Summary: Polypharmacy

George is 78. Every morning he opens a pill organizer the size of a paperback novel. Fourteen pills. Three prescribers. None of them has seen the complete list.

Over 90% of adults over 65 take at least one prescription medication. More than a third take five or more. Close to half of those over 80 are on five or more simultaneously. Each prescription was probably reasonable when written. Together, they constitute a system no single clinician designed or fully understands.

Medications accumulate through the prescribing cascade. A blood pressure drug causes swelling. A diuretic is added. The diuretic depletes potassium. A supplement is prescribed. The supplement irritates the stomach. A proton pump inhibitor follows. Each step makes clinical sense alone. In sequence, it is a chain reaction no one intended. Hospitalization accelerates the process: new drugs started during admission are frequently continued at discharge without a clear plan for stopping. Specialist fragmentation compounds it further: each doctor manages their domain while the interaction effects between domains go unreviewed.

The body at 78 does not process medications the way it did at 50. Kidney function declines, liver metabolism changes, body composition shifts. A dose appropriate at 60 may be excessive at 75. Sedating medications increase fall risk. Anticholinergic drugs carry cumulative burdens of confusion, constipation, and cognitive decline. Proton pump inhibitors reduce absorption of calcium, magnesium, and B12 when used long-term. Each additional medication increases adverse event risk not linearly but on a curve: by ten concurrent prescriptions, clinically meaningful interactions are near-certain.

Deprescribing, the supervised reduction of medications whose risks outweigh benefits, is supported by evidence and underused in practice. Physicians are trained in prescribing, not stopping. The 15-minute visit leaves no room for reviewing fourteen medications. Patients resist, having been told each pill is essential. The psychology is lopsided: starting feels like doing something, stopping feels like giving up.

Ask your doctor or pharmacist for a comprehensive medication review. Bring every bottle, including supplements and over-the-counter drugs. Ask about each one: is this still necessary, at this dose, for this body?