Polypharmacy in the Elderly: What You Need to Know
“Polypharmacy in the Elderly: What you Need to Know” was written by Amy Daniels, RPh & reviewed/edited Katie Dodd, MS, RDN, CSG, LD, FAND. Amy is a Registered Pharmacist, a Dietetic Intern with the Keith and Associates Distance Dietetic Internship Program, and owner of Amy’s Nutrition Rx.
What is Polypharmacy?
In this article we’ll dive deep into polypharmacy in the elderly. First, let’s take a look at what polypharmacy actually is.
Polypharmacy is the daily use of multiple medications by an individual.
It is usually defined as a person taking five or more medications. And the term polypharmacy is often used when a person is taking more medications than necessary.
Polypharmacy is also used to refer to situations where a person is taking medications that may not be appropriate for their condition. (1)
Often, the multiple medications are prescribed by more than one healthcare provider. When the medicines are filled at different pharmacies, there is also an increased safety risk for the patient.
How Common is Polypharmacy?
Polypharmacy is becoming more common in the United States. About 10% of the US population takes five or more medications on a regular basis. Polypharmacy in the elderly is especially common. About 30% of older adults in the US take five or more medications regularly. (2)
Why is Polypharmacy an Issue in the Elderly?
Older adults have an increased potential for taking multiple medicines as they age. This is because they are more likely to have chronic medical conditions and injuries. Chronic conditions and injuries often necessitate the use of medications and most medications have adverse effects. (3)
Over-the-Counter-Medicines and Polypharmacy
In addition to aging, there are other factors that contribute to polypharmacy. One of these factors is the increased use of vitamins, herbs, and supplements that are available without a prescription.
Studies have shown that adults age 65 and older take between one and three self-prescribed medications. This is thought to be due to the increasing costs of prescription drugs and decreased health insurance benefits. (3)
Health Risks of Polypharmacy in the Elderly
Taking multiple medications increases the chance of having harmful drug side effects. The elderly are two- to three-times more likely than younger adults to experience unwanted drug side effects. Polypharmacy also can lead to more drug-drug interactions and drug-nutrient interactions.
Additionally, older adults taking multiple medicines are more likely to experience frailty and falls. Most importantly, polypharmacy can cause an increased risk of illness, hospitalization, and death. Research demonstrates this increased risk even after considering a patient’s multiple health conditions. (1)
Polypharmacy and Malnutrition
Polypharmacy is a significant risk factor for malnutrition.
Malnutrition Has Many Risk Factors
There are many risk factors for malnutrition in the elderly.
They include medical factors, lifestyle factors, and psychological factors. You can read a comprehensive guide to chronic malnutrition in seniors here.
Examples of medical risk factors for malnutrition are:
- poor appetite
- poor condition of teeth
- problems with swallowing
- loss of taste and smell
- breathing problems
- gastrointestinal problems
- physical disability
- other disease states (such as cancer)
- drug interactions
Examples of lifestyle factors for malnutrition are:
- isolation, loneliness
- inability to shop or prepare meals
Examples of psychological factors for malnutrition are:
A 2016 study on malnutrition and chronic illness in an elderly community, found three main factors that influence an older person’s nutritional status: living alone, dysphagia (difficulty with swallowing), and multiple medication use. (4)
Another study from 2016 showed that there are five main causes of malnutrition in the elderly: higher BMI, depressive symptoms, frailty, poor self-rated health, and polypharmacy. Of the five main causes, polypharmacy was a strong indicator of malnutrition in both men and women. (5)
How Medicine Use Can Lead to Malnutrition
Medicine can lead to malnutrition in several ways. Let’s take a deeper look.
How the Body Uses Food
Medicines can affect how the body absorbs, breaks down, and eliminates nutrients in food. Some medicines can change the acidity levels in the gastrointestinal system (GI). This can cause decreased absorption of nutrients in food.
Antibiotics can destroy the healthy bacteria in our GI system. This can speed up the time food moves thought the GI system and result in diarrhea. When this happens, there is less time for the body to absorb nutrients from food.
Laxatives and antacids can also lead to nutrient deficiencies by speeding the passage of food through the digestive system. Laxatives and antacids are common medicines consumed by elderly patients. One solution to this issue is to recommend increasing fiber and fluid in the diet rather than using medicine to treat constipation. This can be useful for patients taking pain medications which often cause constipation.
