Updated May 8, 2023.

This article provides a brief overview of the danger of polypharmacy in the elderly. There is much more to learn and apply.

I delve into this topic much deeper in my eBook and eCourse related to this topic. Some of the topics I cover in those resources are the aging process’s effect on the absorption, metabolism, and elimination of drugs.

Conversely, I illustrate how drugs affect the aging body’s response, some of which are negative and dangerous to the individual, the American Geriatrics Society’s Beers Criteria of Inappropriate Medications, Geriatric Syndromes, and several other important concepts.

I highly recommend you check out these offers – the education you will receive is second-to-none!

OK! Now, let’s jump right in! Before we go in-depth into the topic of polypharmacy, we need to understand some related medical terms first:

Polypharmacy:

The regular use of at least five medications. Includes over-the-counter, prescription drugs, herbals, dietary supplements, and/or traditional/complementary medicines that older adults use.

All medication use may be indicated depending on the patient’s clinical situation.

However, the patient’s chronic conditions, risk factors, the potential for drug-drug, drug-disease, and drug-food interactions, inappropriate dosing, failure to properly monitor for adverse effects, etc., can all contribute to the potential harm of inappropriate polypharmacy.

Adverse Drug Reactions (ADRs) and Adverse Drug Events (ADEs): 

The harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug (including dose reductions and discontinuations of drug therapy)

Medication Non-adherence:

Defined as either the intentional or unwitting failure to take medications as prescribed. By not following the prescriber’s orders correctly, elderly patients will experience decreased treatment effectiveness, worsening their condition.

Functional Reserve:

The remaining capacity of an organ or body part to fulfill its physiological activity; (especially) in the context of disease, aging, or impairment.

Functional reserve capacities of the heart and skeletal muscles decline with age. This is probably a consequence of physiological aging and diminished physical activity levels.

As a result, once taken for granted, daily tasks become progressively more difficult and impossible to perform.

For example, sufficient coordinated absolute muscle force is required for an individual to rise from a chair or climb stairs, and the heart’s reserve capacity is a major determinant of an individual’s ability to remain active and cope with daily stresses and illnesses.

Functional Ability:

The physical, psychological, cognitive, and social ability to carry on normal life activities.

Frailty:

Theoretically defined as a clinically recognizable state of increased vulnerability resulting from the aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is comprised.

Cognitive: 

Relating to the mental processes of perception, memory, judgment, and reasoning.

The video below from my YouTube channel shows you how I systematically identify and eliminate unnecessary medications contributing to polypharmacy and adverse events in an older adult:

Defining Overmedication or Polypharmacy In The Elderly

Polypharmacy or overmedication in the older adult population is a significant healthcare crisis.

Increasingly, this issue is hardly discussed, and many older people and their caregivers are unaware of the immense health implications of this drug epidemic.

National surveys in the United States estimate that polypharmacy occurs in approximately 20% to 30% of older adults, half of them concurrently using nonprescription medications.

Although the number of medications an older adult takes is critical to the definition of polypharmacy, it is important to note that it is not just referring to many medications.

It is more of a constellation of issues surrounding medications in older adults. In addition to the number of drugs in the medication regimens, the term or concept can also refer to inappropriate prescribing of duplicative medications and patience.

It can also refer to prescribing unnecessary medications or medically unnecessary medications. The consequences of polypharmacy are many and dangerous.

The medical literature suggests that a clear consensus does not exist in the medical literature about the exact number of medications that would be considered a clear definition of polypharmacy.

Understandably, there is no clear answer because every older adult is different, and they come with their own set of clinical problems, frailty, and fragility.

What is clear is that the number of adverse drug events associated with medications increases with patients being on at least five or more medications; in other words, the more medications an older adult takes, the higher the chances of them experiencing drug interactions and subsequent hospital admission.

These drug interactions often result in older adults being hospitalized. Polypharmacy also results in medication non-adherence mainly for two reasons.

Firstly, the financial cost burden to the patient and the Healthcare System increases and burdens the patient.

Secondly, pill burden definitely becomes an issue, and the patient cannot handle the multiple doses needed throughout the day.

How Common Is Polypharmacy In Older Adults? 

40-60% of older adults take one or more medications that are not medically necessary. Older adults have a 50% chance of having an adverse drug reaction if they take at least five medications, and the risk goes up to 100% if they take at least 20 medications.

Polypharmacy accounts for almost 30% of all hospital admissions in the US, and it’s the fifth leading cause of death in the US.

Why does polypharmacy occur? 

The reasons why polypharmacy occurs are many. Here are some reasons:

• The medical provider prescribes a new medication inappropriately due to a misdiagnosis
• The medical provider fails to recognize the potential side effects of a prior medication that was prescribed and now prescribes another medication to treat the adverse effects of the previous drug
• The prescriber and the pharmacist fail to recognize clinically significant drug interactions that place the patient in harm’s way
• Older patients have chronic medical conditions such as cardiovascular disease, chronic obstructive pulmonary disease, heart failure, diabetes mellitus, high blood pressure, etc.
• Older individuals have multiple medications that have been prescribed by more than one provider. For example, in addition to their PCP, the older adults may also be followed by a cardiologist, neurologist, nephrologist, etc. The healthcare providers then prescribe their own list of medications without giving due consideration to the medications that the patient’s other providers have prescribed
• Even if a potential drug interaction has been identified by a medical provider, they are hesitant to stop or change the medication that the other provider has prescribed because they do not want to step on the other provider’s “toes”
• The patient is taking multiple over-the-counter medications as well as dietary supplements and herbals, possibly resulting in drug-drug interactions and adverse reactions

How to Recognize Signs Of Overmedication Or Prevalence of Polypharmacy?

