Polypharmacy is the rule rather than the exception in older adults with schizophrenia. Decades of treatment for psychiatric and medical conditions accumulate. Cardiologists add medications for hypertension and lipid control. Endocrinologists add medications for diabetes. Primary care adds medications for reflux, pain, and sleep. Psychiatrists add anticholinergics for movement side effects, hypnotics for insomnia, and sometimes a second antipsychotic. By the time someone reaches 70, a list of 10 or 12 medications is common.
Polypharmacy in older adults with schizophrenia raises the risk of falls, cognitive decline, drug interactions, and death — and a structured review using tools like the Beers Criteria is essential at every transition of care.
Why polypharmacy is dangerous
- Each additional medication increases the risk of adverse drug events
- Drug-drug interactions multiply geometrically with each additional drug
- Anticholinergic burden accumulates across multiple medications and worsens cognition and falls
- Adherence decreases as the regimen gets more complex
- Cost rises, often pushing patients to skip doses
- Hospitalization can lead to a cascade of new prescriptions that are never reviewed
The prescribing cascade
One of the most common patterns in geriatric medicine is the prescribing cascade: a side effect of one medication is treated as a new symptom and gets its own medication. Examples:
- Antipsychotic causes parkinsonism → benztropine added
- Benztropine causes dry mouth and constipation → laxative and saliva substitute added
- Anticholinergic burden causes confusion → cholinesterase inhibitor considered
- Cholinesterase inhibitor causes diarrhoea → antidiarrhoeal added
Each added drug is well-intentioned, but the underlying problem — too high a dose of the original antipsychotic, or the wrong choice for an older adult — is often missed.
The Beers Criteria as a checklist
The American Geriatrics Society Beers Criteria identifies medications that are commonly problematic in older adults. Categories particularly relevant to schizophrenia care include:
- Strong anticholinergics — first-generation antihistamines, oxybutynin, benztropine, trihexyphenidyl, low-potency first-generation antipsychotics
- Benzodiazepines — increased risk of falls, fractures, delirium, and cognitive impairment
- Z-drugs (zolpidem, zaleplon, eszopiclone) — similar concerns
- NSAIDs — bleeding and renal risk
- Tricyclic antidepressants — anticholinergic and cardiac risks
Beers does not say these drugs are forbidden — it asks for justification.
Anticholinergic burden
Many medications used in psychiatric care have anticholinergic activity. Even individually small effects add up. Validated scales (the Anticholinergic Cognitive Burden Scale, the Drug Burden Index) can quantify this. High anticholinergic burden in older adults is associated with:
- Cognitive impairment and confusion
- Increased fall risk
- Constipation, urinary retention, dry mouth
- Worsening of underlying dementia or schizophrenia cognitive symptoms
- Possibly increased dementia risk over years of use
Antipsychotic polypharmacy
Using two or more antipsychotics simultaneously is common in chronic schizophrenia care. Evidence does not strongly support this practice for most patients, and it raises side effect risk. NICE and most consensus guidelines recommend limiting antipsychotic polypharmacy to specific clinical situations — most often during a slow cross-titration. In older adults, the case for simplifying down to one antipsychotic is even stronger.
How to do a medication review
- Get the actual list. Ask the patient to bring every bottle — including over-the-counter, supplements, and as-needed medications.
- Match each medication to an indication. If you can't find the indication, ask why it's still being used.
- Apply the Beers Criteria. Flag everything that's potentially inappropriate.
- Calculate anticholinergic burden. Use one of the validated scales.
- Look for the prescribing cascade. Ask whether any medication is treating a side effect of another.
- Identify deprescribing candidates. Start with the highest-risk lowest-benefit items.
- Plan a slow taper. Most psychotropic deprescribing should be gradual, with monitoring for symptom return.
- Coordinate. Loop in the primary care provider and any specialists.
An older adult develops sudden confusion, falls, urinary retention, or severe constipation after a medication change — these can be signs of a serious medication interaction or anticholinergic toxicity.
What families can do
- Maintain a single up-to-date medication list and bring it to every appointment
- Use a single pharmacy if possible
- Ask about the indication for each medication at least annually
- Ask whether each medication is still needed
- Push for a Brown Bag Review at care transitions, especially after hospitalization
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.