease as a secondary condition.
In truth, Hubbard was the victim of unneeded medications, beginning with the introduction of the statin drug and culminating in the drug-induced stomach bleeds that ultimately led to his fatal—but unrecognized—internal hemorrhage.
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If you think that Kenneth Hubbard’s case is an aberration—something that could never happen to you, someone you love, or someone you know—let me assure you that it isn’t. There’s even a medical term for what happened to him. We call it the “prescription cascade,” where the adverse effects of drugs are misdiagnosed as symptoms of another medical problem, resulting in additional prescriptions and additional adverse effects and additional unanticipated drug interactions. As the consequences of the cascade pile up, further mistakes are all but inevitable.
Adverse reactions from prescription drugs are now the fourth-leading cause of death in the United States, after heart disease, cancer, and stroke, and that’s not counting the drug-induced deaths that are mistakenly attributed to illness or disease or are otherwise chalked up to natural causes (as in Mr. Hubbard’s case). Prescription drugs are estimated to cause at least 100,000 deaths a year, and they injure another 1.5 million people so severely that they require hospitalization.
Older Americans are most at risk. The risk of prescription drug errors is seven times greater for people sixty-five and older than for younger people, according to Medco Health Solutions, a pharmacy benefits manager. While people sixty-five and older account for just 13 percent of the nation’s population, they account for more than a third of all reported adverse drug reactions. Little wonder: many of them are on a mind-numbing and body-numbing array of powerful and often dangerous medications that have been prescribed by doctors who don’t fully understand the changing body chemistries of older people.
I am a pharmacist who specializes in geriatric medicine. I consult with older patients and their families about whether they’re taking the right prescription drugs in the right doses. I do this because too many older Americans are being prescribed drugs that their bodies can’t handle, and, as a result, they’re getting sick and dying sooner than they should.
In the pages that follow, I’ll explain to you what everyone—doctors, patients, and especially their family members—should keep in mind about how our bodies change with age. I’ll show you why these changes need to be taken into account when prescribing medications to older patients, and the catastrophic results that can occur when they’re not.
I’ll walk you through many of the medications that pose the biggest threats to older people, and if you’re a patient or family member, I’ll give you specific questions to ask a doctor in order to ensure you or your loved one is getting the right medication in the right dosage. Armed with the information laid out in this book, you’ll be able to ask questions in an informed and nonconfrontational way, so that you can maintain a respectful relationship with your doctor.
Older age can be a complicated and tough road to navigate. I speak from experience: I’m seventy-three. But it doesn’t need to be made worse with an unnecessary or damaging mix of prescription drugs. Let’s face it: we live in a culture in which it’s much easier to prescribe a pill to control a symptom than to find out the real source of one’s illness. And, unfortunately, the state of our nation’s health care system promotes only this quick-fix response to illness—an approach that I call “cookbook medicine.”
As a patient and as a consumer, you have every right to defend yourself from these shortcuts as you seek care for yourself and for those you love. I hope this book will help arm you with much of the same information that I have passed along to the many thousands of patients I have consulted with over the years.
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I met Kirk Williams in 2006 after taking care of his mother, a retired college professor in her nineties who had been in a nursing home in Blairsville, Georgia, about two hundred miles away from him. A doctor had told him that his mother was dying and that he might want to move her closer to him for the last few months of her life. He moved her into a nursing home that I visit once a month.
I happened to be there the day she arrived, and I reviewed all of her medications—about sixteen drugs. I recommended that all but two of them be stopped, and the doctor and the nursing home, with whom I’ve had a close working relationship, did so.
A few months later, Mr. Williams came to the nurses’ station and asked for the name of the doctor “who saved my mother’s life.” He explained that his mother had come to the nursing home to die, but that after the doctor had cut out all her medications, she was no longer confused and was “doing great”—to the point where she was able to spend weekends with him and his family. He was astonished, apparently, that his mother’s drug bill had been reduced by $1,100 a month.
The nurse at the station that day told Mr. Williams that it wasn’t a doctor who’d cut the medications but the nursing home’s consultant pharmacist (me). He asked for my telephone number, called, and made an appointment to see me in my office in Griffin.
He drove about two hundred miles to see me, and I reviewed his own drug therapy. At sixty, he was having multiple problems consistent with his type 2 diabetes and cardiovascular disease (he’d had a heart attack a few years back). He complained of his hands, feet, and fingers always tingling, feeling numb, or burning, sometimes with sharp pains. He was feeling so weak and fatigued that he couldn’t exercise and was having dizzy spells in the morning and during the night when he’d get up to go to the bathroom. He was also having frequent headaches.
A little while later, I gave Mr. Williams my report, which ran to twenty-three pages and included recommendations for changes in his drug therapy. At the top of the list was discontinuing metformin (brand name, Glucophage), a drug used to treat diabetes that shouldn’t have been prescribed in the first place because of his impaired renal function (as shown by his low creatinine clearance), and replacing it with another antidiabetic drug. I could easily tell that his fatigue and dizziness were consistent with prolonged hypoglycemia, or low blood sugar, and that one of the blood pressure medications prescribed to him—carvedilol (Coreg), a beta-blocker that doubles as an alpha-blocker—was only making things worse. In addition to exacerbating his hypoglycemia, it was also, in all likelihood, responsible for his peripheral vascular disease and, most of all, the symptoms of Raynaud’s disease (the numbness and tingling in his extremities). I recommended the use of diltiazem (Cardizem), a benzothiazepine calcium channel blocker, instead.
Mr. Williams later told me that his cardiologist, on being presented with my recommendations, became visibly enraged, saying that he was going to report me to the state for practicing medicine without a license. And his family physician, who had him on $600 to $700 a month of “nutraceuticals”—food-based dietary supplements and other products—that she was selling him out of her office, had a milder but similar reaction. Both doctors refused to consider any of my recommendations.
Eventually, with my help, Mr. Williams found a physician who agreed with my recommendations and, over a period of weeks, implemented all of them. A few months later, Mr. Williams was back in his cardiologist’s office for a follow-up and mentioned how much better he felt. The cardiologist responded by telling Mr. Williams that he was going to die and that his bloodwork would prove it by showing how much his cardiac enzymes had deteriorated as a result of my recommendations.
As it turned out, Mr. Williams’s cardiac enzymes looked better than they had since his heart attack. His bank account was looking a lot better too. He was saving around $1,100 a month from all the prescription drugs and expensive vitamin preparations that we’d stopped.
For every patient like Kirk Williams that I’ve been able to help over the years, I know that there are countless others who never even realize that they’re being mismedicated or overmedicated. I hope that for at least some of them, this book will be a wake-up call.