Polypharmacy, from the daughter’s chair

The medications aren’t going to be flagged by the person taking them. They’re going to be flagged, or not, by you. The specific changes to watch for, how to have the conversation with the doctor, and what deprescribing actually looks like in practice.

The scene, if you spend time in Japanese pharmacies, is familiar. A woman opens a small notebook — an okusuri techō — and reads off medications with her adult daughter beside her. Blood pressure pill. Cholesterol pill. Sleeping pill. Something for the stomach. Something for the joints. Something for the mood. Sometimes the daughter’s eyes widen as the count climbs.

If you’ve been reading elsewhere on this site, you already know part of this story. The threshold at which adverse drug events rise sharply is six medications. The threshold at which falls rise is five. These aren’t arbitrary numbers — they’re what large Japanese cohort studies have consistently found, and they’re what MHLW’s own guidelines have been built around since 2018.

What I want to write about this time is different. This is polypharmacy from the family caregiver’s perspective — the daughter’s, or son’s, or spouse’s. Because in a lot of Japanese families, the person on the medications isn’t the one who’s going to notice something is off. You are.

The specific dangers, restated

When a person is on five or more medications, several categories of trouble become more likely.

Drug-drug interactions. Two medications that would each be fine alone can interact badly. Sedatives combined with certain painkillers deepen sedation. Blood thinners combined with certain antibiotics amplify bleeding risk. Every additional drug multiplies the number of possible interactions.

Adverse drug reactions in general. Older kidneys and livers process drugs more slowly. A dose that was correct at 50 may be too high at 75. Symptoms — confusion, drowsiness, dizziness, unsteadiness — get written off as “aging” when they’re actually medication effects.

Falls. Sedatives, sleep aids, some antidepressants, and certain blood pressure medications all raise fall risk. A person on five drugs who falls has a decent chance of being on at least one drug contributing to the fall.

The prescribing cascade. A side effect from drug A is mistaken for a new condition, and drug B is added to treat it. Then drug B has its own side effects, and drug C follows. Over years, a person can end up on a whole stack of medications the top one was supposed to prevent.

What to notice, as a family member

These are the specific changes that should make you wonder whether medications are the cause. Any of them, appearing after a medication change or accumulating over months on multiple medications, is worth flagging to a doctor.

• New confusion, memory trouble, or personality change.
• Unusual sleepiness, especially during the day.
• Loss of balance, unsteadiness, near-falls.
• Loss of appetite that doesn’t have another explanation.
• Chronic constipation or diarrhea that starts after a new drug.
• New falls, especially unexplained ones.
• Mood changes — flatness, apathy, or agitation.
• Dry mouth, dry eyes, difficulty urinating.

None of these prove medication is the cause. All of them warrant a conversation.

How to have the conversation with the physician

Doctors are often willing to review and reduce medications, but they need help. They don’t see your family member every day. You do.

Consolidate before the appointment

Gather every medication into one place. The prescribed drugs. The over-the-counter medicines. The supplements. The herbal teas. Put them all in a plastic bag or lay them out on a tray. Take a photo. Bring the photo, or the physical bag, to the appointment.

You’d be astonished how many prescribing physicians have never seen the actual list a patient is taking, because different specialists have different pieces of it.

Report specifically

“Since starting X two months ago, she has been noticeably more tired in the afternoons.” Not “she’s been off.” Specific behavioral changes give the physician a starting point.

Ask the direct question

“Are any of these medications ones you’d consider reducing or stopping?” This gives the doctor explicit permission to open the deprescribing conversation, which many won’t initiate on their own. It’s not a difficult question to ask, and most physicians will engage seriously with it.

Understand what each drug is for

Before the appointment, know what condition each medication is supposed to treat. If any of them are for conditions that have improved or resolved — a temporary anti-anxiety medication after a bereavement, a stomach medication for reflux that’s no longer happening — those are candidates for stopping.

Deprescribing, honestly

The 2024 BMJ review — the largest systematic review of deprescribing trials to date — found that just over half of deprescribing interventions produced better results than usual care on at least one outcome. Not miraculous. Not useless either. The effect depends heavily on which drugs and which patients.

Some medications are easier to reduce than others. Sleeping pills, particularly benzodiazepines, are among the drugs geriatric medicine most wants to eliminate — they raise fall risk and worsen cognition, and there are behavioral alternatives that work. Certain blood pressure medications can often be reduced as body weight falls or as physical activity rises. Statins in very old adults with limited life expectancy are a legitimate conversation to have with the physician.

Other medications should almost never be reduced without careful supervision. Blood thinners for atrial fibrillation. Insulin for type 1 diabetes. Anti-seizure medications. Some blood pressure medications will produce serious rebound if stopped suddenly.

The point is not to strip down to zero drugs. The point is that every drug should have a current reason to be on the list.

Practical tools

One medication booklet

Japan’s okusuri techō system exists to solve this exact problem — put all prescriptions in one place, from all providers. Use it. Bring it to every appointment, including specialists. Every pharmacy will update it.

One pharmacy

Where possible, fill everything at the same pharmacy. Pharmacists are trained to catch interactions, and they only catch what they can see. Using three pharmacies for three different specialists means no one has the complete picture.

Weekly pill organizers

Prevents doubling up on doses when memory falters. Some Japanese pharmacies will pre-fill the organizer as a service — ask.

Annual comprehensive medication review

Ask your family doctor for a specific appointment focused on this. Not squeezed into a regular checkup. A dedicated conversation where the goal is to look at everything, together, and simplify.

The line I want you to remember

Medications are tools to support life, not the star of the show. If your family member is spending a meaningful part of every day dealing with pills — remembering them, feeling their side effects, worrying about missing doses — that is a signal that the medication load has grown past what the person actually needs.

Bring the whole list to the next appointment. Ask the direct question. Watch what happens over three months as unnecessary items are peeled off. In most cases, the person feels better with fewer medications than they did with more. That is not a comforting story about care — it’s a small indictment of how prescribing accumulates when nobody is looking at the whole picture. The person looking at the whole picture, most often, is you.