Medication Appropriateness in Vulnerable Older Adults

Healthy Skepticism of Appropriate Polypharmacy

Terri R. Fried, MD; Marcia C. Mecca, MD


J Am Geriatr Soc. 2019;67(6):1123-1127. 

In This Article

Debate Over Polypharmacy in Older Persons

Both sides of the debate agree that polypharmacy is a problem because it is associated with multiple adverse outcomes including falls, fall-related injury, hospitalizations, mortality, impaired function and cognition, and adverse drug effects.[2] The disagreement surrounds the mechanism(s) by which polypharmacy results in these outcomes. On one side of the debate is the belief that older persons are being prescribed too many medications, regardless of the specific medications prescribed. Aging is associated with changes in pharmacodynamics and pharmacokinetics that increase the risk of several classes of medications, and multiple medications increase the risk of drug-drug and drug-disease interactions. According to this position, the goal for patients with polypharmacy is to reduce the number of medications and eliminate polypharmacy.

On the other side of the debate is the belief that older persons are not being prescribed the right medications, but that the number of medications in and of itself is not the problem. Polypharmacy is associated with both the prescription of medications that may be inappropriate for older persons (potentially inappropriate medications [PIMs]) and the lackof prescribing appropriate medications (potential prescribing omissions [PPOs]).[3] This argument leads to the concept of so-called appropriate polypharmacy.[4] This view places an emphasis on prescribing the right medications, regardless of number.

Little direct evidence is available to address this question. A Cochrane polypharmacy review demonstrated that no studies examining interventions directed at PPOs include clinical outcomes.[5] Studies using the strategy of identifying and deprescribing PIMs have mixed results, with several showing a reduction in hospital admissions but none an effect on health-related quality of life. The review concluded that these studies are ultimately limited by small sample sizes, poor quality, and heterogeneity.[5]