The classic definition is: Polypharmacy is the simultaneous, long-term use of five or more prescribed medications. The German Society of Internal Medicine defines severe polypharmacy as the use of ten or more medications.
However, the sheer number 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—in accordance with guidelines and to prolong life. An 85-year-old female patient with dementia, frailty, and malnutrition may be overtreated with the same eight medications because the side effects now outweigh the benefits.
That is the crucial point: It is not the number that matters, but the individual fit. And this fit must be reassessed at regular intervals—because the body, the diseases, and the treatment goals change with age.
- In Germany, among those over 65: More than 40 percent take five or more medications on a long-term basis.
- Germans over 80: The rate rises to as high as 60 percent.
- Nursing home residents: An average of 8.5 long-term medications per person.
- Severe polypharmacy (>10 medications): About one in five patients over 75 receiving inpatient geriatric care.
The same pattern is evident across Europe: The SHARE study (Survey of Health, Ageing, and Retirement in Europe) documents a steady increase in the number of prescriptions across all age groups. Polypharmacy is therefore not an isolated problem, but a structural feature of modern geriatric medicine.
In geriatrics, we call it the “prescribing cascade.” The mechanism is alarmingly predictable:
- Step 1: The patient is prescribed medication A for condition X.
- Step 2: Drug A causes side effect Y (e.g., edema caused by calcium channel blockers).
- Step 3: Side effect Y is diagnosed as a new condition.
- Step 4: Drug B is prescribed to treat Y (e.g., a diuretic).
- Step 5: Drug B causes side effect Z (e.g., hyponatremia).
- Step 6: Drug C is prescribed to treat Z. And so on.
Each individual step follows the logic of “we have to do something.” The end result is a patient on twelve medications, whose original underlying condition has long since disappeared behind a fog of drugs.
The fundamental diagnostic question in geriatrics is: Is the new symptom a new disease—or a side effect of an existing medication? This question is asked far too rarely.
The clinical consequences have been sufficiently documented in large studies. Each additional medication increases the risk of:
- Falls: by about 7 percent with each additional medication. With ten medications, the risk of falling is nearly doubled compared to taking a single medication.
- Delirium: particularly due to benzodiazepines, anticholinergics, and opioids. Polypharmacy is the strongest predictor of delirium, alongside pre-existing dementia.
- Cognitive decline: caused by the accumulation of anticholinergic effects (e.g., amitriptyline, oxybutynin, older antihistamines). See also: Mild cognitive impairment (MCI).
- Hospital admissions: Up to 30 percent of all unplanned hospitalizations among older adults are medication-related, about half of which are preventable.
- Mortality: Severe polypharmacy is associated with a doubling of 1-year mortality in cohort studies—regardless of underlying medical conditions.
- Reduced adherence: Anyone who has to take fifteen pills a day is bound to forget. And when they forget, they often fail to take the most critical ones.
→ To learn how medications specifically cause falls—and which drugs are particularly risky—read the article “Falls in Older Adults.”
→ On the role of polypharmacy in acute confusion: “Delirium Prevention in Older Adults.”
Geriatrics has two tools developed specifically for Germany that allow for a structured assessment of medications in older adults:
The PRISCUS List
The PRISCUS list (updated as PRISCUS 2.0 in the *Deutsches Ärzteblatt* in 2023) is a negative list: It identifies active ingredients considered potentially inappropriate (PIM, Potentially Inappropriate Medication) for older adults. Specifically affected are, among others:
- Benzodiazepines with a long half-life (diazepam, flurazepam)
- Z-drugs as long-term medication (zolpidem, zopiclone)
- Tricyclic antidepressants (amitriptyline, doxepin)
- Strongly anticholinergic agents (oxybutynin, older antihistamines)
- Certain neuroleptics used for dementia (haloperidol at higher doses)
- NSAIDs in patients with impaired renal function
If a medication on the list is part of the patient’s regimen, this does not automatically mean “discontinue.” It means “review.” There are cases in which a PRISCUS medication is appropriate—when the alternatives are worse or the patient’s condition is stable.
