Standard modern medical practice, he said, is built around disease prevention (think, for example, of statins for cholesterol and various blood pressure medications) and "rescue"-oriented crisis response to injury or acute illness.
Both approaches, which Sloan said work well for the bulk of the population, fail spectacularly when they collide with the special needs and circumstances of the fragile elderly. Preventing heart disease with medication doesn't make as much sense when you're 90 as it does at 45, and "rescue" interventions can often cause more trouble than they cure.
When taken together with the often desperate emotional, physical and economic stresses that face those who care for the elderly at home, the "rescue and prevention" paradigm can lead to sudden unnecessary hospitalization, unneeded and very expensive testing procedures and catastrophic over-medication, Sloan said.
"Typically," he said, "the crisis comes in the middle of the night, and if the care giver doesn't have someone to call outside of office hours, someone who can respond immediately, the absolutely understandable impulse of a caregiver who is already pushed to the limit, is to dial 911. Then you get a cascade of response, with ambulances, a fire truck, a police car and sometimes more. This sort of scenario doesn't fit for a 90 year old lady with a bit of dementia and arthritis."
After the middle of the night trip to the emergency ward, Sloan said, too often the real trouble begins.
"The wonderful people who work in hospitals are stuck in a box of risk avoidance pathways," Sloan said. Practice guidelines and hospital protocols typically require a range of expensive test procedures, which often reveal ongoing pathologies and problems. The drugs that are often prescribed in response to the test results can have serious and unintended side effects, often, for example, making it more likely the patient will be unsteady on her feet and thus liable to a dangerous fall, or increasing already present confusion or cognitive difficulties.
"One of the procedures I often have to perform when I start working with a new patient is what I call a 'drugectomy,' a careful staged process of getting him or her off some of the medications that have been piled on," Sloan said.
http://thetyee.ca/Books/2010/07/26/JohnSloan/index.html
1 comment:
As a geriatric pharmacy consultant I agree with Dr. John Sloan and the need for many older folks to "go under the knife." The drugectomy knife that is!!! Medicines are meant to help and not harm and all to often polyprescribing that leads to polypharmcy is detrimental to older folks-Golden Adults- who no longer are candidates for benefiting from the plethora of medicatiions meant to "prevent" disease. Golden Adults desire to enjoy their remaining years or months and not be burdened down by their medication regimen---the burden of too many medications. Many older adults are marinated in drugs....gaining no demonstrable benefit...and unfortunately are slowly being poisoned by polypharmacy. I commend Dr. Sloan on his willingness to wield his "scalpel"!
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