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Clinical Considerations: Older Adults Taking Multiple Medications

1.5 Contact Hours including 1.5 Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Saturday, January 23, 2027

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will have more awareness and knowledge about the prevalence of older adults taking multiple medications.

Objectives

At the completion of this course, the participant will be able to:

  1. Identify the prevalence of older adults taking multiple medications.
  2. Describe individual and societal costs of older adults taking multiple medications.
  3. Explain the process of assessment of medication use in older adults.
  4. Outline a process for evaluating multiple medications for older adults.
  5. Summarize adverse events, such as falls and delirium, that older adults taking multiple medications may experience.
  6. Consider pharmacological management of multiple health conditions that older adults experience.
  7. Apply principles associated with managing multiple medications to a clinical case.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Clinical Considerations: Older Adults Taking Multiple Medications
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Author:    Lisa Onega (PhD, RN, MBA, FNP-BC, PMHNP-BC, GNP-BC, CNS-BC)

Introduction

The purpose of this course is to provide information that may enable clinicians to decrease risks associated with older adults taking multiple medications. Many older adults take multiple medications and are at risk of developing an adverse drug reaction. Adverse drug reactions can be serious, costly, and result in decreased quality of life and increased depression, falls, frailty, morbidity, mortality, and hospital admission rates. Assessment and evaluation of multiple medications that older adults take is necessary to identify potentially inappropriate medications and make a thoughtful determination about whether to continue, lower the dose or frequency, or discontinue the medication. Assessment involves gathering and organizing pertinent medication-related information for older adults and identifying potentially inappropriate medications. Evaluation involves using a systematic process to decide whether to continue, adjust, or discontinue potentially inappropriate medications. Adverse medication events may occur, including falls and delirium. Ultimately, making pharmacological decisions that optimize the health of older adults with multiple medical problems requires thoughtful consideration, knowledge regarding drug effects and interactions, and individualized treatment plans.

photo of patient sorting lots of medication

Scope and Significance

Prevalence of Older Adults Taking Multiple Medications

Approximately 31% of older adults take five to nine medications (polypharmacy), 10% to 20% take ten or more medications (excess polypharmacy) (Fernández et al., 2021), 17% take potentially inappropriate medications (Al-Busaidi et al., 2020), and 50% living in long-term care facilities take one or more unnecessary or harmful medications (Birt et al., 2022). Polypharmacy, excess polypharmacy, polymedication, and potentially inappropriate medication use increase adverse health outcomes and healthcare costs for individuals and society (Aljeaidi et al., 2022; Fernández et al., 2021). Please see Table 1 for terms associated with multiple medications in older adults.

Table 1: Terms Related to Multiple Medications in Older Adults
Polypharmacy5-9 medications.
Excess polypharmacyTen or more medications.
PolymedicationMore risks than benefits of a medication for a particular older adult.
Potentially inappropriate medicationMedication, by itself or in combination with another medication, that should be avoided because the risks outweigh the benefits.
(Fernández et al., 2021)

The risk of an adverse drug reaction is 13% for older adults taking two medications, 38% for those taking four medications, and 82% for those taking seven or more medications (Al-Busaidi et al., 2020; Nwadiugwu, 2020). Adverse health outcomes include decreased quality of life and increased depression, falls, frailty, morbidity, mortality, and hospital admission rates (Al-Busaidi et al., 2020; Aljeaidi et al., 2022; Fernández et al., 2021).

Individual and Societal Costs of Older Adults Taking Multiple Medications

The individual and societal costs of older adults taking multiple medications are significant. Pooled data from over 30 countries found that approximately 10% of hospitalizations occur as a result of harmful adverse medication events, and during hospitalization, 20% of hospitalized individuals experience a harmful adverse medication event (World Health Organization [WHO], 2024). The World Health Organization estimates the cost of inappropriate polypharmacy management is $18 billion annually (WHO, 2019). Please see Note 1, which highlights cost-related medication findings from research studies conducted in Canada, Estonia, Finland, Iran, and Sweden.

