Polypharmacy is commonly defined as taking five or more medications, which would include prescriptions, over-the-counter drugs, herbs, and supplements. An additional category of “excessive” polypharmacy” is defined as taking 10 or more medications. Due to the potential risks associated with taking multiple medications, some experts suggest de-prescribing, or the process of tapering, stopping, discontinuing, or withdrawing drugs to monitor and manage medications.

There has been increasing attention to the issue of polypharmacy as a public health concern with an emphasis on de-prescribing as one way to address it. This should be a thoughtful and “systematic process of identifying and discontinuing drugs (only) when existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, functional status, life expectancy, values, and preferences” (JAMA Int Med 2015;175.)

At the outset, it is important to add that even with a long list of medications, every medication on that long list may be necessary and appropriate. If there is an opportunity, however, to simplify the number of medications an individual is taking, this reflects good quality of care.

A growing problem

An expanding list of medications can happen to anyone, but polypharmacy tends to increase as we get older, and it is a relatively new phenomenon.  In 1999, the prevalence of polypharmacy among adults over age 65 in the U.S. was around 24%, and by 2020 this nearly doubled to 40%.  (JAMA:2024:332(7). It is not surprising that it is most common in individuals with multiple medical conditions, especially those with cardiac disease, and in the nursing home setting. 

One of the concerns is that the more medications, the higher the risk of drug-drug interactions, where one medication may make another more or less effective, or the drug for one condition may worsen another. The risk of side effects can also accumulate.

Polypharmacy has been implicated in impaired cognition, problems with mobility, falls, increased hospitalizations and emergency room visits. Trying to manage refills and take multiple medications correctly can become a full-time job for the individual or their caregiver and lead to error.  This daily task can also impact quality of life, with increasing “pill burden.” The cost of medications also needs to be considered, which can be daunting. 

How did we get here?

There are several factors that have contributed to the increase in polypharmacy.  To be fair, advances in today’s medications and drug therapies continue to save lives, slow disease progression, and alleviate symptoms, but balancing the risks and benefits for each individual and over time is required.

As life expectancy has increased, we are living longer and with chronic illnesses that often need to be managed with medication(s). Having multiple healthcare providers and medical specialists prescribing drugs, it is not always clear who is responsible for reviewing the entire medication list.

As pharmaceutical companies began marketing directly to the consumer, their spending went from $985 million in 1996 to at least $10 billion in 2024. This has had a measurable impact on consumer behavior, with increasing demand for many different drugs.

The market for dietary supplements has been expanding, especially over the past decade, and should be included on a medication list to be sure that there are no contraindications or interactions with other drugs being taken.

From the healthcare provider perspective, there tends to be less education and fewer guidelines about stopping or tapering medications. In response, the National Institute of Health now has a De-prescribing Research Network to direct research into education and evidence-based guidelines for de-prescribing and what medications to prioritize. https://deprescribingresearch.org/

When a patient has been told a medication was important and/or has taken it for an extended period, they may be reluctant to reduce the dose or stop a drug without understanding the rationale. They may perceive discontinuing a medication as “giving up.”

Interventions

Given the potential risks with polypharmacy, there is a principle in geriatric medicine that when a new medication is added, equal consideration should be given to stopping another medication when that is safe and appropriate. This is not always possible.  There are some categories of medications that should be avoided or used with caution in older adults, and they are listed as part of the American Geriatric Society BEERS Criteria.  This list can be found on their website: https://www.americangeriatrics.org/

The majority of older adults indicate that they would like to reduce the number of drugs they are taking. A study in the American Journal of Geriatrics found that 87% stated they were willing to de-prescribe if their provider recommended it. Communication is key to providing education around polypharmacy and when de-prescribing may be possible and may even help them to feel better. This needs to be a personalized approach.

The goal is not to simply reduce the number of medications, but to align them with what is important to the patient. Maybe it is the cost or the pill burden or side effects. To be clear, there can be “appropriate” polypharmacy where each medication continues to be effective, well tolerated, and aligned with the patient’s preferences. 

Medication reviews, or what is called “medication reconciliation,” should occur with each clinic appointment, and during admission and discharge to a hospital, home care, nursing home, or emergency room.  Following a fall, a new symptom, or change in mental status or function, all medications should be considered guilty until proven innocent, especially one that is new or had a recent change in dose.

Pharmacists can play an important role in helping to monitor and review medications. A primary care provider can also discuss opportunities to optimize the medications an individual is taking and/or to collaborate if another medical provider initiated the prescription.

What you can do …

Keep an updated medication list accessible that includes your prescription medications, all over the counter drugs, and any supplements or herbal remedies. Using one pharmacy allows the pharmacist to be aware of all medications you are taking. If a new medication is added, take the time to learn about it: the side effects, how to store it, what to do if you miss a dose, and how long it should be taken. If needed, consider scheduling an appointment to specifically review and discuss your medications.

Bonnie Evans, RN, MS, GNP-BC, GC-C, lives in Bristol and is a geriatric nurse practitioner, End of Life Doula, and certified grief counselor. She can be reached at bonnie@bonnieevansdoula.com.