It is common for an older adult to take eight or ten medicines prescribed by three or four different doctors, none of whom has seen the complete list.
Each drug may have been appropriate when started. The combination frequently is not, and adverse drug effects are a substantial and preventable cause of admissions in this age group.
Why Older Bodies Handle Drugs Differently
The same dose has different effects at seventy five than at forty five.
- Kidney function declines with age, so drugs cleared by the kidney accumulate. Note that creatinine can look normal despite reduced function because of lower muscle mass
- Liver metabolism slows
- Body composition changes, with more fat and less water, altering how drugs distribute
- The brain becomes more sensitive to sedatives and drugs affecting cognition
- Blood pressure regulation on standing becomes less reliable, increasing fall risk
This is why doses appropriate for a younger adult can cause confusion, falls or kidney injury in an older one.
The Prescribing Cascade
This is a common and avoidable pattern worth recognising.
A drug causes a side effect. The side effect is interpreted as a new condition. Another drug is prescribed for it. That drug causes its own side effect, and so on.
Common examples: a blood pressure drug causes ankle swelling, which is treated with a diuretic, which causes low potassium and dehydration. Or a drug causes tremor, which is diagnosed as Parkinson disease and treated accordingly.
Whenever a new symptom appears in someone on multiple medicines, the first question should be whether a drug is causing it, not which drug to add.
The Drugs That Cause the Most Harm
Certain classes are disproportionately responsible for adverse events in older adults.
- Sedatives and sleeping tablets: falls, fractures, confusion and dependence. Among the most commonly continued unnecessarily
- Anticholinergic drugs: found in many bladder, allergy and stomach medications. Cause confusion, constipation, urinary retention and dry mouth, and the cumulative burden across several drugs is what matters
- Anti inflammatory painkillers: kidney injury, stomach bleeding and raised blood pressure
- Long acting sulfonylureas: prolonged low blood sugar
- Multiple blood pressure drugs: dizziness on standing and falls
- Proton pump inhibitors continued for years without indication
- Opioids: constipation, confusion and falls
The anticholinergic burden is particularly under recognised. Several individually modest drugs can add up to significant cognitive impairment that is mistaken for dementia and improves when the drugs are reduced.
Symptoms That May Be Drug Related
These are frequently attributed to ageing when a medication is responsible.
- Confusion or memory difficulty
- Falls or unsteadiness
- Dizziness on standing
- Drowsiness and daytime sleepiness
- Constipation
- Loss of appetite and weight loss
- Urinary difficulty or incontinence
- Low mood
- Tremor
If any of these has developed or worsened, note when it started and check it against when medications were started or doses changed. That timeline is often the diagnosis.
How to Prepare for a Medication Review
Ask specifically for a medication review, and prepare for it properly.
- Bring every medicine box, including those prescribed by other doctors
- Include over the counter medicines, painkillers, ayurvedic and herbal preparations and supplements
- Bring eye drops and inhalers, which are frequently forgotten
- Note what you actually take rather than what is prescribed, since these often differ
- List any new symptoms and when they started
- Bring recent blood test results, particularly kidney function
- Bring a family member if memory is a concern
Honesty about what you actually take matters. Many patients stop drugs they dislike without telling anyone, and doses are then increased on the assumption that the drug is not working.
Questions to Ask About Each Drug
These questions structure the review usefully.
- What is this for, and is that condition still present?
- Is it still doing what it was intended to do?
- What would happen if I stopped it?
- Is the dose right for my kidney function and my age?
- Could it be causing any of my current symptoms?
- Does it interact with anything else I take?
- Is there a simpler regimen, such as a combination tablet or once daily dosing?
- Is there a planned end date?
The question about what would happen if you stopped is particularly clarifying, and it often reveals drugs continued out of habit.
Deprescribing Safely
Stopping medicines is a clinical decision requiring the same care as starting them.
Never stop on your own. Several drugs cause serious problems if stopped abruptly, including steroids, beta blockers, some antidepressants, anticonvulsants and blood thinners.
Safe deprescribing involves stopping one drug at a time so effects can be attributed, tapering gradually where needed, monitoring for return of the original condition, and reviewing again after a few weeks.
The goal is not the fewest possible tablets. It is the right ones. Some older adults are undertreated for conditions such as osteoporosis, atrial fibrillation and heart failure, and a review may add a drug as well as removing several.
Our geriatric medicine department conducts structured medication reviews.
Practical Systems That Prevent Errors
Even the right medicines fail if they are not taken correctly.
- Use a weekly pill organiser with compartments for each time of day
- Keep a single updated list of all medicines, carried in a wallet and available to any doctor
- Use one pharmacy where possible, so interactions can be flagged
- Link doses to daily routines rather than to clock times
- Set phone alarms for critical medicines
- Ask for larger print labels if reading is difficult
- Ask for combination tablets where available to reduce the number
- Review the list at every hospital admission and discharge, when errors are most common
Hospital discharge is the highest risk point for medication error. Ask specifically what has been changed, stopped or started, and get it in writing.
If you or a relative over sixty takes several medicines, ask for a formal medication review with every box on the table, including supplements and remedies. New confusion, falls or dizziness are more often drug related than age related, and reviewing the list is frequently more useful than adding to it.
Our geriatric medicine department at T. Nagar provides medication review for older adults.
Related Topics
