Medications for the Elderly: What to Consider When Prescribing

As people age, most people live with multiple chronic conditions and take multiple medications. Research shows that over 90% of people over 65 take at least one prescription medication, and over 66% take three or more, often concurrently with over-the-counter medications and dietary supplements. This combination increases the risk of drug interactions, side effects, falls, and cognitive decline, especially in the context of fragile health and reduced functional reserve. [1]

A special branch of clinical pharmacology that studies drug effects in the elderly is called geriatric pharmacology. In older adults, the absorption, distribution, metabolism, and elimination of drugs, as well as tissue sensitivity to drug effects, change. All this makes elderly patients particularly vulnerable to adverse reactions, even if the medication is well tolerated in younger individuals and prescribed at standard doses. [2]

The goal of drug therapy in geriatrics is not only to treat individual symptoms or "normalize" laboratory parameters, but also to maximally maintain a person's quality of life, independence, and functional activity. To achieve this, it is important to constantly assess the extent to which each drug is truly needed, what goals it should achieve, and whether it interferes with other therapeutic goals, such as preventing falls or maintaining mental clarity. [3]

In practice, key problems include polypharmacy (the simultaneous use of multiple medications), potentially inappropriate prescribing, and poor adherence. Polypharmacy is associated with an increased risk of hospitalization, falls, cognitive decline, and death, especially if medications are selected without consideration of age and comorbidities. Large reviews emphasize that reducing the number of unnecessary medications (deprescribing) often has the same effect on a patient's condition as prescribing new medications. [4]

Special tools have been developed to assess the safety and necessity of medications in older adults: the American Geriatrics Society's Beers criteria and the STOPP and START criteria (Screening Tool of Older Persons Prescriptions and Screening Tool to Alert to Right Treatment). They help identify potentially dangerous medications and missed prescriptions that would be beneficial to the patient. These lists do not replace clinical judgment, but they provide a convenient reference for regularly reviewing treatment regimens. [5]

Table 1. How drug therapy in the elderly differs from treatment in middle-aged people

Peculiarity	In older people	Clinical significance
Number of diseases	Often 3 or more chronic diseases	Complex treatment regimens are required
Number of medications taken	Often 5 or more medications at the same time	Risk of interactions and errors
Organ reserve	Decreased (heart, liver, kidneys, brain)	Toxicity develops more easily
Pharmacokinetics	Delayed elimination, altered distribution	Dose and interval adjustments are needed.
Pharmacodynamics	Hypersensitivity to a number of drug groups	Start with low doses and titrate slowly
Goals of therapy	Focus on quality of life and prevention of complications	Not all "aggressive" schemes are justified

How age changes the pathways of drugs in the body

Pharmacokinetics describes the pathway of a drug from its entry into the body to its elimination. In older adults, each stage of this pathway changes. During absorption in the stomach and intestines, decreased acidity, a decrease in the absorptive surface area, slower peristalsis, and decreased blood flow in the intestinal wall are observed. These changes can slightly reduce the rate and predictability of absorption of some drugs, particularly those for which active transport or an acidic environment are important, although for many drugs absorbed by passive diffusion, the effect of age remains modest. [6]

Drug distribution depends on water volume, muscle mass, adipose tissue, and plasma protein levels. With age, total water and muscle mass decrease, while the proportion of adipose tissue increases. As a result, hydrophilic drugs (which prefer an aqueous environment) are distributed over a smaller volume, their plasma concentration is higher at the same dose, and the risk of toxicity increases. Conversely, lipophilic drugs are more readily absorbed into adipose tissue, are eliminated more slowly, and have a longer duration of action, which increases the risk of accumulation and morning drowsiness, especially for hypnotics and sedatives. [7]

A decrease in serum albumin levels and a simultaneous relative increase in alpha-1 acidic glycoprotein alter the protein binding of many drugs. The bound fraction of the drug is inactive, while the free portion is responsible for its effect and toxicity. When several drugs with high protein affinity are administered simultaneously, one drug may displace the other, increasing the proportion of the free form and enhancing its effect. This is particularly true for anticoagulants, cardiac glycosides, nonsteroidal anti-inflammatory drugs, and some anticonvulsants. [8]

Drug metabolism in the liver also changes with age. Hepatic blood flow and liver parenchyma mass decrease, and cytochrome P450 enzyme activity declines. It has been described that the so-called "first pass" through the liver decreases by approximately 1% per year after age 40, leading to higher concentrations of certain drugs at the same oral dose. Conjugation processes (e.g., glucuronidation) are better preserved, so drugs inactivated primarily by such reactions may be more predictable in old age. [9]

