Category: Medication safety

Our attendants and the families we work with spend hours a day in the same homes. They are the ones who see someone steady themselves on the door frame getting out of bed, or sit back down halfway through standing up. Almost none of that reaches a clinic, because a blood pressure taken seated in an office after a five-minute rest is a measurement of a situation that never happens at home.

That gap matters, because the medication list is among the most common reversible causes of serious harm in later life — and the earliest signs of it are behavioral, not numerical.

How a medication list grows without anyone deciding to grow it

Polypharmacy — commonly defined as five or more regular medications — is rarely the result of a single bad decision. It is the accumulated residue of many reasonable ones.

A cardiologist starts a blood pressure medication. A year later a hospital adds a second during an admission. A primary care physician adds a statin. A urologist adds an alpha-blocker. Each prescriber is acting correctly within their own remit, each drug was right on the day it was written, and nobody owns the list as a whole. Meanwhile the person taking it has lost fifteen pounds, become less active, and their kidneys clear drugs more slowly than they did at 68.

The dose has not changed. The patient has.

The specific mechanism: orthostatic hypotension

This is the pathway worth understanding properly, because it is the one that ends in a hip fracture.

Orthostatic hypotension is a fall in blood pressure on standing — formally, a drop of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing up. It affects roughly one in five community-dwelling older adults, and reviews of the condition identify medications as the leading contributing factor.

What it looks like in a home is not a number. It is a few seconds of gray-out on standing, a hand reaching for furniture, a complaint of lightheadedness on the way to the bathroom at night. Some people get aching across the neck and shoulders — the so-called coat-hanger distribution — or blurred vision rather than obvious dizziness.

The consequences are not proportionate to how minor it looks. Orthostatic hypotension is associated with a substantial increase in falls, and reviews report up to a 50 percent increase in the relative risk of all-cause mortality. A hip fracture at 80 carries a risk of death and of permanent loss of independence that has nothing to do with blood pressure at all. The medication preventing a stroke can cause the event that ends independent living.

Antihypertensives: named in the guidelines, specifically

This is not a fringe concern raised by sceptics. Two of the most widely used prescribing-safety frameworks in geriatric medicine call out particular blood pressure drug classes by name.

• The AGS Beers Criteria — the American Geriatrics Society’s expert-consensus list of medications often inappropriate in older adults — identifies a high risk of orthostatic hypotension and related harms with certain antihypertensive classes, and does not recommend them as routine treatment for hypertension in this population.
• The STOPP/START criteria, updated to their third version in 2023, recommend stopping alpha-blockers and centrally acting agents in people at risk of falls, precisely because the resulting vasodilatation produces postural hypotension.

Neither framework argues that older people should not have their blood pressure treated. Both argue that which drug, at what dose, deserves review as the person changes.

More on blood pressure monitoring in older adults →

Statins: a real trade-off, not a scandal

Statins deserve a place in this discussion for a different reason, and it is one that gets lost between two bad arguments — that they are miracle drugs, or that they are a fraud. Neither is true.

Statins increase the risk of new-onset type 2 diabetes. This is established and uncontested:

• In February 2012 the FDA added a class-wide safety label change to statins, warning of increases in HbA1c and fasting blood glucose.
• A collaborative meta-analysis of randomized statin trials published in The Lancet in 2010 found roughly a 9 percent increase in incident diabetes.
• An individual-participant-data meta-analysis published in 2024 in The Lancet Diabetes & Endocrinology confirmed effects on both new-onset diabetes and worsening glycemic control.

The risk is higher with intensive dosing and concentrated in people already near the diabetes threshold — which describes a large share of the older population. Cardiology bodies including the American College of Cardiology hold that for patients at meaningful cardiovascular risk the benefit still outweighs this harm, and that remains the mainstream position.

But “outweighs” describes a trade-off, not an absence of harm. A person taking a statin for primary prevention at 84, with a limited life expectancy and a fasting glucose creeping upward, is in a genuinely different position from a 58-year-old who has already had a heart attack. Both may be prescribed the same drug.

More on cholesterol in older adults →

Deprescribing is a discipline with formal tools

Deprescribing — the planned, supervised reduction or withdrawal of medication that no longer earns its place — is not the absence of treatment. It is a recognized part of good geriatric practice, with published instruments behind it.

• AGS Beers Criteria. Medications often inappropriate in older adults because harms outweigh benefits at that age.
• STOPP/START, version 3 (2023). A systems-based review covering both potentially inappropriate medications and potential prescribing omissions — it flags what is missing as readily as what should stop.
• STOPPFrail. Aimed at people with limited life expectancy, where a preventive medication’s time to benefit may exceed the time available.

That last concept is the one families find most clarifying. A drug that prevents events over ten years offers little to someone whose prognosis is two — while its side effects, including falls, arrive immediately. Weighing that is a clinical judgment, but it is a legitimate one, not a form of giving up.