Note 1: Cost-related Medication Findings from Research in Canada, Estonia, Finland, Iran, and Sweden
  • In Canada, the societal cost of inappropriate opioid prescriptions is approximately $6 billion annually. A study of healthcare costs in Canada found an average increased cost of almost $3,000 per person for inappropriate medication use involving opioids in older adults compared to older adults with no opioid use (D'Aiuto et al., 2023).
  • A study in Estonia found that reviewing and optimizing the medication profile of older adults living in nursing homes, on average, decreased each resident's medication cost by $47 per year. If optimization of the medication profile occurred for all nursing home residents 75 years of age and older, Estonia would experience a 2% reduction in its pharmaceutical budget (Jänese et al., 2024).
  • A 12-year study in Finland found that potentially inappropriate medication use in older adults was associated with an increased risk of fractures and death as well as a 15% increase in hospital costs (Hyttinen et al., 2019).
  • A study from Iran examined 9,381 households and found the annual mean out-of-pocket medication cost per household with at least one family member 65 years of age or older was $8,065 per year. When adverse effects from a medication occurred, out-of-pocket costs increased significantly (Faraji et al., 2024).
  • A study of 813 older adults in Sweden found that healthcare costs for three months doubled ($2,290 per person) for those with potentially inappropriate prescriptions. Individuals who were taking potentially inappropriate medications had ten times as many adverse drug reactions as those who were not taking potentially inappropriate medications. Those with adverse drug reactions caused by potentially inappropriate medication prescriptions represented 8% of the study but used 25% of total costs ($5,435 per person) (Robinson et al., 2022).

Assessment and Evaluation of Multiple Medications in Older Adults

Assessment and evaluation of multiple medications that older adults take is necessary to identify potentially inappropriate medications and make a thoughtful determination about whether to continue, lower the dose or frequency, or discontinue medications. Assessment involves gathering and organizing pertinent medication-related information for the older adult and identifying potentially inappropriate medications using explicit and implicit strategies. Evaluation involves using a systematic process to decide whether to continue, adjust, or discontinue potentially inappropriate medications. Evaluation is best done in the context of an interprofessional team; however, it can be done by an individual clinician.

Assessment of Medication Use in Older Adults

Clinicians need to accurately and systematically assess medication use in older adults. The first step in assessment is to obtain a complete list of the medications an older adult is taking, including over-the-counter, alternative, and complementary medications. Then, medications on the list should be organized in a way that will facilitate wise clinical decision-making. Depending on clinicians' preference, medication lists may be organized by body system, disease processes, or alphabetically. Next, clinicians need to evaluate the appropriateness of each medication as well as its dose and frequency.

Strategies to assess the appropriateness of medications in older adults are categorized as explicit or implicit. Explicit approaches involve checking each medication the older adult is taking to see if it is on a predesigned list of medications to avoid, and implicit approaches involve the use of clinical judgment and analysis of clinical information (Fernández et al., 2021; Zidan & Awaisu, 2024). Many clinicians begin a medication assessment by using an explicit list, such as the Beers Criteria, the Screening Tool of Older Person's Prescriptions (STOPP), and the Screening Tool to Alert to Right Treatment (START) (Please see Table 2.)  Once potentially inappropriate medications are identified, clinicians often use an implicit approach to determine the appropriateness of medications. Implicit strategies employ a clinical or structured medication review, which is a structured process for analyzing older adults' medications in the context of their health conditions, diagnoses, preferences, goals, and health complaints (Silcock et al., 2023; Verdoorn et al., 2021).

Table 2: Examples of Explicit Medication Lists
The Beers list of medications to be avoided was developed in 1991 and has been periodically updated by the American Geriatric Society (Al-Busaidi et al., 2020; By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel, 2023; Fernández et al., 2021).
The Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) are guidelines organized by physiological systems (Silcock et al., 2023; Verdoorn et al., 2021).

When conducting evaluations, clinicians should consider that inappropriate prescribing involves failing to prescribe preferred medications based on best practice (medication selection) and prescribing appropriate medications at a higher dose, frequency, and duration than is clinically indicated (Al-Busaidi et al., 2020). Implicit and explicit strategies to evaluate the appropriateness of medications have not been widely implemented in clinical practice because of provider time constraints and lack of reimbursement (McCarthy et al., 2022). Interprofessional medication reviews that include a pharmacist, physician, advanced practice registered nurse, physician assistant, and nurse are preferable to one clinician reviewing the older adults' medications for appropriateness; this is because consideration of various disciplinary perspectives tends to result in wiser decision-making than when reviews are conducted by one team member. Factors that facilitate interprofessional medication reviews include an organizational culture characterized by respectful and open communication, consistency and continuity in implementation and collaboration, dedicated time, financial compensation, and leadership and organizational support (Coenen et al., 2024).

