Too Many Medicines: How to Ask for a Proper Review
Medicines get added when something goes wrong and are rarely removed when the reason passes. Over years, a person can accumulate a list where nobody has ever reviewed the whole thing at once, and where some items are treating the side effects of others.
What the problem looks like
Polypharmacy is generally defined as taking five or more regular medicines. The number itself is not inherently wrong; many conditions genuinely require several drugs, and under-treatment is also a real harm.
The distinction that matters is between appropriate polypharmacy, where every medicine has a current indication, benefit and acceptable risk, and problematic polypharmacy, where some do not.
Why it causes harm
- Interactions rise steeply with the number of drugs
- Side effects are often mistaken for new conditions and treated with yet another medicine, a pattern called the prescribing cascade
- Falls, confusion, kidney injury and hospital admission are all associated with higher medicine counts, particularly in older adults
- Adherence falls as regimens get complex
- Cost
- Anticholinergic burden accumulates across medicines that individually seem mild, producing dry mouth, constipation, urinary retention, blurred vision, confusion and increased fall risk
The prescribing cascade, with examples
Recognising this pattern is the most useful single skill here.
- A calcium channel blocker causes ankle swelling, which is treated with a diuretic
- A diuretic causes urinary urgency, which is treated with an anticholinergic bladder drug
- The anticholinergic causes constipation and confusion, which are treated with a laxative and investigated as dementia
- An NSAID raises blood pressure, which is treated with another antihypertensive
- Metoclopramide causes a tremor, which is treated as Parkinson disease
In each case the correct action is to reconsider the first drug, not to add the next one.
Medicines most often continued without a current reason
- Proton pump inhibitors started for a short course years ago and never stopped
- Sleeping tablets, benzodiazepines and Z-drugs, intended for short-term use
- Antidepressants continued long past the planned duration without review
- Anticholinergic bladder medicines with limited benefit and significant cognitive risk
- Antipsychotics started during a hospital admission for delirium and never stopped
- Statins in people with very limited life expectancy, where the benefit horizon exceeds it
- Bisphosphonates continued beyond the recommended duration without a drug holiday review
- Vitamin and mineral supplements started without a documented deficiency
- Inhalers continued after the diagnosis was revised
- Aspirin for primary prevention, where guidance has shifted substantially and many people are still taking it without a current indication
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Preparing your ad…
Preparing for a review
A proper medication review needs an accurate list, which is harder than it sounds.
Bring everything in a bag. Not a list, the actual boxes. This includes:
- Prescription medicines
- Over-the-counter medicines, including painkillers and antacids
- Vitamins and supplements
- Herbal and traditional preparations, which interact more than people expect
- Creams, drops, inhalers and patches, which are routinely forgotten
- Anything prescribed by a different specialist
Write down for each one: what you think it is for, when you started it, who prescribed it, whether you actually take it, and whether you have noticed any effect or side effect.
Note the symptoms that started after a new medicine. The timing is the clue.
Questions worth asking
- What is this medicine for?
- Is that reason still true?
- What happens if I stop it?
- How will we know whether it is working?
- When should this be reviewed again?
- Are any of these treating the side effects of another?
- Can anything be simplified, combined, or taken less often?
- Is the dose right for my kidney function at my age?
- Which of these should I pause if I am vomiting, have diarrhoea, or am dehydrated?
That last one deserves emphasis. Sick day rules apply to several common medicines, including ACE inhibitors, ARBs, diuretics, metformin, SGLT2 inhibitors and NSAIDs, which may need temporary pausing during acute illness to protect the kidneys. Most people have never been told this.
Deprescribing is a process, not an event
Some medicines can be stopped immediately. Others need tapering, because sudden withdrawal causes rebound or withdrawal effects. These include benzodiazepines, antidepressants, proton pump inhibitors, beta blockers, steroids and opioids.
A sensible approach:
- Stop one at a time, so effects are attributable
- Taper where required
- Agree in advance what to watch for and when to review
- Document what happened, because if a symptom returns you have learned the medicine was doing something
Do not stop prescribed medicines on your own. This is a conversation with the prescriber or pharmacist.
Making the regimen workable
- A weekly pill organiser, or blister packs from the pharmacy
- Align timings where clinically acceptable, to reduce the number of daily points
- A simple written schedule kept where the medicines are
- One pharmacy, so interactions are checked against the full list
- Phone alarms
- Keep an up-to-date list in your wallet and on your phone, which matters enormously in an emergency
For carers of an older person
- Attend appointments where possible, since a second listener catches more
- Watch for new confusion, drowsiness, falls or incontinence after a medicine change and report the timing
- Ask specifically about anticholinergic burden
- Request an annual structured review, which many health systems provide and few people request
- Be clear with the prescriber about what matters most to the person, since goals change with age and a medicine preventing an event fifteen years away may not be the priority
The short version
Medicines accumulate because adding is easier than subtracting. Bring every box in a bag, ask whether the original reason still applies to each one, and look specifically for symptoms that began after a new prescription. Also ask which of your medicines to pause during vomiting or diarrhoea, because that single piece of information prevents a meaningful share of hospital admissions.