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Medication management

A talk by Dr. Michelle Dhanak, M.D.


Story by Bob Waxman, photos by Pat Carvalho

 

 

Are you or a loved one juggling multiple medications at the same time? Have you accumulated a laundry list of prescriptions over a number of years and worry about their effect on one another? Are you wondering if they are all really necessary? Do you know where you can turn for answers and advice? On April 3rd, Dr. Michelle Dhanak, MD-Geriatrician addressed Ashby Village Members, Volunteers and guests on Medication Management for older adults and on the value of consulting with a geriatic specialist. An internist specializing in Geriatic Medicine, Dr. Dhanak returned to the Bay Area after working for ten years in New Zealand. She shares life with her daughter and cares for her 95 year old mother who is living with dementia. Dr Dhanak has been in practice as an MD for nearly 25 years. Unfortunately, practitioners like herself are rare. There are only about 7,500 specialists in Geriatrics in the entire country. Even rarer is her method of practice; Dr. Dhanak sees patients in their homes.


Speaking at Ashby Village’s home in Berkeley, she wasted no time before focusing on 
their topic, namely what people need to know and to look out for both for oneself and for loved ones.


As we age, we often develop more “conditions.” Health matters become more 
complicated as a result of a variety of functions – physical, emotional, social and spiritual. It’s not just about “age.” A Geriatrician looks at how the older patient is functioning today and the current relevance of each medication. Often, once a medication is prescribed it is rarely discontinued. As a person ages, this results in a layering on of medications and often on a prescription cascade. Doctor Dhanak offered one example of a “prescription cascade:”


One pill can increase urination.

Another pill might be prescribed to reduce urination.

A drug might be prescribed for gout.

Ibuprofen might be prescribed which may result in an increase in blood pressure.

A pill is then prescribed to reduce blood pressure.


Another common problem is that many older people are seen by multiple physicians, each 
prescribing medications. The primary care physician often does not have the time or

expertise to take a holistic view of the person, and try to determine which medications are right for the person at this point in their life. Geriatricians do this for every patient they see. One key thing to know is that generally, anybody with four or more medications is at risk for adverse interactions.


As we age, how we metabolize medicines can change. Drugs are distributed differently 
because our fat stores change as we age. Fatty deposits that we accumulate in our bodies can change. Also our kidney function decreases with age. This can result in changes in how we excrete medications. When visiting a physician, patients should bring with them every bottle of currently prescribed medications.

This example illustrates why a physician needs to look at everything together. In other words, your physician needs to look at you and your medications holistically. Often time, the general internist or primary care physician does not do this.


A basic fact of contemporary medical practice is that physicians, including specialists, will 
adhere to practice standards. But the studies that set these standards rarely deal with people over 65 and virtually never deal with people in their eighties.

Dr. Dhanak articulated what she called a framework for appropriate prescribing:

-- Take a holistic view of the patient.

-- Ask what is the patient’s life expectancy.

-- Ask what is the burden on the patient of following recommendations.

And especially important in determining appropriate medications, we must ask what is the actual treatment target of the medication:

-- Are we trying to cure a problem

-- Or are we simply trying to control a problem (i.e. palliative care)


This is why life expectancy is a critical question. Certain prescriptions may only be 
useful in the course of long term use and thus would be helpful to someone with a relatively long life expectancy. On the other hand, a patient with a multitude of serious health issues with a short life expectancy of no more than one or two or a few years at most is most likely to benefit very little, if at all, from certain drug regimens. In other words, we must ask if a particular medications is really beneficial for that person?


Instead of looking at a person as a collection of diseases, we must look at a person’s greatest risks. For example, a doctor looking at an 89 year old patient with multiple health problems must analyze what is really important for that patient. In this case, the doctor may need to focus on quality of life, as opposed to longevity. In fact, a medicine’s benefit may not be as high as people imagine. Its actual value depends on where the patient might be on his or her life’s journey. In other words, we need to ask how long will it take to actually benefit from certain prescriptions. We need to ask what are the risks and what are the benefits.


* * *


In her talk, Dr. Dhanak also specifically addressed medications for dementia and antipsychotic 
medications. These medications have all too often been over-prescribed in older people and are now heavily regulated. They are used to control distress, agitation or aggression that threatens a person’s ability to function in a living situation and that threaten their own safety and the safety of those around them. She emphasized that after treating for pain, it is important for physicians to assess underlying conditions using non–pharmacologic strategies if possible. Nonetheless, in the case of persons diagnosed with dementia, 60 to 70 % will have neuropsychiatric symptoms (ranging from depression and anxiety to psychosis) at some point in their disease. But there is no one size fits all solution for all people. Each person reacts to these medications differently.



Nonetheless, in her practice Dr. Dhanak tells her patients to avoid certain drugs in 
particular. For example, benzodiazepines, such as

-- Attavan

--Xanax

--Klonopin


and sleeping pills, such as


--Ambien

--Tylenol PM

-- Unisom


The remedy for sleep problems is good sleep hygiene. Don’t exercise before going to 
bed and watch stress. Going to a sleep center for treatment is always considered as an option. And definitely, no sleeping pills !!!


Pain can be a particularly thorny issue. Generally, pain tends to be undertreated in older 
people. Pain presents itself differently in older patients, especially people with dementia who often cannot say they are in pain. Pain can be identified with facial grimacing, verbalizations, changes in behavior and aggression. It can affect interactions with others

and activities and routines.


* * *


After finishing the formal portion of her talk, Dr. Dhanak addressed myriad questions 
from her audience. Notably, most of the questions were about specific drugs prescribed to audience members or loved ones. Here again, the doctor emphasized there is no one size fits all solution. Ultimately and ironically, the short answer is going to be the same: It depends on the individual!  Patients need to appreciate that what works for them is most important. Nonetheless, there  is certain advice she tells all her patients. For example, she does not prescribe Aleve and other non-steroidal pain medicine to patients in the upper tier of life. In her opinion, it entails too high a risk of kidney failure and bleeding in the stomach. These medicines can also increase blood pressure.

Dr. Dhanak also wanted to especially comment on a number of other items. Falls are a common but serious problem for older people. Walking and maintaining balance is considered a high order function, involving multiple senses, testing our sensations in our feet and our strength. A fall, often due to a trip, is commonly dismissed, instead of being seen as an indicator that the older person could benefit from intervention. Falls can be due to changes in vision, hearing, strength, balance, sensation or a new medication, to name a few. The cause should be investigated so additional falls are prevented. For example, bifocals are a common cause of falls because they alter depth perception. Vision is key to staying on our feet; studies show that cataract removal from just one eye is the one intervention proven to reduce falls in older adults.

Another 
common cause of falls is low blood pressure. A tip worth noting is that blood pressure for older patients should always be taken both sitting and sitting with two minutes in between.


* * *


Dr. Dhanak can be contacted at Elder Consult at (650) 357-8834 and at

www.elderconsult.com.




Dr. Dhanak
Dr. Dhanak

   Dr. Dhanak Audience
The audience for Dr. Dhanak's talk


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