Evaluating Multiple Medications

After assessment, which includes gathering and organizing pertinent medication-related information and explicit and/or implicit review, has been completed, evaluation begins. Evaluation involves using a systematic process to decide whether to continue, adjust, or deprescribe (discontinue) potentially inappropriate medications (Silcock et al., 2023). Deprescribing can be reactive or proactive. Reactive deprescribing is when a medication is discontinued after an older adult experiences an adverse effect, whereas proactive deprescribing is when a medication is discontinued prior to the occurrence of an adverse effect (Birt et al., 2022). Deprescribing is a systematic process of discontinuing potentially inappropriate medications to improve health outcomes and reduce adverse reactions (Birt et al., 2022; Lau et al., 2023). Ideally, deprescribing should occur in the context of an interdisciplinary team that views the older adult holistically (Birt et al., 2022). The steps of the evaluation process are (Silcock et al., 2023):

  1. Communicate with and engage older adults throughout the process.
  2. Establish shared patient-provider goals.
  3. Ask older adults what they believe the purpose, benefits, risks, and potential adverse effects are of each medication they are taking.
  4. Clinicians should share their perspectives about the purpose, benefits, risks, and potential adverse effects of each medication the older adult is taking.
  5. When different perspectives about the merit of a medication occur, clinicians may choose to share evidence-based information with older adults.
  6. Alternative pharmacological and nonpharmacological treatment options should be discussed.
  7. In conjunction with older adults, clinicians should make decisions about whether medications will be continued, adjusted, or discontinued.
  8. If several medications will be discontinued, prioritization of which medication should be discontinued first should be jointly made.
  9. If several medications will be discontinued, the clinician should explain whether or not tapering is indicated.
  10. At routine intervals, clinicians should check in and evaluate the effectiveness of medications, whether adverse effects are present, and, if applicable, how the discontinuation is going.

While evaluation of multiple medications in older adults should be a routine part of care, often, due to time and resource constraints, thoughtful decisions are not made regarding medication continuation, adjustment, or discontinuation. To identify feasible ways of including medication evaluation in the care of older adults, innovative models to reduce the adverse effects of multiple medications are being implemented in practice and analyzed. Two such innovative evaluation models are:

  1. Electronic clinical decision support systems, such as the Systematic Tool to Reduce Inappropriate Prescribing Assistant, to aid clinicians in systematically determining the appropriateness of medications in older adults (Jungo et al., 2024) (Please see Note 2).
  2. Pharmacists serving as knowledge brokers in long-term care facilities to implement guidelines and evidence-based practice to reduce inappropriate psychiatric medication use (Bell et al., 2024) (Please see Note 3).
Note 2: Research Examining Implementation of an Electronic Decision-Support System
A study of 21 primary care providers implementing an electronic decision support system to evaluate the appropriateness of medications in 160 older adults showed on average, clinicians spent a total of 28 minutes per older adult conducting a systematic medication review. The review time included 13 minutes of entering data in the system, 10 minutes of analyzing findings, and 5 minutes of discussing recommendations with older adults. On average, each review yielded 3.7 recommendations (standard deviation=1.8). Implementation problems included cumbersome and problematic data entry, clinician time required, and electronic recommendations that were not clinically useful (Jungo et al., 2024).
Note 3: Research Examining a Knowledge Broker Model to Reduce Inappropriate Medication Us
In Australia, a knowledge broker model of care is being implemented and evaluated to determine if pharmacists who act as knowledge brokers reduce inappropriate psychiatric medications in long-term care facilities. Knowledge brokers are used to translate clinical guidelines into practice. Outcomes include adherence to guidelines, decreased use of antipsychotics, benzodiazepines, and antidepressants, decreased hospitalizations, falls, injuries, medication errors, and behavioral issues, and improved quality of life and functional ability (Bell et al., 2024).

Adverse Events that May Occur in Older Adults Taking Multiple Medications

While the goal is to prevent adverse events that may occur with older adults taking multiple medications, adverse effects may occur for a variety of reasons. Therefore, clinicians should educate individuals about the purpose, risks, benefits, and potential adverse effects of each medication being taken. A qualitative study of 15 older adults with chronic health problems was conducted in China and identified a broad lack of knowledge regarding the purpose of medications, potential adverse effects, and cues to identify if an adverse effect may be occurring. Participants stated they would benefit from more information about their medications and better communication with healthcare providers (Wang et al., 2023). Two types of adverse effects that commonly occur in older adults taking multiple medications are falls and delirium.

Falls

Annually, 33% of older adults have at least one fall, and 20% of those falls result in injury. Approximately 40% of falls in older adults are preventable. A study of 6,220 hospitalized individuals found that persons taking ten or more medications were ten times as likely to have their admitting diagnosis be a fall as compared to individuals taking no medications. Whenever possible, fall risk-increasing medications that may cause dizziness, imbalance, mobility issues, and reduced attention should be discontinued (Zaninotto et al., 2020). A case-control study of 1,028 older adults found that falls by frail older adults were increased by the use of five or more medications and by urinary incontinence (Enes et al., 2023).

Delirium

Polypharmacy is associated with delirium (Han et al., 2019; Kurisu et al., 2020). A retrospective cohort study of 113 hospital patients identified an association between taking six or more medications and the persistence of and increase in delirium (Kurisu et al., 2020). A study of 158 emergency department patients found that supratherapeutic psychotropic medications, such as alprazolam, lorazepam, and sertraline, were associated with longer duration of delirium in patients in the emergency department (Han et al., 2019).

