Open the cabinet where you keep your medicines. Then open the cupboard where the vitamins sit, check the nightstand, and look in the kitchen drawer with the ibuprofen and the antacids.
All of that, together, is the real picture of what goes into your body. Almost nobody has ever seen the whole set at once. Your cardiologist sees part of it, your primary care doctor a different part. The pharmacy sees what it filled, not what you bought off a shelf or ordered online.
Researchers once went and looked. In a study published in 2016 in JAMA Internal Medicine, a team led by Dima Qato visited the homes of adults aged 62 to 85 and inspected the actual containers. Between 2005-2006 and 2010-2011, the share using dietary supplements climbed from 51.8% to 63.7%. The share taking five or more prescription drugs rose from 30.6% to 35.8%. The share at risk of a potential major drug interaction nearly doubled, from 8.4% to about 15.1%. Those figures are more than a decade old, and supplement use has not gone backward since.
Here is what this article will and will not do. It will not tell you to stop anything, start anything, split anything or combine anything. It cannot. It does not know you. Its job is to tell you what to ask and who is qualified to answer.
Why age changes what a medicine does
A pill does not change with time. You do.
Kidneys filter more slowly. The liver clears some drugs less efficiently. Body composition shifts, with less water and often more fat tissue, which changes how a drug spreads through you and how long it lingers. The nervous system also becomes more sensitive to certain drugs, so the same blood level produces a bigger effect. A 2026 review in Current Pharmaceutical Design, led by Canan Akman, describes exactly this combination: slower renal and hepatic clearance, a larger volume of distribution, and heightened pharmacodynamic sensitivity.
The practical translation is blunt. A dose that was right for you at 55 is not automatically right at 78, even though the label never changed.
The same review makes one more point. The chance of an adverse drug event rises as the number of drugs rises, independent of age and of how many conditions a person has. The count itself is a risk factor.
Polypharmacy, and the cascade that makes it worse
Polypharmacy is the ordinary word for taking a lot of medicines at once. Most definitions put the threshold at five or more taken regularly, which is where the Akman review sets it.
Five is not a scandal. Plenty of people need seven, and stopping any one would be dangerous. The problem is that nobody looks at the whole set as a set.
Which brings us to the most useful idea in geriatric pharmacy, and the one almost no patient has heard of. A prescribing cascade happens when a medicine causes a side effect, the side effect gets read as a brand new medical problem, and a second medicine gets prescribed to treat it. Lisa McCarthy, Jessica Visentin and Paula Rochon described the concept in a 2019 paper in the Journal of the American Geriatrics Society, widening the definition to cover both the cases where a clinician recognizes the side effect and the cases where nobody does.
Picture how it goes. A blood pressure drug causes ankle swelling. The swelling gets treated with a water pill. The water pill drops potassium and causes dizziness. The dizziness gets blamed on age. Now there are three problems and two extra prescriptions, and the first drug is still there.
Those same authors note that not every cascade is a mistake. Adding a second drug to manage a known side effect is sometimes the right call, made deliberately. The dangerous version is the accidental one, where nobody traces the chain backward.
You cannot diagnose a cascade yourself. You can do one thing that helps. When a new symptom shows up, ask whoever is treating it: could this be coming from something I already take?
The Beers Criteria is a conversation starter, not a ban list
In 1991, a physician named Mark Beers and colleagues at UCLA built a list of medications where the likely harm in nursing home residents outweighed the likely benefit. A 1997 update widened it to older adults generally. The American Geriatrics Society took over stewardship in 2010 and has revised it on a cycle since.
The full name matters, so read it slowly. It is a list of potentially inappropriate medications for use in older adults. That word potentially is doing enormous work, and dropping it is exactly how the document gets misread.
The 2023 edition is the seventh overall update and the fourth under AGS. It sorts concerns into five kinds. Some drugs raise flags in older adults generally. Some matter only alongside a particular condition, such as heart failure or a history of delirium. Some are flagged for caution rather than avoidance, where the evidence is thinner. Some entries describe pairs and trios of drugs that interact badly rather than any single drug. The last group is about kidney function, where the drug is fine but the dose has to match how well your kidneys filter.
Now the part people get wrong.
The word avoid, in the Beers Criteria, does not mean banned. The AGS panel states plainly that avoid is not an absolute contraindication unless the drug’s own label says so, and that a flagged drug can be the right choice when a safer option failed or when it fits a person’s goals. The panel warns that many entries carry exceptions and should not be flattened into a blanket rule about everyone over 65. It says in writing that the criteria are not to be used punitively, and calls the list a blunt instrument that cannot capture every legitimate exception. The criteria do not apply at all to hospice and end-of-life care.
The American Geriatrics Society sums up its own intent this way: the criteria “should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.”
So if you find your medicine on the list, you have not discovered that your doctor made a mistake. You have found a question worth raising at your next appointment. Those are different things.
Two more details. The criteria are written for clinicians, and assume a reader who knows what a drug is for, what the alternatives are and what happens if you take it away. And currency matters with any guidance document. As of late 2026 the 2023 edition is still the current one: a correction notice in the Journal of the American Geriatrics Society in September 2026 still referred to it, and studies published through 2026 were still applying it. AGS revises on a cycle, so check the year before you trust any summary, including this one.
Supplements are not regulated like medicines
The Food and Drug Administration does not approve dietary supplements before they go on sale. The agency says so directly: by law, it does not approve supplements or their labeling. Manufacturers and distributors carry what FDA calls the initial responsibility for making sure a product is safe and its claims are not misleading. FDA’s main lever is enforcement afterward, plus review of adverse event reports. Prescription drugs work the opposite way, and must be shown safe and effective before sale.
