Ben Basger takes a look at some of the issues around older people taking multiple medicines

When polypharmacy is practiced on our vulnerable older patients, bad outcomes occur. Adverse drug events and inappropriate medication use become almost inevitable.

Vulnerable characteristics of old age consist of multiple co-morbidities, cognitive decline or dementia, frailty, limited life expectancy, impaired medication clearance and reduced physiological reserve.

These factors markedly alter the risk–benefit balance of medications, typically reducing anticipated benefits and increasing risk.

Notwithstanding the fact that under-prescribing exists, here is a confronting list of negative outcomes associated with inappropriate medication use resulting from polypharmacy; medication-specific adverse effects, medication interactions, medication-disease interactions, cognitive impairment/delirium, weight loss/malnutrition, falls, hip fractures, urinary incontinence, functional impairment, poor mobility/immobility, hospitalisation, nursing home or long term care placement, decrease in quality of life, death, poor treatment adherence and increased cost to the individual and to society.

A new approach is necessary. Without evidence of definite benefit, prescribing for many older patients is best viewed as ‘less is more’.

This approach differs from most other current recommendations and guidance in medical care because here the focus is on what, when, and how to stop medications, rather than on when to start them.

Altering the mindset that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition will require a large philosophical shift.

Many risk factors, such as elevated cholesterol, glucose, and blood pressure have been shown to lose much of their negative portent in older age and some risk factors reverse to become predictors of better outcomes.

Therefore, treating conditions to target goals developed for younger people may be ineffective and damaging (Drugs Aging https://doi.org/10.1007/s40266-018-0554-2).

Dr Ben Basger PhD MSc BPharm DipHPharm FPS AACPA is a clinical pharmacist and educator at Wolper Jewish Hospital and The University of Sydney, NSW.