Too Many Medicines: Polypharmacy in Older Adults
A great many older adults take five or more regular medicines, and a substantial number take ten or more. Each was prescribed for a reason. Together they frequently cause more harm than the conditions they treat.
How it happens
The prescribing cascade. A drug causes a side effect; the side effect is mistaken for a new condition; a second drug is added to treat it. A classic sequence: a calcium channel blocker causes ankle swelling, a diuretic is added, the diuretic causes urinary urgency, a bladder drug is added, the bladder drug causes confusion and constipation, and so on.
Multiple prescribers. A cardiologist, an orthopaedic surgeon, a diabetologist and a general practitioner each prescribing without full sight of the others’ lists.
Guidelines applied one disease at a time. Following every single-condition guideline for a person with six conditions produces an unmanageable regimen, and the trials behind those guidelines mostly excluded frail older adults.
Nothing is ever stopped. Drugs started for a short course continue for years. Proton pump inhibitors started during a hospital admission are a particularly common example.
Over-the-counter and traditional medicines added without being mentioned to anyone.
The harms
- Adverse drug reactions, which rise steeply with the number of drugs and are a major cause of hospital admission in older adults
- Drug interactions, which multiply rather than add
- Falls and fractures
- Confusion and cognitive impairment, especially from the cumulative anticholinergic burden across several drugs none of which is individually a strong anticholinergic
- Kidney injury, since ageing kidneys clear drugs more slowly
- Low sodium, commonly from diuretics and antidepressants
- Hypoglycaemia from tight diabetes control that is no longer appropriate
- Bleeding from combinations of anticoagulants, antiplatelets and NSAIDs
- Poor adherence, simply because complex regimens are hard to follow
- Cost, which leads to silent rationing of the most expensive drug regardless of its importance
Drug classes that deserve particular scrutiny in older adults
- Benzodiazepines and Z-drugs: falls, fractures, confusion, dependence
- Strong anticholinergics: older antihistamines, some bladder antimuscarinics, some antidepressants and antipsychotics
- Proton pump inhibitors continued indefinitely without a current indication
- NSAIDs: kidney injury, bleeding, heart failure and blood pressure
- Antipsychotics used for behavioural symptoms of dementia, which increase stroke and death risk
- Sulfonylureas: hypoglycaemia
- Multiple antihypertensives producing postural drops in someone who has lost weight
- Statins in very advanced frailty or limited life expectancy, where the balance changes
- Iron, calcium and multivitamins continued long after the reason has passed
Unlock More Content
Watch a short ad to continue reading the rest of this article for free.
Preparing your free unlock…
Deprescribing, done properly
Deprescribing is planned, supervised reduction or withdrawal, not abandonment of treatment. It is as much a clinical skill as prescribing.
The process:
- Make a complete list. Bring every box, strip, bottle, drop, inhaler, ointment, supplement and traditional preparation to the appointment. A brown bag review finds things no record shows
- For each drug, ask: what is this for, is that reason still valid, is it working, is it causing harm, does the benefit arrive within the person’s remaining life expectancy, and would they choose to continue it knowing the trade-off
- Prioritise. Stop the highest-risk, lowest-benefit drug first, and one at a time
- Taper where needed. Benzodiazepines, antidepressants, beta blockers, opioids, steroids and proton pump inhibitors all need gradual reduction; abrupt stopping causes rebound or withdrawal
- Monitor and review. Note what improves and what returns
- Document and inform every prescriber involved
Several validated tools exist, including STOPP/START criteria and the Beers list, which doctors use to flag drugs that are usually inappropriate in older adults.
Never stop medication on your own. Some drugs are genuinely essential, and abrupt withdrawal of others is dangerous. This is a conversation to request, not an action to take.
What goals change with age
Treatment targets are not fixed. In a frail 85-year-old, an HbA1c of 8 percent may be safer than 6.5, because hypoglycaemia is more dangerous than mildly raised sugar. Blood pressure targets may be relaxed where postural drops cause falls. The question shifts from preventing a complication in 15 years to maintaining function and avoiding harm now.
This is not giving up on treatment. It is matching treatment to what the person actually stands to gain.
Practical steps for families
- Maintain one written, updated list of all medicines, and photograph it
- Take it to every appointment and every hospital admission
- Use a weekly pill organiser
- Ask at every new prescription: what is this for, how long for, what side effects should we watch for, and does it replace something
- Request a formal medication review at least once a year
- Ask specifically whether any drug on the list could be causing the dizziness, confusion, constipation or tiredness being blamed on age
- Use one pharmacy, so interactions can be flagged
- Do not add herbal or over-the-counter products without checking, since many interact, including with anticoagulants
The question worth asking
When an older relative becomes confused, unsteady, constipated or exhausted, the first question should be whether a medicine is responsible. It very often is, and that is the easiest cause to fix.
This is general information. Never stop or change a prescribed medicine on your own; ask the prescribing doctor for a structured medication review instead.