The FORTA Classification
FORTA stands for Fit fOR The Aged. It classifies medications into four categories:
- A: Clear benefit, even in older patients.
- B: Proven benefit, but with limitations.
- C: Questionable suitability; critical review required.
- D: Generally to be avoided in older adults.
The advantage of FORTA over purely negative lists is that it also evaluates what should be prescribed—not just what should be omitted. This is important because underprescribing (the lack of medications that are actually beneficial) is just as much of a problem as overprescribing.
→ For the practical application of the deprescribing process, see: Reducing Medications—Deprescribing in Older Adults.
To illustrate what a structured geriatric medication review can achieve, I will describe a real-life case from my work at the Main-Kinzig Clinics in Schlüchtern.
An 81-year-old female patient was admitted from her home. Reason for admission: repeated falls, increasing confusion, and a decline in mobility over the course of a few weeks. Her initial medication regimen consisted of 19 drugs:
- 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)
- A benzodiazepine as a sleep aid (for 8 years)
- An SSRI for depression (for 3 years)
- An opioid patch for back pain
- An NSAID as needed
- A stomach protector to counteract the NSAID
- Four dietary supplements (vitamin D, magnesium, B-complex, herbal)
- Two additional herbal preparations
Each individual medication was historically justifiable. Taken together, they produced a combination of hypotension, electrolyte imbalance, anticholinergic accumulation, sleep-wake cycle disturbance, and pharmacogenic delirium. The falls were not the disease, but the symptom.
The Process
Over the course of three weeks, we systematically carried out the following: a comprehensive geriatric assessment including the Barthel Index, Tinetti Scale, MMSE, GDS, and MNA; a medication review according to PRISCUS 2.0 and FORTA; comparison with current guidelines; and, for each substance, the question: Is the indication still valid? Is the dose age-appropriate? Is an alternative more appropriate? Is discontinuation possible?
In the end, six medications remained—an ACE inhibitor, a low-dose beta-blocker, diabetes medication readjusted, vitamin D for a confirmed deficiency, pain management switched to a more appropriate regimen, and gastric protection maintained for a limited time. The patient went home walking upright, lucid, and without a cane.
This is not an exception. In our geriatric department, we reduce the number of medications by an average of 30 to 50 percent—almost always without compromising health, and very often with significant improvements 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 stop everything at once: Always stop one medication at a time, with a monitoring period between steps.
- Taper off gradually, do not stop abruptly: This applies to benzodiazepines, SSRIs, opioids, beta-blockers, corticosteroids, and several other classes of medications. Abrupt discontinuation can be more dangerous than continuing the medication.
- Define target symptoms: What changes are expected as a result of discontinuation? And what would justify resuming the medication?
- Involve family members: Many older patients are overwhelmed by the plan without support.
- Document and provide a copy: Every medication change should be documented in writing and given to the patient, their family members, and the primary care physician.
The most important request to family members: Never stop medications on your own. Even if you’re convinced that one of the medications is doing more harm than good—the proper course of action always involves consulting a doctor. Many dangerous withdrawal symptoms aren’t caused by the wrong medication, but by stopping it the wrong way.
→ Detailed instructions for a structured medication review and deprescribing algorithm: Reducing Medications.
Not every patient on multiple medications needs geriatric care. However, the following situations are clear indications:
- Five or more long-term medications and new-onset falls, dizziness, or confusion
- Severe polypharmacy (ten or more medications) without an annual medication review
- A medication on the PRISCUS list as part of long-term therapy
- A hospital stay during which new medications were prescribed that the primary care physician has not explicitly adopted
- Increasing fatigue, apathy, or memory impairment of unknown cause—if necessary, have the patient evaluated for dementia or depression
- Prior to planned surgeries in patients over 75 with polypharmacy—relevant to surgical risk in older adults
The most common mistake is the unspoken consensus among all involved that “everything has already been reviewed.” Often, the last structured review took place years ago. A geriatrician brings a holistic perspective—working together with the primary care physician, not against them.
→ Learn how a structured geriatric assessment is conducted here: Geriatric Assessment.
