Proof medicines betray the elderly: Older people have paid the most into our NHS yet are often denied cancer treatment, barred from drug trials, and see their mental health neglected
- Gregory Kay was admitted to a nursing home aged 66, six weeks before he died
- At the time the retired engineer was taking 930 pills a month – 31 pills every day
- By the time of his death, Gregory was incontinent, restless and incoherent
When retired engineer Gregory Kay was admitted to a nursing home aged 66, six weeks before he died, he was taking 930 pills a month — 31 pills every day.
Gregory had been diagnosed with Parkinson’s in 2006 and had been on medication ever since, says his widow Mary, 70, a writer and mother-of-four with five grandchildren, from Southsea, Hampshire.
She adds: ‘Over the years, new drugs would be added, for example for constipation, and depression as a result of his Parkinson’s, and stomach pain, which only worsened.’
In the years before he died in September last year, Gregory’s ever-larger array of heavy-duty painkillers included co-codamol, tramadol and morphine.
Treasured memory: Mary and Gregory Kay before he died. Gregory was admitted to a nursing home aged 66
‘We’d see a doctor or nurse when he’d experience new symptoms and they’d simply suggest another pill,’ says Mary.
‘I could see they only wanted the best for Gregory. Yet none of them was looking at him as a person, only at an individual symptom at the time. They’d say ‘try this’ or ‘try that — and if it doesn’t work we’ll increase the dose’,’ she recalls.
‘I have no idea if any of them were checking the medication that had already been prescribed for Gregory. It was a worry that all these drugs might be affecting an already ill person and that some of his new symptoms could have been the result of the medication he was taking.’
By the time of his death, Gregory was incontinent, restless, unable to sleep, constantly sweating or complaining of being cold and increasingly incoherent.
Gregory had been diagnosed with Parkinson’s in 2006 and had been on medication ever since, says his widow Mary (pictured), 70, a writer and mother-of-four with five grandchildren, from Southsea, Hampshire
He suffered from hallucinations, too, ‘seeing’ monkeys in the pot plants and even a large hole in the wall where he said he saw his youngest granddaughter disappear.
Mary says: ‘It was partly the result of the dementia that affects people with Parkinson’s, but it could also have been the result of the powerful painkillers and morphine substitutes he was taking, possibly interacting with the medication for Parkinson’s or antidepressants. Who knew what were real symptoms of his illnesses and what were side-effects of the medication.’
Little is known about how drugs such as painkillers might interact with or impact the effectiveness of Parkinson’s medication, explains David Dexter, deputy director of research at Parkinson’s UK and a professor of neuro-pharmacology at Imperial College London.
He says: ‘This is especially a problem as Parkinson’s patients get older. And with an increasingly ageing population and the number of people with Parkinson’s expected to have doubled by 2065, this urgently needs addressing.’
Nor is this a problem specific to Parkinson’s. According to U.S. research published last week in the Journal of the American Geriatrics Society, over-65s who regularly take multiple prescription drugs — specifically for sleep and pain — are at increased risk of losing their independence and even of dying within eight years.
The implication is that it’s the combination of drugs that puts patients at risk. Last month UK experts warned that older people are being routinely ‘poisoned’ by drugs they are prescribed.
‘Too little is known about how different drugs interact with each other and what the correct doses are for older people,’ Sir Munir Pirmohamed, a professor of molecular and clinical pharmacology at Liverpool University, told the House of Lords Science and Technology Committee.
Clinical trials for new drugs routinely exclude people over 65, which means older patients are given drugs ‘at conventional doses which have only been tested in younger populations and people who don’t have multiple chronic diseases’.
The failure of doctors and researchers to take into account differences in the physiology and needs of older patients is just one example of the ageism that plagues medicine
Sir Munir said: ‘The result is that older people are less able to cope with side-effects.’ He cited NHS England figures showing that in 2018, 6.5 per cent of hospital admissions — around 772,000 people — were because of adverse drug reactions.
‘If you look at the age and profile of patients admitted to hospital after developing adverse drug reactions, it is mostly older people on multiple medications,’ he told the committee, which was looking at healthy living in old age.
The failure of doctors and researchers to take into account differences in the physiology and needs of older patients is just one example of the ageism that plagues medicine.
Another issue is that when problems are detected, they are often dismissed as a normal part of ageing rather than properly investigated or treated. Doctors — and their patients — generally believe pain, fatigue and dependency are just part of getting older, says Tom Gentry, senior health and care policy officer at Age UK.
