by Michael Wasserman, MD, CMD

I like to tell people that as a Geriatrician I’ve discontinued more prescription medications in my career than I’ve started.  I’ve done this without the benefit of randomized controlled trials in the population that I am used to caring for.  The demographic of 85-year-old women with multiple chronic diseases is an apt description of my typical patient population.  There have been many times that I’ve discontinued most, if not all, of my patients’ medications and had them demonstrate clinical improvement.

There is epidemiological data that people who live into their 90s tend to have elevated blood pressure readings.  Are elevated systolic blood pressures harmful in the very old?  How about nursing home residents?  We don’t really know.  And then there is the infamous “J curve.”  Does lowering blood pressure too much cause problems in older adults?

There is no question that hypoglycemia is dangerous to older people.  Tight blood sugar control has definitely been called into question in older diabetics.  What is an ideal blood sugar in frail older adults?  How about nursing home residents?  Sliding-scale insulin is not considered appropriate therapy in nursing home patients, yet we still see many nursing home residents being treated with this antiquated, reactive 20th-century throwback.

Then we come to the question of cholesterol treatment.  While there is evidence that lipid-lowering agents reduce the incidence of cardiac events, there has always been some question about their impact on mortality.  The number needed to treat is in the hundreds to prevent one cardiac event, and the potential side effects are significant.  Furthermore, there is little evidence in those over 80 years of age, much less than a nursing home population. 

With this background in mind, I read with great interest a recent study published in the Journal of the American Geriatric Society (S Hamada, M Gulliford, Mortality in Individuals Aged 80 and Older with Type 2 Diabetes Mellitus in Relation to Glycosylated hemoglobin, Blood Pressure , and total Cholesterol, JAGS 64:1425-1431, 2016).  In a population-based cohort study that looked at nearly 26,000 individuals aged 80 and older with Type 2 Diabetes in the United Kingdom, the findings were remarkable.

Low glycosylated hemoglobin, blood pressure and cholesterol appeared to be associated with higher mortality.  Granted, this wasn’t a randomized, double-blinded clinical trail, but it definitely calls into question aggressive treatment of diabetes, blood pressure and cholesterol in older adults.  In the context of many of our own experiences with the frail older population, it certainly calls into question any aggressive treatment of nursing home residents.

Adding fuel to this fire is another recent study (D Rothschild, E Novak, M Rich, Effect of Statin Therapy on Mortality in Older Adults Hospitalized with Coronary Artery Disease:  A Propensity-Adjusted Analysis, JAGS 64:1475-1479, 2016).  In a retrospective analysis of 1262 individuals aged 80 and older discharged from the hospital with known CAD, it was concluded that statin therapy had no significant effect on long-term survival. 

I often tell people that I can probably discontinue half of the medications of most nursing home residents.  This isn’t idle chatter.  This is based on nearly 30 years of caring for frail older adults.  We don’t have the full evidence basis to make these decisions, but articles like the ones I’ve quoted certainly can give us food for thought.  Don’t assume that the prescription medications that our nursing home patients are on are necessary.  They might do better without them.  Moreover, consider the impact that reducing unnecessary medications would have on med pass time for nurses.  Nurses would have more time to spend on direct patient care.  This could be far more beneficial than any medication!

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