I remember visiting my grandmother in her retirement home back in the 1990s and watching her count out her pills for the week. She had a pill organizer with a color for each day of the week and a few pills in each compartment. If these visits took place today, it is likely that my grandmother would have had several pill organizers, with compartments for different times of the day, and many more pills. In 1994, 14 percent of adults age 65 and over were taking 5 or more prescription medications; by 2014, that number had grown to 42 percent of older adults.[i] Including over-the-counter drugs and supplements, 67 percent of older adults take 5 or more medications every day.[ii]
Many patients benefit from taking multiple drugs, and taking several medications may be necessary for people with more than one chronic disease. However, the growing use of multiple medications puts millions of people over the age of 65 at risk for medication overload, which refers to theharm caused by too many medications.
Taking multiple medications greatly increases a person’s risk of suffering serious, sometimes life-threatening side effects, including falls, cognitive decline, and internal bleeding. The risk of a serious side effect or reaction from a medication (called an “adverse drug event”) increases by 7-10 percent with each medication added.[iii] A 2019 report by the Lown Institute, a nonprofit think tank, estimated that one in five older adults suffers an adverse drug event every year.[iv]
Ironically, women’s longer lifespans and attentiveness to their own health put them at greater risk of medication overload. Women live longer than men, on average, and the number of medications one takes tends to increase with age. Women may benefit from taking more trips to the doctor for preventive care, but these visits can also lead to more prescriptions that are unnecessary or harmful.[v] And, women are more likely than men to be taking psychiatric medications, many of which have serious side effects for older adults.[vi]
Women’s physiological differences also put them at risk for medication-related side effects. As we age, we process medications differently. Because older people weigh less than younger adults, have a higher fat-to-muscle ratio, and often have decreased liver and kidney functions, medications stay in their systems longer.[vii] Women are generally smaller than men and have higher fat-to-muscle ratios compared to men, which makes them even more sensitive to medication side effects.
Although medication overload is a serious problem for older women, there are ways to reduce the risk for you and your loved ones. The first step is to recognize that taking more medications in of itself increases the risk of adverse drug events. The second is to know which specific medications are likely to cause harm in older adults. In particular, sleep medications, anti-anxiety medications, antipsychotics, opioids, highly anticholinergic medications (such as drugs for urinary incontinence), and muscle relaxants are not recommended for adults age 65 and older because they increase the risk of falls and hospitalizations.[viii]
Other medications, such as acid reflux medications and antidepressants, are not meant to be taken for more than a few months, but are often continued long-term unnecessarily.[ix] Antidepressants in particular can lead to adverse effects in older adults such as insomnia, dizziness, falls, and hyponatremia (abnormally low sodium levels).[x] For chronic health conditions such as high blood pressure, heart failure, and Type 2 Diabetes Mellitus, certain medications, when used in combination or at high doses, can lead to serious side effects as well such as bleeding, falls, and hospitalization.[xi]
If you or a loved one are troubled by medication side effects and/or the burden of managing too many pills, ask your doctor for a “Prescription Checkup” to talk about any concerning side effects and identify medications that can be stopped or tapered down. For such a visit, it is helpful to bring along all of your medications to review what they are for and which doses can be reduced or eliminated. Remember to never stop or adjust your medications without first discussing it with a provider.
Lastly, the best way to prevent harm from medication overload is to avoid taking unnecessary
medications in the first place. Consumers (or their family members/caregivers) should consider asking their provider the following questions before adding any new medication:
- What is this medication for?
- How many patients like me benefit from taking this medication, and how large is the benefit?
- How many patients like me experience harms from taking this medication, and what are the potential harms?
- How will we know when the medication is working or not working?
- When should I stop taking this medication?
- Can I start on a lower dose and see if that works?
- Are there side effects I should watch out for if I take this medication?
In the 21st century, multiple medication use has become more prevalent in for older adults, especially older women. But this trend is not making us healthier and, in fact, leads to significant harm from adverse drug events. Patients and family members should feel empowered to push back against our culture of prescribing and the idea that there is a “pill for every ill.” We need to normalize conversations with our providers (and our family members) about medications, rather than accept medication overload as the “new normal.”
Judith Garber is a Health Policy and Communications Fellow at the Lown Institute. She is co-author of the Lown Institute’s white paper series on medication overload, which can be found at www.LownInstitute.org/pills.
[i] National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville, MD. 2017.
[ii] Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. “Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011.” JAMA Internal Medicine. 2016; 176(4): 473-82.
[iii] Hanlon JT, Pieper CF, Hajjar ER, et al. “Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay.” J Gerontol A Biol Sci Med Sci 2006; 61(5): 511-5; Viktil KK, Blix HS, Moger TA, Reikvam A. “Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems.” Br J Clin Pharmacol 2007; 63(2): 187-95; Gandhi, Weingart, Borus, et al. “Adverse drug events in ambulatory care.” New England Journal of Medicine 2003; April 2017(348).
[iv] Garber J, Brownlee S. Medication Overload: America’s Other Drug Problem. The Lown Institute. 2019.
[v] National Center for Health Statistics. New Study Profiles Women’s Use of Health Care. Centers for Disease Control and Prevention. 2001.
[vi] Fiore, K. “Use of Psych Drugs Up, Women Biggest Users.” Medpage Today. November 17, 2011. Accessed December 26, 2020; Das A, Maiti A, Sinha S. “Antidepressant Prescription in the Geriatric Population: A Teachable Moment.” JAMA Intern Med. 2016;176(11):1608–1609. doi:10.1001/jamainternmed.2016.5535
[vii] Klotz U. “Pharmacokinetics and drug metabolism in the elderly.” Drug Metab Rev. 2009;41(2):67-76. doi: 10.1080/03602530902722679. PMID: 19514965.
[viii] American Geriatrics Society. American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. 2019.
[ix] Mangin D, Lawson J, Cuppage J, Shaw E, Ivanyi K, Davis A, Risdon C. “Legacy Drug-Prescribing Patterns in Primary Care.” The Annals of Family Medicine, Nov 2018, 16 (6) 515-520. doi: 10.1370/afm.2315
[x] Das A, Maiti A, Sinha S. “Antidepressant Prescription in the Geriatric Population: A Teachable Moment.” JAMA Internal Medicine. November 2016, 176 (11) 1608-1609. doi:10.1001/jamainternmed.2016.5535.
[xi] Garber J, Brownlee S. Medication Overload: America’s Other Drug Problem. The Lown Institute. 2019.