Renal elimination of drugs typically slows. With age, renal blood flow decreases, as does glomerular filtration rate and tubular secretory function, even with normal blood creatinine levels, which masks the decrease in filtration due to decreased muscle mass. Many authors suggest considering elderly patients as individuals with functionally impaired renal function, especially in the presence of diabetes, hypertension, or heart failure. This requires cautious use of drugs dependent on renal elimination and dose recalculation based on creatinine clearance, not solely on the estimated filtration rate. [10]

Table 2. Age-related changes in pharmacokinetics and their consequences

Stage of the drug's journey	Major age-related changes	Possible outcome for treatment
Suction	Slower peristalsis, less blood flow, altered acidity	Slightly later onset of action, variability of effect
Distribution	Less water and muscle, more fat, less albumin	Higher concentration of hydrophilic, accumulation of lipophilic
Protein binding	Decreased albumin, altered alpha-1 acid glycoprotein	More free fraction of a number of drugs
Metabolism	Decreased liver blood flow and enzyme activity	Higher levels of some drugs at the same dose
Withdrawal	Decreased kidney and tubule function	Risk of accumulation and toxicity at standard doses

Pharmacodynamics: Why does the same dose act differently in an elderly person?

Pharmacodynamics describes how a drug affects organs and receptors. In older adults, the number and sensitivity of receptors, as well as compensatory mechanisms, change. For example, a decrease in the number of dopamine receptors in the brain has been proven with age. Therefore, antipsychotic drugs that block dopamine receptors are more likely to cause extrapyramidal symptoms, parkinsonism, slowed movement, and cognitive impairment, even at low doses. [11]

Medications that affect the central nervous system are particularly sensitive to age-related changes. Benzodiazepines, hypnotics, some antidepressants, and combination regimens with multiple psychotropic medications are associated with an increased risk of falls, daytime sleepiness, confusion, and delirium. Prospective studies show that it is the combination of polypharmacy with such medications, and not just the antipsychotics themselves, that significantly increases the risk of falls in older adults in long-term care facilities. [12]

Cardiovascular sensitivity also changes. Elderly patients are more likely to experience a significant drop in blood pressure in response to nitrates, some antiarrhythmic drugs, and antihypertensive medications, especially with sudden dose changes. Orthostatic hypotension (a sudden drop in blood pressure upon standing) leads to dizziness and falls and often remains an underrecognized cause of injury. Conversely, the response to some adrenergic stimulants may be reduced, making drug selection and dosage more challenging. [13]

Paradoxical reactions sometimes occur in the elderly. For example, sedatives can cause agitation and insomnia, while anticonvulsants can increase gait instability and the risk of falls. Increased sensitivity to anticholinergic effects (dry mouth, urinary retention, impaired accommodation, confusion) makes many "common" medications, including some antihistamines, tricyclic antidepressants, and antispasmodics, dangerous when used long-term. [14]

All these changes support the key rule of thumb: "start low and increase slowly." It's recommended to start with approximately half the standard adult dose (and even lower for some groups), then gradually titrate, carefully assessing the effect and side effects. This strategy reduces the risk of a sharp drop in blood pressure, delirium, falls, and other dangerous complications during the first weeks of therapy, when the body is just getting to know the new drug. [15]

Table 3. Drugs with an increased risk of adverse effects in the elderly

Group of drugs	Potential problems in the elderly
Benzodiazepines and hypnotics	Drowsiness, falls, delirium, memory impairment
Antipsychotic drugs	Extrapyramidal symptoms, orthostatic hypotension, stroke in dementia
Strong anticholinergic drugs	Urinary retention, confusion, constipation
Nitrates and some antihypertensives	A sharp drop in pressure, dizziness, falls
Antidepressants and anticonvulsants	Impaired coordination, falls, interactions

Polypharmacy and potentially inappropriate prescribing

Polypharmacy is most often defined as the simultaneous use of five or more medications. For clinical practice, the combination, rather than the number, is more important: how well the medications are justified, how well they interact, and whether they meet the patient's individual goals. Reviews show that polypharmacy is associated with an increased risk of hospitalizations, falls, cognitive impairment, and mortality, especially in frail patients and people with dementia. [16]

