The classic definition is: polypharmacy is the simultaneous, permanent intake of five or more prescribed medications. The German Society for Internal Medicine speaks of severe polypharmacy from ten preparations onwards.
The mere number, however, is only a rough measure. What is clinically relevant is the question of appropriateness. A 78-year-old patient with heart failure, diabetes and hypertension may need eight medications — guideline-compliant and life-prolonging. An 85-year-old patient with dementia, frailty and malnutrition may well be overtreated with the same eight medications, because the side effects now outweigh the benefit.
That is the decisive point: it is not the number that decides, but the individual fit. And this fit must be re-examined at regular intervals — because the body, the illnesses and the treatment goals change in old age.
- Germany over 65: More than 40 percent permanently take five or more medications.
- Germany over 80: The rate rises to up to 60 percent.
- Nursing home residents: On average 8.5 long-term medications per person.
- Severe polypharmacy (>10 preparations): About one in five patients over 75 in inpatient geriatric treatment.
Across Europe the same picture emerges: the SHARE study (Survey of Health, Aging and Retirement in Europe) documents a continuous increase in prescription figures across all age groups. Polypharmacy is thus not an isolated-case problem but a structural feature of modern medicine for the elderly.
In geriatrics we call it the “prescribing cascade”. The mechanism is frighteningly predictable:
- Step 1: Patient receives medication A for illness X.
- Step 2: Medication A causes side effect Y (e.g. edema from calcium channel blockers).
- Step 3: Side effect Y is diagnosed as a new illness.
- Step 4: Medication B is prescribed against Y (e.g. a diuretic).
- Step 5: Medication B causes side effect Z (e.g. hyponatraemia).
- Step 6: Medication C is prescribed against Z. And so on.
Every single step follows the logic of “we must do something after all”. The overall result is a patient on twelve preparations in whom the original underlying illness has long since disappeared behind the medication fog.
The diagnostic core question in geriatrics is: Is the new symptom a new illness — or a side effect of an existing medication? This question is asked far too rarely.
The clinical consequences are sufficiently documented in large studies. Each additional medication increases the risk of:
- Falls: by about 7 percent with each additional preparation. With ten medications the fall risk is almost doubled compared with a single preparation.
- Delirium: particularly through benzodiazepines, anticholinergics, opioids. Alongside pre-existing dementia, polymedication is the strongest delirium predictor.
- Cognitive deterioration: through anticholinergic accumulation (e.g. amitriptyline, oxybutynin, older antihistamines). See also: Mild cognitive impairment (MCI).
- Hospital admissions: up to 30 percent of all unplanned admissions of older people are medication-associated, of which about half are avoidable.
- Mortality: in cohort studies severe polypharmacy is associated with a doubling of 1-year mortality — independent of underlying illnesses.
- Reduced adherence: anyone supposed to swallow fifteen tablets a day forgets. And whoever forgets often fails to take the crucial one.
→ How medications concretely trigger falls — and which preparations are particularly risky — you can read in the article Falls in old age.
→ On the role of polypharmacy in acute confusional states: Delirium prevention in older people.
Geriatrics has two instruments developed specifically for Germany with which medications in old age can be evaluated in a structured way:
The PRISCUS list
The PRISCUS list (updated as PRISCUS 2.0 in the Deutsches Ärzteblatt 2023) is a negative list: it names active substances that are considered potentially inappropriate (PIM, Potentially Inappropriate Medication) in older people. Concretely affected are, among others:
- Benzodiazepines with a long half-life (diazepam, flurazepam)
- Z-substances as long-term medication (zolpidem, zopiclone)
- Tricyclic antidepressants (amitriptyline, doxepin)
- Strongly anticholinergic substances (oxybutynin, older antihistamines)
- Certain neuroleptics in dementia (haloperidol at higher dose)
- NSAIDs with impaired kidney function
If a preparation on the list is found in the medication, that does not automatically mean “discontinue”. It means “review”. There are cases in which a PRISCUS medication is right — when the alternatives are worse or the regimen is running stably.
The FORTA classification
FORTA stands for Fit fOR The Aged. It classifies medications into four categories:
- A: Clear benefit even in older patients.
