This article, from RGA's ReFlections newsletter, examines how polypharmacy reflects the growing complexity of managing multiple chronic conditions in older adults and introduces significant risks that can compromise stability and long‑term health.
Advances in modern healthcare have significantly extended average life spans, but increased longevity presents new challenges in the care of older adults, especially in managing multiple chronic diseases.
As people age, they often develop long-term conditions such as diabetes, hypertension, arthritis, and heart disease, increasing the need for multiple medications at once – a practice known as polypharmacy. While this approach can be essential and beneficial, it also introduces significant risks that may compromise quality of life, increase healthcare utilization, and affect mortality. Evaluating these factors is particularly important in the context of assessing risk profiles in older lives for insurance underwriting purposes.
There is no clear or universal definition of polypharmacy, but it typically refers to the concurrent use of five or more medications daily.1 This includes prescription drugs, over-the-counter medicines, and dietary supplements. Excessive polypharmacy (EPP) refers to concurrent use of 10 or more daily medications.2
Studies indicate that polypharmacy is widespread among older adults. A meta-analysis of 54 studies estimated an overall prevalence of 37% in individuals over 65 years of age.3
Polypharmacy can be categorized based on the necessity and balance of risks versus benefits:4
Many studies confirm a dose-dependent, independent association between polypharmacy and increased mortality risk, even after adjusting for other factors like comorbidities and demographics. A meta-analysis of more than 24 studies found that polypharmacy increases the risk of death, with a relative risk of 1.28, meaning a 28% higher risk of all-cause mortality compared to those not on polypharmacy regimens.5
A large population-based study of nearly 3 million older adults found that polypharmacy (≥5 medications for over 180 days) was associated with a 63% increased risk of death (adjusted hazard ratio HR: 1.63) compared to those with no polypharmacy. For hyper-polypharmacy (≥10 medications), the risk of death was more than doubled to HR: 2.57.6
Polypharmacy significantly increases the likelihood of emergency visits and hospital admissions. One study showed that polypharmacy patients were 1.29-1.33 times more likely to be hospitalized or to visit the emergency room than those without polypharmacy – even after adjusting for the number of comorbidities.6 Chronic polypharmacy regimens (long-term use of five or more medications with higher daily doses) are linked to up to 61% increased hazard of hospitalization compared to those not on polypharmacy.7 Adverse drug reactions, drug-drug interactions, and inappropriate prescriptions are common in polypharmacy and play a significant role in increased hospitalizations.
Polypharmacy contributes to increased rates of falls, disability, and frailty. A longitudinal study published in BMJ found the rate of falls was 21% higher in people with polypharmacy compared with people without. Using a ≥four drug threshold, the fall rate was 18% higher in people with polypharmacy; using a ≥10 drug threshold, the rate was 50% higher over a two-year period.8
Polypharmacy is also strongly associated with an increased risk of disability and loss of disability-free survival (DFS), especially in older adults. Frail individuals exposed to polypharmacy face a hazard ratio (HR) for reduced DFS of approximately 4.24, meaning they are over four times more likely to experience death, dementia, or persistent physical disability compared to non-frail individuals without polypharmacy. Even pre-frail individuals with polypharmacy have an HR of about 2.21 for these outcomes.
Overall, polypharmacy increases the risk of functional decline, cognitive impairment, falls, and hospitalization – all major contributors to long-term disability. Studies link polypharmacy to a greater likelihood of developing geriatric syndromes, which directly contribute to increasing rates of disability.9
Polypharmacy is a common and complex issue in older adults, significantly influencing mortality, hospitalization, and disability risks. Its presence often reflects the burden of multiple chronic diseases and challenges in maintaining optimal care. For underwriters, reviewing medication patterns provides crucial insight into health stability and future risk potential. Continuous medication review and appropriate management can help mitigate these risks and enhance the quality of life in senior populations.
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