Some possible signs of polypharmacy are:

• Loss of appetite
• Falls/Fractures
• Abdominal pain
• Confusion/Mental cloudiness
• Tremors
• Dizziness
• Depression
• Anxiety
• Incontinence
• Agitation
• Insomnia/ sleepiness
• Walking difficulties/lack or loss of coordination
• Fatigue or decreased alertness
• Hallucinations, delusions, psychosis
• Memory impairment and Difficulty concentrating (can be confused with dementia)
• Unexplained weight loss or gain
• Dramatic changes in mood

Very important disclaimer here – I have to caution everyone reading this – If you are experiencing these symptoms, you should not discontinue any of your medications because you suspect they could contribute to polypharmacy.

You may, in fact, be experiencing a medical condition completely unrelated to your medications.

The appropriate thing to do is immediately seek proper care from your medical provider.

Discontinuing your prescribed medications without your provider’s knowledge or approval may immediately place you in harm’s way, as most, if not all, of the medications you take for your chronic medical problems, are likely life-saving.

Common Medication ADRs In The Elderly

A word about over-the-counter Medications, dietary supplements, and herbal supplements.

It is important to note that these agents are not approved or regulated by the Food and Drug Administration.

Because they are classified as dietary supplements, the manufacturers of these products do not have to show that they contain the list of active ingredients or amounts.

Besides being an extremely expensive endeavor, this could also be extremely dangerous to the person’s health.

One classic example is Prevagen. See why this supplement is so dangerous in my review here.

A number of them do have clinically significant interactions with prescription medications.

Common organs that get damaged are the brain, liver, and kidneys.

Certain prescription drug and dietary supplement interactions can actually cost result in hospitalizations and premature death.

Polypharmacy puts older adults at increased risk for many adverse outcomes, including adverse drug reactions, falls, fractures, hospitalizations, nursing home placement, loss of Independence, malabsorption and malnutrition issues, and premature death.

Many prescribers who are not well-versed in geriatric care are not familiar with the adage, “Start low, go slow, but go all the way.”

In my clinical practice, I see this issue daily where a certain patient gets appropriately started on a low dose of a medication, but then the prescriber is apprehensive about increasing the dose because of concerns for adverse drug reactions, resulting in the continuation of the medication at subtherapeutic levels.

This practice results in inadequate treatment of the medical condition and increases the patient’s pill burden.

Polypharmacy Interventions In The Elderly/How can polypharmacy be prevented? 

• Deprescribing
• Prudent, clinically appropriate consultation of the Beers Criteria
• Team Effort (Nursing, Pharmacist, MD, Social Work, Caregivers)
• The American Board of Internal Medicine created The Choosing Wisely Initiative in 2013. The mission was to promote conversations between clinicians and patients by helping patients choose care that is:
• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

In so doing, the Choosing Wisely Initiative offers the following ten things medical providers and patients should question:

• Careful hand feeding is recommended over tube feeding for patients with severe dementia. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers
•  Don’t use antipsychotics as a first choice to treat agitation and psychological symptoms of dementia. These medications provide very little and inconsistent benefits and instead cause much more serious risks, including oversedation, cognitive worsening, and increased likelihood of falls, fractures, and death
• For patients with diabetes, tight control of blood sugars is not recommended, and oral medications other than metformin are not recommended to achieve hemoglobin A1c levels of less than 7.5%. Moderate control of diabetes is considered less risky for older adults
• The use of anti-anxiety drugs such as benzodiazepines (Xanax, etc.) and other sedative-hypnotics such as Ambien is not recommended to treat insomnia, agitation, or delirium in older adults. Evidence consistently shows that the risk of motor vehicle accidents, falls, and hip fractures leading to hospitalization and death is more than double in older adults who take these medications. The use of anti-anxiety medications such as alprazolam and diazepam, etc should be reserved for alcohol withdrawal symptoms or severe generalized anxiety disorder that is unresponsive to other therapies
• The use of antibiotics to treat bacteria in the urine that is not accompanied by specific urinary tract symptoms is not recommended. The use of these agents in this manner does not provide extra benefit and, in fact, increases the risk for antibiotic-associated adverse effects and promotes bacterial resistance
• Use of cognitive enhancers such as Aricept is not recommended unless it is accompanied by periodic and regular monitoring by the medical provider. The risk of adverse events outweighs any modest benefits for patients who are on these medications
•  Screening for breast, colorectal, prostate, or lung cancer is not recommended unless the medical provider considers life expectancy and the risks of testing, overdiagnosis, and overtreatment
• Treatment of unintentional weight loss by using prescription appetite stimulants or high-calorie supplements is not recommended. Instead, social support and inappropriate drug discontinuation should be optimized
• New medications should not be prescribed without an appropriate and thorough drug regimen review by the medical provider
• The use of physical restraints to manage behavioral symptoms of older adults with delirium while hospitalized is not recommended. If physical restraints are absolutely necessary, they should only be used as a last resort in the least restrictive manner and for the shortest period of time

Summary

• Polypharmacy is common in older adults and poses significant risks associated with hospitalization and death
• Tackling polypharmacy is the responsibility of all parties that are involved in the care of the older adult. This includes primary care physicians, specialists, pharmacists, social workers, therapists, family, and caregivers
• Older adults and caregivers should advocate for themselves and request their medical providers complete a thorough medication review annually. This includes periodically reviewing the older adult’s drug regimen and simplifying it to reduce pill burden. For example, changing twice-daily medications to once-daily formulations is entirely appropriate.
• Every medication that the older adult is taking must have an indication and clear dosing and labeling
• Older adults and their caregivers must be well informed about all medication-associated side effects