Polypharmacy is getting younger: what pharmacists need to know

Polypharmacy is thought of as a problem of aging but increasingly younger patients are being prescribed a number of medications, sometimes by different clinicians. Pharmacist Shilpa Patel sets out what needs to be considered for this group of patients

You’re halfway through a medication review when something doesn’t quite sit right.
The patient in front of you is 38. They look well. They’re working, raising a family, getting on with life. But their medication list tells a different story.

Six regular medicines. Two pro re nata – as needed – medicines. Prescribed by three different clinicians. And suddenly you realise; this isn’t what polypharmacy is supposed to look like.

Polypharmacy is usually framed as a problem of ageing. We think about frailty, falls risk and care home medication rounds. But increasingly, the medication lists I review at WellBN GP practice tell a different story.

Patients aged in their 30s and 40s are presenting with six, seven or more regular medicines. They are working, parenting and outwardly functioning, so their medication burden is rarely labelled as polypharmacy. Yet the clinical risk is real and growing.

For community and practice pharmacists, this is an area we cannot afford to overlook.

Why polypharmacy in younger adults is a growing issue

There are several drivers behind this shift.

First, long-term conditions are being diagnosed earlier and managed more intensively. Patients with type 1 diabetes, inflammatory bowel disease, rheumatoid arthritis or epilepsy may accumulate complex regimens over decades.

Second, mental health prescribing has increased significantly. Antidepressants, antipsychotics, mood stabilisers and anxiolytics are often layered over time. Add medication for sleep, neuropathic pain or migraine, and the list grows quickly. Studies show that mental health conditions are strongly associated with higher levels of polypharmacy across age groups.¹

Third, chronic pain management frequently involves multiple drug classes. Opioids, gabapentinoids, antidepressants and non-steroidal anti-inflammatory drugs may sit alongside proton pump inhibitors and laxatives prescribed to manage adverse effects.

Finally, care is often fragmented. A younger patient may see a general practitioner, a psychiatrist and one or more hospital specialists. Each prescribing decision may be clinically reasonable in isolation, but the cumulative effect is not always reviewed holistically.

Multimorbidity is also increasing in working-age adults, further contributing to medication burden.²

What makes this different to older adults

In older adults, polypharmacy is expected. Structured medication reviews are routine, and risks such as falls and anticholinergic burden are actively considered.

In younger adults, the red flags are less obvious.

A 35-year-old reporting fatigue may be told it is work stress. Poor concentration may be attributed to lifestyle. Emotional blunting may be seen as part of depression rather than a medication effect. Subtle sedation or cognitive slowing may not trigger review in the same way it would in an older patient.

There is also less policy focus on this demographic. National polypharmacy guidance often centres on frailty and older populations, despite clear evidence that medication burden is increasing earlier in life.^3,4

The risk is that we normalise complex regimens in younger people because they appear resilient.

The role of pharmacists

Pharmacists are uniquely positioned to identify this issue.

In community pharmacy, we often see the full dispensing history. We notice incremental additions, early repeat requests and patterns of use over time. We also hear directly from patients about how medicines are affecting their daily lives.

In general practice, structured medication reviews provide an opportunity to step back and assess the whole regimen. We are not limited to one specialty lens and can consider the cumulative impact of treatment.

Practical steps include:

• Reviewing indication, duration and ongoing benefit for every medicine
• Checking for prescribing cascades
• Considering cumulative sedative or anticholinergic effects
• Identifying duplication across specialties
• Exploring non-pharmacological alternatives where appropriate

Prescribing cascades, where medicines are added to treat side effects of other medicines, are a recognised contributor to problematic polypharmacy and should be actively considered.⁵

Clinical red flags in younger adults

Red flags in this group are often functional rather than clinical.

Look out for:

• Persistent fatigue or “brain fog”
• Reduced work performance or increased sickness absence
• Emotional blunting or reduced motivation
• Multiple prescribers with no clear lead clinician
• Medicines added to manage side effects of other medicines
• Repeated dose escalation without clear benefit

When a patient says, “I just don’t feel like myself anymore,” it is worth reviewing the full regimen.

Example cases

A woman in her late 30s attended for a structured medication review. She was prescribed an antidepressant, a low-dose antipsychotic for sleep, a gabapentinoid for back pain, a proton pump inhibitor and intermittent opioid analgesia. She described constant tiredness and difficulty concentrating at work.

Individually, each medicine had been started for a reason. Together, they were contributing to sedation and poor functioning. A gradual deprescribing plan was agreed with her general practitioner, alongside referral to physiotherapy and psychological therapy for pain management. Over several months, her regimen was simplified and her daytime alertness improved.

Another patient in his early 40s with inflammatory arthritis was prescribed disease-modifying therapy, non-steroidal anti-inflammatory drugs, a proton pump inhibitor and an antidepressant for low mood related to chronic pain. He was also using a benzodiazepine intermittently for anxiety.

A joint review identified opportunities to rationalise treatment and strengthen non-drug approaches, including exercise therapy and structured pain management. The focus shifted from adding medicines during flare-ups to reviewing overall burden.

In both cases, no single prescription was inappropriate. The issue was cumulative complexity.

What we can do to address the problem

First, we need to widen our definition of polypharmacy. Five or more medicines in a 40-year-old warrants the same level of clinical curiosity as in an older patient.

Second, proactive review is essential. Do not wait for a crisis. Use repeat prescription reviews, new patient checks and structured medication reviews as opportunities to assess total burden.

Third, ask outcome-focused questions. What is this medicine achieving? How would we know if it was no longer needed? Are side effects outweighing benefits?

Fourth, collaborate effectively. Communication between community and practice pharmacists and general practitioners is key to preventing duplication and inappropriate continuation.

Finally, empower patients. Many assume more medicines mean better care. Explaining that simplification can improve quality of life is often well received.

Conclusion

Polypharmacy is no longer confined to older age. Younger adults with mental health conditions, chronic pain and lifelong illnesses are accumulating complex regimens earlier in life.

For pharmacists in community and general practice, this presents both a challenge and an opportunity. By recognising subtle red flags, conducting thorough reviews and initiating earlier deprescribing conversations, we can reduce long-term harm and improve day-to-day functioning.

Polypharmacy may be getting younger. Our vigilance needs to adapt accordingly.

Key take-home messages

• Polypharmacy is increasingly affecting younger adults, particularly those with mental health conditions and chronic pain
• Red flags are often subtle and functional rather than clinical
• Pharmacists are well placed to identify cumulative medication burden
• Prescribing cascades should be actively considered during reviews
• Early, proactive deprescribing can improve quality of life

Shilpa Patel is a pharmacist and GP practice partner at WellBN, Brighton, East Sussex and is a member of The Pharmacist's editorial board.