Appropriateness over Numbers: Pharmacological Burden and Scalable Medication Review in Older Adults

Polypharmacy in older adults is common, rising and inconsistently defined, and it is widely treated as a problem of how many medicines a person takes. This non-systematic narrative review argues that its harm depends more on the appropriateness of the regimen and the pharmacological burden the regimen imposes, with the number of drugs a partly confounded marker rather than the principal cause. Drawing on evidence published mainly since 2020, it traces the shift from counting medicines to weighting them; the prescribing cascade as a patterned and detectable source of inappropriate use; the explicit criteria (Beers, STOPP/START, EURO-FORTA) and implicit measures (the Medication Appropriateness and Drug Burden indices) that give appropriateness operational form; and the evidence that deprescribing is feasible and generally safe, although its benefit is conditional and depends on how it is done. Because these criteria can be applied to medication lists held in routine data, potentially inappropriate prescribing can increasingly be identified beyond the single encounter and at population scale, even as automated tools remain unreliable at judging whether a flagged criterion applies to the individual patient. The review concludes that medication review should prioritise appropriateness and the individual benefit–risk balance rather than the medication count, and that detection can increasingly be scaled even though the clinical decision and the patient’s agreement cannot.