More Older Adults Than Ever Are Taking Multiple Drugs
Polypharmacy, where a person regularly takes 5 or more prescription drugs, has become more common
At age 84, Elizabeth Thaler of Rochester, New York, was lucky. Her daughter and son-in-law lived nearby and noticed when her memory began to slip, and she became too weak to cook. Soon she stopped getting out of bed.
They hired an experienced caregiver who suggested, "we have my mother's medications checked," says Ruth E. Thaler-Carter, her daughter and a freelance writer. But when Thaler-Carter took Elizabeth to her longtime doctor, "the doctor didn't change a thing," she says.
Her mother had no chronic conditions other than low blood pressure. Yet she was taking at least six prescription drugs.
Thaler-Carter was disappointed. Her mother had no chronic conditions other than low blood pressure. Yet she was taking at least six prescription drugs. Thaler-Carter worried that some might be unnecessary or interacting with one another and doing more harm than good. So she signed her mother up for a service that sends doctors, nurses and technicians to people's homes.
After a thorough evaluation, the team eliminated some medications and cut the dosage of others. Soon after, her mother became more coherent and took meals at the table instead of in bed, says Thaler-Carter. "She seemed to be more like her real self." Her mother lived for five more years, dying at 89.
Older Populations Are Taking More Drugs Than Ever
There are many others, like Elizabeth Thaler. More than 40% of Americans age 65 and older take five or more prescription drugs, a phenomenon known as polypharmacy, entailing a 200% increase over the past 20 years, as the Lown Institute (2020) reported.
In addition, nearly 20% of older adults take ten drugs or more.
When the harms of polypharmacy outweigh the benefits, medication overload results.
"As we age, our cellular functions and organ systems continue to change, and those physiologic changes result in both increased risk of developing chronic conditions and increased severity of existing conditions," says pharmacist Barbara Zarowitz, a senior advisor with The Peter Lamy Center on Drug Therapy and Aging at the University of Maryland Baltimore.
As a consequence, older Americans are particularly susceptible to polypharmacy. "Multiple medications can be beneficial for some patients," says Judith Garber, a senior policy analyst at the Lown Institute. Nevertheless, research shows that each additional medication raises a person's risk of suffering an adverse drug event by 7 to 10%.
Such events send as many as 750 older Americans to the hospital each day. "Side effects can range from dizziness or digestion issues to much more serious side effects such as falling, hemorrhaging, brain bleeds and even death," says Garber.
Garber adds that when the harms of polypharmacy outweigh the benefits, medication overload results.
Factors Driving Medication Overload
Experts say many factors contribute to the rising percentage of older adults taking multiple medications and the heightened risk of medication overload, including:
"There is a prevalent view in the United States, and other countries too, that a pill is the best way to deal with every health issue you have."
• Pharmaceutical company advertising: Only the United States and New Zealand allow direct-to-consumer ads for prescription drugs, which may lead patients to pressure doctors for a prescription. Companies also advertise to doctors and visit their offices, often bringing food and small gifts. "It's been shown in study after study that giving a free lunch or even pens can make a difference in what doctors prescribe," says Garber.
• Culture: "There is a prevalent view in the United States, and other countries too, that a pill is the best way to deal with every health issue you have. And that is not always the case," says Garber.
• Cascade effect: Doctors may prescribe a drug for one condition and then prescribe others for the resulting side effects, says Zarowitz. "Rather than someone stopping and saying, 'What started this whole cascade?' it just continues."
• Miscommunication: Specialists caring for a patient may not communicate with one another, which can result in medication duplication or dangerous drug interactions.
• Time pressures: Doctors often have only 10 minutes to spend with each patient. "If the physician feels that pressure of a full waiting room and having to turn people around to make a profit, then there is an incentive to write a prescription and get them out the door," says Zarowitz.
Future Lines Of Research
Dr. Michael Steinman, a professor of geriatrics at the University of California, San Francisco School of Medicine, would like to see more physicians regularly review the necessity of their older patients' medications. But it isn't an easy task.
"If someone comes to their clinician with concerns about their medications, it's not always clear to that clinician how to figure out which medications might be causing which symptoms because people can feel bad for all sorts of reasons," Steinman says.
Steinman co-directs the US Deprescribing Research Network, founded in 2019 with a grant from the National Institute on Aging to support and coordinate research into deprescribing. Until recently, such research was scant.
The network defines deprescribing as "the thoughtful and systematic process of identifying problematic medications and either reducing the dose or stopping these medications in a manner that is safe, effective and helps people maximize their wellness and goals of care."
"I think raising awareness is a collective responsibility."
The network's broad research mandate includes using Medicare data to identify common medications that cause problems and studying how to deprescribe safely without a rebound in symptoms, says Steinman.
Likewise, he says that researchers study the most effective ways to communicate with patients because suggesting a patient stop a medication can confuse and scare them. Raising awareness among clinicians and patients about medication overload is at the top of the agenda.
The network posts evidence-based guidelines for clinicians about how to deprescribe. It also has handouts with advice for patients interested in reducing their medications. "I think raising awareness is a collective responsibility," says Steinman. "It can come from government, individual doctors and from patient advocacy organizations."
Some medical societies, particularly in cardiology, are beginning to discuss deprescribing in their guidelines to members, Steinman says, but he adds that the process could be faster.
In a 2021 study of health care practitioners in Veterans Affairs primary care clinics, most of the 411 survey respondents reported having patients taking unnecessary medications. But less than one-third recommended deprescribing to their patients.
What Families and Patients Can Do
Patients and their families with concerns about polypharmacy and its possible harms should not wait for their health care providers to bring it up, say experts. Instead, there are several steps they can take:
• Read medication inserts and become familiar with your medications' side effects.
• Consult with a pharmacist about side effects and drug interactions. If your local pharmacist is too busy, you can find a senior care pharmacist at the American Society of Consultant Pharmacists.
• Armed with this information, make a list of questions for your health care provider.
• Use 'I,' statements when talking with your doctor, says Zarowitz, such as, 'I wonder if I need all these medications,' or 'I would find it easier if I had to take only five medications instead of eight.'
On the other hand, avoid statements such as "You have me on too many medications." In this way, "you are not threatening their authority or their judgement, and you're not accusing them of overprescribing," says Zarowitz.
Editor’s note: This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations, and The Commonwealth Fund.