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I read the “American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults” and thought it might be useful to share some perspectives that were helpful to my senior patients.
Gladys was referred to me by one of my other senior patient. She had moved to Ajax and placed herself on another family doc’s waitlist. She finally got a call to meet the new physician; and was told after their first meeting that she can’t be accepted due to her need for sleeping pills.
Gladys was referred to me by one of my other senior patient. She had moved to Ajax and placed herself on another family doc’s waitlist. She finally got a call to meet the new physician; and was told after their first meeting that she can’t be accepted due to her need for sleeping pills.
I remember in our first meeting, Gladys was wearing makeup, thin, slightly tremulous, anxious and earnest.
I think after I finally assured her that I will do my best to look after her; her attention switched from the fear of rejection to the fear of running out of her sleeping pills.
She explained to me that she has been on her sleeping pills for well over 20 years and can sleep only a little even with the meds; and that she must have them or she can’t sleep at all. I explained to her the nature of addiction; that there is a real need, a substitute solution and a real solution.
I explained to her the real need is an increased ability to pay attention. An increased ability to pay attention will allow her to redirect her attention from her incessant thoughts to other aspect of her moment by moment experience, such as tactile sensation. I explained that such increased ability will not only help her quiet her thoughts but also help her with day time anxiety.
I then explained to her that benzodiazepines, like all “depressive” substances (alcohol, cannabinoids, opioids, OTC sleep aids) are all substitutes. I then explained to her the problems with substitutes are three fold; real needs unmet, mental suffering associated with the 4c’s of addiction, the host of side effects (relevant examples useful for illustration are plentiful) of the substitutes.
Finally I explained to her that I can show her mental exercises that will improve her attention. She repeatedly expressed her doubts but when I pointed out to her that things weren’t really satisfactory even with the pills; she hesitantly agreed to listen and to give it a try. I showed her how to BAM (Breath Awareness meditation).
Within 2 weeks, she was sleeping without benzodiazepines or any seditions. I also encouraged her to increase non-starchy vegetable intake towards 400 grams per day. In a short time, she quit her antidepressants and began volunteering at a nursing home. I should also mention that Gladys was 76 years old.
This strategy has worked in my practice over and over again. No patient leaves with a script for any habit forming substance without a “heart to heart” conversation on diet and addiction. I have not had to start anyone on benzodiazepine for a long time.
One of my patient brought her elderly mom, Edith, to see me for the first time. Edith was a 87 year old lady sitting in a wheelchair. Edith used to live in the city independently but had to move in with her daughter recently due to the loss of power in her left leg and intractable sciatica. She had already seen the neurosurgeon and was told that there was no surgical solution. She had been to ER on several occasions. At her last ER visit, her hydromorphone dose was tittered up. She can no longer walk, lost her appetite, became constipated, continue to suffer intolerable pain, felt generally weaker and a sense of hopelessness. She was placed on waitlist for bed in a chronic care facility.
I explained to her the importance of getting off the opioids; and for her to discover core muscle actions that restores sensations to her left leg. I explained to her ways to use increased intra-abdominal pressures to stretch para-lumbar muscles and decompress the lumbar spine. I asked her to begin these exercises while laying in bed. She was fortunate to have her dedicated daughter’s support. (Her daughter learnt to manage her own fibromyalgia using mindfulness-based practices and uses no analgesics.)
Within a month, by following those instructions, she stopped using her wheelchair, hydromorphone and laxatives. Her appetite was restored and her pain managed with mindful posture core muscle engagements.
Then there is Anna, a friend’s elderly mother, who began living in a retirement home following her coronary bypass surgery. I was asked to help. Post-op, she was unable to eat, losing weight, weak, unable to get out of bed, diapered and depressed and wanting to die. Her sulphonyluria, DDP4 and metformin were eliminated and replaced with basal insulin and a diet containing 5 oz of non-starchy vegetables three times a day. Now her am glucose is 7.2-8.4 based on glucose logs faxed weekly to my office. I can always tell when she is off her diet. Even though the nutritional order is in her chart, implementation by her retirement home is inconsistent. I think I will give her director of home a call and share the “Effect of eating vegetables before carbohydrates on glucose excursions in patients with type 2 diabetes” - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882489/
Anna is now waking with a walker. She know to keep her back nice and straight, chest out and cores engaged. She only uses the walker for balance.
She had some transient SVT post-CABG. She is now off amiodarone, NOAC, furosemide, potassium and magnesium.
She is also off her quetiapine, mirtazapine and pantoprazole.
She now no longer asking Jesus to take her; instead she loves life, lives one moment at a time, says her rosaries every night and asks God to send an angel to sleep with her. She now sleeps soundly every night till the morning. She tells me how much she enjoys her family and last night’s Valentine’s dinner at the retirement home.
Disclaimer:
To respect patient privacy, all names are changed.
These are specific examples which may or may not apply to you. Please only change or discontinue medication under guidance of your own physician.
