Alan Cassels

The problem with trying to develop a good conspiracy theory these days is that commerce inevitably spoils your theory. It's a trick to weave a conspiracy theory that doesn't sound too wacko because what seems conspiratorial is actually normal business pathology at work.

I tripped over this stark fact recently when my friend Wendy, an expert in consumer health issues, laughed when she let slip that she thought there was a conspiracy between the pharmaceutical companies, drug stores, investors, and the builders and operators of new, long-term care facilities for the elderly. That seemed wacko enough for me to take a closer look.

There are many businesses eager to capitalize on the growing market to provide housing, meals and medical treatments for the elderly, but to say it's a massive potential market is an understatement. As the fastest growing demographic group in Canada – by 2030, the population of people over 85 will grow three times as big as it is now – those people, the majority of whom will be women, will need somewhere to live and supports of all kinds to keep them alive.

It used to be that we expected public money to provide adequate housing and care for Grandma, but not anymore, at least not in any serious way. We've "modernized" by embracing the market, largely getting governments out of the business of constructing and regulating care homes. We've switched to relying on private real estate developers and contracts with private "care agencies" to service the needs of the elderly.

Take a look at almost any community in BC and you'll find fresh examples of sprouting condo developments, retirement villas, "assisted" and "independent living" communities, unfailingly described in the brochures as "deluxe" and "elegant" and usually adorned with ghastly peach stucco. The market is being harnessed for this expected horde of greying customers, but like any market where profit maximization is the goal, how do you expand to attract and then satisfy investors? How does one "grow" the market?

For an immediate jolt of the reality of what life is like for the majority of older people, peek into their medicine cabinets. You'll find a veritable ocean of drugs: stool softeners and laxatives, pain relievers, anti-coagulants, vitamin supplements, drugs to alter cholesterol, blood pressure, blood sugar, mood, anxiety and your libido and drugs to improve bone density. About 20% of Canada's population is 60 or older and this group consumes about 60% of all prescribed treatments and half the national prescription drug bill. On average, each Canadian consumes about 13 prescriptions per year, yet among the truly heavy drug users – most of whom would be among the elderly – it's not unusual to find people routinely swallowing 30 or 40 prescribed pills per day.

This is not automatically a problem as some of those drugs may be serving a valuable purpose, but on a practical level, for anyone trying to manage 30 pills a day – some to be taken in the morning, some at mid-day, some before meals, some after meals and some before bed, etc., etc. – it can be a nightmare. Even a person whose elevator goes all the way to the top would have trouble trying to press the right buttons if they had the complex drug regime faced by many older people every day.

Human ingenuity has countered this problem with the dosette, or bubble pack, a package of clear bubbles usually containing a week's worth of medications arranged with a column for each day. Dosettes make things easier and helps caregivers monitor whether or not someone is taking their pills because missed pills might be the first warning sign that Grandma needs some help. Since most of us preach at the altar of "medication compliance", missing a drug is one of the seven deadly sins. With pills left unconsumed, terms like medication assistance and assisted living become part of the everyday discussions about Grandma's ongoing care.

Routinely ignoring your doctor's orders may signal the end of independent living for you, but some people, even those with memory problems or befuddled thinking, are often just fine living in their own homes surrounded by their belongings, provided the challenges aren't too overwhelming and they have someone to call upon for help when necessary.

Is it worth moving a person into an assisted-living situation or nursing home just because they don't take their meds? Call me naïve, but I think what a person needs in this situation is a doctor or pharmacist they can trust – someone who can help figure out which drugs are truly necessary, giving priority to the drugs that help with the comfort and daily functioning of the patient, for example and those which are not – and then streamline the drug-taking mess.

Sadly, that's not really part of the current medical system/industry. Instead, we have real estate developers, private-for-profit care home operators and, of course, the drug industry and retail pharmacies that can all collectively treat the "doesn't-take-her-meds-"related diseases.

In the new, for-profit models, the system subtly shifts the costs of medications and dispensing – historically included in long-term care settings – to the people receiving the care or their families. Drug stores bring in extra dollars to the care home by supplying pre-packaged medications for each resident and the dispensing fees are a cash cow. Some facilities charge as much as $150 to $300 extra per patient for "medication assistance." Sweet.

Yup, it's a pretty sweet deal for all concerned, except perhaps for the elderly patient who now has to pay someone to make sure she swallows her 30 meds a day in her deluxe, peach stucco condo.

Can the complex medication regimes of older people be the primary reason that so many of them end up in long-term, assisted care facilities? I can't answer that, but it would seem we need a major push to help people manage their drugs – or even ditch many of them – so they can stay at home. I would admit that this line of thinking raises many uncomfortable questions: Does Grandma need all those drugs in the first place? Do the private care facilities see incentives in staffing their facilities with fewer and fewer trained and available staff? Is there a reason why these facilities use so much "control" medication (mostly anti-anxiety, anti-psychotic and anti-depressant drugs) for their elderly residents?

Keep asking questions, but whatever you do, don't call this a conspiracy. Just follow the money and watch who stands to gain from overmedicating Grandma to the point that she's too befuddled to live on her own anymore and then offers her the keys to her own peach stucco box.

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and a frequent commentator on prescription drug issues.