Monday, October 2, 2023
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My New Patient Was Taking 43 Prescription Drugs

Mark E. Williams, MD

“Hello, Dr Williams. We have a new admission to the facility from the medical center and I need you to approve the orders.”

Allison was the new admission. Until recently, she had been a resident at another chronic care facility. But a few days earlier, she had been transferred to the local hospital for altered mental status that was probably related to inappropriate polypharmacy. She required long-term care, primarily for bipolar illness. After she was stabilized at the hospital, she was transferred to my facility.

Despite being admitted to the hospital for adverse drug reactions related to polypharmacy, Allison was discharged to my facility on 43 prescription medications and an almost equal number of over-the-counter (OTC) drugs. It took more than 10 minutes for the nurse to review the admission medications with me over the phone.

Because I am in the facility every day, my general strategy is to approve all but the most egregious potential adverse drug interactions on admission and then follow up with my own medication review the next day. And that’s what I did.

More Are Not Better

When I saw Allison the next day, she had a laundry list of symptoms (fatigue, dizziness, muscle aches, headache, nausea, insomnia) and wanted to see me immediately to get additional medications for each of her ailments. She had an indwelling urinary catheter and did not want it removed because it was convenient for her not to worry about bladder control.

Allison was short and plump. She had a cherubic face and curly red hair; she wore eyeliner, rouge, and bright vermilion lipstick and nail polish. She was divorced and had a daughter who enabled her demands. They teamed up during our first conversation — and those that followed — so that most medication discussions were two against one. Her daughter had no concerns about adding medications but was very resistant to any reductions in the medication regimen. She (and her mother) truly believed that if one pill was good, two must be better.

“Dr Williams, I don’t want you to change any of my medications. I worked with the doctor at the last facility to put together this plan and I am scared that you are going to change it.”

“Allison, you are taking way too many medications, and we need to work together to review the number of drugs you take,” I said. “You were hospitalized because of confusion, and I’m fairly certain that you were having adverse reactions to your medications.”

“You don’t understand,” she said. “I feel fine, and you will make me sick if we stop them.”

Her daughter jumped in. “If you felt so strongly, why did you approve them all yesterday?”

“Because I wanted to meet with your mother first,” I said. “She is on duplicate medications for the same symptoms and is on additional medications to treat common adverse effects. The ‘chemical soup’ in her body is leading to mental and physical problems. We may even be able to take out the catheter.”

“But I don’t want the catheter taken out,” Allison said.

“The catheter poses a significant risk for infection, and we only use indwelling catheters as a last resort and usually with urologic evaluation. You are on several medications that poison the bladder and keep it from contracting. Let’s stop those medications, take out the catheter, and monitor your progress.”

The conversation lasted another 30 minutes, but I was steadfast in my deprescribing. Allison’s daughter was not happy.

Making Progress

Over the next 3 months we were able to reduce Allison’s medication burden to about 15 medications. She was subsequently able to void spontaneously without residual urine, so the catheter was removed. Allison improved, both mentally and physically. She zipped around the facility using a bright red rolling walker with a seat. If anyone in the facility had a birthday, she was there, wearing a party hat to offer personal greetings and to put a hand-drawn “Happy Birthday!” sign on their door.

Then Came a Direct-to-Consumer Ad

One morning while I was rounding, Allison stopped me in the hall. She said she had something very important to ask me. We walked back to her room, which was wallpapered from ceiling to floor with multicolored pages from recreation projects. Some were decorated with glitter. I commented on her productivity.

“Oh, that’s nothing,” she said. “I can do six or seven pictures in an hour.”

But then her tone grew serious.

“Dr Williams, do I have dementia?” she asked. “I saw something on television that a chemical from jellyfish can improve my memory. My memory is terrible. Will you prescribe it for me? Please?”

“Allison, I don’t want to prescribe that medication until there is more clinical evidence that it works,” I said.

“But how will you know if it works if you don’t prescribe it for me?”

I acquiesced and agreed to a limited trial with close follow-up. The “miracle memory cure” did not improve Allison’s cognition and I discontinued it. But her daughter continued to debate its merits with me.

“Maybe her memory would be even worse if you hadn’t started the medicine,” she said.

More Miracles in a Bottle

One day, Allison’s condition declined precipitously. The nursing staff urgently asked me to see her for lethargy, confusion, and slurred speech. When I spoke with Allison, she said that her daughter had brought her something to help her sleep. She showed me an opened bottle of a popular sleep aid loaded with diphenhydramine. She admitted taking three tablets when she woke up in the middle of the night and could not get back to sleep.

“Allison, why didn’t you tell me that you were having difficulty sleeping? We could have discussed a number of options,” I said.

“A stronger pill?” she said.

“No, you are still taking too many medications. I am concerned that you could have seriously hurt yourself.”

“But my daughter bought it in the drugstore, so it must be safe. I saw it on television.”

Allison’s daughter was advised that going forward, she could not bring any medications directly to her mother. She would need to leave them with the nursing staff, and they would contact me for a medical order to administer them.

Despite the adverse effects that the sleeping aid had caused, Allison’s daughter was not apologetic. In fact, she seemed miffed that she had to run OTC products past the medical team.

Shortly thereafter, Allison’s daughter had her transferred to another facility. Just before Allison left, she gave me a hug.

“You can keep all of my artwork,” she said. “I can always make more.”

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