Medication Misuse in an Aging Society: Pain, Cognitive Decline, and Polypharmacy

Immersion Experience

My immersion experience was at the Lebanon office of a passionate nonprofit with roots throughout Cincinnati, the Talbert House. The Talbert House actively works on both the prevention and treatment aspects of public health problems, including substance abuse and mental health disorders. This nonprofit is actively engaging in prevention techniques like education and resource distribution for community-specific issues of substance misuse, older adults raising their grandchildren, inadequate access to routine healthcare, mental health disorders in older adults, and confusion regarding new technology and medical system logistics. To combat these public health problems, the Talbert House distributes pill organizers at community events, gives lesson plans to grandparents for important talks with their grandchildren, helps fund a mobile free clinic, holds group sessions for older adults to recognize and combat mental health issues, and educates the community on resources available to help them navigate the healthcare system (like call centers). These prevention strategies are extremely successful, evidenced by the general community’s high regard for the Talbert House and the abundant funds they receive from the whole city of Cincinnati. Recently, in November 2024, Hamilton County passed, with a 63% approval rate, Issue 34.3 This issue supported an annual tax increase to fund family services and treatment programs provided by the Talbert House, estimated to generate $6.76 million a year.3 I had the opportunity to personally witness all of these prevention strategies in action and even designed an educational brochure on proper medication use, storage, and disposal, which was, and will continue to be, distributed to older adults at community events. While I was using these brochures to explain the importance of following prescription directions and using only medication prescribed to you, I was inspired to research why older adults are increasingly misusing medications. The adults I spoke with at the community event stressed their frustrations with their complicated medication regimen, which was constantly changing and not meeting their healthcare needs. In addition, older adults are frustrated with the time-consuming and expensive process of simply picking up their prescriptions and communicating with a pharmacy. Paired with my experience as a pharmacy technician, where I see countless older adults struggling with these issues every shift, I wondered why the United States is facing this public health problem and what can be done to both prevent and treat it. 

Introduction

The percentage of adults over the age of 65 continues to rise and will reach ⅕ of the United States population by 2030.4 Thus, public health issues concerning this demographic are of growing importance. With a rise in life expectancy, there is a proportional increase in the amount of lifetime medication use and the extent of medication use.4 In fact, middle-aged and older adults use prescription opioids at a higher rate than younger adults in the United States.5 This is mainly due to the fact that older adults often experience chronic pain associated with their burden of co-morbidities and the effects of aging on the body’s health.5 The degradation of health in the rising population of older adults in the United States has led to an increase in the amount of opioids prescribed and misused.4,5

Pain

National surveys have revealed that 57% of older adults, those 65 years of age and older, report chronic pain lasting longer than a year that is unrelated to cancer.4 Additionally, not even half of older adults experiencing pain are receiving effective pain management and treatment options from their primary care providers.4 The inadequate treatment of chronic pain in older adults can be attributed to a lack of physician training for treating pain and patients underreporting pain, impacted by the cultural attitudes surrounding the aging process in the United States.4 It is socially normal in the United States to deal with pain, and cultural attitudes tell older adults that pain is a normal part of the aging process, which cannot be managed or treated.4 Since most older adults experience pain attributed to age-related physiologic deterioration, many physicians question the effectiveness of medications in properly treating this pain.6 As a result, older adults are the most likely age group to receive undertreatment of their pain, leading to a decrease in their quality of life.6 This demographic has reported intentionally taking more medication than prescribed, and therefore non-adhering to the regimen, in an attempt to treat their pain or speed up recovery.7 

The opioid epidemic in the United States, which was declared a public health emergency in 2017, has certainly affected middle-aged and older adults. From 1999 to 2011, the rate of accidental opioid poisoning for older middle-aged adults had a six-times increase to 6.3 people per 100,000.8 Individuals struggling with chronic pain are at risk of suicide, opioid abuse, and overdose because of their dependence on opioids to manage their constant battle with the degeneration of their health.8 Chronic pain has been suggested as a common reason for prescription drug misuse and pain medication use for undiagnosed conditions. Yet, more information on the details of opioid misuse and diversion among older adults is necessary to fully understand the relationship between the United States' aging population and the opioid epidemic.

Cognitive Decline

A burden that further complicates the United States' healthcare system is prescription medication labels (PMLs).9 Older adults are less likely than younger adults to recall verbal information, which makes it even more difficult for them to understand their medication regimen.9 PMLs are incredibly important to reinforce directions that were given verbally to older patients, yet inclusive language is vital for labels to be understandable by all older adults, including low-literate and non-English speakers.9 Research in pharmaceutical settings has shown that simplifying medication information, improving readability, and adding additional information to prescription medication labels reduces the level of confusion for older adults.9 Verbal directions are important to continuously explain the importance of adhering to the medication regimens, as older adults' visual acuity may impair their ability to read PMLs.9 Even with clear directions, managing multiple medications, sometimes alone, is difficult for older adults. 

