Irresponsible headlines linked to alarmist media reports

This story first appeared in episode #049 of our podcast Skeptics with a K. Subscribe and download. You know it makes sense.

I was recently surprised to see the following headline on the BBC News website:

Common medicines linked to death

I’ll be honest, this struck me as scaremongering. And this wasn’t some obscure article tucked away in the health pages…  it was the lead story, on the homepage, for a whole morning. The article said:

Drugs used by half of elderly people have been linked to a greater risk of death and declining brain function.

Eighty drugs were rated for their “anticholinergic” activity: they were given a score of one for a mild effect, two for moderate and three for severe. Some were given by prescription only, while others were available over the counter.

A combined score was calculated in 13,000 patients aged 65 or over, by adding together the scores for all the medicines they were taking. A patient taking one severe drug and two mild ones would have an overall score of five.

20% of patients with a score of four or more died. Of those taking no anticholinergic drugs only 7% died.

My first reaction on reading this was “no shit”.  To score four or more, you must taking at least two and perhaps as many as four different drugs, potentially for several different conditions. If you’re on more drugs, the chances are that it is because there is more wrong with you. People aren’t taking anticholinergic drugs for a laugh — they have been prescribed because of certain indications (or suggested by a pharmacist, or even just the side of the packet). The thrust of this story seemed to be “if there is more stuff wrong with you, you are more likely to die”.

What an insight.  Of course, the reality was a bit more complicated than that.

This story actually came from a paper titled “Anticholinergic Medication Use and Cognitive Impairment in the Older Population: The Medical Research Council Cognitive Function and Ageing Study”, published in the Journal of the American Geriatric Society.

It was a two-year longitudinal study, which observed 13,000 patients aged 65 or older, and as the BBC says:

This study cannot say that the drugs caused death or reduced brain function, merely that there was an association.

Which is honest of them. It’s just a shame they didn’t reflect that in the alarmist headline they put up on their homepage for a whole morning.

As I said, my initial criticism was that if you’re on more medication, you’re probably more ill.  And in that case, of course there would be increased mortality. This turned out to be a little hasty of me, as the abstract of the study claims that the authors have corrected to age, sex, social class, comorbid health conditions.   That said, correcting for things like increased mortality rates due to underlying disease is tricky and we shouldn’t rule out the possibility that the conditions the patients were taking the medication for may have still influenced mortality rates.

But let’s leave that to one side and assume the data has been corrected appropriately.  There are still several limitations of this study:

  1. The data are 20 years old, having been gathered between 1991 and 1993. A lot has changed in 20 years, and the data may not reflect current practice.
  2. This was an observational study, not a controlled study.  There is no guarantee that the participants actually took their medication as directed.
  3. The data were gathered by asking patients what medication they were taking.  Especially as the patients were elderly, and perhaps suffering from the early stages of mental decline, they may not have correctly recalled the medication they were taking.
  4. No account was taken of the dosage. So a patient taking 20mg of Drug X daily, and another taking 100mg of the same drug thrice daily, would have received the same score.
  5. The cognitive function of the patients was assessed by Mini-mental state examination, or MMSE. This is essentially a standardised questionnaire, which gives patients 10 minutes to answer 30 questions on arithmetic, memory and orientation.  This is not an uncommon outcome measure for these types of studies, but as this was the only factor used to assess the patient’s cognitive function, we don’t know to what degree it reflected cognitive problems encountered in daily life. Despite a decline in their MMSE score, patients could have been functioning perfectly well on an every-day basis.
  6. Most strikingly, no data was presented on the benefits of the medication, only the potential side effects. Though it may be true that patients taking Drug X for Indication Y see a 4% decline in their MMSE score over two years – patients with Indication Y who aren’t taking Drug X could (to use an extreme example) be dead because they weren’t getting treatment.

When it comes down to it, my problem isn’t with this study. It is, in itself, an interesting and valuable piece of research. It was published in a respectable peer-reviewed journal, it has an excellent sample size, and the sample is representative of the community being studied. The MMSE is a recognised tool for measuring cognitive function, and the authors have attempted to correct for as many confounding factors as they were able. It’s a good study, in a good journal, the findings are good cause for more research into the side effects of anticholinergic medication.

My problem comes from the alarmist way this study was reported by the press. BBC News initially ran with “Common medicines linked to death”, although they later changed this to the marginally more sensible “Warning over combining common medicines for elderly“.

Other headlines included:

This is ridiculous alarmist reporting, which takes no account of the limitations of the study and runs the risk of frightened elderly people, taking themselves off much-needed medication.

The Financial Times seemed to go meta with the whole thing.  Their headline was “Alarm raised over medicines for elderly“.

Yes, alarm was indeed raised. But it was raised by irresponsible alarmist headlines in publications which should know better. And many of them did know better, taking the time and trouble in the body of their articles to say something akin to “this doesn’t show cause-and-effect; you shouldn’t stop taking your pills”.  But they still topped the article with an OTT headline like “Common medicines linked to death”.

The final word goes to the MHRA, who the NHS Choices website reported as saying:

All medicines have side effects – no effective medicine is without risk.

Our priority is to ensure that the benefits of medication outweigh the risks. The known side effects of anticholinergic medicines are described in the product information for prescribers and in patient information leaflets. Where it is known that taking a combination of medicines may increase the risk of experiencing side effects, it will be reflected in the product information.

It is important for people taking anticholinergic medicines not to stop taking them. If they have any questions or concerns then they should contact their doctor in the first instance.

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