Polypharmacy and medication reviews: When your medicine cabinet becomes a potential health hazard

Modern medicine has achieved extraordinary milestones, transforming chronic illnesses into manageable conditions and extending life expectancy. However, as medical treatments advance, a growing public health challenge known as polypharmacy is increasingly affecting older adults. When multiple prescriptions interact with an aging body, side effects like dizziness, falls, and confusion can emerge, leading to what doctors call a prescribing cascade. Recognising when a medication is doing more harm than good and having regular medication reviews are vital steps in protecting long-term well-being.

There is something rather strange about modern medicine.

We have never had so many effective medicines, never known so much about disease and never been better at keeping people alive. And yet we may have reached the point where some elderly people are being made ill by the very medicines intended to keep them healthy.

A recent report in The Sunday Times has highlighted a problem that has been around for years but which, frankly, deserves considerably more attention. It estimates that around 1,000 elderly people a day are admitted to hospital in England because of adverse reactions to medicines. Almost eight million people are taking five or more medicines, and more than two million are taking ten or more.

Now before anyone accuses me of being anti-medicine, let me make something absolutely clear. I am not. Quite the opposite.

Modern medicine is one of the great achievements of civilisation. Antibiotics, blood-pressure medication, anticoagulants, insulin, statins and hundreds of other drugs have transformed our lives and prevented an incalculable number of deaths and disabilities.

The problem isn’t medicines. The problem is when we have too many of them.

Doctors call it polypharmacy. Traditionally, that meant taking five or more medicines, although these days we recognise that simply counting tablets doesn’t tell us whether the prescribing is appropriate.

Someone taking seven medicines might need every single one of them. Someone else taking seven might need three, and that distinction is becoming increasingly important as we live longer.

How ageing affects drug absorption and sensitivity

As we age, our bodies change. Our kidneys and liver may not process drugs as efficiently. We can become more sensitive to medicines that affect blood pressure, balance or the brain. A dose that was perfectly appropriate at 60 may be less appropriate at 80 – but there is another problem.

Most medicines are prescribed for a particular condition.

• You have high blood pressure – here’s a tablet.
• Your cholesterol is high – here’s another.
• You have atrial fibrillation – here’s an anticoagulant.
• Your bones are becoming thinner – here’s another.
• You have reflux – another one.
• Your arthritis hurts – another.

And so on. Every prescription can be perfectly reasonable when considered on its own, but your body doesn’t know that.

It doesn’t have a separate department for blood pressure, another for cholesterol and another for arthritis. All those drugs end up in the same person, interacting with each other and with the ageing body. That’s where things can go wrong.

What is the prescribing cascade? How drug interactions lead to overmedication

Take an elderly person who is taking several medicines that lower blood pressure. Individually, they may all be appropriate. Together, they might make the person dizzy when they stand up.

They fall. They break a hip. They go into hospital. Then perhaps they develop constipation from one of the drugs they’ve been given, so another medicine is prescribed.

They become confused. Perhaps that’s regarded as another medical problem. Another prescription follows.

Suddenly we have a patient taking ten or twelve medicines when the original problem might have been that they were taking too many in the first place.

This is known as a prescribing cascade, and it is one of the great ironies of modern medicine.

We sometimes treat the side effect of one medicine with another medicine, which produces another side effect, which requires yet another medicine. It can become a pharmaceutical version of painting yourself into a corner.

Single-disease guidelines vs whole-patient medical care

There is another issue that particularly concerns me.

We have become remarkably good at diagnosing diseases and treating them according to guidelines. That’s a good thing. But guidelines are generally written around diseases. The patient, unfortunately, isn’t.

A doctor treating high blood pressure will quite properly follow the evidence for treating high blood pressure. A doctor treating diabetes will follow the evidence for diabetes. The cardiologist will follow the evidence for heart disease.

But what happens when the patient has all three – plus another four conditions? Suddenly we have a person who is being treated according to seven sets of guidelines, and nobody has necessarily stopped to ask the most important question:

Do we still need all of this?

That question is particularly important in older people.

The answer isn’t necessarily to stop medicines. Sometimes the correct answer is to continue them. A statin, an anticoagulant or a blood-pressure tablet can be enormously beneficial. But sometimes the balance between benefit and risk changes, and that’s where I think medicine needs to become rather more comfortable with the idea of stopping things.

The benefits of deprescribing: When less medication means better health

There is even a word for it: deprescribing. It sounds rather ominous, doesn’t it? As though somebody is taking away your treatment.

In reality, it can be every bit as much a part of good medicine as prescribing in the first place.

The NHS itself now recognises problematic polypharmacy as a significant issue. Its current guidance says that around 10 per cent of primary-care prescriptions are inappropriate and that the risk of adverse effects, falls, cognitive impairment and hospitalisation increases as the number of medicines rises. And this isn’t just theory.

A study of more than 1,000 hospital admissions found that adverse drug reactions accounted for 16.5 per cent of admissions in the study population. Those experiencing drug reactions were taking, on average, more medicines than those who weren’t. Importantly, researchers judged about 40 per cent of the adverse reactions to be avoidable or possibly avoidable. That’s the bit that should make us uncomfortable.

Some of these problems could have been prevented.

The essential role of pharmacists and comprehensive medication reviews

I don’t think we should simply blame doctors.

GPs are under enormous pressure. A ten-minute consultation isn’t much time in which to review someone’s entire medical history, discuss their symptoms, examine them, make a diagnosis and then reconsider twelve different medications prescribed over the previous decade.

And the doctor may not even be the person who prescribed half of them. There might be a cardiologist, a rheumatologist, a hospital consultant, another GP and perhaps several different pharmacies involved.

Everyone is doing their job, but who is looking at the whole picture?

That’s where pharmacists have an increasingly important role to play. A proper medication review should not simply ask whether each individual drug is still licensed or whether it appears on the prescription.

It should ask a much more fundamental question: Is this medicine still doing more good than harm for this particular person?

Questions to ask your GP or pharmacist about your prescriptions

If you are taking five, six, eight or ten different medicines, don’t stop them yourself. Some drugs can be dangerous if discontinued suddenly. That’s an important point to underline.But at your next appointment, ask your doctor or pharmacist to go through them with you:

• What is each one for?
• Do I still need it?
• Is the dose still right?
• Could any of them be interacting?
• Could one of them be responsible for my dizziness, tiredness, confusion or falls?

And, perhaps most importantly:

“If you were prescribing these medicines for me today, knowing what you know about me now, would you prescribe all of them again?”

That is not challenging your doctor, it is taking an interest in your own healthcare. We have spent decades fighting the idea that older people should simply accept declining health as part of getting old. Quite rightly. But we should also be careful not to assume that every new symptom is another disease requiring another prescription.

Sometimes the problem isn’t that a person needs another medicine. Sometimes they need one less.

Medicine has become extraordinarily good at keeping us alive. Now perhaps we need to get equally good at making sure that the treatment itself doesn’t make life unnecessarily difficult.

Sometimes the best medical decision isn’t to prescribe another medicine. Sometimes it is to stop one.