Aging and Medications

Many of the improvements in the health and function of older adults during the past several decades can be attributed to the benefits of medications.

• Vaccines help prevent many infectious diseases (such as influenza, respiratory syncytial virus [RSV], COVID-19 infection, and pneumonia) that once killed many older adults.

• Antibiotics are often effective in treating serious bacterial infections, including urinary tract infections and pneumonia.

• Medications to control high blood pressure (antihypertensives) help prevent strokes and heart attacks.

• Medications to control blood sugar levels (insulin and other antihyperglycemic drugs) enable millions of people with diabetes to lead normal lives. These medications also reduce the risk of eye and kidney problems that diabetes can cause.Medications to control blood sugar levels (insulin and other antihyperglycemic drugs) enable millions of people with diabetes to lead normal lives. These medications also reduce the risk of eye and kidney problems that diabetes can cause.

• Medications to control pain and other symptoms enable millions of people with arthritis to continue to function.

However, medications can have effects that are not intended or desired (side effects). Starting in late middle age, the risk of side effects related to the use of medications increases. Older adults are more than twice as susceptible to the side effects of medications as younger people. Side effects are also likely to be more severe, affecting quality of life and resulting in visits to the doctor and in hospitalization.

Older adults are more susceptible to the side effects of medications for several reasons:

• As people age, the total amount of water and muscle mass in the body decreases, and the amount of fat tissue increases. Thus, in older adults, medications that dissolve in water reach higher concentrations because there is less water to dilute them, and medications that dissolve in fat accumulate more because there is relatively more fat tissue to store them (see Drug Distribution Within the Body).

• As people age, the kidneys are less able to excrete drugs into urine, and the liver is less able to break down (metabolize) many drugs (see Drug Metabolism). Thus, drugs are less readily removed from the body (see Drug Elimination).

• Older adults usually take more medications and have more disorders.

• People who take more medications have a higher risk of drug interactions.

• Fewer studies have been done in older adults to help identify appropriate doses of medications.

• Older adults are more likely to have chronic medical disorders that may be worsened by medications or that may affect how the medications work.

Because of these age-related changes, many medications tend to stay in an older person’s body much longer, prolonging the medication’s effect and increasing the risk of side effects. Therefore, older adults often need to take smaller doses of certain medications or perhaps fewer daily doses. For example, digoxin, a medication sometimes used to treat certain heart disorders, dissolves in water and is eliminated by the kidneys. Because the amount of water in the body decreases and the kidneys function less well as people age, digoxin concentrations in the body may be increased, resulting in a greater risk of side effects (such as nausea or abnormal heart rhythms). To prevent this problem, doctors may use a smaller dose. Or sometimes other medications can be substituted.Because of these age-related changes, many medications tend to stay in an older person’s body much longer, prolonging the medication’s effect and increasing the risk of side effects. Therefore, older adults often need to take smaller doses of certain medications or perhaps fewer daily doses. For example, digoxin, a medication sometimes used to treat certain heart disorders, dissolves in water and is eliminated by the kidneys. Because the amount of water in the body decreases and the kidneys function less well as people age, digoxin concentrations in the body may be increased, resulting in a greater risk of side effects (such as nausea or abnormal heart rhythms). To prevent this problem, doctors may use a smaller dose. Or sometimes other medications can be substituted.

Older adults are more sensitive to the effects of many medications. For example, older adults tend to become sleepier, dizzier, and more confused compared to younger adults when using certain antianxiety medications or sleep aids to treat insomnia. Some medications that lower blood pressure tend to lower blood pressure much more dramatically in older adults than in younger people. Larger decreases in blood pressure can lead to side effects such as dizziness, light-headedness, and falls. Older adults who have such side effects should discuss them with their doctor.

