Why Polypharmacy Hits Older Adults Hardest
In this installment of the Summer Conference Series from Elevate-Derm in San Diego, host Lisa Weiss, PA-C, sits down with a husband-and-wife duo: dermatologist Dr. Daniel Butler, who has a special interest in skin disease in older adults, and geriatrician Dr. Julia Cremer. Cremer opens with the working definition clinicians should keep in mind: polypharmacy is technically five or more medications, counting supplements, vitamins, and anything a patient takes over the counter.
Cremer explains that the geriatric population is doubly exposed. Older adults are often more susceptible to medication side effects, and they're also simply prescribed more because they carry more diagnoses, see more specialists, and accumulate more prescriptions along the way. That stacking creates more room for error, drug interactions, and unintended effects, especially when patients can't keep straight what they're taking.
Butler adds another dimension: the burden of the regimen itself. Patients fatigued by a handful of topicals, a stack of pills, and an injection may quietly stop doing any of it. He notes this plays out both on a large scale ('I just don't feel like I'm getting better') and a small one ('I just got three prescriptions and I'm done'). As the group acknowledges, this is partly a problem providers created—and now have to help unwind.
Deprescribing as a Deliberate Skill
Butler reframes deprescribing not as withholding medication but as intentional, targeted prescribing. His chair-side speech to patients: he's not worried about them simply because they're older—he wants a regimen that's as targeted and as safe as possible, cutting the unintentional or peripheral 'fat' that creates confusion and errors.
Cremer points out that buy-in is often already there. Many patients know they take too many pills and welcome the news that part of her job is to find what can be stopped. The harder conversations involve a medication the patient likes—say an antihistamine used for sleep or anxiety. There she lays out the concrete risks, especially falls and fractures, and notes the growing research linking some of these agents to delirium, confusion, and dementia. When patients still push back, she returns to her oath to do no harm, and proposes decreasing the dose today with a plan to revisit.
Butler stresses pivoting from risk to a more targeted alternative. His example: antihistamines aren't good at treating itch at all, so he explains the risks, removes the drug, and offers a topical that better targets immunologic or neuropathic itch. He'll even get into the weeds on why ice hits a receptor more active in a patient's type of itch—low-budget, but safer, easier, and cheaper.
The 5M's and Shared Decision-Making
Cremer walks through the 5M's of geriatrics as a quick recall tool: Mind, Medications, Mobility, Multi-complexity (multiple conditions, specialists, medications, and social complexity), and Matters Most—knowing what the patient values and engaging in shared decision-making. She urges clinicians not to judge by chronologic age alone: an 85-year-old may be physiologically more like a robust 65-year-old, while some patients in their 60s are frail enough to warrant more caution.
Butler calls shared decision-making the most important thing they do and even frames it as a cure for burnout because it reconnects clinicians with patients. The mechanics: clearly communicate what you’re trying to do and the risks, then put the ball back in the patient’s court by asking about their main concerns and what they're looking for. That exchange naturally surfaces what matters most, flavors of multi-complexity, and caregiver observations about cognition or mobility.
Weiss offers the pediatric analogy that resonates with both guests: pediatricians take care to confirm parents understand the plan, but clinicians may give older adults too much credit and move too fast. Butler agrees the skill applies to all patients but is emphasized in under-discussed, higher-risk populations—older adults, women of childbearing age or pregnancy, and those with disabilities.
Itch With No Rash When You're 30 Minutes Behind
Butler tackles the dreaded scenario: running 30 minutes late with a geriatric patient who has itch and no rash. First, he normalizes the time crunch—being behind is a truism of American medicine—and urges clinicians to steady themselves and be present for the person behind the door. A practical, evidence-based tip he picked up from a GI colleague at UCSF: sit down, point your hips toward the patient, and make eye contact, which makes patients perceive you spent more time with them.
For the itch itself when time is short, Butler starts with a targeted empiric approach aimed at the two most common causes—an overactive immune system and an overactive nervous system—often a topical for each, with a short-interval follow-up. If it's not better by the next visit, that’s when he escalates to labs and possibly a biopsy.
His 'can't miss' isn't a single diagnosis—it's therapeutic rapport. Because chronic itch may take several visits to sort out, the thing clinicians most need to avoid is damaging that rapport early. Butler closes with a dual warning: in geriatric dermatology you're just as at risk of over-treating as under-treating. Don't withhold a needed treatment simply because a patient is old, and don't over-treat a 90-year-old just because of their age. And, he adds, derm clinicians can honor healthy aging while still reversing some visible signs of it.