Every time Jodie Pepin’s mother saw another physician, it seemed like she was prescribed yet another medication. Each time Pepin wondered, “Why are they giving her that? She already has dementia.”
Pepin, clinical pharmacy program director at Harbor Health in Austin, TX, knew the medications could exacerbate dementia, cause drowsiness and affect gait. When her mother fell, multiple times, she blamed the drugs.
“These medications just kept making it worse,” said Pepin, PharmD, who is also a clinical assistant professor at the College of Pharmacy at the University of Texas at Austin. “It frustrated me to no end.”
Pepin lived in another state, so she reviewed her mother’s medications and had many conversations with doctors over the phone. Each time, the doctor would stop one or two drugs. Then another health issue would arise for her mother, who would see another doctor, who would prescribe yet another medication.
That kind of medical doom loop is not uncommon among older people, particularly those with multiple chronic conditions. Polypharmacy—taking five or more medications—is associated with increased hospital admissions, falls and premature mortality.
The problem has led to a growing movement among medical schools and hospital systems toward “deprescribing” medications: discontinuing drugs that are either potentially harmful or no longer required, or reducing the dosage or frequency, always with medical supervision.
Almost 90 percent of adults 65 and up take at least one prescription drug regularly; 54 percent of older adults report taking four or more prescription drugs. As the number of medicines goes up, medication management becomes more complex, and the risk of adverse reactions grows.
As people age, kidney and liver functioning decrease, along with lean body mass, affecting the way drugs are metabolized. Medications may stay in an older person’s system longer, increasing the risk and severity of side effects.
Troubles with the System
The fragmented nature of the US health care system also contributes to the problem.
“Many older people see multiple doctors in multiple specialties,” said DeLon Canterbury, PharmD, founder of GeriatRx, a concierge telehealth service. “One is focused on the kidney, the other is focused on the heart, and so on. These providers are following their guidelines but not thinking about the whole picture.”
As a result, patients may end up with duplicate prescriptions for similar medications or medications that interact.
Older patients are also at risk for what medical professionals call a “prescribing cascade,” according to Dominick Trombetta, PharmD, associate professor of pharmacy practice (geriatrics/internal medicine) at Wilkes University School of Pharmacy in Wilkes-Barre, PA.
A common scenario: a doctor prescribes amlodipine, a medication for high blood pressure. It’s generally safe but can cause a patient’s feet to swell. Instead of trying a different blood pressure medication or adjusting the dosage, the provider assumes the edema is yet another age-related condition and prescribes a diuretic.
The diuretic, in turn, creates an electrolyte imbalance, which leads to a prescription for a potassium supplement, which causes heartburn, which leads to a prescription for antacids.
Some whole categories of drugs carry special risks for older people.
Some medications can be dangerous for older people or patients with certain health conditions. Canterbury saw this with his grandmother, Mildred, who had mild dementia. When she began declining rapidly, the family moved Mildred out of assisted living. But she didn’t improve.
“She was wandering around the house, hiding her dentures, hiding her glasses and not remembering us,” Canterbury said. “It was heartbreaking.”
A medication review by the family’s pharmacist revealed that Mildred was taking an antipsychotic with a “Black Box Warning” (the Food and Drug Administration’s highest safety-related warning). The drug was associated with “increased mortality in elderly patients with dementia-related psychosis.”
Mildred returned to her baseline level of functioning after she stopped the meds.
Trombetta notes that some drug categories tend to be inappropriately prescribed for older patients. Proton pump inhibitors, such as omeprazole, omeprazole or pantoprazole, are often prescribed in hospitals to prevent gastrointestinal bleeding. That’s appropriate while the patient is in the hospital, but the patient may no longer need it after discharge, and continued use increases the risk for fractures, severe diarrhea, pneumonia or B12 deficiency.
Diabetes medications are also frequently prescribed inappropriately. For younger or middle-aged patients, doctors prescribe for tight control of blood sugar levels, because high blood sugar can harm the heart and pose other long-term risks. For older people, it often makes sense to relax the control of blood sugar levels and reduce or change medications accordingly. The goal is to minimize the risk of hypoglycemia (dangerously low blood sugar), which can lead to falls or even death.