Many commonly used medications have anticholinergic effects. These medications include some antidepressants (amitriptyline and imipramine), many antihistamines (such as diphenhydramine, contained in over-the-counter sleep aids, cold remedies, and allergy medications), bladder medications (such as oxybutynin and tolterodine), and many antipsychotics (such as chlorpromazine and clozapine). Older adults, particularly those with memory impairment, are particularly susceptible to anticholinergic effects, which include confusion, blurred vision, constipation, dry mouth, and difficulty starting to urinate. Some anticholinergic effects, such as reduction of tremor (as in the treatment of Parkinson disease) and reduction of nausea, are desirable, but most are not.. These medications include some antidepressants (amitriptyline and imipramine), many antihistamines (such as diphenhydramine, contained in over-the-counter sleep aids, cold remedies, and allergy medications), bladder medications (such as oxybutynin and tolterodine), and many antipsychotics (such as chlorpromazine and clozapine). Older adults, particularly those with memory impairment, are particularly susceptible to anticholinergic effects, which include confusion, blurred vision, constipation, dry mouth, and difficulty starting to urinate. Some anticholinergic effects, such as reduction of tremor (as in the treatment of Parkinson disease) and reduction of nausea, are desirable, but most are not.

A medication may have a side effect because it interacts with

• A disorder, symptom, or condition other than the one for which the medication is being taken (drug–disease interaction)

• Another medication (drug–drug interaction)

• Food (drug–food interaction)

• A medicinal herb (drug–medicinal herb interaction)

Because older adults tend to have more diseases and take more medications than younger people, they are more likely to have drug–disease and drug–drug interactions. In many drug-disease interactions, taking a drug can worsen a disorder, symptom, or condition.

Patients, doctors, and pharmacists can take steps to reduce the risk of drug–disease and drug–drug interactions. Because over-the-counter medications and medicinal herbs can interact with other medications, people should ask their doctor or pharmacist about combining the use of these medications with prescription medications.

Not following a doctor’s directions for taking a medication (called nonadherence) can be risky (see Adherence to Medication Treatment). Older age alone does not make people less likely to take medications as directed. However, up to half of older adults do not take medications as directed. Not taking a medication, taking too little, or taking too much can cause problems. Taking less of a medication because it has side effects may seem reasonable, but people should talk to a doctor before they make any changes in the way they take a medication.

Older adults and the people who care for them can do many things to maximize the benefits and reduce the risks of taking medications. Any new symptom that occurs after starting a medication should be reported to a health care professional to help identify if the symptom is a medication side effect. Questions about or problems with a medication should be discussed with a doctor or pharmacist. Taking medications as instructed and communicating with health care providers is essential for avoiding problems and promoting good health.

Know about the medications and disorders being treated:

• Keep a list of all medical problems and drug allergies.

• Keep a list of all medications being taken, including over-the-counter medications and supplements, such as vitamins, minerals, and medicinal herbs, and update the list of medications or doses if they change.

• Learn why each medication is taken and what its benefits are supposed to be.

• Learn what side effects each medication may have and what to do if a side effect occurs.

• Learn how to take each medication, including what time of day it should be taken, whether it can be taken with food, or taken at the same time as other medications, and when to stop taking the medication. If the medication schedule is interfering with quality of life, discuss with the doctor or pharmacist ways to adjust the medication.

• Learn what to do if a dose is missed.

• Write down information about how to take the medication or ask the doctor, nurse, or pharmacist to write it down (because such information can easily be forgotten).

Use medications correctly:

• Take medications as instructed.

• Use memory aids, such as a medication organizer, to take medications as instructed.

• Before stopping a medication, consult the doctor about any problems—for example, if side effects occur, if the medication does not seem to work, or if the cost of the medication is burdensome.

• Properly discard any unused medication from a previous prescription, unless instructed not to do so by a doctor, nurse, or pharmacist.

• When discarding a drug, follow the disposal instructions on the label, review the information at the Food and Drug Administration's web site, take medications to an authorized disposal center (possibly at a pharmacy or local law enforcement site), or, if there are no other options, mix the medication with kitty litter or coffee grounds, tightly wrap in plastic or a similar material, place in a sealable or watertight container or bag, and discard in the trash.

• Do not take another person’s medication, even if that person’s medical problem seems similar.

• Check the expiration date on medications, and do not use the medication if it has expired.