A study from 2011 showed that adults age 70-90 taking three or more medicines per day were more likely to have lower levels of folate, vitamin B6, vitamin D, and vitamin K. (7)
Vitamins and Minerals
Some frequently prescribed medicines that affect the body’s vitamin and mineral status are: (1)
- Proton pump inhibitors: may cause vitamin B12 deficiency and may worsen iron levels in patients with anemia. B12 deficiency can lead to anemia, fatigue, and cognitive impairment.
- Aspirin (long-term, high dose): may cause vitamin C deficiency. This can lead to a thinning of the stomach lining.
- Loop diuretics: may affect calcium balance in older adults and may lower thiamin and potassium levels.
- Thiazide diuretics: may lower magnesium, potassium, and zinc levels
- ACE inhibitors: may lower zinc levels. This can lead to loss of taste, anorexia, tiredness, and poor wound healing.
- Statins: may lower CoQ10 levels in older adults and may lower beta-carotene levels. Lower CoQ10 levels may cause muscle problems.
- Metformin: may cause vitamin B12 deficiency. This can lead to anemia, fatigue, and cognitive impairment.
Medicines can directly and indirectly affect appetite. For example, medicines such as chemo drugs can cause mouth sores, nausea, vomiting, and diarrhea that can make eating unpleasant. Some medicines can affect neurotransmitters in the brain that regulate appetite and cause anorexia.
Loss of Taste
Loss of taste is a common side effect of many medications. Some common high blood pressure medicines can lower levels of zinc in the body. Zinc deficiency is a common cause of loss of taste. Other symptoms of zinc deficiency are poor appetite, tiredness, and poor wound healing. Zinc levels can be monitored in patients taking these medications. (1)
Medicines can make it difficult for a person to eat. Pain medicines and anxiety medicines can cause sleepiness, dizziness, headache, or weakness. (6) This can make it hard for people taking these medicines to feed themselves.
Malnutrition and Medication Side Effects
Malnourished people are more susceptible to drug side effects.
This can happen due to several reasons.
Malnourishment can cause protein depletion in the body. Many medications bind to proteins after consumption as they are absorbed and moved throughout the body. Disrupted protein levels can cause a more rapid elimination and breakdown of the medicines.
This could lead to a need for a higher dose of the medicine or more frequent administration of the medicine and ultimately, more side effects. (8)
Malnutrition causes a person to have less adipose (fat tissue) storage in relation to fat-free tissue storage in the body. Since drugs are distributed in the body by moving into body tissues, this can affect how a person’s body responds to medicines.
Changes in body composition can make a person more susceptible to a drug’s harmful effects. For example, a person with cancer and unintended weight loss can experience more side effects from chemotherapy than a person with higher amounts of lean body mass. (9)
Malnourished patients can also experience dehydration. Having less body water can alter the blood concentration of a medicine. This can lead to a higher chance of drug side effects.
Also, dehydration can affect kidney function. Since the kidneys eliminate some medicines from the body, a decrease in kidney function can cause higher amounts of the medicine to stay in the body. This can also lead to harmful medication side effects.
Other Health Problems
Not only can polypharmacy lead to malnutrition, but malnutrition itself can result in a person having to take more medications.
Malnutrition can lead to:
- A weakened immune system
- Psychological effects
- Muscle weakness
- Broken bones
Weakened Immune System
A weakened immune system can increase risk for infection and the need for antibiotics.
Malnutrition may be associated with depression, anxiety, and self-neglect. A person with these feelings may need drug therapy to treat their poor mood.
Muscle Weakness and Broken Bones
Broken bones can lead to an increased chance of hospitalization and medicines for pain.
These are only a few examples of how malnutrition can lead to health problems that necessitate more medications.
You can read more about the effects of malnutrition on the body here.
Strategies to Reduce Side Effects
There are several ways to reduce the occurrence of drug side effects in malnourished patients.
Work with a Dietitian
A dietitian can assess and track body composition and look for signs of muscle wasting. A dietitian can recommend a meal plan with higher protein levels to help prevent muscle loss. Also, a dietitian can recommend high calorie foods or dietary supplements to combat unintended weight loss.
