After the age of 65, the body processes medicines differently, and many patients take five, seven or ten preparations every day. This combination — a more sensitive organism plus many medicines — makes the elderly person the patient at greatest risk of adverse reactions, interactions and avoidable hospital admissions. The good news is that a large part of these problems can be prevented through a periodic review of the medication list, carried out together with the doctor and the pharmacist.
Why the elderly body reacts differently to medicines
As we grow older, both the pharmacokinetics (how the body absorbs, distributes, metabolises and eliminates the medicine) and the pharmacodynamics (how sensitive the body is to its effect) change. A medicine that was appropriate at 50 may become too strong at 80.
The kidneys and the liver filter more slowly
Kidney function declines gradually with age, even in people with no known kidney disease. An important detail: the creatinine in blood tests may appear „normal” because muscle mass decreases with age, even though the kidney is actually filtering more weakly. That is why doctors estimate kidney function (glomerular filtration rate, eGFR) before deciding on a dose. Medicines eliminated through the kidneys — digoxin, metformin (see metformin and the oral antidiabetics), lithium, some antibiotics and the direct oral anticoagulants — can accumulate to toxic levels. The liver has reduced mass and blood flow, which slows the metabolism of many medicines.
Body composition and brain sensitivity change
- More fat, less water: fat-soluble medicines (for example diazepam) are stored in fatty tissue and have a greatly prolonged half-life — the sedative effect can last for days.
- Lower serum albumin: the „free”, active fraction of medicines that are strongly bound to proteins (such as acenocoumarol or phenytoin) increases, so the effect may be more intense at the same dose.
- A more sensitive brain: sedatives, opioids and medicines with an anticholinergic effect more easily cause drowsiness, confusion and loss of balance, increasing the risk of falls.
Polypharmacy: when „many medicines” becomes a risk in itself
The World Health Organization defines polypharmacy as the routine, concurrent use of five or more medicines. The problem is not only the number, but the fact that the risk of interactions rises rapidly with each medicine added: with five medicines the probability of a relevant interaction is already considerable, and with ten it becomes almost the rule. The WHO has included polypharmacy in its global „Medication Without Harm” programme, precisely because avoidable adverse reactions in the elderly are a frequent cause of hospitalisation.
Be aware, however, of one nuance: not all polypharmacy is „bad”. A patient with heart failure, diabetes and atrial fibrillation needs, according to the guidelines, several medicines — this is appropriate polypharmacy. The aim is not to take as few pills as possible at any cost, but that each medicine should have a clear indication and a benefit that outweighs the risk. Classes such as antihypertensives and anticoagulants and antiplatelet agents are often necessary, but they are also the ones that demand the most careful monitoring of the dose.
Potentially inappropriate medicines: the Beers and STOPP/START criteria
To help doctors and pharmacists identify high-risk medicines in the elderly, the medical community has developed scientifically validated lists:
- The Beers criteria, updated periodically by the American Geriatrics Society (the latest edition in 2023), list the „potentially inappropriate” medicines in patients aged 65 and over.
- STOPP/START, the European tool developed by geriatricians (STOPP = medicines to stop; START = useful treatments that are missing from the regimen), widely used in Europe and recommended by the NICE guidelines on medication optimisation.
These lists do not mean „forbidden” — they are warning signals that call for a reassessment together with the doctor. The table below summarises a few frequently flagged classes. The details of prescribing in the elderly are also addressed in the BNF, the British reference formulary.
| INN / class | Why it is risky in the elderly | Examples of brand names (RO) | Note |
|---|---|---|---|
| Benzodiazepines (alprazolam, lorazepam, diazepam) | Sedation, confusion, loss of balance, falls and hip fractures, dependence | Xanax, Anxiar, Diazepam | Not to be stopped abruptly; see anxiolytics and sleeping pills |
| „Z” hypnotics (zolpidem) | Nocturnal falls, memory disturbances | Stilnox, Sanval | Risks similar to the benzodiazepines |
| First-generation antihistamines / anticholinergics (diphenhydramine, clemastine, oxybutynin) | Confusion, urinary retention, constipation, dry mouth, blurred vision | Tavegyl, Driptane | The „anticholinergic burden” accumulates; see the antihistamines |
| NSAIDs in chronic use (ibuprofen, diclofenac, ketoprofen) | Gastrointestinal bleeding, kidney damage, fluid retention, raised blood pressure | Nurofen, Voltaren, Ketonal | Paracetamol is often preferable; see NSAIDs |
| Long-acting sulfonylureas (glibenclamide) | Prolonged, sometimes severe hypoglycaemia | Maninil | Alternatives with a lower risk of hypoglycaemia are preferred |
| Tricyclic antidepressants (amitriptyline) | Strong anticholinergic effect, drowsiness, falls, arrhythmias | Amitriptilină | See the antidepressant alternatives |
| PPIs in prolonged use (omeprazole, pantoprazole) | Possible risk of fractures, B12 and magnesium deficiency, certain infections | Omez, Controloc | Reassess the need after ~8 weeks; see PPIs and antacids |
The prescribing cascade: how an adverse reaction becomes a new „diagnosis”
One of the most insidious causes of polypharmacy is the prescribing cascade: an adverse reaction to one medicine is mistaken for a new disease, and yet another medicine is prescribed for it — which, in its turn, may cause side effects. Classic, well-documented examples:
- An NSAID raises the blood pressure → an antihypertensive is added instead of stopping the NSAID.
