How Deprescribing Reduces Medication-Related Risks in Older Adults

As we age, we are more likely to develop conditions requiring medication. Because of that, some older adults rely on many medications to maintain their health.  

But sometimes, the medications that are supposed to help you unexpectedly end up causing harm. This becomes even more likely if you’re taking multiple medications at the same time, which can interact with each other and cause adverse reactions like confusion, dizziness, and falls.    

For some, reducing or stopping medications — also known as deprescribing — can make a positive difference. As an academic geriatrician at Hebrew Rehabilitation Center in Boston and clinical researcher at the Hinda and Arthur Marcus Institute for Aging Research, where I’ve studied medication management and falls, I’ve seen it happen! I had one patient who was taking multiple medications for heart rate and blood pressure and experienced a number of falls. By reducing the dosages of some of these medications and switching to safer alternatives, their falls decreased considerably. They became much more functional, and their quality of life improved.

However, deprescribing isn’t as simple as looking at someone’s medication list and telling them they shouldn’t be taking one of them. It’s a process that requires careful consideration and trust between physicians and patients. 

What is polypharmacy? 

Polypharmacy is a term used to describe taking multiple medications at the same time. How many medications do you need to take for it to be considered polypharmacy? According to research, polypharmacy is most commonly described as using five or more medications at the same time. However, hundreds of research studies have been published on the topic, and definitions of polypharmacy have ranged from taking as few as two medications to as many as 11 or more.

What’s important to know is that taking multiple medications every day can pose risks. These risks increase as we age and our body’s ability to handle medications changes. And for older adults, who may take medications for conditions such as high blood pressure, high cholesterol, cognitive impairment, chronic obstructive pulmonary disease, and diabetes, the risk of polypharmacy causing harm is particularly high.

One Centers for Disease Control and Prevention survey estimated that over one in three U.S. adults ages 60 to 79 had used five or more prescription drugs in the previous 30 days. Polypharmacy is even more prevalent in people with dementia and those living in long-term care settings, with a study finding that nursing home residents were using an average of eight medications.

Medications can be key to managing chronic conditions and pain, but there’s a caveat to taking so many of them — the more medications you take, the more likely they are to interact with each other. If that happens, you may experience side effects that are mistaken for new health problems, leading to a “prescription cascade.”

A prescription cascade occurs when one medication’s side effects are treated with another prescription medication. What if that new medication causes another unexpected side effect? You could get yet another prescription, which may lead to more unexpected side effects. The cycle continues, leading to a cascade of prescriptions. Prescription cascades are more common in older adults who have multiple health conditions, as the symptoms caused by prescription interactions can be misinterpreted as new health concerns rather than flagged as side effects.   

How deprescribing may benefit older adults

Deprescription is the process of reducing or stopping medications that you either don’t need anymore or are causing you harm. It’s worth noting that you should never try to deprescribe on your own, as that could pose serious health risks. It’s also not recommended for everyone, as medical needs vary from person to person. With the guidance of a medical professional, many older adults can deprescribe safely.

Deprescribing can improve many older patients’ lives in a number of ways, including reducing the likelihood of experiencing a fall. While some risk factors for falls — such as changes in our vision or reflexes with aging — are out of our control, the medications we take are something we can adjust. In fact, medications are one of the most common and modifiable risk factors for falls.  

Medications can increase your risk of falling for a number of reasons. A medication may affect your balance and reaction time, your ability to regulate your blood pressure, or even your blood sugar levels. Other medications may not increase your risk of falling but be harmful to your bone strength, making it more likely for you to have a serious injury or fracture if you do fall.

Certain medications can also cause cognitive side effects like dizziness, disorientation, and confusion. These not only contribute to fall risk but also affect the quality of life. For those with cognitive impairment or dementia, these side effects can exacerbate existing symptoms.

This underscores the importance of regularly reviewing your medications to make sure each one serves a clear purpose and that the benefits outweigh the potential risks. In some cases, that may mean revisiting medications that you’ve been on for years to see if they’re still necessary. Reviewing your medication list periodically with a health care provider is a great way to manage your medication risk. 

The complexities of deprescribing 

Deprescribing may sound simple: if a medication is causing harm or may not be serving you anymore, why not deprescribe it? However, it’s a bit more complicated than that.

From a physician’s perspective, we need to honor our patients’ preferences and thoroughly consider the risks and benefits of each medication before moving forward with any deprescription recommendation. That can include conversations with patients, family members, and trusted doctors. It can take time to do these things!

For patients, the thought of stopping a medication that they’ve been taking for years can bring up some difficult emotions. You may trust the primary care physician or specialist who prescribed your medication and now have a new doctor questioning whether you need it. That can feel uncomfortable.

Some patients worry their original symptoms will return if a medication is deprescribed. Others feel resistant to deprescribing a medication that validates the very real illness and experience they are going through, especially if they have a chronic illness or disability. Those fears and anxieties are completely understandable and are an enormous reason why trust between the doctor who recommends deprescribing and the patient is so important for it to work.

Patients should feel heard and understood by their physicians when discussing deprescribing. It can be easy to perceive deprescribing as “taking something away” or “doing nothing.” In reality, it’s the opposite! It’s a way for a provider to find better, safer options aside from prescription medications to make you feel better. That could mean switching to a new medication, or it could involve non-drug treatments. Physicians should be mindful when speaking with their patients so it’s clear that the goal isn’t to withdraw care — it’s to improve it. 

When to talk to your doctor 

If you or a loved one is taking multiple medications, how do you know if it’s time for a medication review? For starters, it’s a good idea to keep an eye out for changes in your energy levels, balance, or alertness. Additionally, if you’ve been on the same medication list for years without revisiting them, it may be worth speaking with your doctor about your medications, including whether they’re the best choice for you, whether you still need them, and how they might be interacting with one another.

Herbal supplements and over-the-counter medication like ibuprofen and aspirin can interact with prescription medications, so tell your doctor if you’re taking anything other than your prescribed medications when you talk about your medication. 

A patient-centered approach to medication management 

Polypharmacy is common in older adults and can be necessary when managing multiple chronic health conditions. But it also comes with risks. While deprescribing can address some of these risks, it requires careful consideration and a patient-centered approach built upon trust.  

At Hebrew SeniorLife, that’s what we aim to do. For example, at the Deanna and Sidney Wolk Center for Memory Health, our memory health care team not only prescribes medication for dementia but assesses whether other medications you take may be worsening your dementia symptoms. We can work with your primary care physician and other specialists to make necessary medication changes, all while keeping what matters most to you at the center of the conversation.

Our unsurpassed, patient-centered health care services in Greater Boston range from long-term chronic care to post-acute rehabilitation, comprehensive outpatient care related to brain health at the Wolk Center for Memory Health, a range of outpatient clinics, and more. Find a service or community online or call us at 617-363-8000 for more information.

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