Nov 27th 2015

How the health system is skewed towards harm for pill-popping pensioners

by Nikesh Parekh

Research Fellow in Ageing, Brighton and Sussex Medical School
".....it is time to step away from the status quo of a pill for every ill."

"For example, Statins,.....is one of the most commonly prescribed drugs.......despite an absence of robust evidence to make an informed risk-to-benefit analysis."


The population of Europe is ageing rapidly. But as we add years to life, are we successfully adding life to years? A recent analysis suggests not. The concept of healthy ageing – emphasising physical, social and mental well-being – has become a policy priority with the EU’s ambitious target to increase healthy life expectancy by two years by 2020. To achieve this, we will need to tackle head-on the crucial, yet often neglected, problem of medication-related harm among older people.

The World Health Organisation (WHO) estimates that one in every four people in Europe will be aged over 65 by 2050. This reflects a doubling in the older adult population, and the fastest population growth will be in those aged 80 years and over. This growing cohort of older people is the largest consumer of healthcare services and prescription medications in Western society.

It is a global trend, and the US gives us some useful data to describe it. Between 1990 and 2000, prescription drug spending in America grew by 11.6%. It cost US$263 billion in 2011, when it represented almost 10% of national health expenditure. Over a similar period, the expenditure on marketing of prescription drugs by pharmaceutical companies tripled to over US$4 billion.

War on inappropriate drugs

The situation in the UK is no different, where two-thirds of the primary care prescribing budget is spent on older people in an NHS which has a rising drugs bill currently sitting at more than £14 billion annually. Over the last decade, there has been a 55% increase in the number of prescription drugs dispensed in England. Excessive demands on GPs have contributed to this.

As the UK government pushes almost £22 billion in efficiency cuts on the NHS by 2020 and £200m removed from the public health budget for the 2015-16 financial year, “deprescribing” medications that have poor evidence for benefit and good evidence for harm should be a priority. This can be done safely, and has been shown to improve health.

Despite this, public health programmes which are evidence-based, cost-effective with a focus on primary prevention, and with low potential to cause harm are suffering the brunt of austerity. Inappropriate prescribing of antibiotics has attracted attention with the first World Antibiotic Awareness Week launched by the WHO, but this must be considered within the wider public health context of over-medicalisation and harm.

Medication harm

The alarming fact at the centre of this is that at least one in every six hospitalisations of older people is due to a harmful effect of their medication. The vast majority of these are preventable. In 2004, it was estimated that adverse drug reactions cost the NHS £466m but given the substantial increase in prescriptions since this estimate, it is reasonable to assume that the cost today is greater. The most commonly implicated drugs in preventable hospital admission are anti-platelets, diuretics, nonsteroidal anti-inflammatory drugs and anticoagulants.

Medicine is conceptualised as both a science and an art. The science is about evidence-based patient management and the art is about considering the person as a whole rather than a single disease entity. Much of the management of older patients is based on extrapolation from clinical trials that exclude this population, particularly those that are frail or have cognitive impairment which today represents a significant proportion of this population.

Furthermore, clinical trials are far from representative of real life for the average patient. They do not have a research team monitoring and supporting an ideal use of a medication to achieve therapeutic benefit.

As such, the evidence for benefit of many commonly prescribed medications is patchy at best, and is dependent on large numbers of older people adhering to the medication regimen for a long period of time. For example, Statins, a class of drug that commonly attracts public attention, is one of the most commonly prescribed drugs for older people at risk of cardiovascular disease despite an absence of robust evidence to make an informed risk-to-benefit analysis.

Laser-guided treatment

The art of treating an older person requires consideration of this complex analysis, including their multiple possible chronic illnesses, their life expectancy, and most important their own informed wishes for medical management. “Successfully” treating one illness at the expense of the patient is no success at all.

Medicine for an active old age. REUTERS/World Masters Games/Craig Golding/Handout

The National Institute for Health and Care Excellence (NICE) has been criticised for its guidance on the management of many conditions that affect older people such as hypertension and diabetes. This is because the guidance is disease-specific, treating patients as an example of the disease rather than as a whole, complex person. This misguided patient management has even been incentivised through payment mechanisms in primary care which reward doctors for tackling certain chronic illnesses through the quality and outcomes framework.