In addition to medication regimes being inherently confusing, the cognitive decline and memory loss associated with older demographics further impair their ability to adhere to prescription schedules.10,11 For older adults with dementia, which was 50 million individuals worldwide in 2015, experience forgetfulness, sensory deficits, and difficulty accessing and opening prescription vials.12 Older patients with cognitive impairment were shown to have a six-fold higher risk of nonadherence.12 Consequences of medication nonadherence include 33% to 69% of medication-related hospital admissions, compromises in the effectiveness of treatment plans, and increases in both the cost and burden of illness.12 Without a caregiver or other support at home, it is difficult for older adults, who have a high chance of experiencing some degree of cognitive impairment, to properly manage their medications.11 A study testing different interventions to improve medication adherence among older adults found voicemail reminders to significantly reduce the frequency of missed doses.11 As cognitive decline is an inevitable consequence of aging, it is crucial that the United State’s healthcare system assesses and improves medication adherence in order to most effectively care for older adults with multiple diseases, or taking multiple medications. 

Polypharmacy

Data from the early 2000s shows 61% of older adults in the United States were taking at least one prescription medication, and most were taking an average of 3-5 medications.7 From 1988 to 2010, the number of prescriptions that older adults were taking doubled from 2 to 4, and the percentage of adults taking 5 or more medications increased from 12.8% to 39%.13 The trends over the last few decades indicate that these numbers have and will continue to rise as more drugs are created and physicians attempt to treat the array of medical problems faced by our aging society. Although multiple medications are necessary to effectively treat the complex medical problems of older adults, a complicated medication regimen increases the risk of adverse drug events, medication misuse, and nonadherence.7 The rate of nonadherence in older adults ranges from 21% to 55%, attributed to multiple medications taken each day, confusion with medication directions, and intentional nonadherence because of drug side effects or adverse events.7 Therefore, both the prescribing physician and pharmacist must explain why it is harmful if any medications are not taken as prescribed. Other effective methods for improving adherence to medication regimens are pill organizers, calendar blister packs, and locked automatic pill dispensers.14

In addition to nonadherence, further complications associated with polypharmacy, which is the use of multiple medications at the same time, include an increased risk of cognitive impairment, impaired balance, and adverse drug reactions.15 Adverse drug reactions are unintended harms as a result of medications, which account for a significant number of hospitalizations.15 Individuals on more medications have a higher frequency of healthcare visits, have a greater number of chronic health conditions, and have more confusion and memory problems than those on fewer medications.13 The negative side effects of polypharmacy are specifically concerning older adults who are already susceptible to chronic health conditions, medication burden, and physical and cognitive decline.13

Future Directions and Possible Solutions

As previously analyzed, older adults are the largest prescription medication users, yet are underrepresented in clinical trials that test the efficacy of possible new medications.15 This can be attributed to the fact that most clinical trials’ inclusion criteria exclude older adults, even though they have higher rates of common medical problems like diabetes and hypertension.15 Although research is abundant on the impacts of medications for individuals with these conditions, information specific to older adults is lacking. This makes it more difficult to design medication regimens that are safe and effective for this specific demographic. Thus, more research needs to be conducted that ethically includes older adults in the study design to understand the effects of polypharmacy and specific medications on the unique health challenges of older adults. Additionally, pharmacists can complete medication reviews to help reduce polypharmacy by seeing potential overlap in prescription effects missed by prescribers and communicating suggestions to practitioners that can reduce the overall number of medications older adults are taking.15 This is also an additional opportunity to review a patient’s medication schedule with them to promote adherence and eliminate confusion. Screening older adults can also help identify potentially inappropriate medications to reduce the cost and confusion related to drugs and the pharmacy itself.15 As previously mentioned, automatic pill dispensers, calendar blister packs, voicemail reminders, and illustrated medication schedules are existing interventions to improve medication adherence, which have the potential to help all older adults self-manage their prescriptions if these interventions are properly advertised and distributed.11,14

Conclusion

With older adults projected to compose ⅕ of the United States population by 2030, the use of prescription medications will only continue to rise.4 Although polypharmacy is very common for older adults, their complicated medication regimen does not properly treat their chronic pain.4,6 Consequently, older adults are at a greater risk of misusing medications to alleviate untreated pain, which can result in adverse health events and even overdoses.7,8 Complicated medication regimens make it difficult for older adults, especially those lacking additional support or care, to manage their medications on their own.11 Verbal reminders, an increase in the availability and accessibility of healthcare providers like pharmacists, and calendar pill organizers are effective methods to improve medication adherence and general understanding.11,14 As new medications continue to be developed, it is crucial to complete medication reviews to reduce polypharmacy when appropriate, as this will decrease the risks associated with medication use and misuse.15 Although there has been more research on medication misuse in older adults in recent years, there is still a need for more studies to evaluate the efficacy and effectiveness of polypharmacy in older adults and the potential benefits of interventions aiding in medication adherence. 

