Medication …….. It’s time for a review

Maree O’Connor, Physiotherapist interviews Dr Sue Hodson, General Practitioner

Lymphoedema practitioners often have elderly clients that are on a long list of medications. Do they cause oedema? Do they affect their activities of daily living? Do they affect their memory? Are there other options? Do they need them? When was the last time they were reviewed?

As a lymphoedema practitioner, what is our role? To answer these questions I asked Dr Sue Hodson General Practitioner.

Maree: Elderly people may need to be on certain medications for various issues. Do you think the elderly population could be taking too many medications and is there evidence that these can be reduced?

Sue: Yes. Polypharmacy is when people have more than 5 daily medications, and it is more common as we age. Older people are more likely to have had more medical problems and can remain on long-term medication well after a condition has settled.

Most medication guidelines are designed for ‘single diseases’, not for people with multiple co-morbidities, and they are rarely designed for the elderly. Hence the recommended medication for an older person with co-morbidities differs from the standard guidelines.

Older people break down medications less efficiently than young people, so at standard recommended doses they may be over-dosed, and they are more likely to have side-effects. This is important when the side-effects are mental slowing or poor balance, as other factors are all adding to falls risk and memory impairment.

Medication reviews are especially important for frail people, or after major health events.

Maree: What are the benefits of having their medications reviewed?

Sue: The first step towards de-prescribing is to look at all the medications, including over-the-counter (OTC) medications, and medications taken intermittently. NSAID can be purchased OTC and they have the potential side-effect of increased oedema. Antihistamines can cause drowsiness, and increased falls risk.

A medication review by the GP or Pharmacist is a check-up about which medications are still needed, about the dosage of the medication, and importantly a check on whether medications interfere with each other, or together are more toxic.

Maree: Sue do you feel that lymphoedema practitioners should ask their elderly clients to have their medications reviewed?

Sue: Yes. Several medications, including OTC drugs and topical preparations, can contribute to oedema. It may be possible to find substitutes for these medications. Some people will be on diuretics only for their lymphoedema, and as this is ineffective, it should be ceased. This requires monitoring in the elderly as heart failure may be unmasked.

Maree: Who is the best person to review their medications?

Sue: Both the GP and the Pharmacist can review medication, and the best outcome is when they work together. De-prescribing is also one of the roles of Geriatricians. There can be patient concerns when a GP ceases medication initiated by a Specialist who gave advice that ‘the medication needs to be taken for life’, and these concerns need to be addressed.

GPs are in the position to recommend alternate non-drug therapies when medications are ceased. This might be using a heat-pack for joint pain or lifestyle advice about diet and exercise.

Preventative medications may avoid a heart attack in 5 out of 100 patients after 10 years. Continuing this medication is a different proposition at 60 compared to at 80.

Maree: Any other advice?

Sue: Older people should ask their GP to check if their vaccinations are up to date.