Tag Archives: Journal of the American Medical Association

A ghost in the machine

I suppose most people missed this story about life expectancy in the UK. If you didn’t pick it up, this article comes from the Doctors net website. A site for doctors registered to practice medicine in the UK.

Life expectancy fall alarm 14/02/2014

The life expectancy of England’s elderly population has fallen for the first time, it was reported last night. Women at the age of 75 can expect to live a little less longer than they would have at the beginning of the decade, according to new figures.

The figures for 2012 are still provisional and represent a reduction of two and half months in life expectancy for women at the age of 75.There was no change in life expectancy for men, who could expect to live 11.3 years.

The Department of Health calculations, obtained by the Health Service Journal, show that life expectancy for women at that age fell from 13.2 years to 13 years. The figures may reflect the growing problems of caring for an elderly population – or simply growing numbers of elderly people.

John Newton, of Public Health England, told the journal: “Life expectancy reflects what has happened in people’s lives, and these people were born in wartime, when there were profound changes in diet. We have seen an unprecedented increase in life expectancy and it’s possible that is coming to an end.

“But we do also expect fluctuation. As we have an older population, the proportion of deaths that will fluctuate due to flu and cold weather is greater.

So it seems that life expectancy in the UK is falling amongst elderly women, and it is staying stationary for elderly men. Which is rather the opposite of what was supposed to happen, and reverses many years of increasing life expectancy.

Why is this happening? Ten years ago the UK Government embarked upon the most expensive, and extensive, initiative ever undertaken in preventative medicine. The Quality Outcome Framework (QoF). This was launched with a great fanfare.

QoF is a system whereby GPs have to screen the entire population for conditions such as diabetes, high blood pressure, chronic kidney disease, high cholesterol, etc. etc.

Once any early stage diseases had been picked up, treatment is instigated. Then there is regular monitoring to ensure that targets for blood pressure lowering, blood sugar control, and suchlike were met. This system has cost billions upon billions of pounds.

It was supposed to stop people dying prematurely from diseases, or conditions that could be properly ‘treated’ and ‘controlled.’ Because the elderly are, by the nature of being elderly, far more likely to have various early stage diseases, and are therefore at highest risk, this is the population that has been most tightly monitored and ‘treated’.

I work, part-time, in Intermediate Care. A unit where elderly people who have had an accident, broken a hip, or suffered other acute illnesses are cared for. Our job is to get them as fit as possible to return home. There are nurses, physiotherapists, occupations therapists, and me, sorting out underlying medical conditions such as anaemia. Some patients arrive from the community, others from hospital.

I did a small audit last year, and found that the average number of drugs that our patients are taking when they arrive in the unit is ten point three. That is, ten point three different drugs. Some of which are taken three or four times a day. So, a total of twenty or thirty tablets a day, in many cases.

This is the very definition of polypharmacy. And how much harm could polypharmacy do? Well here is a study from Israel, looking a study where people in nursing homes had drugs discontinued [They stopped as many drugs as was considered ethical]. Here is the abstract of the paper.

The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.

Background:

The extent of medical and financial problems of polypharmacy in the elderly is disturbing, particularly in nursing homes and nursing departments.

Objectives:

To improve drug therapy and minimize drug intake in nursing departments.

Methods:

We introduced a geriatric-palliative approach and methodology to combat the problem of polypharmacy. The study group comprised 119 disabled patients in six geriatric nursing departments; the control group included 71 patients of comparable age, gender and co-morbidities in the same wards. After 12 months, we assessed whether any change in medications affected the death rate, referrals to acute care facility, and costs.

Results:

A total of 332 different drugs were discontinued in 119 patients (average of 2.8 drugs per patient) and was not associated with significant adverse effects. The overall rate of drug discontinuation failure was 18% of all patients and 10% of all drugs. The 1 year mortality rate was 45% in the control group but only 21% in the study group (P < 0.001, chi-square test). The patients’ annual referral rate to acute care facilities was 30% in the control group but only 11.8% in the study group (P < 0.002). The intervention was associated with a substantial decrease in the cost of drugs.

Conclusions:

Application of the geriatric-palliative methodology in the disabled elderly enables simultaneous discontinuation of several medications and yields a number of benefits: reduction in mortality rates and referrals to acute care facilities, lower costs, and improved quality of living.

The first thing to say here is that, if there ever was a ‘war’ against polypharmacy, then polypharmacy won a long time ago…at least in the UK.

For those who find scientific papers somewhat opaque, the key point from this paper is the following

The one year mortality in those who did not have their medications reduced was 45%

The one year mortality in those who did have their medications reduced was 21%

This is a fifty three per cent absolute reduction in overall mortality risk in a year. Which is a better figure than I have seen for any drug intervention, ever, anywhere. So it would seem that the best possible drug treatment discovered…. is to stop taking drugs. As an added bonus you save lots of money, and make the patient feel much better, all at the same time.

Just one paper? No, of course not. There are a number of different studies demonstrating that discontinuing medication in the elderly is a good thing to do. A review paper in the Journal of the American Medical Association (JAMA) came to the following conclusions:

‘The finding that simultaneous discontinuation of many drugs is not associated with significant risks and apparently improves quality of life should encourage physicians to consider testing this in larger RCTs (randomised controlled studies) across a variety of medical cultural settings. Polypharmacy may have different faces in different countries or clinics but there is no doubt that the problem is global. This approach has international relevance; it combines our best existing evidence with patient-focused care while actively avoiding extrapolation from inappropriate populations where no evidence exists for treatment in elderly patients.’

In fact, I cannot find any evidence that polypharmacy, however you define it, does anything but harm. In the face of such evidence what did the UK authorities decide to do? Why, they set about create a system designed to drive the biggest explosion of polypharmacy ever seen. What else would you expect them to do?

So why has the mortality gone up in the elderly population in the UK? Well, I know where I would put my money. On the very system designed to stop them dying in the first place.