Walk into most residential aged care facilities in Australia and you will find residents taking not five, not eight, but ten or more medicines every single day. Some take considerably more. It has become so normalised that many care teams barely notice. But the evidence is substantial and growing: polypharmacy is one of the most significant and underaddressed clinical risks in aged care, linked to falls, hospitalisation, delirium, cognitive decline and increased mortality in the oldest and most frail residents -- yet it continues to receive far less attention than the conditions it is prescribed to treat.

The Scale of the Problem

Polypharmacy is generally defined as the concurrent use of five or more medicines. In residential aged care, this threshold is almost a baseline. The Australian Commission on Safety and Quality in Health Care reports that about two-thirds of Australians aged 75 and over take five or more medicines, including over-the-counter and complementary products. Among residential aged care residents, the burden is far higher. A 2025 study in the Australasian Journal on Ageing estimated polypharmacy affects up to 91% of people in residential facilities, with some residents prescribed up to 25 medicines simultaneously.

This is not simply a reflection of residents' complex clinical needs. It is also a reflection of fragmented prescribing, inadequate review processes, and a healthcare system that has historically been better at adding medicines than stopping them.

Why Polypharmacy Is Different in This Population

In younger adults, managing multiple medicines for multiple conditions is often entirely appropriate. In frail older adults, the same approach carries different risks. Physiological changes associated with ageing, such as reduced kidney and liver function, altered body composition, lower albumin levels and slower drug metabolism, mean that medicines behave differently in older bodies. Doses calibrated for a 65-year-old may be significantly more potent in a 90-year-old.

The risks compound with each additional medicine. Drug-drug interactions become increasingly likely. Medicines prescribed to treat the side effects of other medicines, a phenomenon known as a prescribing cascade, add further layers of risk. Falls, delirium, constipation, urinary retention, excessive sedation and hospitalisation are among the most common downstream consequences.

Anticholinergic and sedative medications are of particular concern. Research from Australian aged care settings has found that more than half of residents are prescribed at least one potentially inappropriate medication, with antipsychotics, benzodiazepines and opioids among those most frequently implicated. The Royal Commission into Aged Care Quality and Safety identified a clear overuse and significant over-reliance on chemical restraint in residential aged care, with inappropriate antipsychotic prescribing among the three issues prioritised for immediate action -- a finding that brought lasting attention to prescribing culture in residential facilities.

A System That Struggles to Review

Despite well-established risks, medication review in residential aged care remains inconsistently implemented. Australia has had a federally funded Residential Medication Management Review (RMMR) program since 1997, designed to give pharmacists a formal role in reviewing residents' medicines. Yet a systematic review of medication reviews in Australian residential aged care found that GPs accepted pharmacist recommendations to resolve medication-related problems in only 45 to 84% of cases, and actual implementation rates were lower still.

The barriers are real and systemic. Time pressures on GPs visiting facilities, limited communication between multiple prescribers, reluctance to stop medicines that have been prescribed for years, and concerns about withdrawal effects all contribute. Residents or their families may also resist change, particularly when medicines feel like a form of security or continuity.

The good news is that new funding introduced in 2024 for onsite pharmacists in residential aged care facilities represents a meaningful step forward. Onsite pharmacists are better positioned to identify medication-related problems in real time, build relationships with nursing staff and GPs, and support a more proactive approach to medication review, rather than the episodic, review-on-request model that has dominated.

Deprescribing: The Evidence Is There

Deprescribing, the intentional, supervised withdrawal of inappropriate or no-longer-needed medications, has a growing evidence base in aged care. A 2025 scoping review published in the Australasian Journal on Ageing, which examined 13 Australian studies covering more than 133,000 residents, found that successful deprescribing interventions consistently involved multidisciplinary teams, had an educational component, engaged nursing staff, and followed residents longitudinally.

Importantly, the most successful studies were not physician-led alone. Pharmacist-led medication reviews using evidence-based algorithms have demonstrated that 77% of deprescribing recommendations are accepted by GPs, and 74% of those are successfully implemented within 12 months. The most common reason for deprescribing? The medicine was simply no longer needed.

A cost-consequence analysis of the Australian Opti-Med deprescribing trial found that the cost of the intervention was more than offset by medicines savings, with a potential net saving to the health system of $1 to $16 million per annum if applied nationally. The clinical and economic case for deprescribing in aged care is strong.

What Clinicians Can Do

For nurses, allied health professionals and GPs working in aged care, polypharmacy demands active attention rather than passive acceptance. Some practical starting points:

Treat any new symptom as a potential drug side effect before adding another medicine. Falls, confusion, constipation and urinary incontinence are all commonly medication-related in this population and are frequently managed by prescribing further medicines rather than reviewing existing ones.

Use structured medication review as a clinical trigger, not just an administrative task. The Residential Medication Management Review (RMMR) and Home Medicines Review (HMR) programs exist to support this work. Engage the pharmacist as a clinical partner.

Involve residents and families in conversations about deprescribing. Research consistently shows that older Australians are generally receptive to stopping medicines when the conversation is approached thoughtfully, nearly 80% are willing to deprescribe if their doctor recommends it.

For residents with advanced dementia or who are receiving palliative care, revisit the goals of preventive medicines. Statins, antihypertensives and bisphosphonates prescribed for long-term risk reduction may have little relevance, and real burden, in a person approaching the end of life.

A Cultural Shift, Not Just a Clinical One

Addressing polypharmacy in aged care is not only a matter of clinical skill. It requires a cultural shift in how the sector thinks about medicines, moving away from the idea that more treatment equals better care, and toward a more honest reckoning with what medicines can and cannot achieve in the oldest and most frail members of our community.

The medicines cabinet is one of the most powerful tools in aged care. Used well, it relieves suffering and supports function. Used without regular scrutiny, it can quietly become one of the greatest sources of harm.