The terms "potentially inappropriate medications" and "potential missed prescriptions" are used to describe the quality of prescriptions. The first group includes medications whose risk of complications in the elderly often outweighs their benefits (for example, some long-term sedatives or strong anticholinergics). The second group includes important medications that should have been prescribed but, for some reason, were not. The STOPP and START criteria, version 3, help identify such situations during routine therapy reviews. [17]

The American Geriatrics Society's Beers Criteria are another widely used tool. The list includes several dozen drugs and classes that should be avoided in most older adults, used with caution in certain situations, or adjusted based on kidney function. The guidelines emphasize that this is not a "ban list," but rather a reason to consider whether a drug can be replaced with a safer alternative or avoided entirely. [18]

The problem of polypharmacy is particularly acute during transitions between levels of care, such as upon discharge from a hospital. At this time, it's easy to "stack" regimens from several specialists and not remove temporary medications prescribed only for the duration of the hospitalization. High-quality studies show that clinical pharmacist involvement and the use of structured STOPP and START criteria help reduce the number of inappropriate prescriptions and potentially reduce the risk of complications, although such programs are not yet widely implemented. [19]

Deprescribing—a targeted reduction in medication load—is becoming an important part of working with elderly patients. It's not a sudden, phased approach, but a planned, step-by-step review, where each medication is examined to see if it has a clear purpose right now, and if there's a safer alternative. This approach takes time and requires the patient and family to be involved in the discussion, but it can reduce fatigue, dizziness, constipation, nighttime confusion, and other common problems often attributed to "aging." [20]

Table 4. Typical examples of potentially inappropriate prescriptions

Situation	Potential problem	Possible solution
Long-term use of benzodiazepines	Falls, delirium, addictions	Gradually reduce the dose, switch to non-drug sleep methods
Prescribing several sedatives at once	Additive effects, respiratory depression	Selecting one drug, reviewing indications
Use of strong anticholinergic drugs in dementia	Increased confusion and urinary retention	Search for alternatives with less anticholinergic effect
High doses of antihypertensive drugs in fragile patients	Orthostatic falls, organ ischemia	Softening target pressure values, reducing doses
Lack of anticoagulant in atrial fibrillation	Risk of stroke	Risk-benefit balance assessment, discussion with the patient

How to Safely Prescribe Medications to Older Adults

The first principle of safe pharmacotherapy in geriatrics is the "minimum necessary number of drugs." It is recommended to avoid prescribing on a "one-pill-for-every-symptom" basis and to check for non-drug alternatives each time. Reviews emphasize that regular, structured review of treatment regimens with the participation of a physician and pharmacist can significantly improve their rationale and reduce the number of potentially dangerous combinations. [21]

The second principle is individualized dose selection, taking into account renal and hepatic function. Elderly patients are often considered to have reduced clearance of drugs excreted by the kidneys, even with "normal" creatinine levels. Many authors recommend calculating creatinine clearance using formulas that take into account age and body weight, and adjusting the doses of anticoagulants, antidiabetic agents, certain antibiotics, and other medications accordingly. For drugs with predominant hepatic metabolism, evaluation of liver function tests and clinical signs of liver disease is important. [22]

The third principle is routine safety monitoring. This includes regular blood pressure measurements in the supine and standing positions, assessment of pulse rate and body weight, laboratory monitoring (e.g., electrolytes, renal and liver function when taking diuretics and certain antiarrhythmic drugs), as well as assessment of cognitive function and fall frequency. Changes in laboratory tests and symptoms should be considered not only as manifestations of the disease itself but also as possible side effects of medications. [23]

The fourth principle is the use of validated tools. Using the Beers, STOPP, and START criteria as a template for reviewing medication lists helps systematically evaluate each prescription for risk and missed benefits. Practical projects have shown that implementing such approaches in geriatric departments and outpatient settings reduces the frequency of potentially inappropriate prescriptions and can improve outcomes. [24]

The fifth principle is clearly planning the timing of therapy reviews. When prescribing a new medication, it is helpful to predetermine a checkpoint at which the physician and patient will assess whether the expected effect has been achieved and whether there are any side effects. If the goal is not achieved, a dose adjustment, replacement, or discontinuation is considered, rather than leaving the drug in the regimen "indefinitely." This "prescription-evaluation-adjustment" cycle reduces the risk that temporary prescriptions will remain on the list for years. [25]

Table 5. Algorithm for prescribing a new drug to an elderly patient

Step	Question between doctor and patient
Goal formulation	What exactly needs to change and how to measure it
Checking alternatives	Is it possible to get by with non-drug methods?
Choice of drug	The safest product with the least number of interactions
Starting dose	More often than not, half the standard, taking into account the kidneys and liver
Control point	How long does it take to evaluate the effect and side effects?
Cancellation plan	Under what conditions will the drug be discontinued or replaced?

