Polypharmacy Risks in Nigeria: When More Drugs Equals More Harm

Picture an 80-year-old woman sitting across from her doctor in a busy Nigerian hospital. She reaches into her bag and places her medications on the desk one by one. A beta-blocker for hypertension. A statin for cholesterol. A proton pump inhibitor for reflux. An antidepressant. Sleeping tablets. Metformin for diabetes. A handful of supplements.

This is not unusual. In fact, it represents one of the most overlooked sources of patient harm in Nigerian clinical practice: the risks of polypharmacy accumulating silently, drug by drug, until a regimen that looked rational becomes dangerous.(1)

Understanding polypharmacy risks in Nigeria is essential for every clinician, pharmacist, and healthcare student in the country. Furthermore, with the rising burden of non-communicable diseases across Nigeria and West Africa, the problem is only going to grow.

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What Is Polypharmacy and Why Does It Matter in Nigeria?

Polypharmacy is defined as the concurrent use of five or more medications by a single patient. Ten or more medications is called excessive polypharmacy.(1) The concern is not the number itself. Sometimes multiple medications are genuinely necessary and prescribing them represents good clinical practice. However, the concern is what happens when the cumulative drug burden crosses the line from therapeutic to harmful.

According to a large cross-sectional study published in the Journal of Clinical Medicine, 36.2 percent of adults aged 65 and over across 27 European countries were living with polypharmacy, with rates ranging from 25 to 51.8 percent across countries.(2) A five-year follow-up study of men aged 80 and above found that 70 percent met criteria for polypharmacy, with a mean of nearly ten medications per person.(3) While large-scale Nigerian polypharmacy prevalence data remains limited, the same drivers are fully present in Nigeria: rising multimorbidity, fragmented care, and a growing elderly population.

Why the Ageing Body Changes Drug Risk

The body at 80 is not the body at 40. As we age, kidney function declines, increasing the risk of drug accumulation and toxicity.(4) Hepatic drug clearance also falls with age.(5) In addition, body composition changes further increase the retention of fat-soluble drugs.(6)

Therefore, a dose that is safe and therapeutic in a 40-year-old can be excessive and toxic in an 80-year-old who is also taking several other drugs competing for the same metabolic pathways. In Nigerian clinical settings, where renal function is often not checked before prescribing, this risk is particularly significant.

Polypharmacy Risks Nigeria: What the Evidence Shows

The evidence on polypharmacy risks is clear and consistent. Here are the most important clinical consequences that every Nigerian clinician must be aware of.

1. Falls and Hospitalisation

Falls in older adults are a leading cause of hospitalisation, functional decline, fracture, and death.(7) Data from the English Longitudinal Study of Ageing show that fall-related hospital admissions increase progressively with the number of medications taken.(7) Sedatives, benzodiazepines, antidepressants, and medications with anticholinergic properties are among the drug classes most strongly associated with increased fall risk in older patients.(7,13)

2. Adverse Drug Events

Polypharmacy is associated with a significantly increased risk of adverse drug events.(2) Furthermore, each additional medication increases the likelihood of harm.(3) Drug interactions become exponentially more complex as the number of medications grows. A patient on five drugs has ten possible two-drug interactions. A patient on ten drugs could have as much as 45 drug to drug interactions.

Checking for drug interactions in complex regimens is one of the most important safety steps a clinician can take. The Medituri Drug Interaction Checker allows clinicians in Nigeria and West Africa to check interactions instantly at the point of care.

3. The Prescribing Cascade

One of the most insidious consequences of polypharmacy is the prescribing cascade. A drug causes a side effect. That side effect is mistaken for a new medical condition. As a result, a new medication is prescribed to treat it. The drug list grows while the original problem and the side effects remain unaddressed.