‘It means that older patients are generally less likely to seek help — and once they do, they’re less likely to be adequately treated,’ he adds.
While older patients can be more frail, which may mean some treatments are not deemed suitable, this applies to a relatively small number. Only one in ten aged 65 to 69 is frail (defined as ‘a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves’), according to the British Geriatrics Society.
Yet as a result simply of their age, older people are missing out on life-saving treatment, including cancer surgery.
As well as outright discrimination, for instance, in the case of exclusion from clinical trials, there is also institutional ageism in healthcare. This is a ‘national scandal’, says Professor Martin Green, chair of the International Longevity Centre in London.
GIVEN TOO MANY MEDICINES
At the heart of the problem is a system failure within the NHS that has ‘evolved to treat single problems in the body and is poorly equipped to deal with multiple problems in one person — as is the case with many older people’, according to Miles Witham, a professor of drug trials for older people at Newcastle University.
The continuing rise in the number of older people with multiple health problems, including cancer, type 2 diabetes, dementia and arthritis, is set to lead to a massive increase in over-prescribing as doctors are under pressure to prescribe drugs to treat each condition, says Tom Gentry.
The tragic irony is that NHS policymakers bear some responsibility for this, he says, pointing to the fact that just 20 years ago, it was relatively common for over-65s to be taking no medicine. A 2017 study by Cambridge University involving 15,000 older people in England and Wales found that in the late-1990s one in five was taking no pills at all. By 2017, one in two was taking at least five different drugs a day, with some taking up to 23 tablets daily, the journal Age and Ageing reported.
What changed was that in 2004, GP contracts were changed so that doctors were rewarded for how frequently they diagnosed and prescribed for illnesses such as asthma, type 2 diabetes, high blood pressure and cholesterol.
‘It was a great idea to ensure that they would make more of an effort to help patients,’ says Tom Gentry.
But since then, prescriptions for older people have risen. The latest figures from the Cambridge study found that one in ten over-65s takes at least eight different prescribed medications a week.
Six out of ten prescriptions written by GPs in 2017/18 were for people aged over 65. While increased drug use reflects better diagnosis and treatment, and many patients benefit, the researchers warned that some patients may not need all the drugs they are prescribed and the intake could be harmful.
Lead researcher Carol Brayne, a professor of public health medicine, says: ‘We know that polypharmacy [taking multiple medicines at the same time] is associated with a higher risk of dying and the evidence for combination therapies on the scale that we have seen them in the older population is not good.’
DRUGS NOT TAILORED TO OVER-65s
Well over half of the NHS drug budget is spent on treating older people. But until recently, over-65s have been excluded from clinical trials — even when the drug being tested will be used in older people.
‘The upshot is that evidence gained from clinical trials is not fit for purpose,’ said Miles Witham, a professor of drug trials for older people at Newcastle University.
He points out that liver and kidney function — which is important because these are the parts of the body that process medication — deteriorate with age so older people will have a different response to the drug to the younger, healthy adults who feature in trials.
Dr Sheuli Porkess, of the Association of the British Pharmaceutical Industry (ABPI), says: ‘In the past, the industry has felt obliged to carry out ‘clean’ trials that show clearly that a particular drug is effective for a single health problem — and that meant excluding older people and those with ‘multi- morbidities’ [i.e. they have more than one medical condition] or who are seen as frail as their results would complicate the final data.
But hopefully that’s changing.’ She said the ABPI is now engaging with regulators, academics, clinicians and ‘above all patients, to find a way to design trials that would ensure drugs are safe for older people, including those with multiple health problems’.
Professor Witham adds: ‘It’s a matter of accepting the fact that there is going to be some messiness [i.e. the trials may be more complicated or yield mixed results], and that the costs of the trials are likely to be higher.’
So what should be done? Hemant Patel, a community pharmacist in North East London and former president of the Royal Pharmaceutical Society, says: ‘Older people require extra care and monitoring as their ability to metabolise drugs decreases with time, which means the dose of a drug needs to be adjusted to take account of a patient’s age, their ability to absorb the drug and their susceptibility to its sensitivity.
‘Take digoxin, a drug prescribed for heart failure. The recommended dose is 250 mcg; but for an elderly person, the dose should be 125 mcg and if he or she has kidney disease, it should be 62.5 mcg.