Nevertheless, it is an encouraging sign that NICE will publish guidance for the management of patients with multiple long-term conditions next year which is hoped to rationalise the medicalisation of older people.

Ivan Illich infamously described the medical establishment as a major threat to health in the opening line of his polemic “Limits to Medicine”. While I wholeheartedly disagree with this assertion, it is time to step away from the status quo of a pill for every ill and remind ourselves of a central tenet of medicine primum non nocere – first, do no harm.


This article was originally published on The Conversation. Read the original article.



Dr Nikesh Parekh is a medical doctor training in General Practice, research fellow in ageing and part-time public health medical associate in London. 

He has a wide range of academic interests reflected in his publications including childhood injuries, health inequalities, and increasing participation of older people in applied health research. He also lectures on the Global Health MSc course run by the Wellcome Trust Brighton and Sussex Centre for Global Health Research.

Browse articles by author

More Essays

Succession: Logan Roy’s hand-picked directors cover up wrongdoing, just like in real life
by Jia Liu, Nader Atawnah and Rashid Zaman
Oct 21st 2021
EXTRACT: "So much of Succession holds a mirror to real life, and the way that Logan Roy’s hand-picked board members allowed these abuses to continue by turning a blind eye to them is a good example. We have just published research that shows that public companies whose directors are chosen by their CEOs are statistically more likely to be involved in corporate misconduct, along with various other shortcomings. So why does this happen, and what should be done about it? "
Abdulrazak Gurnah: what you need to know about the Nobel prize-winning author
by Melanie Otto
Oct 10th 2021
EXTRACT: "Born in Zanzibar in 1948, Gurnah came to Britain in the 1960s as a refugee. Being of Arab origin, he was forced to flee his birthplace during the revolution of 1964 and only returned in 1984 in time to visit his dying father. Until his retirement, he was a full-time professor of English and postcolonial literatures at the University of Kent in Canterbury."
No Time to Die: the problem with Bond villains having facial disfigurements
by Jessica Gibson
Oct 7th 2021
EXTRACT: "As the 25th James Bond film No Time to Die hits the cinemas, we are once again reminded of the way that disability is depicted negatively in Hollywood films. The new James Bond film features three villains, all of who have facial disfigurements (Blofeld, Safin and Primo). If you take a closer look at James Bond villains throughout history, the majority have facial disfigurements or physical impairments. This is in sharp contrast to the other characters, including James Bond, who are able-bodied and presented with no physical bodily differences. Indeed, many films still rely on outdated disability tropes, including Star Wars and various Disney classics. Rather than simply being part of a character’s identity, the physical difference is exploited and exaggerated to become a plot point and visual metaphor for villains" ----- "The British Film Institute (BFI) was the first organisation to sign up and has committed to stop funding films that feature negative representations depicted through scars or facial differences – a step in the right direction."
Microbiome: ‘good’ gut bacteria really could help you lose weight – new study
by Ana Valdes and Amrita Vijay
Oct 5th 2021
EXTRACT: "The trillions of microbes inside of our gut play many very important roles in our body. Not only does this “microbiome” regulate our metabolism and help us absorb nutrients from food into the body, it can also influence whether we are lean or obese."
Alzheimer’s disease: hyperbaric oxygen proposed as treatment in new study
by Osman Shabir
Sep 16th 2021
EXTRACTS: "Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurised chamber. In the chamber, the air pressure is increased two to three times higher than normal air pressure. It is commonly used to treat decompression sickness (a condition scuba divers can suffer from), carbon monoxide poisoning,......" ---- "Blood flow to the brain is reduced in people with Alzheimer’s. This study showed increased blood flow to the brain in the mice receiving oxygen therapy, which helps with the clearance of plaques from the brain, and reduces inflammation – a hallmark of Alzheimer’s." ----- "The researchers then used these findings to assess the effectiveness of oxygen therapy in six people over the age of 65 with cognitive decline. They found that 60 sessions of oxygen therapy, over 90 days, increased blood flow in certain areas of the brain and significantly improved the patients’ cognitive abilities – improved memory, attention and information processing speed."
