Medications in Older Adults: Why Extra Caution Is Needed from Age 65
People over 65 take more than four active substances per day on average — over 60% take five or more (polypharmacy). The problem is not the number alone, but the combination: it is estimated that tens of thousands of patients each year suffer lasting harm from adverse drug reactions — many of them older adults.
Why Medications Work Differently in Older Adults
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Kidneys slow down
Many active substances are excreted via the kidneys. Standard doses for 40-year-olds can lead to overdose in 75-year-olds. Affected: Metformin, Ramipril, many antibiotics.
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Liver metabolises more slowly
Medications are broken down more slowly and remain active for longer. Critical for Simvastatin, benzodiazepines, and many antidepressants.
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More fat, less water
Fat-soluble medications (benzodiazepines) accumulate in fatty tissue and act for longer. Water-soluble medications reach higher concentrations — increased risk of overdose.
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Brain becomes more sensitive
The blood-brain barrier becomes more permeable. Sleeping pills, sedatives, and antidepressants have stronger effects: more drowsiness, more confusion, higher fall risk.
Potentially Inappropriate Medications: What's Risky in Older Adults
The internationally used STOPP/START criteria identify medications that are potentially inappropriate or potentially missing in older adults. Similar to the German Priscus list, these are expert-developed tools used by geriatricians and pharmacists. "Potentially inappropriate" does not mean forbidden — it means there is often a better alternative, and the prescriber should weigh up the benefit-risk balance with extra care.
Tip: A basis for conversation, not a veto
If your doctor prescribes a medication flagged as potentially inappropriate for older adults, ask: "Is there a better-tolerated alternative for me?" — This is good patient advocacy, not a lack of trust.
Significantly increase the risk of falls, can cause confusion, and create physical dependence. In older adults they are broken down more slowly — the effect often persists until the following morning.
Alternatives: Sleep hygiene, valerian, low-dose mirtazapine following careful medical assessment. ✓ Alternative available
⚠ Certain antidepressants (tricyclics such as amitriptyline)
Alternatives: SSRIs such as citalopram, escitalopram, or sertraline — better tolerated in older adults. ✓ Alternative available
⚠ PPIs (Pantoprazole) with long-term use beyond 8 weeks
Risks of long-term use: magnesium deficiency, increased fracture risk, possible kidney effects. In many older patients, pantoprazole continues to be prescribed out of habit long after the original indication has resolved.
⚠ NSAIDs (ibuprofen / diclofenac) at high doses or long-term
Increased risk of gastrointestinal bleeding, kidney failure, and heart attack — particularly in combination with blood thinners or blood pressure medications.
Alternative:Acetaminophen (paracetamol) as a first-line painkiller in older adults (lower stomach risk), physiotherapy, heat treatment. ✓ Alternative available
Polypharmacy: When 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 water retention — a common side effect of this blood pressure medication.
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The swelling is interpreted as a new condition → a diuretic (water tablet) is prescribed.
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The diuretic lowers potassium levels → a potassium supplement is prescribed.
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Three medications — where one would have done: switching to a different blood pressure medication without this side effect.
Warning Signs: New Symptoms as Possible Drug Reactions
Any new symptoms appearing after starting or changing a medication should always be considered as a possible drug reaction:
Medication review with your doctor or pharmacist
Many countries offer structured medication reviews for patients on multiple medications — often available as a funded service through health insurance. Bring all medications (including over-the-counter ones) and ask: Do I still need all of these? Are there any interactions? Are the doses still appropriate?
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Request an up-to-date medication plan
Anyone taking three or more prescription medications is typically entitled to a comprehensive medication plan from their doctor. In practice, these are often incomplete or out of date. Solution: supplement and maintain it digitally with brite.
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Use the STOPP/START criteria as a basis for conversation
Ask your doctor or pharmacist whether any of your medications appear on lists of potentially inappropriate medications for older adults. Review your medications at your next appointment and ask about alternatives — never stop anything on your own.
Frequently Asked Questions
From 5 simultaneous medications (polypharmacy), the risk of interactions and side effects rises significantly. This doesn't automatically mean too many — but a regular medication review becomes important.
STOPP/START are internationally recognised expert criteria that identify medications that are potentially inappropriate or potentially missing in older adults. They are widely used by geriatricians and clinical pharmacists to optimise complex medication regimens.
No. "Potentially inappropriate" doesn't mean forbidden. Sometimes there is no better alternative. But you can ask: "Is there a better-tolerated alternative for me?" — This is good patient advocacy, not a lack of trust.
For drug interactions, the pharmacist is often the better contact — checking for interactions is a core competency. The ideal combination: the doctor prescribes, the pharmacist reviews, and brite keeps it all in order.
Set up a digital medication plan in brite — all active substances, doses, and times in one place. Activate dose reminders. Schedule an annual medication review with the GP or pharmacist.
All your loved one's medications in one view
With the digital brite medication plan, all active substances, doses, and times are instantly available for the next doctor's appointment, the pharmacy, or the emergency department.
Medical disclaimer: This page does not replace medical advice. Any changes to medication in older adults should always be made in consultation with a doctor or pharmacist. Never stop medication on your own. Last updated: March 2026.
