Polypharmacy and Deprescribing in the Elderly
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Direct answer
Polypharmacy is the regular use of five or more medicines, and in older adults it raises the risk of adverse drug reactions, falls and hospital admission. Deprescribing is the planned, supervised withdrawal of medicines that no longer benefit the patient, guided by explicit tools such as the Beers criteria. The aim is to remove inappropriate drugs without losing therapy the patient needs.
What you must remember
- Definition: polypharmacy is commonly defined as five or more regular medicines, and hyperpolypharmacy as ten or more.
- Beers criteria: the AGS Beers Criteria list potentially inappropriate medicines for older adults and drug-disease combinations to avoid.
- Anticholinergics: first-generation antihistamines such as diphenhydramine, tricyclic antidepressants and oxybutynin worsen cognition, constipation and urinary retention.
- Benzodiazepines and Z-drugs: raise the risk of falls, fractures, delirium and dependence, and are tapered gradually when stopped.
- Long-acting sulfonylureas: glibenclamide (glyburide) causes prolonged hypoglycaemia in older adults with reduced renal clearance.
- Proton pump inhibitors: long-term use is linked to fractures, Clostridioides difficile infection and low magnesium, so the indication is reassessed.
- NSAIDs: chronic use risks gastrointestinal bleeding and renal injury, particularly alongside ACE inhibitors and diuretics.
A stepwise pathway for medication review
A 78-year-old man on fourteen regular medicines is admitted after a fall with confusion. A structured review, rather than adding another drug, is the first step in managing him.
- Build the full list: collect every prescription, over-the-counter product, herbal remedy and supplement, using the patient's own bottles and pharmacy records, since older patients often forget non-prescribed medicines.
- Ask the indication: for each drug, identify why it was started, what benefit it was meant to provide and whether that indication is still active.
- Flag high-risk drugs: mark sedatives, anticholinergics, antipsychotics, long-acting sulfonylureas, NSAIDs and long-term proton pump inhibitors for review against explicit criteria.
- Prioritise and plan: stop one drug at a time, starting with those causing harm, and taper where withdrawal is risky, such as benzodiazepines and long-term beta blockers.
- Monitor the change: check symptoms, blood pressure, glucose and cognition after each change, and record which drug was stopped and why.
- Share the plan: explain the reasons to the patient and carer, and inform all prescribers so that the removed drug is not restarted through cascade prescribing.
Where the exam tries to catch you
Exam questions reward stopping harm before adding benefit.
- Trap: adding a drug to treat a fall-related problem Correct: a medication review first identifies drugs that cause falls and dizziness, such as sedatives and antihypertensives given at high doses.
- Trap: stopping benzodiazepines abruptly after years of use Correct: abrupt withdrawal risks seizures and rebound anxiety, so the dose is tapered gradually.
- Trap: treating a drug-induced complaint with a second drug Correct: cascade prescribing creates polypharmacy, so the original offending drug is identified and reviewed first.
Frequently asked questions
Which drug classes are most often flagged by the Beers criteria for older adults?
The Beers criteria flag anticholinergics, benzodiazepines and Z-drugs, long-acting sulfonylureas, chronic NSAIDs and long-term proton pump inhibitors. Antipsychotics and first-generation antihistamines are also flagged in many lists. Each flagged drug is reviewed against the patient's diseases and kidney function.
How is polypharmacy defined in older adults?
Polypharmacy is commonly defined as five or more regular medicines taken by one patient, and hyperpolypharmacy as ten or more. The definition is a screening threshold rather than a judgement that every medicine is wrong. Appropriateness depends on each drug's indication and the patient's overall health.
Which medicines should not be stopped abruptly during deprescribing?
Long-term benzodiazepines, antiepileptic drugs and beta blockers should not be stopped abruptly, since withdrawal can cause seizures, rebound anxiety or rebound tachycardia. Long-term corticosteroids also need a taper because of adrenal suppression. Each taper is planned with the prescriber and follows an agreed schedule.
What is cascade prescribing in the context of polypharmacy?
Cascade prescribing occurs when a drug causes an adverse effect that is treated with a second drug, which may cause a further problem. A classic example is an antipsychotic causing parkinsonism, which is then treated with an anticholinergic that worsens cognition. Recognising cascades prevents unnecessary additions and supports deprescribing.