Polypharmacy in the Elderly — When More Medicines Means More Harm

If your elderly parent is on five or more medicines, you need to read this.

Polypharmacy — the concurrent use of five or more medications — is one of the most common and most dangerous problems I encounter in my geriatric practice. It is not always the fault of any individual doctor. It is often the predictable result of a healthcare system where patients see multiple specialists, each of whom manages one organ system and prescribes accordingly, without anyone reviewing the full list.

The cardiologist prescribes for the heart. The endocrinologist prescribes for diabetes. The neurologist prescribes for memory. The orthopaedic surgeon adds a supplement after a fracture. The GP adds a sleeping tablet. Nobody looks at what all these medicines do together — until something goes wrong.

Why the elderly are uniquely vulnerable

Ageing changes the body’s ability to process drugs. Kidney function declines gradually with age — by 70, many people have lost 30 to 40 percent of their renal function, even without a diagnosed kidney disease. Liver metabolism slows. Body composition changes, meaning fat-soluble drugs accumulate differently. The blood-brain barrier becomes more permeable, making elderly patients more sensitive to drugs that affect cognition.

A drug dose calculated for a 50-year-old is not automatically safe for a 75-year-old. Yet most clinical drug trials — the evidence base on which prescribing guidelines are built — exclude elderly patients with multiple conditions. We are, in many cases, prescribing by extrapolation.

Add to this the fact that elderly patients are far more likely to have multiple conditions simultaneously, and you begin to understand why polypharmacy is almost inevitable in this age group — and why it requires active management.

What polypharmacy actually causes

The consequences are not abstract. Polypharmacy causes falls — certain combinations of blood pressure medicines, sedatives, and diuretics dramatically increase fall risk. It causes delirium — sudden confusion in an elderly patient is, until proven otherwise, a medication problem. It causes malnutrition — some drug combinations suppress appetite or impair nutrient absorption. It causes hospitalisation. In some cases, it causes death.

A study I worked on during my postgraduate training examined antibiotic resistance patterns in geriatric UTIs — a problem directly linked, in part, to the cumulative antibiotic exposure that polypharmacy enables. The same system that creates polypharmacy also creates the conditions for resistant infections.

How geriatricians approach this

In my practice, I use the STOPP/START criteria at every Comprehensive Geriatric Assessment. STOPP (Screening Tool of Older Persons’ Prescriptions) identifies medicines that are potentially inappropriate in elderly patients — those that carry risks that outweigh benefits in this age group. START (Screening Tool to Alert to Right Treatment) identifies medicines that are indicated but missing — equally important, because under-prescribing is a real problem too.

The output is a written Medication Safety Review — a structured letter to the patient’s treating doctors identifying specific concerns, potential interactions, drugs that may be deprescribed, and drugs that should be added. I do not change prescriptions unilaterally. I give the prescribing doctor the full clinical picture they may not have, and I do so in writing so it is documented.

What families can do

Bring a complete medicine list to every doctor’s appointment. Not just the blister packs — a written list with the name of each medicine, the dose, who prescribed it, and why. Update it every time anything changes.

If your parent is on more than five medicines and has never had a systematic medication review by a geriatrician, ask for one. It is one of the highest-value interventions in geriatric care — and it is entirely reversible if the changes don’t suit your parent.

Polypharmacy is not inevitable. With the right clinical oversight, it can be managed, reduced, and made safer. That is what geriatric medicine is for.