What to watch for, and report

This is the part that belongs to whoever is in the house. None of it requires clinical training — it requires being present and paying attention.

Ask for a medication review

Families are often unsure whether they are allowed to raise this. They are. A structured medication review is ordinary care, not a challenge to the prescriber.

1. Gather everything into one bag — prescriptions, over-the-counter medicines, supplements, eye drops, creams, and anything prescribed by a specialist the primary physician may not know about. Supplements matter; they interact.
2. Take the bag to the appointment rather than a list from memory. What is in the cupboard and what is on the record are frequently different.
3. Bring your written observations — dates, times of day, what happened.
4. Ask three questions: what is each of these still for; which of them could be contributing to the dizziness or falls; and is there anything here we could reduce or stop.
5. Ask what to expect if something is changed, and what should prompt a call back.

What not to do

Sources

• U.S. Food and Drug Administration — 2012 class-wide statin safety label change on HbA1c and fasting glucose (summarized by the American College of Cardiology)
• Sattar N et al., The Lancet 2010 — Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials
• The Lancet Diabetes & Endocrinology 2024 — Effects of statin therapy on new-onset diabetes and worsening glycaemia: an individual participant data meta-analysis
• American Geriatrics Society — AGS Beers Criteria for potentially inappropriate medication use in older adults
• O’Mahony D et al., European Geriatric Medicine 2023 — STOPP/START criteria for potentially inappropriate prescribing in older people: version 3
• European Geriatric Medicine — Centrally acting antihypertensives and alpha-blockers in people at risk of falls
• American Family Physician 2022 — Orthostatic hypotension: a practical approach
• Journal of General Internal Medicine — Antihypertensive deprescribing in older adults: a practical guide
• CDC — Older adult fall data

Hypertension is one of the most common conditions in older adults; research has put the prevalence among Western populations over 60 at around 60 percent. It is so routine that the diagnosis, once made, often stops being questioned — and so does the prescription.

What the study found

A study published in Age and Ageing analyzed more than 11,000 patients over the age of 70 and found that a substantial number — over 1,200 of them — were taking antihypertensive medication while measuring hypotensive, meaning their blood pressure was below the normal range rather than above it.

The researchers linked persistent low blood pressure in this group to increased mortality and hospital admission.

Why this happens

It is rarely anyone’s mistake in particular. It is what happens when a correct decision is never revisited. Blood pressure genuinely falls with age, with weight loss, with illness, and with reduced activity. A dose that was right at 68 can be too much at 78, and nobody notices unless somebody measures.

The consequences of overshooting are not abstract in an older person: dizziness on standing, falls, fainting, confusion, and hospital admissions that follow from those.

The path from an over-tight dose to a broken hip

It is worth spelling out the mechanism, because “blood pressure a bit low” sounds harmless and the endpoint is not.

An antihypertensive dose that is too much for the person taking it produces orthostatic hypotension — blood pressure dropping on standing. That causes dizziness, unsteadiness and fainting, most often on getting out of bed or up from a low chair. In an older adult that means falls; falls mean fractures and head injuries; and a hip fracture at 80 carries a mortality and loss-of-independence risk that has nothing to do with blood pressure at all. The drug that was preventing a stroke can end up causing the event that ends independent living.

Geriatric medicine treats this as a named, actionable problem rather than bad luck. Both the AGS Beers Criteria and the STOPP/START criteria flag medication classes for exactly this reason — centrally acting antihypertensives and alpha-blockers in particular are singled out for causing postural hypotension and falls, and are not recommended as routine treatment for hypertension in older adults.

Deprescribing is a clinical discipline

There is a formal body of practice around reducing or stopping medications that no longer earn their place, and it applies to antihypertensives specifically. Published tools — Beers, STOPP/START, and STOPPFrail for people with limited life expectancy — exist to identify candidates for review, and there is trial evidence on structured withdrawal rather than guesswork.

The point is not that older people should be on fewer blood pressure medicines as a rule. It is that the decision deserves the same deliberate attention going down as it got going up, and that in practice it rarely gets it. A dose set at 68 is often still running unexamined at 82, after twenty pounds of weight loss and a decline in activity that both lower blood pressure on their own.

What the researchers recommended

Not stopping treatment — reviewing it. Consistent follow-up after starting or changing an antihypertensive, and awareness that hypotension is a real risk in a frail population, not just hypertension.

Why this matters more in home care than in a clinic

Blood pressure is measured in a clinic, sitting down, after a rest. The problems caused by it being too low happen somewhere else entirely — standing up from a low chair, getting out of bed at 3 a.m., turning quickly in a bathroom. A reading taken in the right conditions can look perfectly acceptable while the person is nearly fainting at home every morning.

This is called orthostatic hypotension — a drop in blood pressure on standing — and it is both common and under-detected in older adults. It is also one of the most direct causes of the falls that end independent living. The information that closes the gap between the clinic reading and the reality is behavioral, and it comes from whoever is in the house.

