As populations age worldwide, the management of chronic conditions among the elderly has led to a growing reliance on multiple medications-a phenomenon known as polypharmacy. Defined as the concurrent use of five or more medications, polypharmacy is increasingly common among older adults, particularly those with comorbidities such as hypertension, diabetes, arthritis and cardiovascular disease. While the appropriate use of multiple medications can be essential for managing complex health issues, excessive or uncoordinated drug use poses significant risks. These include adverse drug reactions, harmful drug–drug interactions, medication non-adherence, cognitive impairment, falls, hospitalizations and even mortality [1-3].

In India, where the elderly population is projected to reach over 300 million by 2050, the issue of polypharmacy presents a pressing public health concern. Factors such as self-medication, over-the-counter drug access, fragmented healthcare systems and limited patient education contribute to irrational drug use. Moreover, elderly individuals often consult multiple providers or pharmacies without full transparency, increasing the risk of duplicative or contraindicated prescriptions [4-6]. In smaller districts like Mandi, Himachal Pradesh-characterized by mixed urban-rural demographics and varying levels of health literacy-the challenge is further compounded by lack of awareness, limited geriatric counseling and cultural reliance on home remedies or informal prescriptions.

Despite the serious implications of polypharmacy, public understanding of the issue remains low, especially among older adults and their caregivers. Many elderly individuals continue to view medication as a measure of wellness-more medicines equating to better health-without fully comprehending the cumulative risks or the importance of periodic medication reviews. There is limited research in India, particularly at the district level, that assesses public awareness of polypharmacy, its associated risks and practices around medication management among older populations.

This study seeks to explore the awareness, attitudes and practices regarding polypharmacy among the elderly in Mandi district. By identifying knowledge gaps, behavioral patterns and influencing factors such as education, income and healthcare access, the research aims to provide a foundational understanding of the public’s perception of polypharmacy. The insights gained will be instrumental in guiding targeted interventions, community education efforts and policy recommendations to promote safer, more rational drug use among the elderly.

Study Design

This study adopted a descriptive, cross-sectional design to assess the level of public knowledge, attitudes and practices regarding polypharmacy among the elderly population in Mandi district, Himachal Pradesh. The objective was to evaluate the extent of awareness, identify potential risks associated with multiple medication use and understand the factors influencing drug-related decisions among older adults and their caregivers.

Study Area and Population

The study was conducted in Mandi district, a geographically diverse region encompassing both urban centers and rural communities. The target population comprised elderly individuals aged 60 years and above, as well as their immediate caregivers who were involved in healthcare decisions and medication management. The district's mixed demographic, coupled with varied levels of access to healthcare services, provided a relevant context for exploring perceptions around polypharmacy.

Study Duration

The survey was carried out over a three-month period from January to March 2025. This allowed for sufficient time to disseminate the questionnaire, ensure representative participation across urban and rural zones and conduct necessary follow-ups to improve response quality.

Sample Size and Sampling Technique

A minimum sample size of 400 was estimated using a 95% confidence level, 5% margin of error and assuming a 50% prevalence of basic awareness regarding polypharmacy, due to limited prior data. A 10% oversampling buffer was added to accommodate potential incomplete responses. Participants were selected through a combination of purposive and snowball sampling, initiated via community health workers, local NGOs, elderly welfare groups and digital platforms such as WhatsApp and Facebook. Special efforts were made to include voices from underrepresented rural segments by leveraging health outreach volunteers and local influencers.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Elderly residents of Mandi district (aged 60 years and above)

• Adult caregivers involved in elderly medication management

• Ability to read and respond in Hindi or English

• Informed consent provided digitally or verbally (where applicable)

Exclusion Criteria:

• Individuals with severe cognitive impairments or psychiatric illness impeding comprehension

• Healthcare professionals (e.g., doctors, pharmacists, or nurses) to avoid knowledge bias

• Duplicate or partially filled responses

Data Collection Tool

A structured, pre-validated questionnaire was developed in bilingual format (Hindi and English) with input from geriatricians, pharmacologists and public health experts. It included both close-ended and Likert-scale questions, divided into four main sections:

• Demographic Details: Age, gender, education, income, residence (urban/rural) and number of chronic illnesses

• Medication Use Patterns: Number and type of medications currently being taken, frequency of physician visits and presence of self-medication or over-the-counter drug use

• Awareness and Knowledge: Understanding of polypharmacy, awareness of risks, recognition of drug–drug interactions and knowledge of the importance of periodic medication reviews

• Attitudes and Practices: Trust in medical advice, communication with healthcare providers and perceived importance of minimizing unnecessary medications

Data Collection Procedure

The questionnaire was disseminated both online (via Google Forms) and offline (paper-based through local healthcare workers) to reach a digitally diverse population. Participants were briefed about the purpose of the study and digital or verbal consent was obtained before beginning the survey. Assistance was provided for illiterate or vision-impaired participants through trained field investigators.