‘Yet there’s a hit-and-miss culture today, with doctors and pharmacists under pressure so that the risk of dangerous side-effects and interactions is being missed.’
Prescribed medication for the over-65s really should be monitored much more closely, adds Mr Gentry. ‘That means a clinician should consider from time to time whether they are still the best for the older patients’ health, not only on their own but when taken together with the other medications that they are on.’
Hemant Patel adds: ‘Any patient who is concerned they may be suffering from unwanted side-effects from the drugs they are taking should ask their GP or pharmacist to review their medication.’
Gregory’s own extraordinary daily tally of pills was finally reduced just before he died, when he was finally seen by a psychogeriatrician — a specialist in treating mental disorders in older people — after Mary raised concerns about his mental health.
This doctor, says Mary, ‘spent time talking to Gregory and finding out what our life was really like. She was really kind to him and suggested that our life was unsustainable at home, even with carers, and he needed residential care’.
Gregory was referred to a nursing home where an assessment was carried out and ‘curiously, almost all the medication my husband had been taking was withdrawn. We were told by a doctor that he did not need the medication and that it was only making his life more difficult.
‘Sadly, we can’t know if this would have led to an improvement had it been done earlier, as he died six weeks later — from a separate complication, not related to his medication.’
SURGERY DELAYS HIT ELDERLY UNFAIRLY
Over-prescription is not the only area of medicine where older patients experience ageism.
Last week it was revealed that more than four million patients are waiting for surgery, the highest number ever. While these are patients of all ages, experts say delays hit older people particularly hard. ‘With so many health conditions that require surgery being age-related, it’s inevitable that the burden will fall disproportionately on older people,’ says Rachel Power, chief executive of The Patients Association.
Of those on the waiting lists, 670,000 are awaiting hip or other joint replacements at an average age of 68. ‘Waiting for more than 18 weeks for their operation can be devastating,’ says Professor Derek Alderson, president of the Royal College of Surgeons. ‘Their physical condition can deteriorate, they can become depressed, suffer in pain and lose their jobs.’
DEPRESSION GOES UNTREATED
Another major issue for older patients is mental health provision — or lack of it. Older people are just as likely as under-35s to become depressed but the treatments they are offered are far more limited, according to the Mental Health Statistics for England, published in April 2018.
These show that eight out of ten older people with depression are not referred for cognitive behavioural therapy (CBT), the most successful talking therapy for depression, for example. This is compared to one in two people aged 18 to 35 getting CBT.
A survey of 211 Clinical Commissioning Groups carried out by a think-tank in 2015 revealed that only three of the 130 that responded had set specific targets around increasing the number of older patients accessing mental health treatment, according to Age UK.
‘We need to change attitudes and challenge negative stereotypes that older people’s mental health doesn’t matter,’ says Dr Amanda Thompsell, chair of the faculty of old-age psychiatry at the Royal College of Psychiatrists.
When it comes to declining brain health, the prospects are equally bleak. While a young person with brain damage will have a care plan from the NHS that includes maintaining links with their family and accessing education, ‘an older person with the same level of functionality but suffering dementia will have a social care plan costing many thousands of pounds less a week, based entirely around getting the older person out of bed, washed and to breakfast, all in half an hour’, says Professor Green.
DENIED CANCER THERAPIES
Around one in three breast cancers are diagnosed in women over 70 yet there’s concern that decisions about older women’s treatment ignore guidelines which stress that NHS treatment should be based on clinical need rather than age.
In 2016, the Association of Breast Surgery and the Royal College of Surgeons set up an audit into the way that breast cancer patients are diagnosed and treated, gathering data from 45,000 patients each year.
The aim of the five-year review is to ‘support the improvement of care for older patients with breast cancer, as research shows there are differences in the care given to younger and older patients’.
Unfortunately, if ageism is to blame, it’s proving stubbornly persistent. The audit’s latest report, published in May, shows that the differences are increasing rather than lessening in some breast cancer units — with some older patients over the age of 70 significantly less likely to be offered breast cancer surgery than others, depending on where they live.
‘Unconscious ageism in the NHS means that many older breast cancer patients are still not receiving surgery, chemotherapy and radiotherapy despite being fit enough to undergo these treatments,’ said Baroness Delyth Morgan, chief executive at the charity Breast Cancer Now, speaking about the audit’s findings.
She called on clinicians ‘to investigate the reasons why older patients may not be getting the treatments they need — and on older patients to feel able to query why this might be happening’.
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