Are you taking too many pills?

90% of Americans 65 and older take at least one prescription medication. Half take 4 or more and 15% take 8 or more. The number of medications taken rises with age.

Add to that the many over-the-counter (OTC) pills such as pain relievers, acid suppressors and supplements that people take, and we are talking about a lot of medications.

While most of these are probably needed, some are not and some are harmful to your health.

There are many reasons people take medication they should not be using. A common reason is that we see many doctors, and each may be unaware of what the others are prescribing. This can lead to duplication – two pills with very similar actions – or to harmful interactions between medications.

Many medications are particularly dangerous to older people. These include muscle relaxants, sedatives and antihistamines, which can lead to dizziness and falls and/or confusion. A very valuable resource in this area is the Beers list of medications that may be harmful to older individuals, maintained by the American Geriatrics Society. It is easily available on-line – just Google “Beers list.”

While medicine has very few “always” or “never” rules, if you find that you are taking medication(s) on the Beers list, ask your doctor about this. You may be healthier stopping them.

I often saw patients taking two different strengths of the same medication. Clearly the dose was changed but the person did not know they were to stop the original pill, and the pharmacy kept refilling both.

There are numerous drug-drug interactions, many dangerous. One pill may affect the way the body handles another, leading to higher than safe levels of one or both. When they are prescribed by the same practitioner, a good electronic record will pick this up, but this will not happen if the prescribers do not share a common record.

If you have a primary care doctor, a valuable visit is the “brown bag visit.” Put ALL your medications, including OTC pills, in a bag and let your doctor review what you are taking. You may be surprised to find how many should be stopped.


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Oh, my aching knees

About 20% of Americans 45 and older have osteoarthritis of the knees, a condition which does not kill you, but which decreases your quality of life.

Osteoarthritis, by far the most common form of arthritis, is more than simple “wear and tear.” It does involve wearing away of the cartilage, the smooth “cushions” that cover the ends of the bones. It also involves the bone itself and the synovium, the lining of the joint.

Obesity is a risk factor for osteoarthritis of the knees and hips, but recreational running is not – it may even be protective. Both sedentary lifestyle and very high volume competitive running do increase the risk.

If you have it, what can you do to decrease your pain and be more active?

Rule number 1 is to stay active. Exercise such as walking lubricates the knees and lessens stiffness. If you enjoy running, keep at it. You may find that running on grass is easier than pavement, and be sure to experiment with different shoes.

In addition to aerobic exercise, strengthen your quads. Exercises such as straight leg raises with ankle weights and squats will build up the muscles that support the knee.

Tai chi has also been found to decrease pain and increase quality of life.

Weight loss, however you achieve it, helps.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can be very helpful, but have side effects on the stomach, kidneys and heart. If you use them, use the lowest dose that works for as short a time as possible.

If you find yourself needing NSAIDs daily, ask your doctor for a prescription for a topical (gel or cream) NSAID, which is much safer. The only one available in the U.S. is diclofenac.

If these measures are not adequate, injection of cortisone-type drugs into the knee will usually give quite a bit of relief. The problem with “cortisone shots” is that the relief is temporary, rarely lasting more than 2-3 months, and repeated injections contribute to worsening of the underlying arthritis.

Hyaluronic acid injections are controversial. There are many trials comparing it to placebo injections and while the majority show benefit, many show no advantage of hyaluronic acid. Insurance companies may cite lack of proven benefit and refuse to pay for these injections. It does appear to be safe should you opt to try this.

If nothing works and you are willing to have surgery, knee replacement is the ultimate choice. This has good results for most people, but not all. Before opting for surgery, it is critical that you are willing to commit to a vigorous physical therapy program. The surgery is the start, but not the end.

To get the optimal benefit from a “total knee” (or a partial one), expect to spend 4 to 6 months of demanding PT; if you are half-hearted with your exercise program, you will be left with a so-so result. You will still probably have less pain than pre-surgery, but you will not have full knee motion.


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Cannabis - what is it good for?

While cannabis (marijuana) is still classified as a Schedule I drug at the federal level, meaning it has no legitimate medical use and a high potential for abuse, the same is not true at the state level. Forty states plus the District of Columbia allow licensed health professionals to prescribe cannabis products for medical use.

(24 states allow recreational use of cannabis – no prescription required.)

One consequence of the federal classification is that the NIH is not allowed to fund studies of medical marijuana use, and this has greatly limited good research on such use. Despite this, 27% of U.S. adults have tried marijuana at least once for medical purposes.