Scoring and Data Classification

Knowledge scores were calculated by assigning one point for each correct answer and zero for incorrect or "don't know" responses. Based on cumulative scores, participants were categorized as having "Very Good" (≥80%), "Good" (60–79%), "Fair" (41–59%), or "Poor" (<40%) knowledge levels. Similarly, attitudes and practices were analyzed using aggregate Likert-scale scores and categorized as positive, neutral, or negative toward rational drug use.

Data Analysis

All responses were cleaned and compiled in Microsoft Excel, then imported into SPSS version 26.0 for statistical analysis. Descriptive statistics were used to summarize demographic characteristics and response frequencies.

The study sample comprised 400 respondents from Mandi district, with the majority (37.0%) falling within the 60–65 years age group, followed by 28.0% aged 66–70 years, indicating a focus on early elderly populations. Gender distribution was nearly balanced, with females accounting for 51.5% and males for 48.5%. Educational attainment varied significantly; 23.0% of participants had no formal education, while 26.0% had attended primary school and 33.0% had completed secondary education. A smaller segment held undergraduate (14.0%) or postgraduate degrees (4.0%). Income-wise, over two-thirds of respondents earned ₹20,000 or less per month, reflecting modest economic conditions. Notably, 68.0% of the participants resided in rural areas, underscoring the study's focus on health literacy in less urbanized settings. The majority of respondents were elderly individuals themselves (81.0%), while 19.0% were caregivers involved in managing their medications (Table 1).

Participants displayed a generally positive awareness of polypharmacy and its associated risks. A substantial 74.0% correctly identified polypharmacy as the use of five or more medications and 79.5% understood that it could lead to adverse drug reactions. Awareness of drug–drug interactions (65.8%) and fall risk (75.3%) was moderately high, while 81.8% acknowledged the importance of periodic medication reviews. However, some misconceptions persisted-for example, only 61.8% were aware that herbal remedies can contribute to polypharmacy risks. Encouragingly, 84.0% agreed that taking multiple medications without a doctor’s advice is unsafe and 85.3% recognized the need to inform all doctors about current medications. Awareness that polypharmacy can increase healthcare costs (76.5%), lead to cognitive impairment (63.3%), or result in hospitalization (73.0%) was also prevalent. High scores were observed in questions regarding safe practices, with 84.3% opposing medication sharing and 83.0% supporting the use of a medication list for elderly patients. Overall, responses reflected a foundational awareness of polypharmacy, though with room for improvement in specific areas like self-medication and herbal drug risks (Table 2).

The classification of knowledge scores reveals that 42.0% of participants fell into the “Good” category (60–79% correct responses), while 33.5% achieved a “Very Good” level (≥80%), indicating a fairly high degree of awareness among the population. Nevertheless, 18.0% demonstrated “Fair” knowledge (41–59%) and 6.5% were classified under “Poor” (<40%), highlighting that a quarter of the sample lacked sufficient understanding of polypharmacy and its risks. These lower scores were more commonly observed among those with no formal education and in rural settings. The overall distribution suggests a promising baseline for educational intervention but also emphasizes the need for targeted community outreach to elevate understanding among vulnerable segments of the elderly population and their caregivers (Table 3).

The findings of this study provide important insights into the awareness, knowledge and practices surrounding polypharmacy among the elderly population and their caregivers in Mandi district, Himachal Pradesh. In an aging society where chronic diseases are prevalent and multimorbidity is common, the phenomenon of polypharmacy has emerged as a critical public health issue-yet one that remains poorly understood at the community level. This study aimed to bridge that gap by evaluating public understanding of polypharmacy and the associated risks, with a focus on the local socio-cultural and healthcare context.

Table 1: Socio-Demographic Characteristics of Participants

Table 2: Awareness and Knowledge of Polypharmacy Among Participants

Table 3: Knowledge Score Classification

A major strength of the study lies in the demographic representation of both elderly individuals and caregivers, across rural and urban settings. The data reveal that while foundational awareness about the concept of polypharmacy exists-evident from 74% correctly identifying it as the use of five or more medications-there are significant discrepancies in knowledge when it comes to deeper understanding of drug–drug interactions, cognitive risks and the role of non-prescribed medications such as herbal remedies and OTC drugs. Only 61.8% of participants recognized that herbal remedies could contribute to polypharmacy-related risks, underscoring a knowledge gap that could have real-world implications in communities where traditional and alternative medicine practices are prevalent.

