NEWS & EVENTS

Second Opinion: How can we tackle the rise of multiple morbidities and the increasing number of patients on multiple medications?

IN BRIEF - 16TH FEBRUARY 2017

Constantly question whether medication is helping a patient or making things worse OR Address the root causes of obesity earlier, before medical interventions are required?

Constantly question whether medication is helping a patient or making things worse

Dr Mashkur Khan
‘Multiple morbidities’ refers to a situation where a patient is being treated for several different conditions—sometimes related, sometimes not—on a long term basis. One of the real issues that is emerging out of the rise in multiple morbidities is polypharmacy, which is where patients find themselves taking a cocktail of different medications. For example, they might be suffering from hypertension, bone frailty and diabetes, and be on medication for all of these conditions: a situation that can go on for years.

There is an old saying that all drugs are poisons and all poisons are drugs, and in these patients the mix of drugs that they take in good faith may actually be acting to make things worse. They combine with each other in ways we don’t always fully understand and may result in the patient suffering extra side effects. I have seen symptoms like dizziness, confusion and hallucination, which can range from irritating to very serious.

A study in 2012 concluded that patients on more than four drugs had a higher risk of falls and increased multiple morbidities. We should go back to that study and really understand that by prescribing these drugs we could be doing more harm than good. Polypharmacy and its associated problems is not inevitable— we just have to be brave enough to act.

As a geriatrician, I actually stop more drugs than I prescribe. I believe we need to adopt regular drug reviews, go through the patient’s drug chart and question everything. Often a patient has been taking a drug for 20 years and no one has ever done a proper review. Does the patient really need to be on drug x or drug y? Has a drug outlived its efficacy? Are better ones now available at a lower dosage? Have the side effects a drug causes crossed a line into being unacceptable? Are there any medications we can discontinue rather than just writing out another repeat prescription? We have to ask some very hard questions and be brave enough to take action.

I also think our preventative work is currently very poor. We wait for a problem to arise before treating it. In a perfect world, we would pick up people who are asymptomatic but heading for a crisis and then take action before they need medication. Also, we need more genetic profiling so we can find out how different drugs work on individual patients. For example, we know that anti-depressants only work on 15-20% of the people they are prescribed to, so you have a great many people taking a medication with all the associated side effects and expense, but which is actually doing them no good at all. We should explore other avenues instead. All too often, especially with the elderly, a pill is not the solution. Let’s look at the core of the problem—is it loneliness, inactivity or isolation, for example—and tackle that.

In the coming years I would like to see a better awareness in both the general and medical populations about the ways to prevent the problem of polypharmacy through better lifestyle and prescribing choices. This will reduce our dependence on medication, reduce the healthcare budget and, I believe, provide a better service to our patients.

Dr Khan is president of the Royal Society of Medicine’s Geriatrics & Gerontology Section

Constantly question whether medication is helping a patient or making things worse

Address the root causes of obesity earlier, before medical interventions are required

Dr Nicola Bridges

One of the clearest indicators of multiple morbidities in later life is childhood obesity. Tackling the root causes of this problem is one way of ensuring that fewer medical interventions are required further down the line.

As a paediatrician with an interest in childhood obesity, I see quite a number of patients who have no underlying problems but who run the risk of developing medical problems in the future: diabetes, cardiac and respiratory disease, orthopaedic problems related to stress and strain on their joints, and also an increased risk of some forms of cancer.

The number of children who are overweight or obese is increasing, and more GPs are referring them to specialists like me. Sometimes the GP has concerns, and on other occasions the patient’s parents insist on a referral because for some reason they feel that there is some kind of hormonal disease involved. They come in the hope that we can cure the problem through medication, and almost always the reality is that we can’t.

As an endocrinologist, I know that there are some hormonal conditions that can result in weight gain, but I also know that this is only the case for a small minority of the people I see. With the vast majority, it is just that the child is eating too much. An awful lot of people bounce around between different specialists looking for a medical cure to their child’s weight problems, rather then accepting, and taking action to tackle, the real cause.

There are a few fringe practitioners who will point to things like food additives, but the majority view is that obesity in children is the result of dietary and activity issues, and that is where we should to tackle it. There needs to be much more understanding in the wider public not only about what constitutes a healthy diet, but also the parents’ role in their child’s overall health. I still see people who don’t understand that they have an active role to play.

Food companies have a responsibility to be more honest about their products because I see a lot of foods being marketed as healthy which in reality are simply junk foods, with too much sugar and salt. I also applaud those who have tried to make school dinners healthier in the face of opposition from some parents and children.

From the healthcare perspective, we should be developing a system for addressing obesity issues earlier. It would be great if there were ways of picking up children who were becoming overweight before they reached a weight where the parents thought a trip to the GP might be called for. I am talking about a real mental shift here—one where many more people start thinking about the early stages of excessive weight gain as a lifestyle issue and get support in taking the steps necessary to prevent it becoming a medical one.

The message that really needs to get through is the extent to which obesity can lead to multiple health issues. For most obese people it is not a case of ‘if’ but ‘when’ they will develop. This is why it is so important to tackle obesity in children and change their dietary habits before the medical complications start to appear.

Dr Bridges is president of the Royal Society of Medicine’s Paediatrics & Child Health Section