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As the global population becomes older, physicians are increasingly navigating the complexities of geriatric medicine. Older adults often have multiple chronic conditions that require ongoing treatment, which frequently results in the practice of polypharmacy — typically defined as the concurrent use of 5 or more medications.1
Although polypharmacy begins as a well-intentioned effort to manage cooccurring conditions, the interaction of these different medications can become a health hazard instead of an optimal solution. Given the increased risks for adverse drug interactions, medication errors, and cognitive impairment, addressing polypharmacy and developing a nuanced approach to geriatric care is crucial to safeguarding the health of older adults.
Increasing Prevalence of Polypharmacy in Older Adults
In a chapter on polypharmacy published in Geriatric Rehabilitation, co-authors Parulekar and Rogers noted that while only 13% of the United States population was aged 65 years and older, this age group accounted for 33% of total prescription medications.2 More than 50% of older adults with multimorbid conditions receive 5 or more medications, with the rate varying between 10% and 55% globally.3 Furthermore, a study of survey data from the Centers for Disease Control and Prevention (CDC) found that the majority of older adults in the US had major polypharmacy and nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common medication type.4
The prevalence of polypharmacy is even higher among women. Research suggests that women are more likely than men to require more than 1 or more specialized medications,1 and older women have higher rates of multimorbidity relative to men — with a consequently higher prevalence of polypharmacy.5
"
Managing polypharmacy requires careful monitoring and coordination by health care providers to deprescribe, optimize medication regimens, and minimize risks for patients.
Erika Ramsdale, MD, an associate professor at the Department of Medicine, Hematology/Oncology at the University of Rochester Medicine, has studied the effects of polypharmacy on older adults initiating cancer treatment6 and spoke about this issue. “Polypharmacy and potentially inappropriate medications are very, very common in older adults, and especially within certain populations, such as older adults with cancer. [However], there is not an easy way to estimate the burden of medication-related adverse effects on patients and the health care system as a whole,” she remarked.
Identifying Polypharmacy Risks and Related Comorbidities
Risk factors for polypharmacy include both patient-level factors (eg, increased age, difficulty self-managing medications, multimorbidity, disabilities) as well as health care system-level components, such as poor continuity of care, prescribing cascades, the use of multiple pharmacies, and inadequately updated medical records.7,8
While polypharmacy is often deemed necessary to treat multimorbidity, the concurrent use of medications has been shown to cause harm in and of itself. In a retrospective cohort study published in 2023, older adults who received multiple medications experienced significantly higher rates of severe comorbidity relative to those who did not experience polypharmacy. Patients with polypharmacy also had a greater rate of all-cause hospitalizations and emergency department (ED) visits.9
Polypharmacy also carries specific neurologic and psychiatric risks. Older adults with polypharmacy and multimorbidity demonstrate greater levels of cognitive impairment, relative to their peers with fewer comorbidities and medications,10 and has been associated with worse self-reported health and depression in older adults.11
Given the risks associated with multiple medications in older adults, many experts have called into question the “appropriate” vs “inappropriate” use of polypharmacy.2 To this aim, Mohamed and colleagues conducted a study to examine the associations between polypharmacy, potentially inappropriate medications, and adverse treatment outcomes in a large national cohort of older adults with advanced cancer. They found that 67% of patients received 1 or more inappropriate medications, and the use of inappropriate medications increased the odds of unplanned treatment-related hospitalization. Additionally, polypharmacy overall was associated with increased risk for postoperative complications, hospitalizations, and mortality risk.8
Dr Ramsdale emphasized the importance of not just the number of medications prescribed to a patient, but also their appropriateness. “Some patients have polypharmacy by number, but all their medications are needed and appropriate.”
Further complicating this medication management issue, Dr Ramsdale addressed the challenge of differentiating between patients who develop symptoms from polypharmacy vs a root cause issue, such as comorbidities/disease. “Often, there is not one ‘root cause’ for a symptom or adverse effect in older adults. There are generally multiple contributing factors and you have to look at all of them and also how the factors interact with each other. One thing you can say is that medications are very often contributing and need to be considered each time something happens.”
