Editor’s view Free

Medication and de-prescribing

Of all the things that doctors can do, stopping and starting drugs are amongst the easiest. Drugs are valuable to help manage ill-health, but are costly and have adverse effects. Polypharmacy, and now “super-polypharmacy” (>10 drugs) and “hyper-polypharmacy” (>15 drugs), increase risks and can make drug regimens all-but-impossible to follow. Geriatricians, and all those who prescribe for older people, must be expert in clinical therapeutics and decision-making. A trio of papers in this issue explores drug prescribing. We often forget that alcohol is a drug; Cousins and colleagues showed that alcohol-medication interactions increase falls risk over up to four years of follow-up. Smith and colleagues studied the difficulties faced by people with sensory impairments in medicines management, and call for additional awareness and new initiatives to help. People with visual and hearing impairment faced problems at every stage, including obtaining, storing and administering medication. They developed some creative solutions to problems, but often relied on memory, which is risky when pharmaceutical forms change, such as the size and colour of tablets. “Dosette” boxes and blister packs were not necessarily helpful. Woodford and Fisher provide a valuable state-of-the-art review of the science and practice of stopping drugs—de-prescribing: its rationale, practical aspects, evidence base and evaluation. They conclude that “fewer drugs is not less care”. Most geriatricians will support this view, but practical schemes for putting it into practice remain challenging in the face of system pressures. Disease-specific guidelines, and incentives to follow them, unfortunately promote the opposite effect.

Successful ageing among the very old

Few of us would nowadays consider being over 65 as old. And we may assume that gains in health and longevity seen over the past century will inevitably continue into the future. On the other hand we may be approaching some hard biological limits. Exploring the epidemiology of health in very old age—and “successful ageing”—is an emerging discipline. Byles and colleagues defined different trajectories of ageing in a large Australian women’s cohort. Most of those in their 70s were “successful agers”, but few remained so in their 90s. A small group of persistently “successful agers” was identified, however, remaining free of disease and disability well into their 80s. Different trajectories had different associated features, with successful ageing being associated with better education and optimal health behaviours.

Increased dementia risk with aggressive glycaemic control in diabetes

Tight diabetic control is associated with fewer microvascular complications amongst younger adults, but for frail older people the priorities change, and avoiding hypoglycaemia is a key imperative. Lee and colleagues studied the onset of dementia amongst people with diabetes in a cohort study. High HbA1C was a risk factor for future dementia, but those who achieved target control within a year also had at least twofold increased risk of incident dementia. This was an observational study, and alternative explanations are possible, but the findings support a cautious approach to diabetic control amongst older people.

Making healthcare responsive for older people

Age and Ageing publishes both original research and a range of review, editorial and opinion pieces. Commentaries include debate articles, comments or personal observations on current research or trends in gerontology or geriatric medicine. Bridges and colleagues remind us that when faced with the multi-morbidity, disability, complexity and diversity characteristic of older healthcare users, flexibility and individualisation is needed, but that this may be constrained by the healthcare systems in which practitioners operate. They describe a divergence between policy and rhetoric on one hand, and the realities of practice on the other. Without “responsiveness” in health services—the ability of a service to dynamically respond to individual needs and expectations—it will not be possible to deliver the best healthcare for older people. The message for the wider healthcare environment—politics, policy, professional and advocacy bodies, and management—is that awareness of responsiveness, or its absence, and action to build it into healthcare infrastructure and processes is imperative. Achieving this will require changes in assumptions, and “disruption of widespread and deeply embedded ways of working”, largely designed to promote efficiency and standardised, safe care. This will require careful and committed leadership.