Drawing conclusions: In search of the French face
by Michael Johnson
Sep 14th 2021
EXTRACT: "Hollywood for years called on Charles Boyer to typify one French look –  bedroom eyes, sly maneuverings, the dismissive look. A face of another type, the massive mug and narrow eyes of Charles de Gaulle, provides the same disdain of the foreigner but also a superiority based on his belief in his own destiny."
Loneliness, loss and regret: what getting old really feels like – new study
by Sam Carr and Chao Fang
Sep 12th 2021
EXTRACT: "The burden of loneliness for older people is intimately connected to what they are alone with. As we reach the end of our lives, we frequently carry heavy burdens that have accumulated along the way, such as feelings of regret, betrayal and rejection. And the wounds from past relationships can haunt people all their lives."
Five ways to use your garden to support your wellbeing
by Emma White and Sarah Golding
Sep 5th 2021
EXTRACT: "Gardens help restore the ability to concentrate on demanding tasks, providing the perfect space for a break when working from home in a pandemic. Natural things – such as trees, plants and water – are particularly easy on the eye and demand little mental effort to look at. Simply sitting in a garden is therefore relaxing and beneficial to mental wellbeing."
Type 2 diabetes: more than one type of diet can help people achieve remission
by Duane Mellor and Adrian Brown
Aug 17th 2021
EXTRACT: "Whether or not a person achieves remission, reducing blood sugar levels is important in managing the negative effects of type 2 diabetes and reducing risk of complications. But when it comes to choosing a diet, the most important thing is to pick one that suits you – one that you’re likely to stick to long term."
Gut bacteria rewind ageing brain in mice
by John Cryan
Aug 10th 2021
EXTRACT: "In our latest study, we show that by taking the microbiome from young mice and transplanting them into old mice, many of the effects of ageing on learning and memory and immune impairments can be reversed. Using a maze, we showed that this faecal microbiota transplant from young to old mice led to the old mice finding a hidden platform faster."
Why spite could destroy liberal democracy
by Simon McCarthy-Jones
Aug 3rd 2021
EXTRACT: "Fukuyama argued that political struggle causes history. This struggle tries to solve the problem of thymos – an ancient Greek term referring to our desire to have our worth recognised. This desire can involve wanting to be recognised as equal to others. But it can also involve wanting to be recognised as superior to others. A stable political system needs to accommodate both desires." .... "Counter-dominant spite can weaken liberal democracies. During the 2016 Brexit referendum, some people in the UK voted Leave to spite elites, knowing this could damage the country’s economy. Similarly, during the 2016 US presidential election some voters supported Donald Trump to spite Hillary Clinton, knowing his election could harm the US. "
Life lessons from beekeepers – stop mowing the lawn, don’t pave the driveway and get used to bugs in your salad
by Siobhan Maderson
Jul 31st 2021
EXTRACT: "If we want to live in a world that is good for pollinators, as well as the rest of us, big changes are needed in our environment, and our food system. This is why many beekeepers change their diet and their shopping, eating more locally grown vegetables that aren’t treated with pesticides. ...... Being willing to buy fruit and vegetables that may have the occasional insect living in it is better for us and for nature. To live more harmoniously with the natural world, we need to relax about larvae in the lettuce and slugs in the spinach."
Billionaire space race: the ultimate symbol of capitalism’s flawed obsession with growth
by Tim Jackson
Jul 22nd 2021
EXTRACT: "You’d think our brush with mortality through the pandemic would have brought some of this home to us. You’d think it would give us pause for thought about what really matters to us: the kind of world we want for our children; the kind of society we want to live in. And for many people it has. In a survey carried out during lockdown in the UK, 85% of respondents found something in their changed conditions they felt worth keeping and fewer than 10% wanted a complete return to normal."
Damien Hirst’s ‘The Currency’: what we’ll discover when this NFT art project is over
by Paul Dylan-Ennis
Jul 20th 2021
