The Growing Concern of Polypharmacy in the Elderly: A Geriatric Nurse Practitioner’s Perspective

As a geriatric nurse practitioner, I witness firsthand the significant challenges posed by polypharmacy—the concurrent use of multiple medications—in elderly patients. Polypharmacy is not a new issue, but it has become an increasingly pressing concern in the care of older adults. Unfortunately, despite the well-documented risks, it seems that the root of this problem is not being adequately addressed by primary care providers (PCPs). I feel strongly this is due to the neglect our medical system puts on pateint outcomes first, in order to make the "system" more money. PCPs are not given the time this takes at an office visit majority of the time. In a patient with 10 or 15 medications, it takes 45-60 minutes to complete. PCPs are given 10-15 minute visits, and the patient is usually in clinic with a different problem they want addressed. The Scope of Polypharmacy in the Elderly: The elderly population is uniquely vulnerable to polypharmacy due to the prevalence of multiple chronic conditions that require management through medication. According to recent studies, nearly 40% of adults aged 65 and older take five or more prescription medications. This number to me, is not correct. I see patients in assisted livings and nursing homes that are VERY RARELY on less than 10 medicaitons and up into the 30's. ! Polypharmacy is often seen as a necessary evil in managing these conditions, but its implications are far-reaching, and the risks should not be underestimated. Why Polypharmacy is So Concerning: The dangers of polypharmacy in the elderly are grossly underestimated by many. First, the aging body is less efficient at metabolizing and clearing medications, making older adults more susceptible to adverse drug reactions, drug-drug interactions, and medication errors. The decline in liver and kidney function, coupled with changes in body composition, means that the same dose of a medication may have a different effect compared to when a person was younger. More concerning, however, is the impact polypharmacy can have on the quality of life. Older adults are often prescribed medications for symptoms that are either side effects of other drugs or related to age-related changes that do not require pharmacological intervention. For example, a patient with memory problems may be prescribed a medication to manage cognitive decline, but in doing so, they may experience adverse effects such as dizziness, confusion, or falls. Similarly, medications prescribed to manage high blood pressure or diabetes can exacerbate other conditions such as frailty or cognitive decline if not carefully monitored. The Lack of Action by Primary Care Providers: Despite these risks, primary care providers (PCPs) often fall short in addressing polypharmacy among their elderly patients mostly due to time constraints as mentioned above. The pace of modern healthcare, driven by time constraints and the growing complexity of managing multiple chronic conditions, leaves little room for in-depth medication reviews. While PCPs may be aware of the dangers of polypharmacy, they are often too busy to engage in the necessary comprehensive medication management or deprescribing practices. Moreover, there is a tendency to prescribe medications as a first-line intervention for symptom management, rather than exploring alternative approaches such as lifestyle changes, physical therapy, or other non-pharmacologic options. In many cases, medications are added without thoroughly reviewing the patient’s current medication list to identify potential interactions or duplications. For instance, if a patient has been prescribed a new antidepressant, their other providers may not be aware of the potential sedative effects it may have when combined with anti-anxiety medications or sleep aids, leading to a dangerous cascade of effects. The result is a "prescribing cascade," where additional medications are prescribed to address side effects from other drugs, thus perpetuating the cycle. Unfortunately, the current healthcare system places significant emphasis on prescribing as a quick fix to problems, rather than taking the time to assess the risks associated with multiple medications. The Role of Geriatric Nurse Practitioners in Polypharmacy Management: As geriatric nurse practitioners, we are in a prime position to address polypharmacy in the elderly. One of our primary roles is to conduct thorough, individualized assessments of our patients’ medications, paying close attention to drug interactions, dosages, and the potential for harm. I try to review medications each visit to see if they still have an active indication. May times they do not, and the medication can be stopped. We work closely with interdisciplinary teams, including pharmacists, specialists, and caregivers, to create comprehensive care plans that prioritize the patient’s safety and well-being. Our ability to intervene effectively is often hindered by the limitations within the current healthcare system. Many patients see several specialists, each with their own prescribing patterns (that are often very narrow focused based on their specific specialty), creating a fragmented approach to care. This makes it difficult to consolidate medications and identify when a drug may no longer be necessary. PCPs, as the gatekeepers of healthcare, should be more proactive in leading these efforts, yet the demands placed on them often prevent such coordinated, patient-centered approaches. What Needs to Be Done: To address polypharmacy in the elderly, we need a more team focused and proactive approach to medication management. Primary care providers must dedicate time and resources to performing regular, detailed medication reviews and actively engage in deprescribing when appropriate. This includes educating patients and caregivers on the importance of understanding their medications, why they are prescribed, and how they may interact with one another. Reaching out to specialists needs to be a daily occurence. There should also be greater emphasis on alternative treatments, including physical therapy, lifestyle changes, and mental health support, to reduce medications. Additionally, interdisciplinary collaboration is crucial, and PCPs should work closely with geriatric specialists, nurse practitioners, and pharmacists to ensure that medication regimens are safe, not resulting in adverse side effects and having the shortest number of drugs as possible. I think pharmacists are very under utilized for polypharmacy. Out of all professions, they are more educated about the actual drug pharmacodynamics and pharmacokinteics than all other providers. They should be consulted more often for medication reviews. When I've had complex cases, I've asked pharmacy for a review and they have always been very happy to help. Polypharmacy in the elderly is a critical issue that cannot be ignored any longer. With the coming grown of the elderly population, this is only going to get worse. The consequences of inappropriate medication use can be severe, leading to diminished quality of life, increased hospitalizations, and even death. Primary care providers must take the lead in addressing polypharmacy through comprehensive medication management, deprescribing, and improved coordination with other healthcare professionals even when it means taking more time. Health care systems claim their #1 goal is patient care and positive outcomes, if that is truly the case, they need to help by providing PCPs time to do the job the way it was meant to be. Until meaningful changes are made, actual meaningful changes where the patient is truly first above financial gain, the elderly will continue to suffer the harmful effects of polypharmacy—an issue that is both preventable and treatable if only given the attention it deserves.