More on the Polypharmacy Conundrum

Chapter 8



While we are on the topic of polypharmacy, let’s visit the question of how we got into this situation (mess). The fact that all of these elements we have been discussing have become part of our “system” of how we, the people provide for our elderly citizens is really quite disturbing! Polypharmacy is only one of these very disturbing factors.

Most nursing home administrators “contract” for certain services at their facility. Common things that are “contracted out” include pharmacy services, therapy services, and billing services. There may be other less common services contracted out – but the ones just mentioned are the ones that can make the most difference to patients in nursing homes.

Busy nursing home administrators fall into the trap of thinking that once these services are “contracted out” that the administrator’s problems are over. The administrator no longer focuses on the contracted services, instead thinking that now the problems belong to someone else. In that process, a loophole is created and accountability is lost. In the case of polypharmacy, the pharmaceutical company who has been contracted gains too much power over how much medication is administered via “recommendations” to the nursing staff and physicians.

The administrator certainly has a choice over which subcontractor they will use and that should establish a foundation for accountability, however, the administrator has so many problems on his/her plate, some of which we have already discussed, that they are simply grateful for the help. So because they are desperate for help, and the pharmaceutical company is more than happy to “take over” this responsibility, a system is established that does not benefit patients and costs we, the people billions.

The resulting conundrum, the use of medications is largely in the hands of the people who make money when patients take medications, is very low on the priority list of problems to be solved because on the face of it – the collective administrators believe it is solved.

Busy physicians who have to order the medications often respond to nurses or pharmacists phoned requests or recommendations that the patient “needs something” without examining the patient. The pharmacist or the pharmaceutical company who is contracted to provide these services makes money for every pill, injection, IV or topical medication that the patient receives. We, the people should not object to this if the medications are indeed benefiting the individual they are given to. Hopefully, we, the people will object strongly that often the benefit is for the staff rather than the patient.

There are estimates published by AARP on their website that indicate that 50% of the medications given to our elderly citizens in nursing homes may be unnecessary. That is huge! Not only subjecting a person to the risks and potential side effects of these medications, but also the cost to we, the people for providing them.

The average number of medications each nursing home patient is given in a day is 12 to 15. There are 16,000 nursing homes nationwide and on average each nursing home has 123 beds equaling 1.9 million nursing home beds. These beds are, on average, 85% occupied meaning that there are 1.6 million nursing home patients on any given day. On an average day, 25 million medications are given nationwide at a cost to we, the people of $300 million each day for an astonishing $109 billion each year. And half of that may be unnecessary!

Should we, the people balk at that? Not if the medication is required for the patient’s benefit. However, when the medication is given to the patient for the convenience of the staff; or, to overcome the staff’s feeling of helplessness. we, the people should protest. We, the people should ask for greater accountability. We, the people should insist that our legislators fix these systemic problems.

What the Heck is Polypharmacy Anyway?

Elderpride: Chapter 7


Polypharmacy is a big word and its meaning is not so obvious at first glance. What it means is that a patient is being prescribed too many medications. Too many for their condition, and often those medications that the patient doesn’t really require for their condition lead to side effects that diminish their ability to understand their surroundings, and comprehend all that is happening around them.

How can this happen? Don’t medications have to be prescribed by physicians? Why would the professionals caring for patients in Long Term Care facilities allow a patient to be taking too many medications? Doesn’t anyone care about these patients?

These are all legitimate questions and they are the same ones I asked myself when I first heard about polypharmacy. I suppose the fact that society, in general, thinks that there is a pill to solve all ills causing most of us to call our physician at the drop of a hat to ask for this common solution to every health problem is at the root of polypharmacy. We have all gotten used to receiving a pill for everything and physicians have gotten used to prescribing them, partly to get us off their back, partly because it is the easy way out, and partly because it keeps us returning to their office for checkups and refills which creates a revenue stream for the physician. And so, a prescription is viewed by society as appropriate and even a validation that the individual really does have something wrong – it’s not all in their head – whew! So most of us see nothing wrong with pills, lots of pills.

How does all this relate to the skilled nursing facility? I am getting to that. What happens is the nurse calls the doctor because Mrs. S. can’t sleep and she is calling out and disturbing everyone else. The next thing you know, Mrs. S. is taking a pill such as Haldol which is commonly used for dementia. And generally this prescription for the patient will be given without benefit of the physician visiting and examining the patient.

The medication prescribed may not be Haldol, it may be some other antipsychotic medication, or it may be two or three of these medications if one doesn’t do the trick. This is why many nursing home patients seem like they are “zombie-like”, or “just not themselves”, or perhaps you would describe them as “they seem to have given up”. It might not be the patient’s fault. Their only sin may have been to call out for help at night.

I think it is normal behavior for an elderly person to call out for help in an environment that is unfamiliar. I believe they are just scared. If you were elderly and your family dropped you off at a nursing home perhaps you would be fearful of your new environment. Or perhaps you would wake up in the middle of the night and not know where you were. You might call out too! I know that when my own father in law had to go to a nursing home for therapy when I went to see him the next day he said to me with a sense of relief, ”How did you find me?” In his mind, he didn’t know where he was, so he didn’t think we knew where he was either. He was quite pleased to see me and knew that everything was OK – for that moment. He had never been to this nursing home before. It was quite understandable that he didn’t know where he was. If he was fearful or calling out at night – it doesn’t mean he was psychotic and needed antipsychotic drugs. It simply meant he didn’t know where he was, nothing was familiar to him and he was scared.

The conclusion that I draw from this is that many patients are put on these drugs that turn them into zombies for the convenience of the staff. The patient is easier for the staff to manage. And no longer makes the staff feel as if they are not doing their job – listen, it is tough to be the staff too, and have to listen to a patient calling out and not have the skills or tools to manage the situation. What the staff learns is that the drugs work. The patient on drugs makes the staff feel like they have done something for the patient and the patient no longer bothers the staff.

However, the patient can be the loser here. As the systemic overmedicating of patients becomes the norm, the patient loses all his/her credibility. Since the patient seems “out of it” no one listens to the patient anymore. So if the patient complains about their care in the nursing home their complaints go unheard, un-noticed and unanswered. In my mind, this sets the stage for elder neglect as it reduces the accountability of the staff to care for the patient properly.

And this is only one example of how new medications get prescribed for nursing home patients, extrapolate that to the fact that on average every nursing home patient takes 12 to 15 medications per day, most medications are given two or three times a day – that can add up to as many as 45 pills each day!

What I am describing is all too common. It is a far cry from Elderpride. And again, I feel like we, the people can do a lot better. You might wonder why this is permitted to happen, what are the financial incentives behind polypharmacy? Well, I wondered that too – it is our next topic!