Taking Precautions
To help avoid polypharmacy issues, the American Geriatrics Society publishes the Beers List, a database that flags medicines that health care providers should either avoid or prescribe with caution for older patients. The list is updated every three years, most recently in 2023.
The Beer’s List includes seemingly innocuous, over-the-counter medications like diphenhydramine (Benadryl), which may lead to confusion or falls for older patients, and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, which should be avoided by older people with kidney disease. Other cautions on the list include antibiotics like Cipro, which may interact with blood thinners, and benzodiazepines like Valium, which can impair cognitive function and cause an unsteady gait. Doctors may still choose to prescribe these medications, but the list helps them proceed with caution.
Some hospitals are implementing programs to avoid over-prescribing medications or to encourage physicians to consider deprescribing.
Pepin was involved in one such effort at a trauma unit. Working with trauma surgeons, she designed an admission order for older patients. Previously, doctors were prescribing the same doses of sleep or pain meds regardless of patients’ ages. Following the Beers criteria, the orders were customized for older patients, which led to a decrease in oversedation or respiratory depression.
Safety Is an Utmost Concern
More than 80 percent of adults aged 50 to 80 would be open to stopping one or more of their prescription drugs, according to the University of Michigan National Poll on Healthy Aging.
Some patients are taking matters into their own hands. More than a third of those polled said they stopped taking a medication without consulting a medical professional—in some cases, due to concerns about cost.
But self-deprescribing is risky, said Sarah Vordenberg, PharmD, a clinical associate professor at the University of Michigan College of Pharmacy, who worked on the poll.
“In our research, we found that the types of medications that older adults are interested in stopping are not always the types that health care professionals think are best to stop,” she said. A patient who discontinues a cholesterol medication, for example, may not notice any changes, but their risk of heart attacks or stroke may be increased.”
Bottom line: deprescribing should always be done in consultation with a physician or other primary care provider.
Taking Charge
Patients and their caregivers can take a proactive role in managing their medications. Start by always keeping an updated list of all medications, including over-the-counter drugs, supplements and vitamins—even non-oral medications like eye drops—with the actual doses being taken, even if not as prescribed. If the cost of a medication is an issue, tell the provider that too.
Bring that list to every doctor visit. Don’t assume the provider has a correct list.
Patients may request a comprehensive medication review by a pharmacist or other provider. Most retail pharmacists can provide this service, which is covered by Medicare and other insurance, but an appointment is usually required. If possible, patients should get all their prescriptions filled at the same pharmacy. Those who use more than one pharmacy, or take nonprescription drugs or supplements, should be sure the reviewing pharmacist has that information.
Medications should also be reviewed at every annual checkup, with an eye toward deprescribing. If a physician does recommend cutting some medications, be sure to get detailed instructions on how. Some medications need to be tapered rather than stopped cold turkey. And always ask how long new medications should be taken.
In addition to the annual checkup, experts advise having all medications reviewed at every medical transition, including:
- After a fall
- Any time there’s a change in medical condition or health needs
- Upon entering or leaving a long term care facility, such as rehab or skilled nursing
- Before and after a hospitalization
“Any time a person is discharged from the hospital, they should follow up with their primary care provider within a week,” said HaVy Ngo-Hamilton, PharmD, a hospital pharmacist and clinical consultant at BuzzRx, a free prescription discount service.
Some older adults aren’t comfortable questioning their doctors, according to Vondenberg. She suggests asking, “Can we talk through all of my medications so I can better understand why I’m taking each one?’”
“That naturally leads to the conversation of, why are you taking the medication, and is it still needed?” she said.
Family members, too, may hesitate to broach the issue of deprescribing for an older family member, fearing they’ll be perceived as pinching pennies or withholding care. To help start the conversation, Vonderberg and fellow researchers created a patient handout, Polypharmacy and Deprescribing, available online on the JAMA Network website.
“At the end of the day, you’re the one taking these medications and they’re impacting your health,” Vondenberg said. “Make sure that they are right for you and align with your health goals.”
Freelance writer Mary Jacobs lives in Plano, TX, and covers health and fitness, spirituality, and issues relating to older adults. She writes for the Dallas Morning News, the Senior Voice, Religion News Service and other publications; her work has been honored by the Religion Communicators Council, the Associated Church Press and the American Association of Orthopaedic Surgeons. Visit www.MaryJacobs.com for more.