The study also highlights a concerning but expected reality: education and income levels significantly influence awareness. Participants with no formal education and those in lower-income brackets were more likely to fall into the “Fair” or “Poor” knowledge categories. This is particularly important given that 68% of the study population resided in rural areas where health literacy is often limited and where informal drug procurement and self-medication are more commonplace. These results echo broader national trends, reinforcing the need for region-specific educational campaigns that are linguistically and culturally accessible.

Encouragingly, many respondents demonstrated an understanding of the risks associated with polypharmacy, including adverse drug reactions (79.5%), falls (75.3%) and hospitalization (73%). These findings suggest a positive shift in risk perception, perhaps due to increased exposure to healthcare facilities, community health workers, or media messaging around medication safety. A particularly notable result is the high percentage (85.3%) of participants who recognized the importance of informing all healthcare providers about current medications-an essential step in preventing duplicative prescriptions and harmful interactions.

However, a gap remains between awareness and practical behavior. For instance, while 84.0% acknowledged that taking multiple medications without a doctor’s advice is unsafe, the persistence of self-medication practices-particularly with OTC drugs-suggests that behavior does not always align with knowledge. Similarly, although 83.0% agreed that maintaining a medication list is beneficial, its actual implementation in daily routines may be inconsistent, especially among those with limited support or digital access.

Caregiver awareness and involvement also surfaced as crucial factors in safe medication practices. As 19% of respondents were caregivers, their inclusion in this study underscores the shared responsibility in elderly health management. Caregivers, particularly family members, often make or influence medication-related decisions and equipping them with accurate knowledge can have a cascading effect on improving compliance, adherence and safety.

Another area of concern is the lack of clarity regarding the roles of different healthcare providers. Only 62.3% of participants correctly stated that pharmacists should check for drug interactions and a notable proportion seemed unaware that general practitioners or geriatricians are best suited to manage polypharmacy. This indicates a potential disconnect in community engagement with the healthcare system, where patients may not fully understand the division of responsibilities or the importance of comprehensive medication reviews.

From a policy and practice standpoint, the study’s findings call for urgent interventions at multiple levels. First, there is a clear need to train community health workers and primary care physicians in geriatric medication counseling, enabling them to educate patients on the risks and safe practices of polypharmacy during regular visits. Second, awareness programs tailored to rural communities-through local radio, visual aids at clinics, or peer education models-can significantly enhance understanding. Third, integrating a simple medication review protocol into existing government programs like Ayushman Bharat or NRHM could institutionalize the practice of rational prescribing, particularly for elderly patients with chronic diseases [6-8].

Finally, the study’s methodological strengths-such as combining online and offline data collection tools and ensuring inclusion of illiterate and digitally disconnected participants-contribute to the robustness and generalizability of the findings. However, it must be noted that certain limitations persist. The exclusion of individuals with severe cognitive impairments, while ethically necessary, means that the most vulnerable segment of the elderly population may have been underrepresented. Additionally, the cross-sectional design captures a snapshot in time, without allowing for causal inferences or longitudinal behavior tracking.

This study highlights that while a significant portion of the elderly population and caregivers in Mandi possess a basic understanding of polypharmacy and its associated risks, substantial gaps persist in comprehensive knowledge and safe medication practices-particularly among individuals with lower education levels and those residing in rural areas. Although encouraging levels of awareness were observed regarding the dangers of adverse drug reactions, falls and the importance of medication reviews, misconceptions about herbal remedies, over-the-counter drugs and self-medication remain prevalent. These findings underscore the urgent need for culturally tailored, community-based educational interventions and strengthened primary care engagement to promote rational drug use among the elderly. Integrating polypharmacy risk management into existing public health frameworks, empowering caregivers through targeted training and enhancing coordination among healthcare providers can collectively mitigate the dangers of excessive or uncoordinated medication use. Ultimately, fostering informed, safe and streamlined medication practices will play a vital role in ensuring healthier aging and reducing preventable health complications among India’s growing elderly population.

Ethical Considerations

Participation was entirely voluntary and no identifiable personal data were collected. All responses were anonymized and stored securely, in compliance with standard ethical guidelines for human subject research. Participants were assured that their responses would be used solely for academic and policy-relevant purposes.

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