Sources

• Age and Ageing — Older people remain on blood pressure agents despite being hypotensive, resulting in increased mortality and hospital admission
• American Heart Association — High blood pressure
• National Institute on Aging — High blood pressure and older adults
• American Geriatrics Society — AGS Beers Criteria for potentially inappropriate medication use in older adults
• Journal of General Internal Medicine — Antihypertensive deprescribing in older adults: a practical guide
• European Geriatric Medicine — Centrally acting antihypertensives and alpha-blockers in people at risk of falls
• To STOPP or to START? Potentially inappropriate prescribing in older patients with falls and syncope

An earlier version of this article presented one side of a contested question as settled fact, and told readers that statin benefits were “grossly exaggerated.” That was not a fair summary of the evidence, and it has been rewritten.

What the review reported

In 2016 a group led by Uffe Ravnskov published a systematic review in BMJ Open covering 19 cohort studies — about 68,000 older people in total. The authors reported that in most of the cohorts they examined, high LDL cholesterol was not associated with higher all-cause mortality, and in a number of cohorts the association ran the other way: higher LDL, lower mortality.

Why it was criticized

Heavily, and by mainstream bodies. The main objections:

• Method. The Oxford Centre for Evidence-Based Medicine and others argued the review relied on aggregated published summaries rather than individual participant data, an approach prone to bias, and that its selection and analysis were not robust.
• It contradicts trial evidence. Observational associations between cholesterol level and death are not the same thing as testing what happens when you lower it. Randomized trials of cholesterol-lowering therapy consistently show reduced heart attacks and strokes, including in older participants.
• Reverse causation is a known trap here. Serious illness — cancer, frailty, advanced heart failure — lowers cholesterol. In an elderly cohort, low LDL can be a marker of being ill rather than a cause of dying, which can manufacture an apparent inverse association.

The diabetes trade-off is real, and it is on the label

The statin debate is often framed as “do they work or not,” which misses the more useful question of what they cost. One documented cost belongs in any honest discussion, and the first version of this article left it out entirely.

Statins raise the risk of new-onset type 2 diabetes. This is not a contested claim. In February 2012 the FDA added a safety label change to the entire statin class warning of increases in HbA1c and fasting blood glucose. A collaborative meta-analysis of randomized statin trials published in The Lancet in 2010 found roughly a 9 percent increase in incident diabetes, and a 2024 individual-participant-data meta-analysis in The Lancet Diabetes & Endocrinology confirmed effects on both new-onset diabetes and worsening glycemic control.

The risk is not evenly spread. It is higher with intensive-dose therapy and concentrated in people who already sit close to the diabetes threshold — which, in an older population, is a great many of them. Cardiology bodies including the American College of Cardiology hold that for patients at meaningful cardiovascular risk the benefit still outweighs this harm, and that remains the mainstream position. But “outweighs” is a trade-off, not an absence of harm, and a trade-off is something a patient is entitled to know they are making.

Deprescribing is a discipline, not a lapse

The most useful frame for an older adult is not whether statins work in general but whether this medication, at this dose, still earns its place on a list that may run to a dozen drugs. Geriatric medicine has formal tools for exactly that question.

• The AGS Beers Criteria, an expert-consensus list of medications that are often inappropriate in older adults because the harms outweigh the benefits at that age.
• The STOPP/START criteria, now in their third version (2023), covering drug-drug and drug-disease interactions, therapeutic duplication, medications that specifically raise falls risk, and treatments that are wrongly omitted.
• STOPPFrail, aimed at people with limited life expectancy, where the years needed for a preventive medication to pay off may exceed the years available.

None of these tools says “stop your statin.” What they do is make periodic review a normal part of care rather than something that only happens after a fall or an admission. If nobody has revisited a prescription in several years, that is worth raising — and it is a very different conversation from stopping the drug yourself.

What is genuinely unsettled

There is a real and legitimate clinical question underneath the controversy, and it is narrower than the headlines: how much benefit does starting a statin for primary prevention give someone in their late 80s with a limited life expectancy and a long list of other medications? Guidelines are genuinely more cautious there, and deprescribing is an accepted part of good geriatric practice.

That is a very different proposition from stopping a statin in someone who has already had a heart attack. “Is this still the right medication for me?” is a good question to bring to a clinician. “I read online that cholesterol does not matter” is not a plan.

Sources

• BMJ Open — Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
• Centre for Evidence-Based Medicine, University of Oxford — Post-publication peer review of the above
• Science Media Centre — Expert reaction to the review
• American Heart Association — LDL and HDL cholesterol
• Sattar N et al., The Lancet 2010 — Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials
• The Lancet Diabetes & Endocrinology 2024 — Effects of statin therapy on new-onset diabetes and worsening glycaemia: an individual participant data meta-analysis
• American College of Cardiology — Statins and diabetes: rethinking the data
• American Geriatrics Society — AGS Beers Criteria for potentially inappropriate medication use in older adults