Polypharmacy and potentially inappropriate medications in older adults !
Polypharmacy is the use of many medicines at once. In older adults it raises the risk of side effects, interactions, falls and confusion.
Updated 2026-11-01
Structures involved
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In the clinical exam
Why it happens
- Injury by therapeutic drugs: the classic examples
- How organs age: normal changes vs disease
- Renal clearance
- Cytochrome P450 system
What it is
The concurrent use of multiple medicines, often defined as five or more, together with the prescription of drugs whose risks outweigh their benefits in older people (potentially inappropriate medications). It is taught as a geriatric syndrome because adverse drug events can mimic new disease.
Who gets it
Polypharmacy rises with age and multimorbidity and is common in Latin American older adults, especially with several prescribers and self-medication. The WHO Medication Without Harm challenge names it a priority because adverse drug events are a leading, preventable cause of hospital admission in older people.
Causes
- Several chronic diseases each treated by its own guideline
- Multiple prescribers with no single medication list
- Prescribing cascade: a side effect is mistaken for a new illness and treated with another drug
- Self-medication, over-the-counter drugs and herbal products
- Medicines continued long after the indication ended
Risk factors
- Age over 75, frailty and multimorbidity
- Chronic kidney disease or liver disease
- Dementia, poor vision or low health literacy
- Recent hospital discharge and transitions of care
- Living alone or in long-term care
Pathophysiology
Ageing changes how drugs behave: less lean mass and more fat, lower kidney clearance and reduced liver metabolism prolong half-lives, and the brain becomes more sensitive to sedative and anticholinergic effects. Each extra drug adds possible interactions, so risk climbs steeply with the number of medicines.
Classification
- By count: polypharmacy (5 or more) and hyperpolypharmacy (10 or more)
- Appropriate versus problematic polypharmacy
- Explicit criteria: AGS Beers Criteria (drugs to avoid) and STOPP/START (stop and start criteria)
Symptoms and signs
- New confusion, sleepiness or delirium
- Falls, dizziness and orthostatic hypotension
- Constipation, urinary retention and dry mouth (anticholinergic burden)
- Loss of appetite, nausea and weight loss
- Poor adherence or confusion about doses
Diagnosis
- Clinical
- A structured medication review (brown-bag review of every drug, supplement and herbal product): indication, benefit, dose for kidney function, interactions and the patient's goals. Screening with the Beers Criteria or STOPP/START and an anticholinergic burden score. Any new symptom in an older adult prompts the question of whether a drug caused it.
- Tests
- Creatinine with estimated clearance, electrolytes, liver tests, glucose, and drug levels when relevant (digoxin, lithium, some antiepileptics); ECG for QT-prolonging drugs.
- Imaging
- Not needed for diagnosis; directed at complications such as a fall injury or bleeding.
Differential diagnosis
- Progression of an underlying disease
- Delirium from infection or metabolic disturbance
- Dementia
- Depression
- Dehydration and acute kidney injury
Goal of treatment
Keep only medicines whose benefit outweighs harm for this person, at the right dose, and add needed treatments that are missing, with the patient and caregiver as partners.
Treatment
- Medical
- Deprescribing: stop or taper drugs without a current indication or with high risk (for example long-term benzodiazepines, strong anticholinergics, long-acting sulfonylureas, prolonged proton pump inhibitors, NSAIDs), one change at a time; start missing beneficial drugs (START criteria).
- Conservative
- Non-drug alternatives for sleep, pain and mood where possible; simplify regimens and use pill organisers or blister packs.
- Follow-up
- Medication reconciliation at every transition of care; one up-to-date list shared by all prescribers; pharmacist review; follow-up after any change to watch for withdrawal or return of symptoms.
- Follow-up
- Nursing priorities: check adherence and ability to self-administer, watch for sedation, falls and orthostatic hypotension, and teach patient and caregiver about each medicine.
Complications
- Adverse drug events and hospital admission
- Falls and fractures
- Delirium and worsening cognition
- Acute kidney injury, electrolyte disorders and bleeding
- Non-adherence, higher costs and prescribing cascades
Prognosis
Regular, structured medication review with deprescribing reduces the number of inappropriate drugs and, in many studies, falls and adverse events, without worsening disease control when done carefully.
Prevention
- Starting new drugs at low doses and increasing slowly
- Reviewing every medicine at least once a year and at each transition of care
- Avoiding self-medication and keeping a single medication list
Test yourself
Think of the answer, then tap the question to see it.
How many concurrent medicines is the most common definition of polypharmacy?
Five or more regular medicines.
What is a prescribing cascade?
A drug side effect is misread as a new condition and treated with another drug, adding further risk.
Which two explicit tools are widely used to detect potentially inappropriate medications in older adults?
The American Geriatrics Society Beers Criteria and the STOPP/START criteria.
Why are long-term benzodiazepines considered potentially inappropriate in older adults?
They increase sedation, cognitive impairment, delirium, falls and fractures, with slow clearance in older people.
Which age-related change most often requires dose adjustment of renally cleared drugs?
The decline in glomerular filtration rate, which may be hidden by a normal serum creatinine because of low muscle mass.
Related conditions
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Medication safety in polypharmacy: technical report (World Health Organization, 2019); Taking multiple medicines safely (MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine), 2025).
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