Theodore Dalrymple explains the dangers of polypharmacy
You are getting old, I suppose, when the professors look young, as they did at a medical meeting I attended last week. I also suppose one should be unambiguously delighted that such excellent and clever people still rise in the world. Oddly enough, it is a powerful reminder – morally necessary no doubt, but psychologically discomfiting – that no one is indispensable, especially oneself.
There was a lot at the conference about polypharmacy, officially defined as the prescription of more than four medications at once to the patient. Polypharmacy is a subject of special interest to the elderly, for they are the principal victims of it. This, of course, is because people tend to suffer from more and more illnesses or conditions as they age, so that they are prescribed medication upon medication.
One of the problems of this is that medications interact, often deleteriously, and the more of them that are taken, the greater the chances of such an interaction. Moreover, while interactions between two medications are frequently well described, those involving more than two are not. It is estimated that about one in 13 hospital admissions is necessitated by the ill effects of medication; and by the time they leave hospital, one in six or seven will have experienced a side effect.
These alarming statistics do not reflect the incompetence of doctors – or at any rate their incompetence alone. There are 1,603 drugs in the British National Formulary, available in 18,408 different preparations. It has been estimated that the half-life of a medical fact – the time taken for half of facts to be superseded by new knowledge – is now but 73 days and shortening all the time. There was an era when it was 150 years. As knowledge increases, so does ignorance, and it is a wonder that all patients and doctors are not paralysed like Buridan’s ass, unable to choose between alternatives.
In prescribing many pills, doctors are only following official guidelines. With five conditions, normal among those aged 80-plus, a person will be treated with ten medications, have 16 lifestyle recommendations, and have eight routine appointments to attend – if they are treated according to guidelines.
Of course, practically no one takes their medications as prescribed, and perhaps this is sometimes just as well, though not always. If you look at a single illness such as asthma, fewer than a fifth of patients take their medication correctly or as prescribed. It has been shown that only half of patients with high blood pressure still take their tablets after one year, and only five to ten per cent after five years. The reasons for this are manifold, not least because the chances of pills making you feel worse rather than better are very great.
Except in the very worst cases, high blood pressure is a symptomless disease: in the normal course of events, you only know you have it once you have a stroke or a heart attack, whereas the side effects of pills for high blood pressure begin at once. This is especially true of diuretics.
About half of the patients with high blood pressure that does not respond to usual treatment do not take their tablets properly. As Goethe said, nothing straight can be made of the crooked timber of humanity. I have been taking tablets (without which I would have been long dead) for 40 years, but I don’t take them correctly. Nevertheless, patients who didn’t take their tablets used to annoy me.