Ethan Henderson, 55, went from taking no drugs to taking seven every day since being diagnosed with Parkinson's disease six years ago. Five of the medications treat his movement symptoms, and two address gastrointestinal problems.
In addition to having to remember each drug's schedule and to pack them in his carry-on bag when he travels (since checked luggage can get lost), Henderson endures side effects that can include stomach cramping, daytime sleepiness, dizziness, dry mouth, and urinary problems. He feels grateful that the medication controls his Parkinson's symptoms, but like anyone with a multidrug regimen, taking the pills becomes a job of its own. And Henderson, who lives in Tucson, is busy enough as senior manager of philanthropy for the Michael J. Fox Foundation.
Doctors call taking more than five medications regularly “polypharmacy.” People with neurologic disorders may take antidepressants or anti-anxiety drugs to treat fatigue, tremors, or insomnia, for instance. Or, they may take medications for conditions such as diabetes, heart disease, or arthritis. Some people also take supplements and over-the-counter medications.
The list can get longer if a visit to a doctor results in a prescription for a new, safer, or better drug, says Douglas Scharre, MD, FAAN, professor of clinical neurology and psychiatry at the Ohio State University Wexner School of Medicine in Columbus. Or, a physician may notice concerning side effects and prescribe a medication to address them.
Taking more than one drug is not necessarily a bad thing, Dr. Scharre says. Many older people take multiple drugs, and each drug may do exactly what it should. In some cases, however, people may take drugs that are no longer effective for them, have side effects, or interact with drugs prescribed for a short time, like pain relievers. Older patients also may have cognitive problems that affect their ability to comprehend and discuss the utility and necessity of their medications with their doctors, he adds.
Watch for Interactions
Identifying why patients use a medication or whether it's still necessary is not always easy for health care providers, especially if multiple clinicians each prescribe drugs. While seeing a different specialist for each health condition can benefit patients, it also can inadvertently lead to unsafe medication combinations. A recent study of patients with dementia who took three or more medications found that more than one doctor had prescribed 75 percent of the medications.
“This reinforces the importance of bringing an up-to-date medication list to every medical appointment,” says Donovan Maust, MD, professor and associate director of the geriatric psychiatry program at the University of Michigan in Ann Arbor.
Most patients work with their doctors and pharmacists to choose drugs that can optimize benefits and minimize side effects, but when a new doctor or trip to the emergency room adds a drug to a finely tuned regimen, it can disrupt their routine and health. One drug may affect how much the body metabolizes another drug and absorbs it into the bloodstream, says Nick Panos, PharmD, a clinical pharmacy specialist at Rush University Medical Center in Chicago.
Depending on the interaction, the competing effects of these drugs may cause one drug to be more toxic or less effective. In either case, the wrong dose can affect cognition, judgment, and thinking, Dr. Panos says. Patients experiencing symptoms caused by new or interacting medications should contact their doctors.
“The more drugs people take, the more side effects they might experience,” says Maria Kataki, MD, PhD, FAAN, associate professor of neurology and division head of cognitive neurology at Albany Medical Center in New York. “We want to know how patients are doing when a new drug is added and whether we should continue it, stop it, change the dose, or change the medicine.”
Marwan Sabbagh, MD, FAAN, professor of neurology and vice chair of research at Barrow Neurological Institute in Phoenix, notes that “it's easy for doctors to have tunnel vision” in these situations.
“As we're treating the symptom of the moment, we forget about how a drug fits into patients’ health conditions and other drugs they are taking,” he says, adding that side effects complicate the process. “We chase those side effects with other medications, and the cycle continues. Now, patients are on lots of medications, half of which [may be] there to treat side effects from other medications.”
Emily Shevitz, 36, of Augusta, GA, developed post-concussive syndrome with migraines after a traumatic brain injury in 2012 and also had a benign brain tumor resection in 2019. She tried different headache medications, but most made her feel tired or sick. “I wasn't warned about the fatigue, nausea, and constipation,” she says. “Be sure to ask about interactions and side effects when a new drug is prescribed, and make sure they're reviewing all of your medications.”
Get the Details
All patients should carry a current list of their medications to share with any provider they see, Dr. Scharre says, adding that patients should ask their physicians to review and update the medications listed in their electronic medical records. During any medication review, patients should inform providers of all the supplements and nonprescription medications they take as well.
