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October 11, 2004

Polypharmacy: A New Paradigm for Quality Drug Therapy in the Elderly?

Arch Intern Med. 2004;164(18):1957-1959. doi:10.1001/archinte.164.18.1957

As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral.—Jerry Avorn, MD

There once was a time when polypharmacy was considered to be a bad thing in older patients.1 It is well known that use of larger numbers of drugs is associated with an increased likelihood of inappropriate prescribing2 and adverse drug events.3 Drug-induced symptoms can also produce prescribing cascades that develop when an adverse effect is misinterpreted as a new medical problem, leading to the prescription of additional drugs.4 Yet, the number of medications prescribed to elderly patients and the complexity of their drug regimens have continued to increase over time.5,6 Therapeutic regimens that include the use of 2 or more different medications to treat a single condition are increasingly promoted for the optimal management of conditions that are particularly prevalent in the older patient population, including hypertension,7 heart failure,8 ischemic heart disease,9 diabetes mellitus,10 and Alzheimer disease.11 Promotion of prescription drugs directly to consumers may also factor into the increased levels of medication prescribing to older persons,12 with advertising focusing heavily on conditions such as osteoporosis, osteoarthritis, hyperlipidemia, and dementia. A national survey of the US noninstitutionalized adult population indicated that more than 40% of persons 65 years or older use 5 or more different medications per week, and 12% use 10 or more different medications.13 Levels of medication use are even higher among elderly persons residing in assisted-living and nursing home settings.3,14