Polypharmacy and Deprescribing: Taking Fewer, Better Medicines

Why older adults take many medicines

• Multiple long-term conditions: high blood pressure, diabetes, heart disease, arthritis, thyroid, bone loss, prostate or bladder problems, depression, sleep trouble.
• Several doctors, each prescribing for their speciality, without a shared list.
• Prescribing cascade: a medicine causes a side effect (for example swelling, dizziness or constipation), the side effect is mistaken for a new illness, and another medicine is added to treat it.
• Medicines continued long after the original need, for example short-term tablets for acidity, sleep or pain that become permanent.
• Over-the-counter products and supplements bought without a record.
• Traditional and Ayurvedic products alongside modern medicines; see supplements and medicine interactions: a safety guide.

Risks of too many medicines

• Side effects: dizziness, falls, confusion, drowsiness, constipation, dry mouth, low blood sugar, bleeding, rashes, kidney strain, poor appetite, weight loss; see medicine side effects families should watch for.
• Interactions between medicines, foods and supplements.
• Falls and fractures; see falls risk assessment at home.
• Delirium and memory problems; see confusion, hallucinations and sudden change: when to call.
• Mistakes: doubled doses, missed doses, wrong timing, wrong person's medicine.

Not all medicines are the problem

It is crucial to say: many medicines are life-saving and must continue. The aim is "fewer, better" medicines, not "no medicines". Heart, blood thinning, diabetes, thyroid, epilepsy, Parkinson's, transplant and many other medicines are essential, and stopping them without advice can be dangerous. Inappropriate under-treatment is also a problem; the review may add or adjust medicines too.

Step 1: make a complete, accurate list

Create one up-to-date list, the foundation of any review.

• Every medicine: tablets, capsules, syrups, injections, inhalers, eye and ear drops, creams, patches, laxatives, sleeping aids, painkillers, vitamins, minerals, protein powders, herbal and Ayurvedic products, home remedies taken regularly.
• For each: name (brand and generic if known), strength, how much, when, what it is for, who prescribed it, when it was started, and whether it is taken regularly or "as needed".
• Collect all the actual packets from every cupboard, bag, bedside and handbag, including expired and leftover ones. This "brown bag" collection is the best tool for a review.
• Include allergies and past side effects.
• Check what is actually taken, not just what is prescribed: ask your parent, and watch a day's routine. Many older adults skip or double doses, take medicines at the wrong time or share them.
• Write it clearly in large print, with a copy for the wallet, the phone and the doctor; see keeping a health record at home and emergency contact card and medical summary.

Step 2: organise safely

• Use one pharmacy where possible so that the pharmacist sees everything.
• Use a weekly pill organiser and a chart, and ask the pharmacist to help fill it; see pill organiser guide and setting up a weekly medicine box.
• Keep medicines in a cool, dry, safe place, in the original packs, away from children and from damp.
• Simplify timing where possible: ask the doctor whether doses can be combined to fewer times a day.
• Reminders: phone alarms, a daily routine, or help from a carer; see medicine reminders for forgetful parents and dementia and medicines: managing safely.
• Do not share medicines or give leftover ones.

Step 3: ask for a structured review

Request a medication review from the family doctor, a geriatrician or a clinical pharmacist, at least once a year and after any hospital stay, fall or new symptom. In India, a review may take time, so book a longer appointment, tell the clinic in advance, and bring all packets and the list.

Questions to ask - What is each medicine for, and is the reason still valid? - What are the expected benefits for my parent now, in light of their age, health and goals? How will we know it is working? - What are the risks and side effects to watch for? - Could any medicine be contributing to my parent's dizziness, falls, confusion, tiredness, constipation, poor appetite, low sugar or other symptoms? - Are there duplicates or medicines that overlap? - Is the dose still right for their kidney and liver function and weight? - Is there a medicine that is risky for older adults, or interacts with another? - Which medicines are essential, and which could safely be reduced or stopped, and how? - Can we simplify the timing and number of tablets? - What are the alternatives, including non-drug measures? - What should we watch for if a medicine is reduced or stopped, and whom do we call? - When will we review again?

Doctors and pharmacists use evidence-based tools, such as the STOPP/START criteria and the Beers Criteria, to identify medicines that may be inappropriate or missing in older adults, and guidance such as NICE NG5 on medicines optimisation. You do not need to know these, but you can ask whether such a review has been done.

What deprescribing is, and is not

Deprescribing is a planned, supervised process: the doctor and the patient, with the family, agree which medicines to reduce or stop, how (some must be reduced gradually), what to monitor and when to review. It is guided by the person's goals: staying independent, avoiding hospital, comfort, and what matters most. It is not the family stopping tablets they think are unnecessary, nor a doctor withdrawing care. It does not mean giving up on treatment.

Typical candidates a clinician may consider (without naming any): - Medicines started for a short time and never reviewed. - Medicines with no clear ongoing benefit. - Duplicates. - Medicines whose risks, such as falls, confusion or low sugar, outweigh benefits in a frail person. - Medicines intended for prevention in someone with limited life expectancy, where time to benefit exceeds the likely time left, while recognising that preferences differ. - Doses that may now be too high. - Medicines that cause side effects that are being treated by other medicines.

Principles of safe deprescribing - One change at a time, so that effects can be linked to the change. - Gradual reduction where the medicine needs tapering. - Monitoring blood pressure, sugar, symptoms and weight, as advised; see how to measure blood pressure at home accurately. - A plan for returning if symptoms come back. - Shared decision-making, respecting the person's wishes. - Communication with all other doctors and the pharmacist. - A written plan, and updated list.

What never to do

• Do not stop, skip, halve or change any prescribed medicine on your own, even if you read that it is unnecessary or if your parent "feels fine". Stopping some medicines suddenly, such as those for the heart, blood pressure, blood thinning, diabetes, epilepsy, Parkinson's disease, thyroid, depression or steroid-type medicines, can be dangerous.
• Do not add supplements, herbs or over-the-counter products without checking.
• Do not give someone else's medicines.
• Do not crush or split tablets unless the pharmacist says it is safe; some are slow-release or coated.
• Do not ignore problems: if you think a medicine is causing harm, call the doctor or pharmacist the same day and bring the list.

Supporting your parent through a review

Your parent may feel fearful that medicines are being taken away, or proud of their tablet box. Explain that the aim is to make them feel better and safer, not to withdraw care. Involve them in decisions; ask what troubles them most; respect cultural views on medicines and traditional treatments; and give time. See preparing for a doctor's visit with a parent and living with several conditions at once: building one plan.

Monitoring at home

• Record blood pressure, pulse, blood sugar and weight as the doctor advises; see how often should an older adult check vitals at home?.
• Keep a symptom and falls diary: dizziness, sleep, appetite, bowel, mood, confusion.
• Note any new symptom after a change and report it.
• Check that the pill organiser and list match the new plan.

Red flags

Call 112 or go to hospital at once for chest pain, severe breathlessness, fainting, signs of stroke, severe allergic reaction (swelling of face or throat, hives, wheeze), uncontrolled bleeding, black or bloody stools, seizures, severe confusion, or very low blood sugar with drowsiness. Call the doctor the same day for new confusion, falls, marked drowsiness, new rash, swelling, persistent vomiting or diarrhoea, or any suspected medicine reaction.

When to ask a professional

Ask the family doctor, geriatrician or clinical pharmacist for a full medicine review, preferably yearly. Ask the pharmacist to check interactions, timing and packaging. Ask specialists to coordinate. Seek help promptly for side effects. See comprehensive geriatric assessment explained.