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Understanding and Reducing Polypharmacy in Senior Living
May 21, 2025Understanding, Reducing Polypharmacy in Senior Living
Polypharmacy is common in senior living populations. As many older adults have at least one chronic health issue – such as high blood pressure, high cholesterol, or diabetes – they often are taking at least one prescription medication. According to the Centers for Disease Control and Prevention (CDC), about one-third of people in their 60s and 70s used at least five or more prescriptions, defined as polypharmacy, to manage their health. As people age, the number of illnesses and issues, as well as the number of medications they take, may increase further. And as the older population grows, so do the dangers of polypharmacy. A recent study in JAMA observed that about twice as many people aged 65 and older experience polypharmacy as compared to 20-25 years ago. Fortunately, there are ways to combat polypharmacy by working with the pharmacist and other team members.
Studies suggests just how common polypharmacy is in older adults. According to an article in JAMDA, up to 91% of long-term care residents take more than five medications, and 74% take more than nine. Arif Nazir, MD, CMD, chief medical officer of Abode Care Partners, said, “Data suggests that when you include PRN medications, many older adults take around 12 medications, which is a heart-wrenching number.” With multiple medications comes the risk of adverse events, including falls and cognitive impairment, drug toxicity, delirium, and drug-drug interactions.
The Rise and Risks of Polypharmacy
It’s not surprising that polypharmacy is common in senior living residents. In addition to having chronic conditions that are treated with medications, they also may be seeing multiple physicians, and their prescriptions may be filled at more than one pharmacy. As a result, polypharmacy isn’t recognized or addressed until it causes or contributes to a problem. This is on top of decades of medical training focused on using medications to manage most illnesses and conditions, Nazir suggested.
While many chronic conditions put senior living residents at risk for polypharmacy, among those most strongly connected with this issue are diabetes, depression, heart disease, hypertension, COPD, and pain. Clinical guidelines for these conditions often call for using two or more drugs, often in the same pharmacologic class. Elsewhere, frailty and polypharmacy are both common in older adults, and some studies indicate that polypharmacy could contribute to an increased risk of frailty.
Another common contributor to polypharmacy is what is known as a prescribing cascade. This is when a drug administered to a patient causes adverse event signs and symptoms that are inaccurately interpreted as a new condition for which an additional medication is then prescribed. In these cases, the added drug can increase the adverse reaction to the first drug or put the resident at risk for additional adverse reactions.
Drugs most frequently involved in the prescribing cascade include opioids, NSAIDs, antihypertensives, and drugs for dementia. Polypharmacy can result is a variety of poor outcomes. These include:
• Falls
• Delirium
• Fatigue
• Memory problems
• Reduced ability to perform ADLs
Adverse drug events (ADEs) are a common result of polypharmacy, and data suggests that 35% of outpatient and 40% of hospitalized older adults experience an ADE at some point, and about 10% of emergency room visits are associated with an ADE. The rate of ADEs among nursing home residents is twice as high in those taking nine or more medications versus those who take fewer.
“If we don’t work together as a team to address polypharmacy, we are missing an opportunity,” said Nazir. He added, “I think teamwork has really ramped up in senior living, so it is important to have a good team and effective team communication to be able to identify opportunities for medication optimization.”
Moving Toward Medication Optimization
Fortunately, in recent years senior living and long-term care practitioners have prioritized the need to address polypharmacy. Nazir said, “We now have established a culture where more is not necessarily better. We have good teams who communicate and identify opportunities to reduce polypharmacy.” As a result, a movement toward reducing the use of unnecessary or inappropriate medications, known as deprescribing or medication optimization, took off.
A number of organizations took up the medication optimization mantel. For instance, the National Institute on Aging developed a network of scientists and established the U.S. Deprescribing Research Network. This was designed to develop and share resources, as well as support research on medication optimization. The organization also offers tools such as guidelines on deprescribing common medications. Elsewhere, clinical leaders have prioritized addressing polypharmacy. For instance, for four years, the American Society of Consultant Pharmacists (ASCP) and Post-Acute and Long-Term Care Medical Association (PALTmed) have been holding meetings and developing resources to help prescribers, pharmacists, DONs, and other team members optimize medication used in the senior and long-term care setting. These activities are components of a multidisciplinary initiative called Drive to Deprescribe.
