Naomi Alexander's collection of brownish orange plastic bottles can tell you a lot about her life. Amid the 10 white-topped containers sitting on the kitchen counter lies the story of the hysterectomy, the gall bladder removal, and the other surgeries she's endured in the last two decades. She's lived through a heart attack and a bout with lung cancer. As if that weren't enough, the 79-year old Stockton, California, resident is now fighting Parkinson's disease.
Nevertheless, upon closer examination, you could say that Alexander has a lot going for her: a devoted husband, James, and a dedicated pharmacist, John Hambright. Using a computer database, he helps James to ensure that every one of Naomi's drugs will help, not harm, her.
Few of the growing number of elderly in similar situations are so fortunate. Usually without much guidance, they often are taking drugs that can inadvertently combine to unleash some harmful, sometimes deadly, side effects. This paradox of well-intentioned medicine will only spread as more baby boomers hit their senior years.
"Drugs are doing so much more than they used to," says Hambright, owner of the Lincoln Family Leader Pharmacy in Stockton. "But there's a price to pay."
The dollar amount figures in the millions when you consider what researchers found during a study published in the January 11, 1999, issue of the Archives of Internal Medicine. They looked at 623 patients, with an average age of 70, who were admitted to the intensive care unit in 1994. About 60 percent were there because they suffered from some type of adverse reaction to drugs.
The Organs That Make Older Bodies Susceptible
Many factors add up to leave aging baby boomers particularly prone to adverse drug interactions. Among those factors, however, is mere biology, which makes the biggest splash when drugs bump heads.
That's what Douglas Schmucker has been studying for 25 years at the Cell Biology and Aging Section at the Veterans Affairs Medical Center in San Francisco. He's found that key drug-processing organs slow with age. At the same time, their burden becomes even heavier with older Americans taking more prescription medications. The average is three for people 65 and older, according to the American Society of Health-System Pharmacists.
The problem starts in the liver, which becomes less efficient at preparing drugs for the kidney, which flushes them out into the urine. Those that the liver doesn't process immediately stay in the blood and exert its effect for much longer. Not only that, the liver uses special protein tools, depending on the drug. If two drugs require the same tool, they'll both stick around longer and the result is one of the many side effects of a drug-drug interaction.
"The more drugs you take at once, the greater the chances of interaction," Schmucker says. He also points out that, in addition, older, flabbier bodies tend to store more drugs than younger, more toned bodies. (The more fat you have, the more medications you're likely to have stored away in your body.)
Some common symptoms of a drug-drug interaction include fatigue, constipation or diarrhea, confusion, incontinence, frequent falls, depression, weakness, excessive drowsiness, hallucinations, agitation, anxiety, dizziness, and a decrease in libido. Plenty of other symptoms can pop up. And whether you suspect that a symptom is a side effect from one drug or multiple drugs, speak to your doctor, who may change the dose or the drug.
Weakening kidneys can exacerbate these symptoms because they can't keep up with all the drugs arriving fresh from the liver. So, again, the drugs are left to dawdle in the body for longer than usual.
Why Doctors Can't Give Full Protection
Why don't doctors take this all into account when they scribble out a prescription? They're not to blame, Schmucker says. Doctors and other health care professionals don't have any kind of manual to guide them in prescribing for the elderly.
"It all boils down to a dearth of information," he explains. "There's no database to help prescribing doctors."
It's little wonder, considering that pharmaceutical companies have always turned to young, white males to sample the goods. Reaching out to women and minorities only started in the past decade, while testing on the elderly has only been mandated since 1998. So, there's very little hard data detailing exactly how an elderly person will tolerate one drug, much less two or more.
Common Drugs That Interact
Doctors and pharmacists are indeed wary of a few basics, however. In a 1999 Archives of Internal Medicine study, for instance, ICU doctors commonly encountered patients who had taken a blood pressure-lowering medication known as an ACE inhibitor such as lisinopril (Zestril) along with a non-steroidal anti-inflammatory medication (NSAID) such as ibuprofen (Advil). Taking a diuretic with either of these could also land some people in the hospital.
Another harmful drug-drug interaction is the popular heart medication metoprolol tartrate (Lopressor) along with common blood pressure medication verapamil HCI (Covera-HS). Together they could possibly cause heart failure, says Ronald Charles, MD, assistant professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas.
In addition, common antacid cimetidine (Tagamet) interacts with a blood-thinning medication called warfarin (Coumadin) and heart medications such as Lopressor to possibly cause bleeding. And antibiotics can sometimes interact harmfully with several drugs.
Watch Over-the-Counter Medications and Nutritional Supplements, Too
Throwing curve balls into an already fragile equation are over-the-counter medications and nutritional supplements. Taking them without telling your doctor or pharmacist can make it difficult for them to protect you from harmful interactions, says Macary Weck, a pharmacist currently completing a residency at the University of Maryland.
Both nonprescription drugs and supplements contain potent medications that can alter how the body responds to prescriptions. For instance, many of the elderly take NSAIDs, usually to alleviate the pain and swelling of arthritis. Together with Coumadin, they make the gastrointestinal tract more prone to bleeding, Weck says.
Pseudophedrine (Sudafed) is another popular over-the-counter medication, which helps to clear up congestion. But it also tends to raise blood pressure, negating the effects of blood pressure-lowering prescription medications.
On the herbal front, is ginkgo biloba, taken for its touted ability to prevent memory loss. Taking it with medications like Coumadin or NSAIDs can result in bleeding or serious blood-clotting problems. This is also why it's best to stop taking ginkgo before going under the knife.
St. John's Wort is also popular among the elderly, many of whom suffer from depression. But because its touted active ingredient is much like a prescription anti-depressant known as an MAO (monoamine oxidase) inhibitor, check with your doctor before taking the herb. Combining it with any prescription anti-depressants can pose problems, which doctors don't fully understand at this point.
What You Can Do
With so much to consider, elderly people have quite a task in managing their medications. They're not alone, though.
"You can really rely on your pharmacist to help you," Hambright says.
Purchasing your drugs from one place gives the pharmacist a chance to know you and the medications you're taking. It's the "best protection against drug interactions," he says. Then, make sure you're talking to your pharmacist about any new medications or supplements you're planning on taking.
For over-the-counter medications, says Weck, be sure to read the labels, which provide direction on how much to take, warnings and other useful information. This can be challenging for some elderly people since many labels are too small. In the coming years, however, the labels will be much more consumer friendly. The change is due to a mandate issued by the U.S. Food and Drug Administration in 1999 that requires all labels to have bigger fonts, following a standardized format. It will help ensure that you know exactly how the medication can help you and potentially harm you. You should notice the labels in the next few years.
Playing by all these rules has been well worth the trouble for James Alexander, who also has the responsibility of giving his wife, Naomi, round-the-clock care. After making the efforts to ensure that every one of Naomi's medications won't cause any harm, they relax and spend precious time together.
"It's all worth it," James says. "I just can't imagine being here without her."
Laura Lane is a San Francisco-based health journalist whose work has appeared in Shape magazine, Men's Journal, Tufts University Health & Nutrition Letter, WebMD, CNN.com, and the Dallas Morning News.
