It shouldn’t be.
Hannah McQueen is a chartered accountant with a Master’s in Taxation Law, the founder of enable.me, and founder/CEO of Age Brightly. Photo / Michael Craig
The five giants of ageing, and the one we overlook
This is not an argument against medication. Many treatments are necessary and lifesaving. The issue is not their use, but continuation beyond when they stopped being beneficial, or the accumulation of inappropriate medications.
In geriatric medicine, the “five giants of ageing” describe the forces most likely to strip people of independence: immobility, falls, incontinence and cognitive decline. The fifth, often overlooked, is harm caused by medical care, particularly medications.
As we age, some medications become more problematic. The more you take, the greater the risk of harm, and that risk rises exponentially. This is known as polypharmacy, commonly defined as five or more regular medications.
In New Zealand, polypharmacy increases with age, meaning many older adults move into higher risk categories of eight or even 10 medications.
Polypharmacy does not sit alongside the other giants. It fuels them.
When more medications create more risk
Polypharmacy doesn’t look dangerous at first. Each medication is usually prescribed for a good reason and a single condition. But over time, our needs change, and what was once appropriate may no longer do more good than harm.
Clinical pharmacist prescriber Julia Brookes says ageing makes us more sensitive to medications, not less. The brain becomes more vulnerable, increasing the risk of confusion, drowsiness and instability.
At the same time, the body slows. The kidneys and liver clear medications less efficiently, allowing them to linger longer. What was once an appropriate dose can quietly become too much.
When multiple medications are layered into that environment, the risk does not simply add up; it compounds.
The number of medications a person takes is now recognised as the single greatest predictor of adverse drug events. Not age, not diagnosis, simply the count. These events, from dizziness and confusion to serious bleeds or fractures, are a leading cause of hospitalisation in older adults.
The risk rises sharply. With two medications, the likelihood of an adverse event is about 13%. At five, it jumps to 58%. At seven or more, it reaches 82%. Five medications marks the tipping point where harm accelerates with each additional prescription.
Half of older New Zealanders are already beyond that point, with higher risk in urban populations and Māori.
The fall that changes everything
Medication-related harm is often misinterpreted because it is subtle. Symptoms such as fatigue, poor sleep, confusion, low mood or unsteadiness are commonly accepted as ageing; endured, but frequently the first indicators of a problem.
The consequences become clear when those small shifts lead to something more serious, most often, a fall.
Brookes says “being on five or more medications increases the risk of falling by around 75%. Not because people suddenly become frail, but because medications interfere with balance, blood pressure and alertness”.
And the fall itself is rarely the end of the story. It is the beginning of a cascade. A fracture leads to hospitalisation. Time in hospital leads to rapid loss of strength. Confidence drops. Independence slips. For many, this is the point where life changes, from living independently to needing ongoing care.
This is where the five giants converge. A medication contributes to instability. Instability leads to a fall. A fall leads to immobility. Immobility accelerates physical and cognitive decline. What looks like a series of separate events is often deeply connected.
When ageing isn’t the cause
Medication-related harm is often misread. Symptoms such as fatigue, poor sleep, confusion, low mood or unsteadiness are easily dismissed as ageing or treated with another prescription.
Brookes challenges this. New symptoms should first be considered a medication side effect until proven otherwise.
The healthcare system makes this difficult. GPs oversee medications but face tight timeframes and growing complexity. Specialists add treatments, but the full picture is not always revisited. Prescriptions and prescribers accumulate, and context is lost. When medication lists reach double digits, proper review becomes a specialist task, hard to do in a standard 15-minute appointment.
No one intends harm. But the outcome can still be harmful.
The preventable accelerator we ignore
Ageing well is often framed around lifestyle, nutrition, exercise, social connection, and maintaining vision and hearing. These are critical, but there is growing recognition of the “preventable accelerators of decline”, factors that speed up ageing but can be modified.
Medications sit firmly among them.
When optimised, they support health and independence. When they are not, they can accelerate decline just as effectively as poor nutrition, inactivity or hearing loss.
The question that protects independence
The goal, as Brookes describes it, is precision, ensuring each medication remains necessary, effective and appropriate, and that no more are taken than needed. In practice, that means aiming for the least number of medications doing exactly the right job.
Instead of looking for a new diagnosis when something changes, for older adults there is value in asking, “could this be my medication?”
It is a simple question, but one that can change outcomes profoundly.
Julia Brookes’ five rules for medications
1. Know what you’re taking – and why
If you can’t explain what each medication is for, you’re taking risk without understanding the benefit.
2. Take them exactly as prescribed
Timing, dose and combinations matter. Getting it wrong can reduce benefit or increase harm.
3. Question every new symptom
Don’t assume it’s ageing. Start with: could this be a medication side effect?
4. Review them regularly
Medications get added over time. Unless they’re reviewed, unnecessary risk builds.
5. Speak up and ask questions
If something feels off or unclear, ask. If you don’t, problems can easily be missed.
Hannah is the founder and director of Age Brightly. She is also the host of The Next Bit podcast on iHeart Radio.