Older man with pills, scary side effect, too many prescriptions, overmedicate

Doctors should pay more attention to the moral of the Goldilocks story: Not Too Much, Not Too Little–Just Right! To refresh your memory, Goldilocks snuck into a house in the forest. She found it to be unoccupied at that moment, but she found bowls of porridge left cooling on the table. One bowl of porridge was too hot, one was too cold and one was just right. She also tried sitting in the chairs. One was too hard, one was too soft and one was just right. Ditto for the beds. If doctors paid closer attention to this story they might be less likely to overmedicate their patients.

Finding the Sweet Spot:

Getting the dose of medicines right can be challenging. These days there is a tendency to treat a number of risk factors aggressively. 

A generation or two ago, doctors were trained to aim for the sweet spot in a treatment program. They often adopted the concept of moderation in all things, including drug therapy. The tendency to overmedicate was constrained by the idea of “just right.”

When my mother was being treated for hypertension 30 years ago, she started complaining of dizziness. Her young primary care physician referred her to an older internist.

The “expert” advised her not to overmedicate. Instead of going along with three or four antihypertensive medicines in an attempt to get her blood pressure down to 120/80, he advised her to back off a bit. He feared that dizziness might lead to a fall.

The new regimen made her feel much better. She lived to 92 and died from a hospital mistake, not a heart attack or stroke or any other complication of hypertension. You can read her story in our book, Top Screwups.

Has Modern Medicine Forgotten Goldilocks?

Modern medicine may have forgotten the message of Goldilocks. In many cases doctors seem to think that if a little medicine is good then a lot is probably better. 

This philosophy has been applied to blood sugar, salt consumption, cholesterol and blood pressure. In every case, medical organizations suggest that the lower the better for such risk factors.

Changing BP Guidelines:

Take blood pressure, for example. Research has established unequivocally that moderate to severe hypertension increases the risk for strokes, heart attacks, kidney damage and dementia. Decades ago, doctors were told that if a patient had blood pressure readings of 160/95, they should be treated aggressively. That threshold dropped to 140/90 two decades ago. More recently, it was lowered again to 130/80.

To achieve such a level, many people need multiple blood pressure-lowering medications. If these work too well and lower blood pressure too much, patients may experience symptoms such as dizziness, fainting, blurred vision, mental confusion, tiredness and nausea.

A devastating complication of high-dose antihypertensive medications, especially for older people, is the increased risk of falls (JAMA Internal Medicine, April, 2014).  A broken hip can lead to disability or even death. The moral: in an attempt to meet the current guidelines a doctor might overmedicate and leave a patient worse off.

The Confusion Over ACCORD:

Blood sugar is another example of the Goldilocks principle at work. The ACCORD clinical trial enrolled 10,251 people with type 2 diabetes. Such patients are a bit like the canaries in coal mines. That’s because they are at high risk for cardiovascular complications. Drug treatment should be especially helpful for such individuals. If they benefit, then less susceptible patients should also benefit.

The results of the ACCORD investigation were somewhat counterintuitive. Lowering blood sugar aggressively “increased mortality” (Diabetes Care, June, 2014).  That’s not to say that blood sugar should be high. Rather it should be more in the sweet spot—neither too high nor too low.

The Low-Salt Challenge:

Salt is another good example of the fallacy of trying to lower a risk factor excessively. Dr. Franz Messerli is one of the world’s foremost experts on hypertension. He has warned that a very low-salt diet can have unintended negative consequences with increases in stress hormones. He cautions this “…may be associated with increased cardiovascular disease events and mortality” (American Journal of Medicine, April, 2017). 

Dr. Messerli advises his colleagues that the Goldilocks message holds here as well:

“Clearly, with sodium restriction, as is true more often than not in medicine, one size does not fit all.”

Mark Twain is purported to have said:

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

We wish more health professionals would be a little more cautious when it comes to prescribing. If they overmedicate ,there can be undesirable consequences.