- B: Benefit proven, but with limitations.
- C: Questionable suitability, critical review required.
- D: As a rule to be avoided in older people.
The advantage of FORTA over pure negative lists: it also assesses what should be prescribed — not only what must be omitted. This is important, because undersupply (the absence of actually useful medications) is just as much a problem as oversupply.
→ For the practical application of the deprescribing process see: Reducing medications — deprescribing in old age.
To make tangible what a structured geriatric medication review can achieve, I describe a real case from my work at the Main-Kinzig-Kliniken Schlüchtern.
An 81-year-old patient was admitted from a home setting. Reason for admission: repeated falls, increasing confusion, deterioration of mobility within a few weeks. The admission medication comprised 19 preparations:
- Three antihypertensives (ACE inhibitor, beta-blocker, calcium channel blocker)
- Two diuretics (torasemide, spironolactone)
- One oral antidiabetic plus insulin
- One statin
- One proton pump inhibitor (for 12 years)
- One benzodiazepine as a sleeping aid (for 8 years)
- One SSRI for depressive mood (for 3 years)
- One opioid patch for back pain
- One NSAID as needed
- One gastric protectant against the NSAID
- Four food supplements (vitamin D, magnesium, B-complex, herbal)
- Two further herbal preparations
Every single medication was historically justifiable. In sum they produced a combination of hypotension, electrolyte disturbance, anticholinergic accumulation, sleep-wake rhythm disturbance and drug-induced delirium. The falls were not the illness but the symptom.
The process
Over three weeks we systematically carried out: a comprehensive geriatric assessment including Barthel, Tinetti, MMSE, GDS, MNA; a medication review according to PRISCUS 2.0 and FORTA; a comparison with current guidelines; and for each substance the question: Is the indication current? Is the dose age-appropriate? Is an alternative more sensible? Is discontinuation possible?
In the end six medications remained — ACE inhibitor, low-dose beta-blocker, diabetes medication newly adjusted, vitamin D in confirmed deficiency, pain therapy switched to a more appropriate scheme, gastric protectant retained for a limited time. The patient went home upright, clear-headed and without a walking stick.
This is no exception. In our geriatric department we reduce the number of medications by 30 to 50 percent on average — almost always without the state of health suffering, very often with a marked improvement in mobility, cognition and quality of life. In addition, many patients subsequently benefit from early geriatric rehabilitation.
Deprescribing is the structured, medically supervised process of reducing or discontinuing a medication. It follows clear rules:
- Never everything at once: Always only one medication after the other, with an observation period between the steps.
- Taper, do not stop abruptly: This applies to benzodiazepines, SSRIs, opioids, beta-blockers, corticosteroids and several other groups. Abrupt discontinuation can be more dangerous than continuation.
- Define target symptoms: What should change as a result of the discontinuation? And what would speak in favor of resumption?
- Involve relatives: Many older patients are overwhelmed by the plan without support.
- Document and hand over: Every medication change belongs in writing in the hands of the patient, the relatives and the general practitioner.
The most important plea to relatives: Never discontinue medications on your own. Even if you are convinced that one of the preparations does more harm than good — the path there always leads through the medical consultation. Many dangerous withdrawal symptoms arise not from the wrong medication but from the wrong discontinuation.
→ Detailed guidance on the structured medication review and deprescribing algorithm: Reducing medications.
Not every polymedicated patient needs geriatric co-management. But the following situations are clear occasions:
- Five or more long-term medications and newly occurring falls, dizziness or confusion
- Severe polypharmacy (ten or more preparations) without an annual medication review
- A preparation from the PRISCUS list in long-term therapy
- Hospital stay with new medication that the general practitioner has not explicitly taken over
- Increasing tiredness, apathy or memory disturbance of unclear cause — if necessary have dementia or depression clarified
- Before planned operations in patients over 75 with polymedication — relevant for the surgical risk in old age
The most common error is the silent consensus of all those involved that “everything has already been reviewed”. Often the last structured review was years ago. A geriatrician brings the perspective of an overall view — together with the general practitioner, not against them.
→ How a structured geriatric assessment proceeds you can learn here: Geriatric assessment.