EXTRACT: "English artist Damien Hirst’s latest project, “The Currency”, is an artwork in two forms. Its physical form is 10,000 unique hand-painted A4 sheets covered in colourful dots. In the same way as paper money, each sheet includes a holographic image of Hirst, a signature, a microdot and – in place of a serial number – a small individual message. The second part of the artwork is that each of these hand-painted sheets has a corresponding NFT (non-fungible token). NFTs are digital certificates of ownership which exist on the secure online ledgers that are known as blockchains. ---- The way that “The Currency” works is that collectors will not be buying the physical artwork immediately. Instead, they will pay US$2,000 (£1,458) for the NFT and then have a year to decide whether they want the digital or the physical version. Once the collector selects one, the other will be destroyed. ---- So what is going on here, and what does it tell us about art and money?"
Beyond Functionality: Modern and Contemporary Ceramics at the Metropolitan Museum of Art
by Sam Ben-Meir
Jul 20th 2021
EXTRACT: "Ellison was an abstract expressionist painter, who, having come to New York City from West Texas in 1962, was as he said “unable to find traction” as a painter. At the same time, he began collecting ceramic objects and educating himself about this field of art as he went along. In 2009 he bestowed on the Metropolitan Museum of Art over 300 extraordinary examples of American ceramics, spanning the years 1876 through 1956. Since then, Ellison has gifted to the Museum over 600 works – including a significant collection of European art pottery in 2013, and most recently over 125 modern and contemporary clay vessels and objects – making the Museum one of the most significant repositories of Art Pottery in the world. ---- The current exhibition presents nearly 80 pieces drawn from Ellison’s latest donation, and it is a thoroughly captivating show; even where (or perhaps especially where) the works are outlandish, bizarre, sometimes almost monstrous, but nonetheless enthralling."
Gareth Southgate: football management as a team sport
by Andre Spicer
Jul 11th 2021
EXTRACT: "Over the course of England’s journey to the Euro 2020 final, one of the most fascinating plays has been happening just off the pitch. Whenever the TV camera cuts to the team’s manager Gareth Southgate, he is occasionally seen standing alone on the edge of the field, urging his team on. ---- But most of the time he is deep in conversation with his assistant Steve Holland. ---- A recent study of English football culture points to a shift away from what the authors term “Beckhamisation”, after the former England captain and Manchester United star player David Beckham – a popular and instantly recognisable symbol of that period of football history (though, it is not suggested the culture was his creation). ---- During the 1990s, the study claims, this “Beckhamisation” saw high octane management practices imported from the corporate world into football. ---- In recent years, this has been replaced by “Southgatism”, a leadership style which that study describes as “modest, self-deprecating, down to earth, diverse and progressive”. "
The Configuration of Sensation: Paul Cézanne’s Drawings at the Museum of Modern Art
by Sam Ben-Meir
Jun 30th 2021
EXTRACT: "New York’s Museum of Modern Art is currently presenting an exhibition devoted to an in-depth review of Paul Cézanne’s drawings. If there is any criticism to be made of this extraordinary show, it is that it is frankly overwhelming: with roughly 280 pencil, ink and gouache drawings and watercolors (and even a handful of oil paintings), there is so much to take in that two or three visits to the exhibition may be required to do it justice."
IQ tests can’t measure it, but ‘cognitive flexibility’ is key to learning and creativity
by Barbara Jacquelyn Sahakian, Christelle Langley and Victoria Leong
Jun 25th 2021
EXTRACT: "Cognitive flexibility provides us with the ability to see that what we are doing is not leading to success and to make the appropriate changes to achieve it." .... "Flexible thinking is key to creativity – in other words, the ability to think of new ideas, make novel connections between ideas, and make new inventions." .... "The good news is that it seems you can train cognitive flexibility."
America’s Flawed Search for Itself
by Zachary Karabell
Jun 17th 2021
EXTRACT: "Confronting our complex history and ultimately embracing a more equitable, balanced, and humble culture may be a tall order in these fractious times. But that makes it even more imperative that we fully reckon with who we are and who we are capable of becoming."
Hiking workouts aren't just good for your body – they're good for your mind too
by Lindsay Bottoms
Jun 11th 2021
EXTARCT: "A further health benefit of hiking is that it’s classed as “green exercise”. This refers to the added health benefit that doing physical activity in nature has on us. Research shows that not only can green exercise decrease blood pressure, it also benefits mental wellbeing by improving mood and reducing depression to a greater extent than exercising indoors can."