Connection to Global Health

My original spark to research the health inequities of older adults came from the interactions I had with frustrated individuals while interning at The Talbert House. This inequity is abundant, yet hidden. Across the United States, older adults are struggling with managing their complex medication regimen, which is further exacerbated when they lack support from a caregiver, pharmacist, or other healthcare professional. Older adults have unique needs due to their degenerating physical and mental health, which are not being met by the current lack of support and resources to help them manage their medications. As their number of prescriptions increases, their pain goes untreated. 

References

1. Lebanon City, Warren County, Ohio - Census Bureau profile. (2024). https://data.census.gov/profile/Lebanon_city,_Warren_County,_Ohio?g=060XX00US3916542364  

2. Kollar GG and M. Income in the United States: 2023. Census.gov. August 30, 2024. Accessed April 5, 2025. https://www.census.gov/library/publications/2024/demo/p60-282.html.  

3. Hamilton County, Ohio, issue 34, Family Services and treatment programs tax measure (November 2024). Ballotpedia. Accessed April 5, 2025. https://ballotpedia.org/Hamilton_County,_Ohio,_Issue_34,_Family_Services_and_Treatment_Programs_Tax_Measure_(November_2024).  

4. Levi-Minzi MA, Surratt HL, Kurtz SP, Buttram ME. Under Treatment of Pain: A Prescription for Opioid Misuse Among the Elderly? Pain Med. 2013;14(11):1719-1729. doi:10.1111/pme.12189

5. Han BH, Sherman SE, Palamar JJ. Prescription opioid misuse among middle-aged and older adults in the United States, 2015–2016. Preventive Medicine. 2019;121:94-98. doi:10.1016/j.ypmed.2019.02.018

6. Bruckenthal P, Reid MC, Reisner L. Special Issues in the Management of Chronic Pain in Older Adults. Pain Med. 2009;10(suppl 2):S67-S78. doi:10.1111/j.1526-4637.2009.00667.x

7. Willlams CM. Using medications appropriately in older adults. Am Fam Physician. 2002;66(10):1917-1924. 

8. Ates Bulut E, Isik AT. Abuse/Misuse of Prescription Medications in Older Adults. Clinics in Geriatric Medicine. 2022;38(1):85-97. doi:10.1016/j.cger.2021.07.004

9. Suppiah SD, Tan YW, Tay SSC, et al. Challenges encountered by pharmacy staff in using prescription medication labels during medication counselling with older adults and solutions employed: A mixed-methods study. Exploratory Research in Clinical and Social Pharmacy. 2023;9:100226. doi:10.1016/j.rcsop.2023.100226

10. Cotrell V, Wild K, Bader T. Medication Management and Adherence Among Cognitively Impaired Older Adults. Journal of Gerontological Social Work. 2006;47(3-4):31-46. doi:10.1300/J083v47n03_03

11. Kröger E, Tatar O, Vedel I, et al. Improving medication adherence among community-dwelling seniors with cognitive impairment: a systematic review of interventions. Int J Clin Pharm. 2017;39(4):641-656. doi:10.1007/s11096-017-0487-6

12. El-Saifi N, Moyle W, Jones C, Tuffaha H. Medication Adherence in Older Patients With Dementia: A Systematic Literature Review. Journal of Pharmacy Practice. 2018;31(3):322-334. doi:10.1177/0897190017710524

13. Charlesworth CJ, Smit E, Lee DSH, Alramadhan F, Odden MC. Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988–2010. GERONA. 2015;70(8):989-995. doi:10.1093/gerona/glv013

14. Pinto JF, Vilaca JL, Dias NS. A Review of Current Pill Organizers and Dispensers. In: 2021 IEEE 9th International Conference on Serious Games and Applications for Health(SeGAH). IEEE; 2021:1-8. doi:10.1109/SEGAH52098.2021.9551894

15. Kwan D, Farrell B. Polypharmacy: Optimizing Medication Use in Elderly Patients. CGS Journal of CME. 2014;4(1):21-27. https://www.CanadianHealthcareNetwork.ca