A well-documented example involves calcium channel blockers, which can cause ankle swelling. In a cohort study published in JAMA Internal Medicine, this swelling prompted diuretic prescribing in a proportion of older adults newly started on a calcium channel blocker.(9) Similarly, anticholinergic medications can cause cognitive impairment, constipation, or dyspepsia, each of which may then prompt further prescribing.(13) Recognising this cascade is one of the most important clinical skills in managing polypharmacy risks in Nigeria.

What Is Deprescribing and How Does It Help?

Deprescribing is the planned, supervised process of tapering, reducing, or stopping medications that are no longer appropriate, either because they carry more risk than benefit or are no longer aligned with the patient’s health goals.(10) It is not abandonment of care. In fact, it is one of the most deliberate and clinically meaningful interventions a prescriber can make.

Despite widespread agreement with the concept, deprescribing is not consistently practiced in Nigerian clinical settings. A narrative review found that while many healthcare professionals feel comfortable with the idea of deprescribing, fewer engage with it regularly. Barriers include limited training, time constraints, and fragmented care.(10)

4 Validated Tools Clinicians Use for Deprescribing Decisions

 

1. 1. STOPP/START Criteria: Developed by Denis O’Mahony and colleagues, now in their third version (2023) with 190 criteria organised by physiological system. These help identify potentially inappropriate medications and prescribing omissions.(12)

1. 1. AGS Beers Criteria: Updated in 2023 by the American Geriatrics Society, these provide a list of medications to avoid or use with caution in older adults, including those with significant anticholinergic effects.(13)

1. 1. STOPPFrail: Focuses specifically on deprescribing in frail older adults with limited life expectancy, where long-term preventive medications may no longer provide meaningful benefit.(14)

1. 1. Medication Appropriateness Index: Provides a structured way to evaluate each medication across domains including indication, effectiveness, dosage, interactions, duplication, and cost-effectiveness.(8)

Important: Deprescribing should always be supervised and gradual. Abrupt discontinuation of some medications, particularly benzodiazepines, antidepressants, and corticosteroids, can cause serious withdrawal effects.

Polypharmacy Risks in Nigeria and West Africa

In Nigeria, polypharmacy risks are compounded by several system-level factors. Fragmented care means patients often see multiple specialists across public and private facilities without a shared medication record. In addition, self-medication and the widespread use of over-the-counter drugs and herbal preparations significantly increase the real drug burden beyond what is visible in the prescription record.

The Nigerian Clinical Reality

A study examining prescribing patterns in a Nigerian tertiary hospital found that a significant proportion of elderly inpatients were receiving medications flagged as potentially inappropriate by the Beers Criteria, including sedating antihistamines, benzodiazepines, and NSAIDs.(11) However, routine medication review and deprescribing practice remain inconsistent across Nigerian health facilities.

Furthermore, the growing burden of non-communicable diseases in Nigeria means that more patients are living longer with multiple conditions, each generating its own drug regimen. Without structured medication reviews, polypharmacy is set to become an increasingly serious patient safety problem in the Nigerian healthcare system.

Conclusion and Key Takeaways

The woman with the bag of medications is not unusual, but her situation is not inevitable. The evidence is clear that polypharmacy causes harm and that structured, patient-centred deprescribing can reduce that harm safely.

What is needed is a shift in how medicine approaches prescribing in older adults in Nigeria: routine medication reviews at every transition of care, pharmacist involvement in deprescribing decisions, and a clinical culture that treats stopping a harmful medication as an active intervention rather than a withdrawal of care. Adding a drug has long felt like doing something. Stopping a medication that causes more harm than good is, in itself, an act of care.

Key Takeaways

 

• • Polypharmacy is defined as five or more concurrent medications. Ten or more is excessive polypharmacy.

• • The ageing body processes drugs differently. Doses that are safe in younger patients can be toxic in older adults.

• • Polypharmacy increases the risk of falls, adverse drug events, and the prescribing cascade.

• • Deprescribing is a planned, supervised clinical intervention. It is not a withdrawal of care.

• • Validated tools including STOPP/START, AGS Beers Criteria, and STOPPFrail help guide deprescribing decisions.