Work closely with the doctor and pharmacist:

• Get all prescriptions from the same pharmacy, preferably one that provides comprehensive services (including checking for possible drug interactions) and that maintains a complete drug profile for each person.

• Bring all medications and supplements being taken to medical appointments if requested to do so.

• Periodically discuss the list of medications being taken and the list of disorders with the doctor, nurse, or pharmacist to make sure the medications are correct and should be continued. For example, people can test themselves by telling their health care providers how they are supposed to take all medications and asking whether what they have said is correct.

• Review the list of medications with the doctor, nurse, or pharmacist every time a medication is changed (doctors and pharmacists can check for interactions between drugs), especially after a hospitalization.

• Make sure the doctor and pharmacist know about all over-the-counter medications and supplements being taken, including vitamins, minerals, and medicinal herbs.

• Consult the doctor before taking any new medications, including over-the-counter medications and supplements.

• Report to the doctor or pharmacist any symptoms that might be related to the use of a medication (such as new or unexpected symptoms).

• If the schedule of taking medications is too complex to follow, ask the doctor or pharmacist about simplifying it.

• If seeing more than one doctor, make sure each doctor knows all the medications being taken.

• Ask the pharmacist to print the label in large print, and check to make sure it can be read.

• Ask the pharmacist to package the medication in containers that are easy to hold and to open.

To benefit from taking medications, people must remember not only to take their medications but also to take them at the right time and in the right way. When several medications are taken, the schedule for taking them can be complex. For example, medications may have to be taken at different times throughout the day to avoid interactions. Some medications may have to be taken with food. Other medications have to be taken when no food is in the stomach. The more complex the schedule, the more likely people are to make mistakes. For example, bisphosphonates (such as alendronate, risedronate, and ibandronate), which are used to increase bone density, need to be taken on an empty stomach and with only water (at least a full glass). If these medications are taken with other liquids or food, they are not absorbed well and do not work effectively.To benefit from taking medications, people must remember not only to take their medications but also to take them at the right time and in the right way. When several medications are taken, the schedule for taking them can be complex. For example, medications may have to be taken at different times throughout the day to avoid interactions. Some medications may have to be taken with food. Other medications have to be taken when no food is in the stomach. The more complex the schedule, the more likely people are to make mistakes. For example, bisphosphonates (such as alendronate, risedronate, and ibandronate), which are used to increase bone density, need to be taken on an empty stomach and with only water (at least a full glass). If these medications are taken with other liquids or food, they are not absorbed well and do not work effectively.

If older adults have memory problems, following a complex schedule is even harder. Such people usually need help, often from family members. The doctor can be asked about simplifying the schedule. Often, doses can be rescheduled to make taking the medications more convenient or reduce the total number of daily doses. Also, over time, some medications may not be needed any longer and can be stopped.

The following things can help people remember to take their medications as prescribed:

• Memory aids

• Medication containers

• Smartphone apps

Medication containers

A pharmacist can provide containers that help people take medications as instructed. Daily doses for 1 week or 2 weeks may be packaged in a plastic pack marked with the days or with the times of the day, so that people can keep track of doses taken by noting the empty spaces. Some pharmacies can package medications in blister packs with a month of medication in a dosing card, so that the daily dose can be easily removed and organized. Other pharmacies can package medications in small pouches, with a full day of medications in one pouch. However, such packaging may cost a little more. Additionally, many pharmacies can adjust refill schedules so that regularly used medications are picked up on a single day each month. This decreases confusion, helps reduce trips to the pharmacy, and minimizes mistakes filling pill organizers.

Medication Organizer

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Photo courtesy of Robert S. Porter, MD.

More elaborate containers with a computerized reminder system are available. These containers beep, flash, or talk at dosing time.

The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.

1. National Institute on Aging—Tracking Your Medications

2. American Geriatrics Society, Health in Aging Foundation: Medications & Older Adults

3. Food and Drug Administration (FDA): Where and How to Dispose of Unused Medicines

4. National Association of Boards of Pharmacy (NABP): Dispose Safely: Help prevent poisoning, misuse, and overdose