There are FDA-approved cannabis-like products (dronabinol, nabilone) which are approved for nausea and vomiting due to chemotherapy and for severe anorexia due to HIV/AIDS. Another, cannabidiol, is approved for rare pediatric seizure disorders. That, according to the FDA, is that.

Advocates, however, claim that cannabis can do wonders for just about every ailment. Are any of these claims valid?

Chronic pain is a common reason for cannabis use, and a recent study found that chronic pain patients using narcotics were able to reduce their narcotic use after using cannabis. Certainly marijuana is less dangerous than narcotics.

Most of the other reasons cannabis is used have limited or no good data supporting this use. Anxiety may improve but may get worse. Cannabis is used for insomnia, but the sleep it induces is often poor quality. Some PTSD sufferers report help.

Inhaled marijuana lowers eye pressure, but this effect wears off within a few hours, making it of minimal benefit for glaucoma.

Migraines, inflammatory bowel disease and fibromyalgia are often treated with cannabis, but again, there is little solid evidence of lasting benefit.

Why not “just give it a try”?

Cannabis is not harmless. Acute side effects include heart racing, drop in blood pressure, dizziness, impaired coordination and slowed reaction time. Driving after cannabis use is as bad as driving under the influence of alcohol.

With chronic use, particularly daily use, there is evidence that cannabis increases the risk of heart attacks and strokes. Use by adolescents and young adults is associated with cognitive defects and lower IQ scores in adulthood. Regular users can have a severe vomiting illness requiring emergency department visits. Susceptible individuals can develop psychosis and/or increased anxiety.

If you are considering using cannabis for a medical condition, discuss it with your doctor. If what you have been using is not working, there may be better options. Marijuana should be a last choice, not your first.


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Could I be having a heart attack?

Until the late 20th century, getting to the hospital quickly with a heart attack was not that critical. Very little was done for heart attack sufferers beyond letting them rest and treating some complications.

Around 1990, use of clot-dissolving drugs to dissolve the clot in the coronary artery that caused the heart attack became the standard of care. The earlier they were given, the better they worked, and the mantra became “time is muscle.” The drugs worked best when given within 6 hours of symptom onset.

In the early 2000’s, an even better treatment became standard: angioplasty - opening the blocked coronary artery by putting a catheter in the artery and opening the artery with a small inflatable balloon. Current best practice is to then put in a stent to keep the artery open.

What has happened in the past 35 years with these advances is that the early (30 day) death rate from an acute heart attack has fallen from over 20% to under 5%. To achieve these results, the earlier the better. Hospitals strive to get a patient from arrival at the emergency room to the cath lab in under 90 minutes. Most hospitals that provide emergency angioplasty have systems in place to achieve this goal.

The weakest link? The patient calling 911! To get the best contemporary care and to have the best odds of surviving a heart attack, it is key that someone experiencing a heart attack gets care ASAP.

How do you suspect you may be suffering a heart attack? The textbook description is crushing pain felt under the sternum (breastbone). The pain is often felt in the jaw and/or left arm as well. You may get sweaty, and you may feel nausea. The pain is not always excruciating – heart attacks are not as painful as childbirth or kidney stones – but there is something about it that tells you “this is serious.”

Unfortunately, your body has not always read the textbook.

Some people experience sudden shortness of breath rather than pain. Some become profoundly weak. Some feel abdominal rather than chest pain. In most situations, this is a new symptom, one you have not had before.

Women, particularly young women, much more than men, are likely to have non-textbook symptoms, and as such are more likely to delay seeking care and/or be treated less urgently than men who show up complaining of “something sitting on my chest.” Some 40% of younger (under 50) women with heart attacks do not complain of chest pain. (By the time women pass 65, they have similar symptoms as men.)

If you experience symptoms that may be a heart attack, call 911 and get an emergency ambulance. Do not drive yourself to the emergency room. In some communities, the advanced Emergency Medical Technicians who arrive may be able to initiate treatment even before you get to the hospital.

In virtually every situation, arriving by ambulance will get you seen and treated faster than presenting at the front desk.

If it is not a heart attack? Great – you will be allowed to go home and follow up with your doctor for any more testing needed. Never be “embarrassed” by a false alarm. Every emergency physician will tell you it is better to come in when you are not having a heart attack than to stay home and suffer the consequences when it is one.


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