gms | German Medical Science

Forum Medizin 21, 45. Kongress für Allgemeinmedizin und Familienmedizin

Paracelsus Medizinische Privatuniversität in Zusammenarbeit mit der Deutschen, Österreichischen und Südtiroler Gesellschaft für Allgemein- und Familienmedizin

22.09. - 24.09.2011, Salzburg, Österreich

Drugs to be discontinued – why and how: the Garfinkel Method

Meeting Abstract

Search Medline for

  • corresponding author Doron Garfinkel - Geriatric-Palliative Department, The Shoham Geriatric Medical Center, Pardes Hana, Israel External link

45. Kongress für Allgemeinmedizin und Familienmedizin, Forum Medizin 21. Salzburg, 22.-24.09.2011. Düsseldorf: German Medical Science GMS Publishing House; 2011. Doc11fom214

DOI: 10.3205/11fom214, URN: urn:nbn:de:0183-11fom2147

Published: September 14, 2011

© 2011 Garfinkel.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

Text

Case reports of community dwelling elderly patients who consume many drugs will be presented to the audience for an open discussion. Then, the actual recommendations given to the patient will be presented along with the follow up and outcomes.

It is much easier to start therapies than to stop them. Patients are taking medications that might have been given at some point in their lives by physicians of different specializations who prescribed the medication for a specific problem in their field of expertise along single disease guidelines with no age limit. Family physician may be reluctant to review decisions, discontinue or change drug regimens determined by “experts” or from guidelines for younger populations. This may occur even when a long time has elapsed, new problems or medications accumulated, or physical changes occurred in the patient. It is also easy to overlook medication adverse effects on a background of complex co-morbidities. However, as age increases there is much less evidence based medicine showing positive benefit/risk ratio of most medications proven beneficial in reducing complications of chronic disease at a younger age. Patients may also have a life expectancy that is shorter than the time needed to benefit from specific drugs prescribed. Lately, an increased number of researchers warn that guidelines and pay-for performance incentives may drive clinician priorities to strive for better “numbers”, placing less priority on the well-being of older patients. Nevertheless, in many countries neither specialists nor the family physicians review all drugs in a search for interactions with drugs prescribed by other doctors; therefore a scheduled, formal drug reevaluation may never be performed.

There are good rationales for back-titration of drug dosages at an older age. For example, a patient who has received antihypertensive drugs or nitrates when still independent and active may not need the same regimen years later when disabled or frail, and with possibly reduced body mass. Overenthusiastic attempts to lower blood pressure may increase mortality and morbidity. Similarly, several authors argue that statins have no beneficial effect on all-cause mortality and morbidity, simply trading one source of morbidity and mortality. On the other hand, these medications may cause muscle weakness. Avoiding the morbidity associated with hypoglycemia rather than achieving perfect glycemic control should represent the main goal in frail elderly patients with diabetes and in those with short life expectancy; a less stringent target for lowering hemoglobin A1c level should be recommended. Similarly, the US Preventive Services Task Force found no evidence for recommending aspirin in people older than 80 years. Continuing Warfarin until death is also questionable in some elders for whom indication existed at a younger age. Many elderly patients continue to take benzodiazepines for sleep, H2 blockers or Metoclopramide for past dyspepsia or nausea, medications for past dizziness, preparations containing combinations of non-steroidal anti-inflammatory drugs, Propoxyphene, Caffeine, opioid derivatives, and/or antihistamines (ie, “anticold” preparations).

Rethinking and re-evaluation is needed for each and every drug in the elderly, including those used for symptom relief. Examples will be presented at the workshop followed by discussions open to the audience.