Pharmacological Management of Multiple Health Conditions

The issue of multiple medications in older adults is complex in that pharmacological intervention is often necessary to effectively manage multiple health conditions older adults experience; however, the more medications individuals take, the more likely they are to experience adverse effects from those medications (Aljeaidi et al., 2022; Zaninotto et al., 2020). Regardless of treatment, the more health issues older adults have, the greater their risk of increased morbidity and mortality. Prescribing no medications when they are indicated or prescribing inappropriate medications leads to worse health outcomes than adherence to best practices in the pharmacological management of health issues that older adults experience. Ultimately, making pharmacological decisions that optimize the health of older adults with multiple medical problems requires thoughtful consideration, knowledge regarding drug effects and interactions, and individualized treatment plans (Nwadiugwu, 2020).

The primary principle of pharmacological management of multiple health conditions in older adults is a periodic evaluation of the risks and benefits of each medication in the context of the older adult's life. While avoidance of preventable adverse medication reactions is necessary, the most important goal of pharmacological management should be improving the health, quality of life, and functional ability of older adults (Nwadiugwu, 2020; Silcock et al., 2023).

Case Study

Patient

72-year-old male taking oxycodone 20 milligrams (mg) four times a day and alprazolam 1 mg three times a day.

The Case

Mr. Jones is a 72-year-old male who was previously seeing another provider at a large outpatient clinic; however, that clinician is no longer at the practice. He has chronic pain, diabetes, hypertension, irregular heartbeat, and nerve damage. Mr. Jones is taking 16 prescription medications, including oxycodone 20 mg four times per day for pain, which he receives from a pain management practice elsewhere, and alprazolam 1 mg three times daily for anxiety, which his previous provider at this practice prescribed. He states he has taken oxycodone and alprazolam for many years.

Mr. Jones' prescription monitoring program report shows: 1. an unintentional overdose risk score identified him as being at significant risk of overdose, 2. he has had three prescribers and used five pharmacies in the past two years, and 3. he has received 57 controlled substance prescriptions in the last two years. He states he previously used crack cocaine and occasionally drinks a glass of wine.

Mr. Jones says he is in a difficult position because his previous provider wrote him a 30-day prescription for alprazolam with no discussion about tapering, no care coordination prior to leaving the practice, and no plan in place to prevent withdrawal symptoms. As a result, he now finds himself taking alprazolam 3 mg daily without a plan to taper off of this medication safely. During the appointment, he vacillated between being tearful and threatening. He demanded that this provider take over prescribing alprazolam.

Next Steps

Documentation from the previous provider was available in the electronic medical record (EMR), and the prescription monitoring program report was available. Records from the pain management provider and other providers the patient was seeing were not available; however, he verified that he was taking no other medications aside from the 16 listed in the EMR. The EMR showed that Mr. Jones was taking three medications for blood pressure, two medications for diabetes, two medications for gastrointestinal issues, six medications for mental health, one medication for pain, and two medications for relaxation.

While several medication adjustments or discontinuations needed to be considered in the future, the priority was the safe discontinuation of alprazolam with an alternate plan to assist him in dealing with his anxiety. The provider and older adult reviewed recommendation #11 of the Centers for Disease Control and Prevention (CDC) clinical practice guidelines for prescribing opioids for pain, which says, when possible, opioids and benzodiazepines should not be used together (Dowell et al., 2022). A 12-week tapering plan of 0.25 mg/week was implemented.

Mr. Jones was informed about the risk of withdrawal associated with the taper and given instructions about the physiological and psychological symptoms of withdrawal that could occur. He was instructed to seek emergency help if he developed significant physiological withdrawal symptoms. The nurse contacted him weekly throughout the taper, and he began counseling to learn healthy coping strategies and relaxation techniques. As alprazolam is a difficult medication to taper, instead of 12 weeks, the taper took 24 weeks. Although other medication changes needed to be considered, they were not addressed until Mr. Jones safely discontinued alprazolam.

While best practice would have involved his previous provider discussing a benzodiazepine taper with him, that provider coordinating care with the new provider and development of a patient-provider relationship prior to initiating a benzodiazepine taper, circumstances are often not ideal in clinical practice. Therefore, adaptability, adherence to best practices, good communication, and focusing on optimizing the older adult's health are priorities.

Conclusion

Older adults are often on multiple medications. It is imperative that healthcare providers take the time to review the patient's medical record, diagnosis, and current medication list to assess and evaluate if any medications inappropriately being prescribed can be discontinued safely. Ultimately, effectively treating the patient's health conditions and avoiding adverse events due to polypharmacy are crucial.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

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