Steps to Optimization
Medication optimization can start with some basic tasks, for example, a medication reconciliation conducted with a “brown bag” review of the resident’s current medications, including over-the-counter products, vitamins, and supplements. This can help identify anything that can or should be eliminated from the regimen. The physician and pharmacist can work together to adjust medications as needed, and they can educate the patient and their family about the importance of discussing over-the-counter and other nonprescription products with a clinician before taking them.
Some other steps include:
• Talk to patients about their medications. Are they experiencing any side effects? Are there any medications they would like to discontinue and, if so, why? Are they taking medications as directed? The review also should address what benefits patients are getting from their medications, any prescriptions that lack an appropriate indication, and any long-term prescriptions that may no longer be necessary. Make a priority of list of medications for special attention. For instance, take a close look at drugs such as antipsychotics, statins, antihypertensives, benzodiazepines, and proton-pump inhibitors, which are a common focus for addressing polypharmacy.
• Use available tools such as the American Geriatric Society’s Beers List and the Anticholinergic Burden Calculator, and resources on deprescribing.org.
• Create personalized deprescribing plan. Educate patients about the importance of reducing polypharmacy and find out how they feel about eliminating or decreasing the use of various medications. If they’ve been taking something for many years and believe (falsely) that they need it, they may resist change. Consider weaning patients off drugs to get their buy-in and reduce any withdrawal issues. Take this opportunity to talk with patients about the benefits and potential risks of their medications and address how reducing polypharmacy can not only keep them safer but lower their out-of-pockets costs.
• Monitor medication optimization/deprescribing efforts and adjust as necessary over time. Continue communicating with the patient and their family to track compliance and the impact of removing drugs or reducing dosages.
• Conduct regular reviews to identify any new prescriptions that are introduced to the patient’s regimen as well as any over-the-counter products they’ve started taking. This will help prevent the number of medications patients are taking from creeping back up.
The Pharmacist’s Role
Part of the pharmacist’s role is to make sure medications are being used safely and effectively for each individual. They are key players in addressing polypharmacy through regular medication regimen reviews, targeted reviews of particular residents or specific medications, staff training and education about medication management and administration, and other efforts. “People often think of pharmacists as professionals who provide them medications, but the consultant pharmacist looks for ways to reduce polypharmacy and the burdens of medications. They know the impact of someone being on a mix of medications, and they focus on deconstructing medication profiles and making them as efficient and effective as possible,” said Chad Worz, PharmD, BCGP, FASCP, chief executive officer of the American Society of Consultant Pharmacists.
Taking a Person-Centered Approach
It is important to note that medication optimization isn’t simply about reducing the number of medications people take. There are instances where multiple medications are “both rational and appropriate” for some patients. That is one reason the term “medication optimization” better describes the goal of efforts to address polypharmacy than “deprescribing.” At the same time, as one study observed, “For some older adults, it may be impossible to avoid certain medications that may otherwise be contraindicated, and extensive discussion around goals of care, life expectancy, and potential drug-drug interactions and adverse effects are necessary with the patients and family or caregivers when assessing medication indications and their risks and benefits.”
Addressing polypharmacy requires a person-centered approach. As Chad Worz, said, “The decision-making process around medications has gotten more complex is some ways, but it’s also become more person-centered; and that’s important.” This means considering “what matters” to each patient, what they want or expect from their medications, and how best to administer medications. For instance, Worz said, putting someone who’s worked the night shift their whole lives on a new schedule can cause them to have trouble sleeping at night, triggering a prescription for a sleep medication because they’re awake and restless at night. Instead, he suggested, “If we adjust to their lifestyle and, for instance, let them sleep during the day and be up at night, can eliminate the need for that medication.”
Summary
Although polypharmacy is common in older adults, there is much the care team can do to help ensure senior living residents consistently have medication regimens that are appropriate and effective. By communicating with residents, understanding their goals and concerns, taking opportunities to reduce dosages or eliminate medications that may no longer be needed, and using therapeutic alternatives to address adverse events and other issues, the prescriber, pharmacist, and other team members can keep residents safe, maximize their quality of life, and prevent avoidable emergency room visits and hospitalizations.