New dizziness, confusion, falls or worsening kidney function in later life can sometimes be caused or aggravated by medications. The explanation may be a single drug, a recent dose change, or the combined effects of several medications that were each reasonable when first prescribed.
As people grow older and develop more long-term conditions, medication lists often become longer and more complicated. Each prescription may have a clear purpose, yet the overall combination can create risks that are easy to miss when medications are reviewed separately.
This is known as polypharmacy, and it is one of the most clinically significant health risks for people over 60.
What polypharmacy actually means
Polypharmacy is generally defined as taking five or more regular medications at the same time. An English population study found that nearly half of adults aged 65 and over were taking at least this many (Gao et al., 2018).
The number alone does not establish whether a medication list is appropriate. Many people need several medicines to manage conditions such as high blood pressure, diabetes, atrial fibrillation, heart disease or osteoporosis. When each treatment remains beneficial and the overall regimen is safe and manageable, polypharmacy may be entirely appropriate.
The greater concern is problematic polypharmacy, where the combined risks, side effects or practical burden begin to outweigh the benefits. This can happen when medicines interact, when side effects accumulate, when a treatment is continued after its original purpose has changed, or when a person’s health has altered without the medication list being reviewed accordingly.
The problem is that clinical guidelines are almost always written for single conditions and tested on populations that are younger and have fewer comorbidities than the average older adult (National Institute for Health and Care Excellence, 2016).
The prescribing cascade
One of the more easily missed consequences of polypharmacy is the prescribing cascade. This occurs when a side effect from one medicine is mistaken for a new medical problem, leading to another prescription to treat it.
A well-recognised example can begin when a calcium channel blocker used for blood pressure causes ankle swelling. If the swelling is interpreted as fluid retention rather than a medication side effect, a diuretic may be added. The diuretic can then contribute to dehydration, dizziness or changes in salt levels in the blood, creating further symptoms without addressing the original cause. (Savage et al., 2020).
Prescribing cascades are not always inappropriate. Sometimes an additional medicine is the best way to manage an unavoidable side effect from an essential treatment. The important point is that this should be a deliberate clinical decision rather than the result of a side effect going unrecognised.
Some risks come from interactions between medicines, especially when treatments are prescribed by different clinicians or include over-the-counter products. For example, ibuprofen can increase bleeding risk or contribute to kidney injury when combined with certain other medications (Lapi et al., 2013; Specialist Pharmacy Service, 2024). Medication reviews should therefore include over-the-counter products as well as prescribed medicines.
The specific risks that matter most after 60
The consequences of medication-related harm can become more serious with age because balance, kidney function, muscle strength and physiological resilience may already be changing.
Falls are among the most immediate concerns. Medicines that lower blood pressure, sleeping tablets, sedatives, strong painkillers and some antidepressants can contribute to dizziness, reduced alertness or unsteadiness. A combination that was previously tolerated may become problematic following illness, weight loss, reduced mobility or the addition of another drug.
The result can be more than a minor inconvenience. A medication-related fall may lead to a fracture, hospital admission and a prolonged loss of confidence or independence.
Cognitive effects also deserve attention. Some medicines have what doctors call an anticholinergic effect, meaning they block the action of acetylcholine, a chemical messenger involved in memory, attention and several other functions throughout the body. Certain bladder medicines, older sedating antihistamines and some antidepressants can have this effect.
When several of these medicines are taken together, their effects can add up. Clinicians call this anticholinergic burden. A higher burden may contribute to confusion, memory problems, blurred vision, constipation and difficulty passing urine. Research has also found an association between prolonged exposure to strongly anticholinergic medicines and an increased risk of dementia. This does not prove that an individual medicine directly causes dementia, but it supports reviewing the combined burden where several relevant drugs are being taken (Coupland et al., 2019).
Kidney function is another important consideration. Many medicines depend partly or largely on the kidneys for clearance, and doses may need to be reconsidered as kidney function changes. Acute illness and dehydration can also cause medicines that were previously well tolerated to accumulate or produce side effects.
This is particularly relevant if the person has symptoms such as vomiting, diarrhoea, fever or during periods of poor fluid intake. A medication regimen that is safe under ordinary circumstances may require temporary clinical review during illness.
What your medication list should prompt you to ask
People taking several regular medicines should be able to understand what each one is for, how its benefit is being monitored and what side effects require attention.
A useful starting point is to ask: Does every medicine still have a clear and current purpose? Some treatments are intended to be lifelong, while others may have been started for a temporary problem and continued without a clear review.
It is also reasonable to ask: Is any medicine on the list primarily being used to manage a side effect from another treatment? This does not automatically mean that the prescription is inappropriate, but it can help identify possible prescribing cascades.
