Vis Medicatrix Naturae
Melissa Coats, ND
Older adults, defined typically as those who are 65 years or older, are one of the fastest growing populations in the United States today. The US Census Bureau states:
In this century, the rate of growth of the elderly population (persons 65 years old and over) has greatly exceeded the growth rate of the population of the country as a whole. The elderly increased by a factor of 11, from 3 million in 1900 to 33 million in 1994. In comparison, the total population, as well as the population under 65 years old, tripled. Under the Census Bureau’s middle series projections, the number of persons 65 years old and over would more than double by the middle of the next century to 80 million. About 1 in 8 Americans were elderly in 1994, but about 1 in 5 would be elderly by the year 2030.1
This means that as an ND your odds of seeing an older adult are greatly increased and that more people will be coming to you at a time in their life when they are most likely taking a wide variety of medications and supplements. Because of this, there are usually multiple sources involved in the prescribing of medications, which leads to one of the major issues with older adults today, known as polypharmacy. This article will discuss this issue and will present a case study about reducing the burden and managing the fear that goes along with helping a patient understand that alternatives can work and can decrease adverse effects.
Polypharmacy is a major issue with the older adult population. In a study2 of more than 150 000 elderly patients, 29% had received at least 1 of 33 potentially inappropriate drugs. A study3 of approximately 27 600 Medicare patients documented more than 1500 adverse drug events in a single year. Most of these events are the result of drug interactions; the more drugs a patient takes, the higher the risk for interactions.4 The estimated incidence of drug interactions rises from 6% in patients taking 2 medications a day to as high as 50% in patients taking 5 medications a day. This leads to many adverse effects, as well as concerns about what is really the underlying cause—a true pathologic condition? a mixture of pharmaceutical processes?—and where did this all start. Here, NDs have the opportunity to use docere (physician as teacher) to help patients on a whole new level.
Focusing on the older adult population as a young physician has definitely sped up my learning curve about the interactions among medications, herbs, and supplements. A deeper understanding of physiology and biochemistry has resulted, but it has taken longer practice to discover that there is also much emotional fear instilled in patients who have been prescribed medications.
To my surprise, many patients are afraid it will anger the other prescribing physician if they alter their medications, even when guided by another physician. In addition, when patients discuss with the prescribing physician adverse drug reactions, many physicians will add another medication, repeat the problem by continuing the same drug class (often noted with statins, in my experience), or tell them to continue, despite a serious reaction, stating that it will pass in time. This is a problem because many people are prescribed medications but are not taught when it is time to think about weaning off of them or if they should even be taken long term. Some patients are taking medications for years without any alteration, and they note feeling bad for about just as long. Another common issue is that older adults who are trying to be proactive will research on their own or be told about products and start them without knowing whether they are really of benefit to their individual case. This leads to much money spent and frustration when things do not work out as promised with some of the fad supplements marketed today.
Although this is just a brief case example, the message is that—as NDs working with older adult populations—we have a great opportunity to make a difference and eliminate much fear about supplements, medications, and herbs. We can make a huge difference in quality of life by getting to the root cause of problems and by teaching our patients to be empowered to take control of their health and move through their fears. Not all patients are willing to question taking numerous medications and even supplements for that matter. It is within our philosophy to help those experiencing poor health—and not understanding why—to find the cause and make it better, even if that means taking fewer supplements sometimes. As NDs with the luxury of spending more time with our patients, we have the opportunity to take the time and explain how to reduce the fear of coming off of prescriptions, which are sometimes unnecessary anyway. By reducing the pill burden, we can improve compliance by addressing what is really necessary and what is not to support our patients’ health.
A 72-year-old woman presented to me in early 2009 with concern about her osteoarthritis symptoms, costochondritis, and weak bladder, along with low energy. At the time, she was very active and caring for her husband, who was fighting cancer. She was eating a semiorganic diet with a variety of fruits, vegetables, and nuts, with some meat. Before meeting me, she had put herself on the following: red yeast rice, coenzyme Q10, a form of calcium ascorbate, chewable vitamin B12, baby aspirin, garlic, fish oil, lutein, bilberry, a multiple vitamin from the local health food store, evening primrose oil, calcium, magnesium, zinc, and a vitamin B complex. Fairly empowered in her health, she just wanted to know what she could do naturally for the pain she was experiencing other than what she had been taking, which was ibuprofen a few times a day. At our first visit, she was taking 2 prescriptions: rabeprazole sodium (a proton pump inhibitor) and metoprolol (a β-blocker for her blood pressure). The day of the visit, her blood pressure was 152/70 mm Hg. We discussed her history thoroughly and tried to figure out what was the best approach to her concerns.