The role of the patient and his relatives

Safe medication therapy is impossible without the active participation of the elderly person and their caregivers. It is helpful for patients to carry an up-to-date list of all medications, including over-the-counter medications and dietary supplements, and bring it to every appointment. Using pillboxes, alarm clocks, checklists, and other simple tools can help reduce missed doses and accidental double-dosing. [26]

Relatives and caregivers play an important role in the treatment of vision, hearing, or cognitive decline. They can help monitor changes in well-being after starting a new therapy, noticing signs of confusion, gait instability, unusual bruising, or appetite changes. Research shows that family involvement and regular discussion of treatment plans with the doctor reduce the likelihood of serious medication errors, especially in the case of polypharmacy. [27]

A useful practice is to periodically bring the doctor "everything the patient is taking." This "medicine cabinet review" helps identify duplicate medications, outdated prescriptions, medications with overlapping effects, and over-the-counter medications that were not considered when planning therapy. Based on this review, decisions are made to simplify the regimen, eliminate unnecessary medications, and adjust dosages. [28]

The role of lifestyle should not be underestimated: adequate hydration, a balanced diet, regular moderate physical activity, fall prevention at home, and the use of assistive devices (ropes, grab bars, non-slip shoes) reduce the need for some medications and improve their safety. Non-drug approaches for insomnia, chronic pain, and anxiety (sleep hygiene, physical rehabilitation, psychotherapy) can often reduce the dose of sedatives and analgesics. [29]

Finally, realistic treatment goals and shared decision-making are essential. For a relatively active elderly patient, the priority may be maximizing active life, while for a very frail elderly person, it may be comfort, the absence of severe pain, anxiety control, and daily predictability. The treatment regimen should be aligned with these goals, rather than tailored to abstract "ideal" blood pressure or sugar levels at the cost of severe side effects. [30]

Table 6. What the patient and his relatives can do

Direction	Concrete steps
Medicine accounting	Maintain an up-to-date list of all medications and supplements
Organization of reception	Use pill boxes, reminders, and a fixed schedule
Observing the effect	Note any changes in your health and report them to your doctor.
Discussion with a doctor	Ask questions about the purpose, duration, and risks of therapy
Prevention of complications	Monitor your drinking regime, nutrition, and home safety

Frequently asked questions about medications in older adults

Should all indicators in an elderly patient be "treated to normal"?
Not always. For frail individuals, aggressively lowering blood pressure or sugar levels can do more harm than good, increasing the risk of falls, hypoglycemia, and hospitalizations. Current guidelines increasingly recommend individualizing target values based on age, comorbidities, and the patient's priorities. [31]

Is any simultaneous therapy with multiple medications dangerous?
Not necessarily. Many older adults truly need multiple medications, for example, when they have a combination of heart failure, diabetes, and coronary artery disease. The problem isn't the number of medications themselves, but the lack of regular review and the potential for inappropriate prescriptions. It's important that each medication has a clear purpose and is tested for compatibility with other medications. [32]

How often should an elderly person's medication list be reviewed?
At a minimum, with each significant change in condition (hospitalization, fall, onset of confusion) and during routine doctor visits. Some experts suggest conducting a structured review of therapy at least once a year, and more frequently in the case of polypharmacy and high frailty, using the Beers criteria and the STOPP and START systems. [33]

Should older adults completely abstain from psychotropic medications and painkillers?
No, we're not talking about a complete ban, but rather about their judicious use. In cases of severe depression, anxiety, severe pain, or psychotic symptoms, such medications can significantly improve life. It's important to choose medications with a favorable safety profile, start with low doses, combine medication with non-medication options, and regularly assess the need for continued therapy. [34]

Can reducing the number of medications actually improve well-being?
Yes, and this is often observed in practice. There are cases where halving the number of medications resulted in reduced fatigue, improved cognitive function, and fewer falls and hospitalizations. For many older people, overmedication causes symptoms resembling disease progression, and eliminating these symptoms is an important step toward improving quality of life. [35]