Changes in health should prompt further questions. Has anything changed that might affect whether these medicines are still appropriate? A dose that was suitable at 58 may need reconsideration at 68 if blood pressure, weight, kidney function, falls risk or the rest of the medication list has changed.
The practical burden matters as well. Is the treatment plan manageable in daily life? A medicine may be effective in theory but difficult to follow if it requires several doses at different times, creates troublesome side effects or conflicts with a person’s priorities. Medication decisions should take account of quality of life as well as disease targets.
Deprescribing is not the same as giving up
Deprescribing is the structured process of reducing or stopping medicines when their risks or burdens have become greater than their likely benefits. It is an active clinical intervention rather than a passive withdrawal of care.
The process requires consideration of which medicines could be reduced, the order in which changes should occur, whether gradual dose reduction is necessary and how the effects will be monitored. Some medicines can cause significant problems if stopped suddenly.
Clinicians may use structured tools such as the STOPP/START criteria to identify potentially inappropriate treatments, important omissions and combinations that warrant closer attention (O’Mahony et al., 2023). Pharmacists also play an increasingly important role in structured medication reviews, particularly for people with complex prescriptions.
A review may be particularly useful after a fall, hospital admission, new confusion, worsening kidney function, a substantial change in weight or health, or the addition of several new medicines. People taking high-risk treatments or managing a particularly long medication list may also benefit from more frequent review.
Making medication reviews count
If you take several regular medicines and have not reviewed them recently, asking your GP practice or pharmacist for a medication review is a sensible starting point. This is particularly worthwhile after a hospital admission, fall, new side effect or significant change in your health.
Before the review, make a complete list of everything you take, including prescribed medicines, over-the-counter treatments, supplements and herbal products. For each medicine, it can be useful to ask what it is for, whether it is still needed, whether the dose remains appropriate, and whether it could be contributing to any symptoms or interacting with something else you take.
The aim of a medication review is not to reduce the number of prescriptions as far as possible. The aim is to ensure that every medicine has a clear purpose, offers a realistic benefit and remains appropriate alongside everything else being taken.
Most medicines on an older person’s repeat prescription are there for sound clinical reasons. Stopping them without medical advice can cause serious harm, particularly with treatments for blood pressure, heart rhythm, epilepsy, mental health conditions or blood clot prevention.
Any changes should therefore be agreed with a GP, pharmacist or relevant prescriber.
A well-conducted review can identify avoidable side effects, unsafe combinations, unnecessary complexity and treatments that no longer reflect a person’s current health or priorities. It can also confirm that a long medication list remains appropriate and should continue unchanged.
Medication lists deserve regular attention because their risks and benefits are not fixed. They change as health, function, priorities and other treatments change. For anyone taking several regular medicines, understanding the combined picture is an important part of protecting health and maintaining independence.
References
Coupland, C.A.C., Hill, T., Dening, T., Morriss, R., Moore, M. and Hippisley-Cox, J. (2019) ‘Anticholinergic drug exposure and the risk of dementia: a nested case-control study’, JAMA Internal Medicine, 179(8), pp. 1084–1093. doi: 10.1001/jamainternmed.2019.0677.
Gao, L., Maidment, I., Matthews, F.E., Robinson, L. and Brayne, C. (2018) ‘Medication usage change in older people aged 65 and over in England over 20 years: findings from CFAS I and CFAS II’, Age and Ageing, 47(2), pp. 220–225. doi: 10.1093/ageing/afx158.
Lapi, F., Azoulay, L., Yin, H., Nessim, S.J. and Suissa, S. (2013) ‘Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study’, BMJ, 346, e8525. doi: 10.1136/bmj.e8525.
National Institute for Health and Care Excellence (2016) Multimorbidity: clinical assessment and management. NICE guideline NG56. Published 21 September 2016. Available at: https://www.nice.org.uk/guidance/ng56 (Accessed: 12 July 2026).
O’Mahony, D., Cherubini, A., Guiteras, A.R. et al. (2023) ‘STOPP/START criteria for potentially inappropriate prescribing in older people: version 3’, European Geriatric Medicine, 14(4), pp. 625–632. doi: 10.1007/s41999-023-00777-y.
Savage, R.D., Visentin, J.D., Bronskill, S.E. et al. (2020) ‘Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension’, JAMA Internal Medicine, 180(5), pp. 643–651. doi: 10.1001/jamainternmed.2019.7087.
Specialist Pharmacy Service (2024) ‘Managing interactions with direct oral anticoagulants’. NHS Specialist Pharmacy Service. Updated 20 June 2025. Accessed 12 July 2026. Available at: https://www.sps.nhs.uk/articles/managing-interactions-with-direct-oral-anticoagulants-doacs/ (Accessed: 12 July 2026).