Resistance training can help prevent muscle loss and keep bones strong. Other benefits include promoting mobility, preventing falls, and protecting against cognitive decline. Consult with a physician before starting a new exercise routine.
Talk to Your Pharmacist
Consult with your pharmacist to discuss possible side effects of a new medicine. Ask if a medicine can affect appetite. If the patient experiences side effects, let the prescriber know. It may be possible to adjust the medication dose to lessen the effects.
Communicate with Healthcare Providers
When changes in body composition occur, make sure to communicate with your healthcare provider. The provider may need to adjust the medication dose or regimen.
Do not assume that loss of appetite or decreased ability to eat is a normal part of a patient’s illness or aging. Ask your healthcare provider or pharmacist to conduct a full medication review to look for drugs that may be responsible for these effects.
Strategies to Reduce Malnutrition
Reducing malnutrition and malnutrition risk in the elderly is possible.
There are many things that can be done to prevent chronic malnutrition in older adults. They are discussed here.
A registered dietitian nutritionist who specializes in geriatric care can help you find the right approach for your situation.
Some strategies to reduce malnutrition are:
- Increase food access. There are many resources available to help seniors receive nutritious meals. You can read about them here. Finding Free Meals for Seniors
- Try fortified foods. These foods add calories to foods normally eaten. Examples are dry milk powder, protein powder, butter, olive oil, or peanut butter.
- Consume smaller meals. Sometimes smaller, more frequent meals can help patients with loss of appetite.
- Consider supplements in addition to food. High calorie drinks between meals may be an option.
- Try food modifications to reduce chewing or swallowing problems
Creative Ways to Combat Malnutrition
- Consider meal prepping. Meal prepping saves time and makes eating regular nutritious meals more convenient. You can read about tips for starting a meal prep system here.
- Discover new high calorie recipes on our food blog here. You will find a growing list of delicious high calorie recipes to stop unintended weight loss.
- Try a phone app that helps with gaining weight. Apps are a great resource for making health journeys a little easier. You can find a short guide to the top 5 apps that are good for weight gain and maintenance here.
Although polypharmacy can decrease vitamin levels, it is not recommended that all seniors take a multivitamin.
Multivitamins do not always solve deficiencies and can increase risk of toxicity. Also, an individual patient’s needs can be higher or lower than the amount found in the supplements. A registered dietitian can help decide if a patient can benefit from a vitamin or supplement.
In general, it is recommended to consume a nutritious diet rather than a specific vitamin or supplement.
Can We Reduce Polypharmacy in the Elderly?
Can we reduce polypharmacy in the elderly? Let’s dig a little deeper.
A study from 2018 examined the attitudes of seniors age 65 and older toward reducing the number of medications they were taking.
The researchers found that 92% of those surveyed would consider stopping one or more of their medications if their doctor allowed it.
This study provides positive information about patient support regarding decreasing polypharmacy.
Common Unnecessary Medications
A study conducted in 2007 had clinical pharmacists look for possible unnecessary medications being prescribed for elderly veterans. The 128 veterans were taking an average of five medications each. The pharmacists found that the most common unnecessary medications were those for GI function, anxiety, and vitamins. (11)
A more recent study from 2019 on overprescribed medications and US adults found four main overly prescribed drugs:
- opioids for chronic pain
- proton pump inhibitors for indigestion
- levothyroxine for subclinical hypothyroidism
- antidepressants for subclinical depression
The authors also found that there has been an increase in prescribing of these medications for older adults in recent years. Additionally, medicines were often prescribed for long periods of time without documented benefit. (12)
Despite the documented risks of polypharmacy, there are also risks for reducing medication use. When deprescribing, there are three important steps a health care provider should follow:
- Consult with the patient
- Use an orderly process
- Follow-up with careful monitoring
First, ensure that the patient is onboard with changes in his/her medication regimen. Often, the patient will want to understand the “why” behind the recommendation to stop a medicine.
Next, the provider should use a systematic process for stopping a medicine. Some medicines need a slow weaning process to avoid drug withdrawal symptoms. Finally, careful monitoring is recommended to ensure the patient’s health status is not compromised.