- A calcium channel blocker (amlodipine) causes ankle swelling → a diuretic is added instead of reassessing the cause.
- Metoclopramide (for nausea) produces symptoms resembling Parkinson’s disease → antiparkinsonian treatment is prescribed.
- A medicine for dementia (donepezil) causes urinary incontinence → an anticholinergic is added, which worsens the memory.
The key to stopping the cascade is a simple question worth asking the doctor: „Could this new symptom in fact be the effect of a medicine I am already taking?”
Periodic review of the list: how the „clean-up” of the regimen is done
The careful and planned reduction of unnecessary or risky medicines is called deprescribing. It does not mean „give up the treatment”, but „adjust the treatment to the current needs”. The guidelines for patients with several diseases (multimorbidity) recommend such a review at least once a year, or whenever a new medicine appears.
The „medicine bag” method (brown bag review)
A practical and recognised approach: put all the medicines and supplements in a bag — including those available without a prescription, vitamins and herbal products — and take them to the consultation or to the pharmacy. The pharmacist and the doctor can check together:
- whether each medicine still has a valid indication today;
- whether there are duplicates (two products with the same INN under different brand names);
- whether dangerous interactions arise;
- whether a dose must be lowered because of kidney function;
- whether a medicine can be stopped gradually (many, such as the benzodiazepines, are not stopped abruptly).
Never stop or change a treatment on your own. Always ask the doctor or the pharmacist before any change — some medicines require a gradual reduction of the dose in order to avoid withdrawal effects.
Adherence and confusion: how to avoid administration errors
The more medicines and different schedules a regimen has, the greater the risk of errors — especially when declining vision, memory or dexterity is added. A few strategies that work:
- The weekly organiser box (with compartments for the days and times of day), prepared by a family member or by the pharmacist.
- A written, up-to-date list, with the INN, dose, reason for administration and time — also useful in an emergency. For practical details, see the guide on the correct administration of medicines.
- Alarms on the phone or watch for each dose.
- A clear plan for missed doses — the rules differ from one medicine to another; read what to do if you have forgotten a dose.
If you notice any unexpected effect — dizziness, falls, newly appeared confusion, bleeding, palpitations — note it down and tell the doctor or the pharmacist. Adverse reactions can also be reported officially to the ANMDMR (the National Agency for Medicines and Medical Devices of Romania), through the pharmacovigilance system; see how in the guide on reporting adverse reactions.
Costs and reimbursement: another reason for a cleaner regimen
Beyond safety, a well-considered list also concerns the budget. Many chronic medicines are reimbursed through the CNAS (the National Health Insurance House), and the maximum price of each product is set in the National Catalogue of Prices (CANAMED — the national catalogue of medicine prices), published by the Ministry of Health. For the same substance, the generic version can be significantly cheaper than the branded one. Details on how the levels of reimbursement work can be found in the guide on medicines reimbursed through the CNAS. The regulation of the quality and safety of medicines in Europe is also coordinated by the EMA.
Warning signs: when to seek help quickly
Go to the doctor, to the emergency room or call 112 if, especially after starting a new medicine, the following appear:
- unusual confusion or drowsiness, sudden disorientation;
- repeated falls or severe dizziness when standing up;
- unusual bleeding (gums, nose, black stools, large bruises) — especially relevant in those on anticoagulants;
- signs of hypoglycaemia (sweating, trembling, confusion) in patients with diabetes;
- irregular heartbeats, difficulty breathing or swelling of the legs.
Remember the central message: in the elderly, any new symptom may be the effect of a medicine. The safest decision is not to add a pill, but to discuss the entire list with your doctor and pharmacist at least once a year. They are the ones who can decide, safely, what stays, what is reduced and what can be stopped.