Harm Reduction from Iatrogenesis, Part I
We spend a lot of time in medicine focusing on making everything better: we want patients to live better, and live longer. We work harder with each passing moment to harness whatever power we can muster to slow the corrosive effect of the sands of Time, trying to squeeze out one more day for our patients, or a few more months, and rarely, if we’re lucky, a few good years. It’s unclear if this is because all industries focus on improvement, or if medicine in particular has a “better, faster, stronger” component to it driving progress and productivity. Forward and onward. Often, this unspoken mantra makes it challenging to step back and identify how the industrial force (and inevitable mechanization) of patient care can be prohibitive when applied without nuance. Nowhere is this sense more palpable than in the care of geriatric patients.
In-hospital geriatric care has a lot of literature to back best practices, but reflecting on the specifics can take more time and effort than we are poised to devote in the midst of family meetings, admissions, and responding to nursing requests. Many of us who care for patients would agree, in spite of forces that drive helping everyone everywhere live longer, that this goal may not, in fact, be best for everyone everywhere. Many of us would agree that sometimes, living longer without living better is not a cause worthy of pursuit. The details are better left to my esteemed geriatrician colleagues and palliative care colleagues, but when thinking about how to make an impact within the hospital, there are two themes worthy of consideration:
- Discontinuing medications
- Avoiding diagnostic testing without clear indications
In this first post, we will discuss medications broadly. Regarding medications, we are often faced with what amounts to a moral quandary when it comes to discontinuation. While we all know the details, it bears repeating: medicine is tested before it is used. The process of medication testing often intentionally and notoriously excludes patients above the age of 65 from clinical trials. We also are acutely aware of two important facts: almost one in five people in the U.S. is over 65, and nearly forty percent of all hospitalized patients are over 65.
This creates a paradox where a drug that may have been developed, designed, and prescribed for some suspected lifesaving, life-extending or life-improving benefit has never actually been tested in the patient population that ends up taking it. Patients are prescribed a medication for a symptom, and then another medication to manage a side effect of the first medication, and so the cycle of medication prescription begets more medication prescription, until we find no way off the medication train. Nearly ten percent of hospitalizations occur due to adverse effects of medications. The way off the train is simple, but demands more time than we often have in the ever-increasing demands of the day, and is more robust than could be covered in one post, but to begin, we can start with two interventions.
The first is the understanding that most patients do not absorb oral multivitamins and minerals. These inevitably do more harm than good, because of possible drug-drug interactions, well-documented inefficacy, and no measurable outputs. For patients who insist they feel better when they take them, perhaps there is some benefit, placebo or otherwise. For others, there are often absolute indications, which can be identified rather clearly. For everyone else, if they don’t have a very clear indication for multivitamins, don’t be afraid to immediately remove multivitamins from their medication list. Will their PCP actually check an ascorbic acid level? How do you know that their vitamin E stores have been replenished? Vitamin C’s relationship with kidney stones is well documented; its benefit for the general population remains unclear. Vitamin E for cancer prevention is questionable at best as is its benefit for cardiac disease. Vitamin A should actually be avoided in patients with osteopenia! And who is at higher risk for osteopenia than patients over 65?
The second intervention that could be implemented is a review of medications that provide more harm than good. These require careful thought. The SPRINT trial certainly gives some evidence towards controlling hypertension aggressively in older patients, but drugs for other conditions demand more pause. Aspirin, for example, can often be avoided in older patients with shorter life expectances. These patients similarly should be allowed to have permissive hyperglycemia to avoid hypoglycemic events when we know their life expectancy is less than ten years. And sometimes, perhaps there is a benefit in stopping the statin, or stopping the proton pump inhibitor. Of course, these are situations that require a careful nuanced, and thorough case-by-case assessment, but it helps to consider the issue in all patients.
In Part II, we can get into the deep dive of avoiding diagnostic testing without appropriate indications, to offer better care to this group of patients.