Supplements vs. Meds
At the first visit I addressed suggestions to help with inflammation and ideas to deal with stress, and we strategized ways to decrease her pill burden. I introduced several topics, including adrenal support, hydrotherapy, homeopathy, and acupuncture, so that if used she would understand their benefit. I walked her through handouts and discussed the pros and cons of supplements and quality concerns and suggested ways to support her chief complaints. We followed up with her a few times afterward, and she was doing very well. It was almost more than a year later until we met again with any major concerns. Her pain level had dropped when taking the supplements I suggested, and other than brief follow-up visits, she was still comfortable with the care of her primary care provider (PCP).
Adverse Effects Create
Fast forward a year or so later, and much had changed with her health. She had been through surgery to correct her prolapsed bladder, and her PCP had prescribed a product containing flavocoxid (a proprietary blend of natural ingredients from phytochemical food source materials) and citrated zinc bisglycinate for her joint pain, but she stated that she disliked it because it was costing her hundreds of dollars each month and was only helping a little. She had stopped the prescription to see if she could do without it and was back on ibuprofen. She also was given the option of a corticosteroid for her shoulder pain but had refused it. After going back on the ibuprofen, her gastrointestinal (GI) issues had returned, and she had been lax about taking the GI supportive powder I had suggested. At a checkup for her blood pressure with her cardiologist, she was switched from metoprolol to nebivolol and amlodipine. She was now experiencing muscle cramps and more fatigue and was scheduled for a stress test because she had had flutters recently after all the changes.
Unfortunately, adverse effects associated with the aforelisted drugs mentioned in her complaints were listed in almost all of the warnings for the medications. She was more tired, she was experiencing allergic rhinitis, and her pain was no longer as controlled. No one had asked her what was going on in her life—her stress, her concerns—or had even explained what to expect with the medications. She stated that both of the visits with the other providers had added up to about 10 minutes of face time. She expressed that she prefers to be off medications, but she feared that not taking the medications would cause health issues or that the relationship would suffer with the other physicians. She already had not been taking the medications fully as prescribed because of the adverse effects and thought possibly that could be an issue. Her husband was soon scheduled for carotid artery surgery, and she was concerned about that, which most likely led to her blood pressure changes. When I checked her vital signs, her blood pressure was worse than I had ever seen it, despite her being on the 2 medications. She also presented me with her recent laboratory reports and the list of medications that her PCP recommended. On reviewing her lipid levels, her total cholesterol was 198 mg/dL, low-density lipoprotein was 111 mg/dL, and high-density lipoprotein was 69 mg/dL. Based on these laboratory values, her PCP wanted her to begin taking a statin. She was concerned because that meant more drugs and more interactions. In my opinion, it was unnecessary because simple changes could alter the very slightly elevated low-density lipoprotein cholesterol level.
Supplements Defeat Meds
In this case, we discussed alternatives to fill in as she would wean off of the medications. Our goals were to decrease the number of prescriptions, reduce her adverse effects and pain, and help her cope with the stress of dealing with her husband’s health. She was very receptive, and after I spoke with her, she was comfortable and understood what to watch for. During this process, we e-mailed and called a few times to ensure that she was making the correct changes. The end result is that she is off both of her prescriptions, with her blood pressure staying around 110/60 mm Hg without medications. She is no longer taking rabeprazole and did not commence the statin. We have reduced her pill burden with supplements, adding in powders when available, and have worked on her stress levels, supporting her adrenals. I also discovered a thyroid condition and have since helped her reduce her fatigue. I supported her through her decision to talk to her PCP about the medications and had her track her results on paper to prove that she is better off of them, so that she herself is reassured, as is everyone in her care. Thankfully, she is more energetic and is feeling great.
Melissa Coats, ND graduated from Randolph-Macon Woman’s College, in Lynchburg, Virginia, with a bachelor’s degree in biology; she then went on to get her master’s degree in bioethics from Midwestern University, in Glendale, Arizona. Subsequently, Dr Coats earned her doctor of naturopathic medicine degree at Southwest College of Naturopathic Medicine (SCNM), in Tempe, Arizona. She is a member of the Arizona Naturopathic Medical Association, American Association of Naturopathic Physicians, and Oncology Association of Naturopathic Physicians. Dr Coats’ most recent appointment was to the executive council of SCNM’s alumni association. Dr Coats offers general naturopathic medicine for patients of all ages, with a focus on special needs of the geriatric community.
U.S. Census Bureau. Population profile of the United States. http://www.census.gov/population/www/pop-profile/elderpop.html. Accessed December 8, 2011.
Simon SR, Chan KA, Soumerai SB, et al. Potentially inappropriate medication use by elderly persons in U.S. health maintenance organizations, 2000-2001. J Am Geriatr Soc. 2005;53(2):227-232.
Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116.
Corcoran ME. Polypharmacy in the older patient with cancer. Cancer Control. 1997;4(5):419-428.