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Polypharmacy in the Elderly: Risks, Symptoms, and Prevention

With expert advice from Cleveland Clinic’s Center for Geriatric Medicine
By Claire SamuelsNovember 17, 2021
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Polypharmacy — a growing concern for seniors and their caregivers — is the use of multiple prescription and over-the-counter medications to treat chronic diseases and other health care needs. Since many older adults have a number of health conditions, several medications may be necessary to improve health and quality of life. However, using too many medications can lead to safety concerns.

Cleveland Clinic Center for Geriatric Medicine Section Chief Dr. Ardeshir Hashmi discusses the definition of polypharmacy, common risk factors, and how to help reduce negative effects associated with polypharmacy for your elderly loved one.

What is polypharmacy in older adults?

Polypharmacy most often refers to the routine use of five or more medications, according to the World Health Organization. However, as life spans lengthen and seniors have increased medical needs, that number can fluctuate.

“The definition of polypharmacy has changed for us, unfortunately, because it is so prevalent for people to be on more medications,” says Hashmi. “It’s closer now to more than 10 medications.” People over the age of 65, and especially people in their 80s, are the most likely to use 10 or more medications, he notes.

While prescriptions get most of the attention when considering polypharmacy in the elderly, you shouldn’t exclude more common medicines and supplements that you can buy off the shelf.

“A lot of the medicine you take over the counter also should contribute to this total count,” Hashmi says. “They do interact, and even though they’re available over the counter, it doesn’t mean they don’t have side effects.”

Risk factors for polypharmacy

Polypharmacy affects between 40% and 50% of all older adults, according to research published in the Journal of Clinical Epidemiology, and this percentage tends to rise as patients age. The likelihood of polypharmacy in older adults also increases with multiple health care providers, cognitive decline, and certain families of medication.

Visiting multiple health care providers increases risk of polypharmacy

As people age, they’re more likely to develop multiple chronic conditions, and this can lead to a need for many health care providers. If each specialist prescribes a different medication, it’s common to end up with a complex prescription regimen that may be difficult to manage. All of these medicines may be necessary for the treatment of multiple conditions. However, if they aren’t adhered to properly, complex drug regimens can result in inappropriate polypharmacy — or too many medications being prescribed — which can cause harmful drug interactions, cognitive decline, heightened fall risk, and other adverse effects.

Cognitive decline can contribute to inappropriate polypharmacy

Memory concerns may make it difficult to remember which medicines to take and when to take them. Ensure your loved one is comfortable managing their medications either by themselves or with your help. Are they struggling with their medication schedule, or do they seem unsure about the purpose of each medication? These may be red flags that become risk factors for polypharmacy.

“If a parent is on eight different medicines, they should be able to explain what they take each one for — even if they don’t know the names,” Hashmi notes. “They might simply say ‘this is why I take the white pill, and this is what the blue one is for,’ but if they can’t, then there’s always a chance of taking the same pill too many times or missing it completely.”

Medications can contribute to dangerous polypharmacy effects

Certain families of medication are more likely to lead to polypharmacy complications, Hashmi explains. Many of these medicines can be necessary and lifesaving, but it’s important to be aware of side effects and potentially harmful reactions.

Anxiety medications. Benzodiazepines like diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax), can lead to memory concerns, dizziness, and more. They also can cause dependence. “People get started on it because they’re really good for anxiety — they really do help — but unfortunately the side effects are cumulative and only manifest many years later,” Hashmi says. “When they do start manifesting, because our bodies are so dependent on it, nothing else really works for anxiety, so we’re hooked on it, and the vicious circle continues.”

PM or DM medicines. A number of common, over-the-counter drugs include “DM” or “PM” in the name, like dextromethorphan (one brand name: Robitussin DM) or acetaminophen (one brand name: Tylenol PM). These abbreviations are generally attached to allergy medications and sleep aids. Though readily available without a prescription, these medications can have significant side effects that compromise memory and balance, according to Hashmi.

Anticholinergic drugs. There are nine major anticholinergic medications on the market used to treat overactive bladder symptoms. “For younger folks they may be OK — for older people, they’re less specific,” says Hashmi. “They slow down the bladder, but they also slow down other things, including production of saliva; thinking, causing confusion; bowels, causing constipation.” In seniors, this family of medications can cause significant drug interactions that lead to cardiac effects, hyperthermia, confusion, and an inability to communicate, according to the Journal of Drugs & Aging.

Blood thinners. While blood thinners can be both beneficial and necessary, it’s important to ensure they’re properly managed. “Should a senior take too much, the risk of bleeding increases exponentially,” Hashmi says. “Or, if they don’t take it regularly enough and even miss certain days, the risk of clots increases.”

Insulin. It’s important to closely monitor insulin administration for aging diabetics who may need extra help with their medications. If a person administers too much insulin — that is, they already took a dose but forget and take another — the resulting low blood glucose level puts them at risk of hospitalization and ER visits.

Effects of polypharmacy in the elderly

Inappropriate polypharmacy can severely harm a senior’s physical, cognitive, and financial well-being. Some side effects of polypharmacy in the elderly include:

Increased fall risk. Falling can lead to serious health consequences in elderly adults, and there’s a link between polypharmacy and falls in the elderly. A study of 5,213 participants conducted by the University of Leicester found the rate of falls was 21% higher in people taking four or more medications compared with those taking fewer. More than 10 medications led to a 50% increase in falls.

