A woman in her late 70s visited my office after traveling a long distance by bus from a small town. She complained of dizziness showing me a handful of prescriptions. She had seen at least 10 doctors over the past year, not only in her town but also at hospitals in Seoul. After reviewing her recent medication list, I discovered that she had been prescribed nearly 20 different medications by five different doctors. The medications were intended to treat dizziness, indigestion, sleep disorders, urinary incontinence, and memory loss. She had no appetite and was losing weight, and had recently started to lose energy a lot. Her medication list seemed to have grown as her sleep disorder and dizziness were not responding well to the treatments. Her memory gradually deteriorated and new medications were added, causing urinary incontinence and indigestion. As the medications piled up, it became increasingly difficult for her to get out of the house and perform daily activities even at home.

We call this piling of medications "prescribing cascade.” The medication she was taking for her dizziness can cause constipation and memory loss, especially in older adults. These drugs are called "potentially inappropriate drugs for older adults" because they are more likely to cause side effects compared to their desired effects. In the healthcare environment of Korea, where there are no primary care physicians and the patients have to decide which doctor to go to, patients who experience these side effects often go to a doctor who treats constipation and memory loss rather than discussing the issue with the doctor who prescribed the dizziness medication. Well-known side effects of the medication she was prescribed for memory loss include urinary incontinence, indigestion, and dizziness. The symptoms and side effects cascade and the medications pile up. Sometimes, in a matter of months, this destructive cycle can transform an independent and mobile person into one confined to a bed. They are forced to spend the rest of their lives under someone else's care, even though they had no problems with their own care. This demonstrates that medication concerns are closely related to public health issues.

The first step in addressing the problems created by the prescription cascade is to identify how it came to be and then reverse the vicious cycle, a process called "de-prescribing" in geriatrics. Successful de-prescribing is not possible in all cases, but when it is accompanied by goal-setting, thorough counseling, and a high level of understanding from the patient and their family, it is often possible to reduce medications and significantly improve overall health.

In the case of my patient, a woman in her 70s, this de-prescribing process did not yield positive results. Difficulties arose as she found it challenging to continue traveling to Seoul for medical appointments, and there were no local doctors available to act as her primary care physician and review her medications. Consequently, during our last consultation, I proposed a revised prescription. However, when she returned to my office approximately a year later, it was disheartening to observe that the number of medications had increased, and no adjustments had been made to her prescription. Her overall condition had worsened.

Upon visiting a new doctor in a different hospital, she was advised to reduce her medications. Unfortunately, this guidance was not followed, and instead, her medication list continued to grow with each new symptom that arose.

Older adults in Korea are heavily medicated. Based on OECD statistics from 2021, a substantial 70.2 percent of older adults in Korea were consistently taking five or more medications for a period of three months or longer. This figure surpasses the OECD average of 46.7 percent and shows an increase from the previous statistic of 67.2 percent in 2013. As individuals age, the number of underlying chronic conditions tends to rise, consequently leading to an increase in the number of medications they are prescribed.

Data from the National Health Insurance Service (NHIS) reveals that the percentage of individuals aged 65 to 74 taking 10 or more medications for 60 days or more was 6.91 percent, while for those aged 75 to 84, it was 14.57 percent. The figure was even higher for individuals aged 85 and older, reaching 15.74 percent. Overall, among the entire population aged 65 and above, the percentage was 10.26 percent. In the field of geriatric medicine, it is widely acknowledged that taking 10 or more medications increases the likelihood of experiencing at least one side effect, approaching almost 100 percent probability. In many cases, the number of prescribed medications naturally rises in correlation with the number and severity of underlying illnesses.

However, there are certainly cases like that of my patient. The specialists in each field must have provided textbook care for individual symptoms from an adult medicine perspective. However, she did not have a physician who could comprehensively review her prescriptions and coordinate her care. Even if a doctor comprehensively evaluates a patient with many illnesses and complaints and develops a treatment plan, the fee for the doctor is no different from a three-minute consultation. This is going against the trend in other countries where physicians try to change healthcare systems for older people from disease-centered to person-centered.

In other countries, the task of organizing and solving the complex medical and functional problems of older patients is primarily the responsibility of primary care physicians with knowledge of geriatric medicine. This role can be taken by a geriatrician, but more often than not, it is a general practitioner or physician from a variety of specialties, such as internal medicine or family medicine, who provides geriatric care from a primary care perspective. In the U.K., geriatricians have had this role since the 1940s. In the U.S., which has a similar healthcare payment system to that of Korea, efforts are being made to improve the effectiveness of the healthcare system by utilizing geriatric medicine. In particular, in Veterans Affairs hospitals, a concept similar to Korea's veterans’ health service hospitals, geriatric medicine plays a role that encompasses medical care and nursing. Some countries have policy support for healthcare providers to reduce medications. Since 2016, Japan has been paying 2,500 yen (21,000 won) to patients taking six or more medications if they reduce their medications by two or more.

Patients are frustrated. They don’t have a doctor who listens to them when they are sick. But doctors are even more frustrated. In the land of the Red Queen in Lewis Carroll's “Alice Through the Looking Glass,” there is a law that if you stand still, you are pushed backward. So if you want to stay in the same place, you have to run as hard as you can, and if you want to go somewhere else, you have to run twice as fast. In Korea, the medical reimbursement system is centered on visible actions such as tests and procedures. The one thing that doesn't go up is the basic examination fee. When you start listening to patients, it's not profitable, at least in economic regards. In order to survive, hospitals and clinics are constantly introducing new, expensive technologies to meet their increasing costs. The amount of time they can spend with individual patients keeps shrinking. The complexity of older people's illnesses and medicines is always pushed to the back burner in favor of other "urgent" issues in health and welfare. As a result, patients and doctors become distant, and prescriptions pile up in the meantime.

Jung Hee-won, a geriatric physician at Asan Medical Center, graduated from Seoul National University College of Medicine and trained at Seoul National University Hospital. During his med-school days, while practicing the horn, he realized the importance of muscle maintenance and became interested in sarcopenia. His main research interests include frailty, sarcopenia and establishing age-friendly health systems for acute hospitals. This column was originally published in Chosun Ilbo in Korean on June 28. --Ed.