It is important to keep in mind that for many health conditions such as high blood pressure, diabetes, and pulmonary disease, multiple medications are often needed to control the condition.
Deprescribing of medications requires individual patient assessment. Careful analysis of the risk versus benefit for each medicine must be performed.
Benefits of Reducing Polypharmacy
In summary, reducing polypharmacy in the elderly can have important benefits including:
- Health benefits for the patient
- decreased risk of malnutrition
- decreased risk of hospitalization
- increased quality of life
- decreased risk for more chronic health conditions
- Cost savings for the patient
- Cost savings for the insurance provider
Tips for Reducing Polypharmacy in the Elderly
Here are some important tips for reducing polypharmacy in the elderly as well as malnutrition risk.
Have a Healthcare Team
As we age, it is important to have a healthcare team to assist with our overall health status. This can include physicians, dietitians, pharmacists, mental health providers, social workers, caregivers, and more.
The healthcare team should work together to reduce the effects of polypharmacy and malnutrition. The team can also coordinate medications and diet plans.
Use One Pharmacy
Patients who use more than one pharmacy are at risk for overprescribing and drug-drug interactions.
Pharmacists can check for drug-drug interactions, medication duplicates, and inappropriate prescribing. However, if not all medications are filled at the same pharmacy these issues are more difficult to find.
Seek Help from a Dietitian
Screening of nutritional status in elderly patients on multiple medications should be done early in the care process.
Dietary interventions for the management of chronic diseases should also occur early in the treatment plan. This can help reduce disease progression and the number of medications the patient ultimately requires.
Resources for Caregivers
There are so many resources available online. Here are some more to get you started!
Malnutrition and Unintended Weight Loss
- Easiest Weight Loss Percentage Calculator
- How to Gain Weight Back After COVID-19
- High Calorie RECIPES e-Cookbook
- Preventing Unintentional Weight Loss
- Which Malnutrition Screening Tool is Best?
- Consumer Reports Article: Should You Still Be Taking That Medicine?
- Helpful links from deprescribing.org
- Read about 8 Essential Questions to Ask the Pharmacist here.
- Little, M. O. (2018). Updates in nutrition and polypharmacy. Current Opinion in Clinical Nutrition & Metabolic Care, 21(1), 4-9.
- Quinn, K. J., & Shah, N. H. (2017). A dataset quantifying Polypharmacy in the United States. Scientific Data, 4(1).
- Heuberger, R. A., & Caudell, K. (2011). Polypharmacy and nutritional status in older adults. Drugs & Aging, 28(4), 315-323.
- Burgos, R., Joaquin, C., Blay, C.,et al. (2016). Strategy to fight against malnutrition in chronic patients with complex health needs. International Journal of Integrated Care, 16(6).
- Maseda, A., Gómez-Caamaño, S., Lorenzo-López, L., et al. (2016). Health determinants of nutritional status in community-dwelling older population: THE VERISAÚDE STUDY. Public Health Nutrition, 19(12), 2220-2228.
- Mahan, L. K., & Raymond, J. L. (2016). Krause’s food & the nutrition care process. St. Louis, MO: Elsevier.
- Fabian, E., Bogner, M., Kickinger, A., Wagner, K., & Elmadfa, I. (2011). Intake of medication and vitamin status in the elderly. Annals of Nutrition and Metabolism, 58(2), 118-125.
- Zadak, Z., Hyspler, R., Ticha, A., & Vlcek, J. (2013). Polypharmacy and malnutrition. Current Opinion in Clinical Nutrition and Metabolic Care, 16(1), 50-55.
- Pin, F., Couch, M. E., & Bonetto, A. (2018). Preservation of muscle mass as a strategy to reduce the toxic effects of cancer chemotherapy on body composition. Current Opinion in Supportive & Palliative Care, 12(4), 420-426.
- Reeve, E., Wolff, J. L., Skehan, M., et al. (2018). Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA internal medicine, 178(12), 1673–1680.
- Rossi, M. I., Young, A., Maher, R., et al. (2007). Polypharmacy and health beliefs in older outpatients. The American journal of geriatric pharmacotherapy, 5(4), 317–323.
- Safer, D. (2019, September). Overprescribed medications for US adults: Four major examples. Retrieved February 09, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731049/