Newsletter Monday
Hello Reader,
It’s tricky not to take some headlines a bit personally when you’re a GP. Here’s one that prickled at me this weekend:
“Doctors prescribe drugs without mentioning dementia risk.”
It’s from The Times, which means it’s behind a paywall. As I’m not currently a subscriber, I was initially left with just a headline to irritate me.
So I went digging.
The article concerns a group of medicines called anticholinergics, many in that category are used to calm an overactive bladder. These medicines can have unwanted effects such as drowsiness and confusion, particularly when combined with other medicines.
There is also concern about a possible link with dementia, rather than proof that these medicines cause it. The UK’s medicines safety regulator recently reviewed those used for bladder symptoms and couldn’t establish a direct causal link, although a small increased risk couldn’t be ruled out.
That deserves attention. But, as I have said often, there are always trade-offs with everything.
Let me illustrate how this looks from the side of the prescriber.
Mrs Jones is 70 and has made an appointment because she’s at her wit’s end with her bladder control. Every time she needs the toilet, she has to go, with a degree of urgency that isn’t compatible with the lack of public toilets in most of the UK.
When she has to go, she has to go.
Urge incontinence has entered the arena.
To avoid running her life around this, she’s started restricting her fluid intake. But despite trying that, she’s up and down in the night and, quite frankly, she is fed up.
“Can you help, doctor?”
Mrs Jones is also prone to a bad back. Sometimes she needs painkillers to manage the flare-ups and, unsurprisingly, when she hasn’t slept well for ages, her back plays up.
I can try to help her bladder control by prescribing a medicine to reduce the urgency, but that medicine falls into the group this article is talking about.
Other medicines she takes, especially for that pesky back pain, may also add to the drowsiness, even if they work differently.
I will explain to Mrs Jones that the medicine may help, but it can cause side effects, including drowsiness.
She isn’t particularly worried about that right now. Lack of sleep is a bigger problem.
But drowsiness can increase the risk of falls, and that is not insignificant.
There is our trade-off.
Leaving her symptoms untreated has consequences too: broken sleep, repeated trips to the bathroom and restricting her drinks.
There is no neutral option.
And today, she wants help.
Recall the last time you had a splitting headache.
In that moment, you want the headache gone. Someone explaining that ibuprofen has risks may be heard, but the possibility of an unwanted effect has to compete with the very real headache you have right now.
Mrs Jones’s bladder symptoms have her attention in much the same way.
I use this example to, if I’m honest, offer a line of defence for my profession.
Articles like this, committees and researchers have an important role. I am not discounting that.
But meanwhile, the person in front of me needs help today, this week. Their suffering now has to be part of that calculation too.
Where appropriate, we should use the minimum effective dose for the least amount of time required, and regularly reconsider whether treatment is still needed. That would be an ideal scenario.
I will not argue with that. Totally agree.
What we don’t have is an ideal situation very often.
Sometimes people are put onto a medicine for a symptom or a side effect. It does its job, yet it’s still being prescribed five years later without anyone being quite sure whether it’s still needed.
Sometimes patients are nervous about stopping a prescription because they remember how bad the pain was, or how often they were wetting themselves. They want to keep that at bay, even if it means accepting side effects.
Sometimes a medicine never really does what was intended, or stops helping as much, but becomes the first step in a prescription ladder, with add-ons accumulating around it.
None of these situations is ideal, but they happen.
Does the conversation about possible dementia risk take place? Yes, sometimes. Ideally, where relevant, it would happen consistently.
Sadly, it doesn’t always.
Sometimes people attend a medication review where this should be discussed, but in the precious ten or fifteen minutes of that appointment, a more pressing matter pushes it out of the conversation.
A blood result that needs attention. Or a “Can I just ask you about my husband while I’m here?”
And the conversation about possible longer-term risks never quite gets going.
That doesn’t make the missing conversation unimportant. It does help explain how it happens.
I would love to work in an ideal healthcare setting where every risk gets explained, documented, understood and considered. But I don’t know what planet that is happening on.
I’ll apply for that post when I see the advert.
What I would say is this:
A prescription isn’t a lifetime contract.
Even a long-term prescription deserves a review. You can request one at any point.
I would include medicines such as blood pressure tablets and statins in that conversation too. I spent a shift on Saturday seeing housebound patients, some of whom now need their blood pressure treatment reconsidered because low blood pressure and falls have become a concern.
I also still see people in the final months of life dutifully taking a statin, where the likely benefit deserves another look in light of their priorities and circumstances.
A medicine may have been the right choice when it was started. That doesn’t mean the same dose will remain the right choice forever.
If you’re unsure why you take something, whether it’s still helping, or whether it could be contributing to symptoms you’re struggling with, ask for a review.
And tell us what matters to you.
Mrs Jones’s fewer toilet trips matter. So does her drowsiness. We need to hear about both.
That doesn’t mean stopping medicines because you can’t feel them working. Some are quietly reducing future risks rather than treating something you can feel today. Any changes need an agreed plan.
But you are allowed to ask:
“What is this doing for me now, and is it still the best option?”
