As we age, the chances that we will be taking multiple medications increase. “Polypharmacy” is defined by physicians as patients who take five or more medications daily and “super polypharmacy” as patients who take 10 or more medications. It used to be an issue that was mostly confined to the older adults, but new research points to more patients piling on the pills in middle age.

By age 40, 1 in 4 patients are already considered polypharmacy, according to the CDC. Experts contend that there are several risk factors associated with taking multiple medications, including dosing errors, adverse drug interactions, falls, cognitive impairment, and hospitalization.

Primary care physicians can play an important role in reducing medication dosage and de-prescribing any medications that a patient no longer needs.

The Risks of Polypharmacy in Middle Age

The number of patients taking more medications at a younger age is increasing and research published recently in the Journal of General Internal Medicine found an association between patients taking five or more medications in middle age and a lower score on physical function.

It’s unclear whether taking too many medications causes frailty or whether those who take a high number of medications are already frail because they have conditions like diabetes and heart failure that may reduce their physical function. But either way, there is evidence that polypharmacy can cause poor outcomes.

“There’s always a concern if people are taking multiple medications that those medications are going to cause compounding side effects and/or that those medications are going to interact with each other,” said Caroline Sloan, MD, lead study author and an assistant professor of medicine at Duke University School of Medicine, Durham, North Carolina.

Multiple diabetes medications, for example, may interact together leading to hypoglycemia or low blood sugar in patients. And anticoagulants and anti-platelet medications taken together can increase the risk for internal bleeding. These medications are used in patients with atrial fibrillation because of the risk for stroke and in patients experiencing blood clotting in their lower extremities.

Those taking multiple medications for hypertension can lower their blood pressure too much, leading to hypotension. If you take a GLP-1 agonist along with a hypertension medication, it can also lower your blood pressure to the point of hypotension, which could cause some patients to faint. What’s more, patients who take too many opiates together can increase their risk for falls as a result of dizziness and instability.

As patients age, some of the drug interactions may also become more pronounced, said Allison M. Mays, MD, a geriatrician at Cedars-Sinai Geriatrics, Beverly Hills, California. “The same medication dose may no longer be appropriate and there may also be medication side effects that become less tolerable with age,” said Mays.

The More Medications, the More Risk for Medical Mistakes

Medications can add up quickly, especially in patients with chronic conditions like heart failure or diabetes. While there’s strong evidence to show that these medications are critical to positive outcomes, as their numbers grow there’s also a concern around medication errors, said Dana Carroll, PharmD, a geriatric pharmacist and clinical professor at Auburn University in Auburn, Alabama.

Patients taking multiple medications are more likely to see multiple specialists for their conditions, which can open the door to errors. Research has shown that Computerized Clinical Decision Support helps physicians reduce medication errors and adverse drug events because these computer programs automatically list any potential drug interactions.

Carroll added that the more medications a patient is taking the more likely they are to have difficulty following the medication instructions, especially if they need to take them multiple times per day. “The more medications that we add, the more it decreases adherence to medications because it’s more complex and patients can get frustrated,” said Carroll.

Drug interactions, medical mistakes, and lack of adherence to medication directions can also increase the chance that a patient will be hospitalized. A study published this year in PLOS One found that polypharmacy was a risk factor for hospitalization and mortality, and that the risk increases with age.

Discussing All Medications With Your Patients

Experts contend that there are many interventions that physicians can take to reduce medications. A study published in JAMA Open Network last year explored what interventions worked in clinical practice.

The bare minimum involved reviewing the medications that patients are taking. This way physicians can look at any potentially inappropriate drugs, said Michelle Keller, PhD, MPH, an assistant professor of gerontology at the University of Southern California in Los Angeles.

The discussion should also include any supplements or vitamins that a patient might be taking because these can also interact with prescribed medications while adding to the overall pill load. Common interactions include St. John’s Wort, ginkgo biloba, and garlic, which can interact with blood thinners and antidepressants.

Patients tend to think that these medications are safe because they’re considered natural, but this isn’t always the case. It’s also difficult to know dosages and ingredients because supplements and vitamins are not regulated by the FDA.

In addition, for medications that already cause drowsiness, physicians should also be discussing the risk of alcohol, which can add to dizziness and instability when combined, especially as a patient ages.

‘De-Prescribing’ Patients Unnecessary Medications

It’s also important for physicians to include patients in the discussion about what is and what is not necessary for patients to continue taking. “Sometimes these discussions happen without including patients and their families,” said Keller. For example, if a clinical pharmacist evaluates medication lists and consults a physician without including the patient.

Some medications may be low hanging fruit when it comes to de-prescribing. For example, if a patient is taking sleeping pills as one of their medications, it might be possible to substitute therapy instead of a medication. Cognitive behavioral therapy can be substituted as a long-term solution to help patients learn to replace negative sleep thoughts and behaviors to support sound sleep without medications.

Medications that were prescribed for short term anxiety, pain, or sleep issues like benzodiazepines should not be taken indefinitely because they increase the risk for dizziness, dependence, and withdrawal symptoms. Long-term antidepressants like selective serotonin reuptake inhibitors have a much better safety profile for treating anxiety and depression in the long term.

Keller said that when patients want to stop taking antidepressants, physicians need to ensure that these medications are tapered off gradually. When antidepressants are suddenly halted, it can cause a shock to the system that includes psychological symptoms, balance issues, insomnia, or sensory disturbances. The higher the dose and the longer a patient has been taking them, the longer it takes to taper off.

Experts contend that while some medications, especially those taken for chronic conditions like cardiovascular disease and diabetes, have been shown to strongly decrease mortality, physicians can play an important role in ensuring that a patient’s medication list is up-to-date and only includes what is necessary.

“So that medications that are supposed to be taken for 4 weeks max, don’t end up on their list 20 years later,” said Keller.