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  1. Susan
    home
    Reply

    In my experience, once you get put on a medication it is almost impossible to get taken off, because doctors believe that you shouldn’t upset the status quo. Unless you are very vigilant, you can end up like my family members who are on over 15 medications each. These people are in their 70s. Taking so many meds simply can not be useful, let alone helpful. They are being prescribed more meds for the side effects of the drugs they are taking, instead of reducing dosages or titrating off the unneeded drug. Not every drug needs to be a lifetime prescription.

  2. Lisa
    Youngstown, OH
    Reply

    Several years ago my 80 year old mother was hospitalized for “observation” because she had passed out one morning. A cardiologist who had never seen her before decided she needed her blood pressure medication changed. It was changed, and she was sent home. Within the 4 days prior to her follow-up with the cardiologist, she needed assistance to stand up and needed to use a walker (she was using no assistive device before this). When I got her to her appointment, I explained what was going on and told the doctor that issues such as these were listed as possible side effects. The doctor replied, “Her body just needs to get used to it. Come back in 6 months.”

    We got in to see her PCP the next day. He listened to our concerns and changed her back to her old medicine. Within 3 days she was back to her old self. Needless to say I canceled her 6 month cardiology appointment and told the receptionist why we would NEVER be returning to see that doctor. Thank goodness for those doctors who actually take time to listen to their patients!

  3. Kim
    Atlanta GA
    Reply

    We have just experienced this exact thing! My husband has COPD and went to his pulmonary doctor because he was severely short of breath. They decided he needed to be in the hospital and wheeled him across the street to the hospital. His CO2 level was high, so they admitted him to the ICU where he spent 5 days. While in the ICU, they began to over-aggressively treat his blood pressure. They checked him once an hour, and if it was over 130, they gave him IV meds. They checked again in an hour and did the same thing. He started telling them he was over-medicated and that he was dizzy, and his vision was blurred. He told them to let what they already gave him have time to work before giving him anything else. They stopped, but labeled him as non-compliant with the medication. They never got his blood pressure to come down while he was in the hospital, so they sent him home with 5 different blood pressure medications.

    His blood pressure started dropping, and at one point went down to 70/30. That frightened him. He went to his PCP for follow up, and she cut out one of his medications. Then he went for a cardiologist follow up visit, and she cut out another one plus had him eliminate one of the doses of another one. She did blood work during that appointment, and the following day when she got the results, called us and said his potassium level was extremely high and he needed to go to the ER for treatment. We followed her instructions and went to the ER, where they did more blood tests and confirmed that his potassium level was extremely high, so they began to treat him for this. The kidney doctor then came to check on him, and we began to ask what causes this and how do we prevent this from happening again. He told us that the problem was the heart medications he had been given, and that when his blood pressure went too low, it caused acute kidney injury. We have learned to ask as many questions as we can!

  4. Barbara
    CT
    Reply

    My doctor prescribed a new medication for me. I was taking Amlodipine Besylate (5 MG tab). He than put me on Amlodipine Benazepril (5 – 10MG capsules.) Within 24 hours, I was totally out of control with body shaking uncontrollably, dizziness, blurred visions, etc. I called him to say that I was not going to take that poison and returned to Amlodipine Besylate. The side effects also state that older patients should not be taking this medication. I am 77. My BP numbers hovered around 133 over 80. My body does not do well with any drugs. Even the little bit of the substance to put me in “la la land” for my cataract surgery had its consequences. All I can say is to be aware of your body and the way drugs take over your body.

  5. Brian K.
    Marion Il
    Reply

    Hello, peoples. Yes the gold is always right. Golden advice and nice too. Thanks.

  6. Jane
    Chapel Hill NC
    Reply

    More good common sense from the Graedons!
    I am used to the idea of ‘Net Benefit’ in medication and medical procedures. This is a common principle in Europe. Is there still a worthwhile benefit after all the positives and negatives have been taken into account? Not medication because it ‘might do something’ or might be of value to 1 person in 100. I abide by this principle here in the US. Not to mention working on maintaining a healthy lifestyle vs trying to ‘medicate away’ problems. I speak as a healthy person, of course, and understand that optimal levels of medication are of benefit to many.

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