Combining pharmacological treatments in geriatric population: weighing the balance.

Sir,

Apropos, the paper by Wisler et al., titled “Pre-injury neuro-psychiatric medication use, alone or in combination with cardiac medications, may affect outcomes in trauma patients,”[1] we appreciate that the author has discussed a clinically significant issue concerning polypharmacy in older patients. Notably, with the increasing age of longevity of the population, clinicians are bound to see many older patients on polypharmacy for various medical comorbidities. However, the conclusion drawn from the study that those patients who were on combination of neuropsychiatric medications and cardiac medications are likely to have increase in-hospital mortality needs to be understood in the correct context. We think this observation holds true for not only these two groups of medications, but also for any two groups of medications, which has been observed in studies on polypharmacy outcomes in elderly patients.[23] It would be discriminatory to blame use of neuro-psychiatric medication for increase in inpatient mortality in this particular group of patients. Moreover, there is no control group to know the treatment outcome in use Vis à Vis non-use group for this group of medications. As psychiatric illnesses are themselves associated with increased risk of intentional as well as unintentional injuries, if left untreated, neuropsychiatric medications do have roles in prevention of injuries and hence overall morbidity.[45]

Additionally, the patients who were receiving multiple neuropsychiatric medications may have been suffering from severe mental illnesses which were uncontrolled and the underlying illness itself may have increased the morbidity and mortality.[6] In that case, the culprit is not the neuropsychiatric medications but the underlying neuropsychiatric condition. Similarly, the role of underlying cardiovascular condition is also crucial which could have contributed to the greater morbidity. Also, the dangerous side effects of neuropsychiatric drugs like neuroleptic malignant syndrome (prevalence rate 0.07% to 2.2%) and serotonin syndrome are rare, and it is unlikely that such rare side effects contributed in increase mortality of the patients.[78]

Finally, the clinicians should not hesitate in using neuropsychiatric medications in old age due to fear of increase morbidity and mortality. The standard approach of “start low-go slow” should be used while prescribing neuropsychiatric medications to older patients.[9] Neuropsychiatric conditions are the cause of significant morbidity in elderly and appropriate management keeping in mind other co-morbidities and drug interactions is a must to improve prognosis and quality of life.