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Polypharmacy in long-term care

The evidence base

Prevalence figures in this field are quoted constantly and correctly almost never. The problem is not that the numbers are wrong. It is that they are quoted without the two things that give them meaning: which population, and by what definition.

Polypharmacy is a counting convention, not a diagnosis

“Polypharmacy” usually means five or more medications and “excessive polypharmacy” ten or more, but these are research conventions chosen for convenience. There is no clinical threshold above which something happens. A person on nine drugs each treating something active is in a different position from a person on six where three are treating the side effects of the other three.

What the figures actually say

European nursing homes

The SHELTER study surveyed 4,023 nursing home residents in 57 nursing homes across seven European countries and Israel, using a simple drug count. It found polypharmacy — five to nine drugs — in 49.7%, and excessive polypharmacy — ten or more — in 24.3%. Together, 74.0% were taking five or more medications.

Two cautions travel with that figure. It is often miscited as “eight European countries,” which is wrong. And it is a polypharmacy figure produced by counting drugs against no appropriateness criterion at all — it is not a measure of inappropriate prescribing and should never be used as one.

Community-dwelling US older adults

A serial cross-sectional analysis of the National Health and Nutrition Examination Survey, covering 6,336 US adults aged 65 and over, found polypharmacy — five or more prescription drugs — in 43.8% in 2017 to March 2020, up from 39.3% in 2011 to 2012. That rise was not statistically significant (p for trend = 0.32) and should not be described as a significant increase. Potentially inappropriate medication use, judged by Beers, was 14.7% in the same period, down from 17.0% — which the authors describe as no substantial change.

Note the population: NHANES samples the non-institutionalized. These figures describe older adults living in the community, not nursing home residents, and the two are not interchangeable.

US nursing homes

A nationally representative US nursing-home figure for potentially inappropriate prescribing as a whole is not something we were able to source to a publishable standard, and so this site does not publish one. What exists, and is solid, is class-specific.

  • Central nervous system polypharmacy. A cross-sectional study of 211,783 long-stay US nursing home residents aged 65 and over with fee-for-service Medicare, using 2021 assessment data linked to Part D, found 23.2% on three or more concurrent CNS-active medications for more than 30 days of continuous exposure. Gabapentin was the agent most frequently involved.
  • Antipsychotics. A 100% national assessment sample covering 3,741,379 long-term care residents aged 65 and over found antipsychotic prescribing fell from 23.0% to 14.4% in non-hospice residents between 2011 and 2017.
  • Benzodiazepines. Among US long-stay nursing home residents, short-acting benzodiazepine use declined from 12.1% in 2016 to 10.6% in 2018, while long-acting use stayed flat at around 4%. The criterion here was a prescription for at least 30 days during the quarter.
  • Proton pump inhibitors. Among Medicare Part A skilled-nursing admissions to 22 Midwestern US facilities between January 2010 and May 2011, 79.7% were prescribed a PPI and 65.3% of those had no appropriate diagnostic code for it. Even after counting chronic NSAID, aspirin and warfarin use as valid indications, 24% of all admissions received a PPI with no relevant gastrointestinal diagnosis.

Age is a weaker predictor than it looks

A 2026 systematic review and meta-analysis of 50 studies covering 210,514 participants found a pooled relative risk of medication-related hospital admission for adults 65 and over versus 16 to 64 of 1.64 (95% CI 1.15 to 2.35) — but with I² of 96%, wide prediction intervals, and GRADE certainty rated very low. The pooled mean age difference between medication-related and other admissions was 2.86 years and not statistically significant (p = 0.21). The authors conclude that age “is an unreliable predictor for medication-related admission without accounting for confounding and context.”

Deprescribing does happen

It is not the case that nothing changes. Following 1,843 nursing home residents on five or more medications, with a mean of 8.6 medications at baseline, deprescribing occurred in 658 residents — 35.7% — over twelve months. The presence of a geriatrician on facility staff predicted it (odds ratio 1.41, 95% CI 1.15 to 1.72).

How to read a prevalence figure

  1. Which population? Community-dwelling, long-stay nursing home, skilled-nursing admission, hospital inpatient — these are four different groups with different numbers.
  2. By what criterion? A drug count, a Beers-based judgment, a STOPP-based judgment, or an indication audit will give four different answers about the same people.
  3. Which year, and which country? Antipsychotic prescribing in US nursing homes fell by more than a third between 2011 and 2017; a 2011 figure describes a different world.
  4. Was it measured or modeled? Claims-based and assessment-based measures disagree, sometimes substantially.

Common questions

How many medications is too many?

There is no clinical threshold. “Five or more” is a research convention, not a limit, and the number of drugs matters far less than what each one is doing. What is measurable is pharmacologic load — anticholinergic and sedative exposure — which tracks physical function better than a count does. Reducing medication burden.

Are nursing home residents overprescribed?

On the specific classes where good data exist, there is clear evidence of prescribing without a supporting indication — most starkly for proton pump inhibitors. On potentially inappropriate prescribing as a whole in US nursing homes, we could not source a nationally representative figure and so do not publish one. Proton pump inhibitors.

Back to the evidence base.

References

  1. Onder G, Liperoti R, Fialova D, et al. Polypharmacy in nursing home in Europe: results from the SHELTER study. The Journals of Gerontology Series A. 2012;67(6):698–704. PMID 22219520 · DOI 10.1093/gerona/glr233.
  2. Pan S, Li S, Jiang S, et al. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011–2020. The Journals of Gerontology Series A. 2024;79(7):glae108. PMID 38644631 · DOI 10.1093/gerona/glae108.
  3. Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
  4. Gerlach LB, Fashaw S, Strominger J, et al. Trends in antipsychotic prescribing among long-term care residents receiving hospice care. Journal of the American Geriatrics Society. 2021;69(8):2152–2162. PMID 33837537 · DOI 10.1111/jgs.17172.
  5. Malagaris I, Mehta HB, Goodwin JS. Trends and variation in benzodiazepine use in nursing homes in the USA. European Journal of Clinical Pharmacology. 2022;78(3):489–496. PMID 34727210 · DOI 10.1007/s00228-021-03244-4.
  6. Patterson Burdsall D, Flores HC, Krueger J, et al. Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities. Journal of the American Medical Directors Association. 2013;14(6):429–432. PMID 23583000 · DOI 10.1016/j.jamda.2013.01.021.
  7. Munshi RM, Ni Sheachnasaigh E, Strugaru M, Olawoye F, Comiskey C, Grimes T. The association between age and medication-related hospital admission in adults: a systematic review and meta-analysis. International Journal of Clinical Pharmacy. 2026;48(4):1267–1283. PMID 42240819 · DOI 10.1007/s11096-026-02167-3.
  8. Onder G, Vetrano DL, Villani ER, et al. Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors. Journal of the American Medical Directors Association. 2019;20(9):1116–1120. PMID 30853425 · DOI 10.1016/j.jamda.2019.01.130.
  9. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.