With new prescriptions, patients and caregivers should always ask the doctor why they are prescribing the medication, how much of it they need, for how long they need it, and when they should check in about it, Dr. Scharre advises. They also should ask which symptoms, if any, should prompt them to stop taking the drug or to call a doctor or pharmacist, he says.
To ensure they know about any potential negative drug interactions, patients should ask the prescriber about the drug's benefits, side effects, and whether it could interact with other prescription and nonprescription drugs, supplements, and vitamins. They also should find out if any of their medications could affect their balance and pose a fall risk, Dr. Panos says. Even if the medications are beneficial, he says, patients should ask about alternatives or instructions on how to prevent a fall.
Writing down this information can help keep drugs meant to be used short-term from getting on a patient's permanent medication list, Dr. Kataki says. Caregivers should accompany loved ones with cognitive problems to their doctors’ appointments so they can take notes for them, she adds.
Check What Is Necessary
Aside from reviewing patients’ medications, physicians can address the problem of polypharmacy by double checking the necessity of each drug, whether it was prescribed at the right dosage, and that it doesn't interact with other medications. At every doctor's visit, patients should ask about whether they could replace any of their medications with one that could provide more benefits and/or fewer side effects, Dr. Kataki says.
Patients also should explain their priorities to their medical team, Dr. Sabbagh says. In a 2023 University of Michigan survey, 80 percent of adults ages 50 to 80 said they would stop at least one of the prescriptions they'd been taking for more than a year if a health care provider said it was possible. In a report about the survey, the researchers reminded people never to stop any drugs without first talking to their doctors.
Reducing the number of medications, which can include prescription and over-the-counter drugs as well as dietary supplements, should be based on conversations among patients, providers, and sometimes family members, says Sarah Vordenberg, PharmD, a clinical associate professor at the University of Michigan College of Pharmacy in Ann Arbor who worked on the survey.
“While we found that more than 90 percent of older adults who take at least one prescription drug expect their provider to review their list of medicines at least annually, research has shown this is often not the case,” Dr. Vordenberg says. “The results drive home the importance of comprehensive medication reviews.”
Drugs possibly worth a second look are the benzodiazepines diazepam (Valium) and alprazolam (Xanax), Dr. Kataki says. These drugs, which depress the central nervous system, are used to treat anxiety disorders, insomnia, seizures, and panic disorder, among other conditions. Although they are meant to be prescribed for a short time, patients end up refilling them repeatedly, says Dr. Kataki, who also is medical director of the Alzheimer's Center of Excellence at Albany Medical Center.
“When I see benzodiazepines on a patient's medicine list, I work hard to find out when and why they were prescribed, and whether there's a current benefit, or if they could be causing harm,” she says, noting that the drugs can impair cognition and balance, which can result in injuries.
When choosing short-term medication, Dr. Kataki prescribes only the amount needed and generally no refills. “For example, if a patient needs an anti-anxiety medication before an MRI, I'll prescribe two pills, not 30,” she says.
Talk to Your Doctor
One of Henderson's five Parkinson's medications slows his thinking but helps with his “off” periods (times when the medications that reduce his jerkiness and tremors become less effective). “I often can't think of the word for something, or I need more time when I'm cooking even though I have a recipe in front of me,” he explains. The slower processing doesn't happen all the time, but it is common in people with Parkinson's, Dr. Kataki says.
“I can deal with the fogginess rather than the off period, so I tell my doctor about the cognitive issue, but I also say that my preference is to stay on the drug,” says Henderson, who feels the same way about the gastrointestinal side effects from some of the drugs. “My father had Parkinson's and also had gastrointestinal problems, and he told me, ‘You learn to dance with it, because that way you get the benefit of the Parkinson's drugs.’” Taking his medication with meals helps lessen that discomfort. “Eating food reduces the drug's effectiveness, but I'm willing to live with that tradeoff,” he says.
Henderson notes that an open relationship with his doctor is key. “There's always medication tinkering, so I am honest about how I'm feeling and what I think is right for me,” he says. “I ask my doctor if my choices are safe and effective.” For anyone taking several medications, Henderson recommends a reminder system. He uses his phone. Other options include digital caps that record when a vial was opened and plastic sorting trays that mark the day and time to take pills.
Have a plan, Henderson says, “whether it's for taking six drugs during a four-hour hike, or talking to your doctor about the side effects of a drug that's otherwise working for you.”