• • In Nigeria, fragmented care, self-medication, and herbal preparations compound polypharmacy risks significantly.

Check Drug Interactions on Medituri

Managing complex drug regimens safely requires reliable, instant access to drug interaction information. The Medituri Drug Interaction Checker gives healthcare professionals and students in Nigeria and West Africa the ability to check interactions across multiple medications quickly at the point of care. Sign up free at medituri.com.

Frequently Asked Questions about Polypharmacy in Nigeria

Q: What is polypharmacy?

A: Polypharmacy is the concurrent use of five or more medications by a single patient. Ten or more medications at the same time is called excessive polypharmacy. The concern is not the number itself but the cumulative risk of adverse drug events, interactions, and prescribing cascades that increase with each additional drug.

Q: What are the main risks of polypharmacy in elderly patients in Nigeria and West Africa?

A: The main risks of polypharmacy in elderly patients include adverse drug events, falls and fractures, the prescribing cascade, harmful drug interactions, cognitive impairment, and hospitalisation. Each additional medication increases the likelihood of harm, and the ageing body processes drugs less efficiently than younger patients.

More Questions about Polypharmacy and Deprescribing

Q: What is the prescribing cascade?

A: The prescribing cascade occurs when a drug causes a side effect that is mistaken for a new medical condition, leading to the prescription of another drug to treat it. For example, a calcium channel blocker causes ankle swelling, which is then treated with a diuretic, unnecessarily increasing the drug burden.

Q: What is deprescribing?

A: Deprescribing is the planned, supervised process of tapering, reducing, or stopping medications that are no longer appropriate because they carry more risk than benefit or are no longer aligned with the patient’s goals. It is a deliberate clinical intervention, not a withdrawal of care.

Q: What tools are used to manage polypharmacy?

A: In Nigeria, polypharmacy management requires structured medication reviews at every care transition, pharmacist involvement in prescribing decisions, and use of validated deprescribing tools such as STOPP/START and the Beers Criteria. The Medituri Drug Interaction Checker at medituri.com helps Nigerian clinicians identify harmful drug combinations in complex regimens instantly.

References

 

1. 1. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230.

1. 1. Gatt Bonanno E, Figueiredo T, Figueiroa Mimoso I, et al. Polypharmacy prevalence among older adults based on the Survey of Health, Ageing and Retirement in Europe: an update. J Clin Med. 2025;14(4):1330.

1. 1. Wang R, Chen L, Fan L, et al. Incidence and effects of polypharmacy on clinical outcome among patients aged 80+: a five-year follow-up study. PLoS One. 2015;10(11):e0142123.

1. 1. Mangoni AA, Jackson SHD. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004;57(1):6-14.

1. 1. McLachlan AJ, Pont LG. Drug metabolism in older people: a key consideration in achieving optimal outcomes with medicines. J Gerontol A Biol Sci Med Sci. 2012;67(2):175-180.

1. 1. Klotz U. Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev. 2009;41(2):67-76.

1. 1. Zaninotto P, Huang YT, Di Gessa G, et al. Polypharmacy is a risk factor for hospital admission due to a fall: evidence from the English Longitudinal Study of Ageing. BMC Public Health. 2020;20(1):1804.

Additional References

 

8. 8. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051.

8. 8. Savage RD, Visentin JD, Bronskill SE, et al. Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Intern Med. 2020;180(5):643-651.

8. 8. Robinson M, Mokrzecki S, Mallett AJ. Attitudes and barriers towards deprescribing in older patients experiencing polypharmacy: a narrative review. npj Aging. 2024;10(1):6.

8. 8. Cherubini A, Mangoni AA, O’Mahony D, Petrovic M, editors. Optimizing Pharmacotherapy in Older Patients: An Interdisciplinary Approach. Cham: Springer Nature Switzerland; 2023.

8. 8. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.

8. 8. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.

8. 8. Lavan AH, Gallagher P, Parsons C, O’Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017;46(4):600-607.