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GuideMarch 2026· 8 min read
Medications in old age: why special caution applies from 65
People over 65 take more than four active ingredients daily on average — over 60 % even take five or more (polypharmacy). The problem is not the number alone, but the combination: in Germany, an estimated 12,000–58,000 patients are permanently harmed each year by adverse drug reactions — many of them older people.
Why medications act differently in old age
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Kidneys get slower
Many active ingredients are excreted via the kidneys. Standard doses for 40-year-olds can lead to overdosing in 75-year-olds. Affected: metformin, ramipril, many antibiotics.
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The liver breaks down more slowly
Medications are metabolized more slowly and act for longer. Critical with simvastatin, benzodiazepines and many antidepressants.
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More fat, less water
Fat-soluble medications (benzodiazepines) are stored in fatty tissue and act for longer. Water-soluble medications are more highly concentrated — a risk of overdosing.
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The brain becomes more sensitive
The blood-brain barrier becomes more permeable. Sleeping pills, sedatives and antidepressants act more strongly: more drowsiness, more confusion, a higher fall risk.
The Priscus list: which medications are risky in old age
The Priscus list 2.0 (2022) is a list compiled by German experts of 177 active ingredients considered potentially inappropriate for people aged 65 and over. "Potentially inappropriate" does not mean forbidden — it means: there are often better alternatives, and the doctor should weigh the benefit-risk ratio particularly carefully.
Tip: a basis for discussion, not a veto
If your doctor prescribes a Priscus medication, ask: "Is there a better-tolerated alternative for me?" — That is not mistrust, but good patient competence.
Massively increase the fall risk, can trigger confusion and cause physical dependence. In old age they are broken down more slowly — the effect often lasts until the next morning.
Alternatives: sleep hygiene, valerian, low-dose mirtazapine after medical assessment. ✓ Alternative available
⚠ Certain antidepressants (tricyclics such as amitriptyline)
Alternatives: SSRIs such as citalopram, escitalopram or sertraline — better tolerated in old age. ✓ Alternative available
⚠ PPIs (pantoprazole) with long-term use over 8 weeks
Risks with long-term use: magnesium deficiency, an increased risk of bone fractures, possible kidney effects. In many older patients, pantoprazole continues to be prescribed out of habit, even though the original reason disappeared long ago.
⚠ NSAIDs (ibuprofen / diclofenac) at high doses or as long-term therapy
An increased risk of stomach bleeding, kidney failure and heart attack — especially in combination with blood thinners or blood-pressure-lowering drugs.
Alternative:paracetamol as a first-line painkiller in old age (lower stomach risk), physiotherapy, heat treatment. ✓ Alternative available
Polypharmacy: when the medications become the risk
💊 Possible interaction pairs — it escalates quickly
3 medications
3 possible pairs
5 medications
10 possible pairs
7 medications
21 possible pairs
10 medications
45 possible pairs
The "prescribing cascade"
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Amlodipine causes fluid retention — a common side effect of the blood-pressure-lowering drug.
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The swelling is interpreted as a new illness → a diuretic (a water tablet) is prescribed.
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The diuretic lowers the potassium level → a potassium supplement is prescribed.
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Three medications — where one would have been enough: switching to a different blood-pressure-lowering drug without this side effect.
Warning signs: new symptoms as a possible drug reaction
New symptoms after starting or changing a medication should always be considered as a possible drug effect:
A medication review with the doctor or pharmacist
Since 2022, patients with statutory health insurance have been entitled to extended medication counselling at the pharmacy — covered by statutory health insurance (in Germany a Kassenleistung). Bring all your medications (including over-the-counter ones) and have them checked: do I still need everything? Are there interactions? Are the doses still appropriate?
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Request the nationwide standardized medication plan
From 3 prescription medications, you are entitled to a medication plan from your doctor (in Germany the bundeseinheitlicher Medikationsplan). In practice it is often incomplete or out of date. The solution: supplement and maintain it digitally with brite.
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Use the Priscus list as a basis for discussion
The Priscus list is publicly available at priscus2-0.de. Check your own medication and ask about alternatives at your next doctor's appointment — never stop on your own.
Common questions
From 5 simultaneous medications (polypharmacy), the risk of interactions and side effects rises markedly. That does not automatically mean too many — but a regular medication review becomes important.
A list compiled by German experts of 177 active ingredients considered potentially inappropriate for people aged 65 and over. The current version (Priscus 2.0) was published in 2022 and is publicly available at priscus2-0.de.
No. "Potentially inappropriate" does not mean forbidden. Sometimes there is no better alternative. But you can ask: "Is there a better-tolerated alternative for me?" — That is good patient competence, not mistrust.
For interactions, the pharmacist is often the better point of contact — interaction checking is one of their core competencies. Ideal: the doctor prescribes, the pharmacist checks, brite keeps the overview.
Set up a digital medication plan in brite — all active ingredients, doses and times in one place. Activate the intake reminder. Arrange a medication review with the family doctor or pharmacist once a year.
All your parents' medications at a glance
With the digital brite medication plan, you have all active ingredients, doses and times immediately available for the next doctor's appointment, the pharmacy or the emergency department.
Medical disclaimer: This page does not replace medical advice. Changes to medication in old age should always be made in consultation with the doctor or pharmacist. Never stop medications on your own. As of: March 2026.