Concerns & Barriers in the Management of Polypharmacy in Clinical Practice
Although a wealth of evidence has demonstrated the adverse health risks associated with polypharmacy, the question remains as to how health care systems should best manage this issue. Researchers conducted a study across 14 countries, including the US and UK, to identify the barriers associated with addressing polypharmacy in primary care. They found the most common barriers were a lack of evidence-based guidance, a lack of communication and decision-making systems, and gaps in support.12
From a clinician’s perspective, Dr Ramsdale stated,
> Older adults tend to have many doctors who are all prescribing [medications], sometimes in different health systems, leading to fragmentation of care. Providers also may not want to alter [a medication] that another provider has prescribed.
>
>
>
>
>
> In-depth review of medications takes a lot of time and thought, as each patient’s situation is unique and everyone has different goals and preferences. In addition, clinicians often do not have the time or resources to accomplish this for all patients because of the way our health care system is set up and [the type] of care it prioritizes.
Because one of the major concerns regarding polypharmacy is the increased risk for drug-to-drug interactions that are associated with adverse events and even death,13 there is a critical need to support physicians in these complicated — but increasingly common — cases of medication management.
How Can Providers Manage Polypharmacy in Older Adults?
Researchers have agreed that screening and interventional tools to optimize medication usage for improved outcomes may be beneficial.9 However, the frequency of prescribing multiple medications needs to be evaluated to reduce adverse events and medication burden in this patient population.4 Clinical studies have shown that one of the ways of reducing exposure to polypharmacy is through the practice of “deprescribing” medications.12
Deprescribing medications involves the identification of inappropriate or unnecessary medications to ultimately taper or discontinue their use. In 2019, the American Academy of Family Physicians (AAFP) developed recommendations for clinicians to help in deprescribing medications and reducing the risks for polypharmacy.7 Some of the key guidelines include the identification and prioritization of medications to discontinue, conducting informed decision-making with the patient, ensuring routine follow-up visits, and considering the risks vs benefits when refilling medications.
“Patients and their caregivers can be excellent advocates. All older adults should be [encouraged to] ask questions about the [safety] of their medications. The US Deprescribing Research Network and the Canadian Medication Appropriateness and Deprescribing Network have excellent patient resources available,” Dr Ramsdale recommended.
One of the key aspects in reducing polypharmacy is medication reconciliation, which can be more effectively achieved by improving the communication between provider and patient and the process of discharge from hospitalization. With the increased use of artificial intelligence and clinical decision support systems, the risks for polypharmacy may be minimized.14
Given that many older patients experience some degree of polypharmacy, pharmacists, specialist nurses, and physician assistants play a vital role in medication management, quality prescribing practices, and safety monitoring.4 Managing polypharmacy requires careful monitoring and coordination by health care providers to deprescribe, optimize medication regimens, and minimize risks for patients. Overall, polypharmacy in older adults is directly related to health care service outcomes,9 which warrants the need for a multidisciplinary, holistic approach to address and evaluate its use among patients.
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FEATURES
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Polypharmacy in Older Adults: Deprescribe to Optimize Medication Use
By Meghna Rao
Dr Erika Ramsdale discusses the risks and complications of polypharmacy in older
adults, an increasingly prevalent medication management and public health issue.
Me and My Heart: Raising Awareness
By MM + M Staff
Me and My Heart: How Do I Live With This?
By MM + M Staff
Me and My Heart: I Have What Now?
By MM + M Staff
FEATURES
Polypharmacy in Older Adults: Deprescribe to Optimize Medication Use
By Meghna Rao
Me and My Heart: Raising Awareness
By MM + M Staff
Me and My Heart: How Do I Live With This?
By MM + M Staff
Me and My Heart: I Have What Now?
By MM + M Staff
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