Memory impairment. Inappropriate polypharmacy may lead to cognitive concerns. In fact, multiple studies have suggested that older adults experiencing polypharmacy are more likely to exhibit mild cognitive impairment and memory concerns. Anticholinergics, anxiety medications, and PM and DM medicines may also have side effects including confusion and delirium.

Non-adherence to prescription medication regimens. A complex drug regimen can be difficult to follow. With 10 or more medications, the likelihood increases that seniors will forget a pill or take a double dose, leading to severe health complications.

Higher health care costs. A vast majority of national health spending goes toward treating people with multiple chronic conditions, which includes about 75% of older adults, according to the National Institute on Aging. In addition to the costs of health visits and the prescriptions themselves, otherwise avoidable emergency room visits and treatments for negative drug interactions contribute to health care spending.

How to prevent polypharmacy in the elderly

Appropriate medication management, communication with your loved one’s doctor, and awareness of symptoms can help prevent complications from polypharmacy in seniors.

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Communicate with your loved one’s doctor. 

Frequent communication with your loved one’s doctor can reduce the likelihood of polypharmacy in seniors. At their next primary care appointment, discuss the following with your relative’s physician:

Review your loved one’s medications. Write the names of all prescription drugs and over-the-counter supplements your loved one is taking, along with doses and frequencies. Ask if certain drugs and supplements shouldn’t be taken together, or if any have duplicate functions. This can help doctors pinpoint the cause of adverse reactions or drug interactions.

Discuss root causes. Sometimes, a medication may be the root cause of a health concern. When a doctor prescribes other medicines to address that concern, the likelihood of polypharmacy increases, leading to other potentially negative side effects. Hashmi cites high blood pressure as an example: If a patient is taking three or four different prescriptions to lower their blood pressure and it isn’t working, there may be a different underlying cause, like stress or pain. Appropriate treatment of that root cause could resolve the problem and eliminate excess medication.

Ask about simplifying medication regimens. Complex medication regimens can lead to confusion, missed doses, and mix-ups. “Sometimes we’re not mindful of an opportunity to minimize the number of times someone takes a medicine,” says Hashmi. For example, someone may be prescribed a blood pressure medicine traditionally taken three to four times a day. But another medicine — an extended release designed to be taken once a day — could be equally effective. “This once-a-day regimen is much easier for our patients to trach, especially with cognitive impairment,” Hashmi adds.

Manage medication effectively

Successful medication management is key in reducing polypharmacy. Ensure your loved one is able to take their medicine either independently or with your help. To learn more, click through the link for Hashmi’s 10 tips for elderly medication management.

Make medication easily accessible. Caregivers and health care providers should try to make medication regimens as simple and accessible as possible, says Hashmi. This could mean pharmacy delivery, medication dispensers, or pictures of pills with accompanying descriptions.

Avoid self-prescribing, and understand the side effects of over-the-counter medications. Your loved one may decide to take their medication more frequently in an attempt to alleviate symptoms faster, or they may want to stop a certain drug that makes them feel unwell. They may choose to add an over-the-counter medicine that has helped in the past. All of these situations can increase the likelihood of inappropriate polypharmacy, negative side effects, and potential harm. Always speak with a doctor before changing or adding medication.

Learn about potential side effects. Before your loved one starts taking a new medication, read the label fully and ask a doctor or pharmacist about potential side effects. Talk to your parent to ensure their reaction to the drug isn’t unusual, and report any negative effects — like changes in balance, sleep patterns, or appetite — to their physician.

Monitor everyday activities

You know your parent better than anyone, so watching out for behavioral changes can help catch red flags before they progress into more serious conditions. Hashmi suggests monitoring instrumental activities of daily living, which include complex tasks like cooking, driving, managing medications, and maintaining personal finance.


A Place for Mom and Cleveland Clinic: Supporting seniors and their families

This article was developed in conversation with Ardeshir Hashmi, MD, section chief of the Cleveland Clinic’s Center for Geriatric Medicine, as part of a series of articles featuring expert advice from Cleveland Clinic geriatricians.


Cleveland Clinic and A Place for Mom do not endorse or intend to endorse any specific medications listed in this article. Drug brand names are included alongside generic drug names only for ease of reference.

This article is not meant to convey medical advice. Consult with your doctor or your loved one’s doctor before taking or stopping any medications.

Sources

Interview conducted with Hashmi, A. Cleveland Clinic. September 14, 2021.

Journal of Brain Sciences. “Polypharmacy is Associated with Lower Memory Function in African American Older Adults.”

Journal of Clinical Epidemiology. “The epidemiology of polypharmacy in older adults: register-based prospective cohort study.”

Journal of Clinical Psychiatry. “Association of Polypharmacy With Mild Cognitive Impairment and Cognitive Ability.”

Journal of Drugs & Aging. “The Problems of Anticholinergic Adverse Effects in Older Patients.”

National Institute on Aging. “The dangers of polypharmacy and the case for deprescribing in older adults.”

Thematic Review on Aging. “Polypharmacy Management in Older Patients.”

University of Leicester. “Association between polypharmacy and falls in older adults.”

World Health Organization. PDF report. “Medication Safety in Polypharmacy.”

Author
Claire Samuels