That gap is not an argument that supplements are useless. It is an argument that the word natural tells you nothing about potency, purity or safety. The National Institutes of Health Office of Dietary Supplements puts it in one line: “Many supplements contain active ingredients that can have strong effects on the body.”
Three well-documented examples follow. In each, the next step is a conversation with your prescriber or pharmacist, not a decision at the kitchen counter.
Vitamin K and warfarin
Warfarin is a blood thinner that works by interfering with vitamin K. So vitamin K intake and warfarin dose are linked, and the dose you are on was calibrated against the diet you were eating at the time.
The NIH Office of Dietary Supplements, in its consumer fact sheet on vitamin K, frames the issue around steadiness rather than avoidance. It advises keeping the amount you get from food and supplements about the same from day to day. A sudden drop can tip toward bleeding. A sudden jump can tip toward clotting.
So a new green smoothie habit and a new multivitamin are both things your anticoagulation clinic needs to hear about. The same fact sheet names other drugs that interact with vitamin K: bile acid sequestrants such as cholestyramine and colestipol, the weight-loss drug orlistat, and long antibiotic courses that disturb the gut bacteria producing some of your vitamin K.
Do not change your diet or your dose based on a web page. Tell the clinic what changed and let them re-check.
St. John’s wort
Among herbal products, St. John’s wort is in a category of its own, and not in a good way.
The National Center for Complementary and Integrative Health states that dangerous, sometimes life-threatening interactions between St. John’s wort and a range of medicines have been clearly demonstrated. The pattern splits in two.
The larger group is drugs it weakens. NCCIH names cyclosporine, used to prevent transplant rejection, and hormonal birth control pills. It names anti-seizure drugs including phenytoin and carbamazepine, heart drugs including digoxin, HIV drugs including indinavir and nevirapine, cancer drugs including imatinib and docetaxel, the statin simvastatin, and warfarin. A transplant patient losing cyclosporine coverage is not a theoretical inconvenience.
The smaller group is drugs it stacks with. Combined with certain antidepressants and other medicines that raise serotonin, it can push serotonin-related effects to a serious level.
NCCIH also describes where the evidence sits. Studies suggest it may help mild to moderate depression, beating placebo and performing roughly like standard antidepressants. Whether it helps severe depression, or holds up past twelve weeks, is not established.
Bleeding, anesthesia and the weeks before surgery
If you have an operation coming up, this is the paragraph to remember. A 2024 review in the Journal of Clinical Anesthesia, led by Ofelia Loani Elvir Lazo, reports that between 50% and 70% of surgical patients never tell their physicians they take herbal products, and most do not stop them before the procedure. The products found most often in that group included garlic, ginseng, ginkgo, St. John’s wort and echinacea. The documented problems run through clotting, blood pressure and heart rhythm, sedation and confusion, and how the body handles anesthetic drugs.
The review notes that the American Society of Anesthesiologists and the American Association of Nurse Anesthetists advise stopping herbal medications one to two weeks before elective surgery. That is guidance written for clinicians, and the timing decision belongs to your surgical and anesthesia team.
Your job is simpler. Hand over the complete list at the pre-operative appointment, early enough that a one-to-two-week window still exists. The Office of Dietary Supplements gives the same instruction for the same reason: some supplements raise bleeding risk, and some change how you respond to anesthesia. It adds one more worth knowing, that antioxidant supplements such as vitamins C and E may reduce the effectiveness of some chemotherapy.
One review, with everything on the table
All of the above converges on a single practical act, and it is unglamorous.
Get all of it in front of one person trained to look at all of it. A pharmacist is often the best choice, because interactions are the core of the job and pharmacists usually have more time for this than a physician does in a fifteen-minute visit.
Not a list from memory. Not the printout from one pharmacy. The actual containers, in a bag.
What belongs in the bag
Prescriptions from every prescriber, including the specialist you see once a year. Anything over the counter: pain relievers, antacids, sleep aids, cold medicine, allergy pills. Every vitamin, mineral, herbal product, probiotic and protein powder. Eye drops, inhalers, patches, creams and ointments, because those are drugs too. Samples. Anything expired. And anything you were prescribed and stopped taking, because the fact that you stopped is itself information.
Bring all of it even if it embarrasses you. Especially then.
What to ask while you are there
The questions are yours. The answers belong to the clinician in front of you.
- What is each of these for, in one sentence?
- Is anything here duplicating anything else, including two products with the same active ingredient?
- Could anything here be causing a symptom I have blamed on getting older?
- Does any of this need a different dose given my kidney function?
- Which one would be the first candidate to come off, and what would we watch for?
- Which one would be the most dangerous to stop suddenly?
- Should any of these be taken at a different time of day, away from food, or away from each other?
- When should the next review be?
A federal mechanism turns this into a formal appointment rather than a favor. Medicare Part D drug plans are required to run Medication Therapy Management programs, and the Centers for Medicare & Medicaid Services makes every sponsor submit its program for approval each year. Pharmacists or other qualified providers deliver the service. Which members qualify is set by each plan within the federal rules, so call the number on your drug plan card and ask whether you are eligible for a comprehensive medication review.
Then put it on a schedule. Once a year is a reasonable floor, plus any time something changes: a hospital stay, a new prescriber, a new diagnosis, a new supplement, a move. Discharge from a hospital is when lists get scrambled most reliably.
Medication review is also one of the steps the Centers for Disease Control and Prevention names for reducing fall risk, which our article on preventing falls covers.
Deprescribing is a plan, not a failure
Stopping a medicine on purpose, under supervision, has a name: deprescribing. It is a legitimate clinical goal with its own evidence base, and it is not an admission that anyone made a mistake.
The AGS panel is candid about why it is hard. Successful deprescribing, it writes, is far more than a clinician telling someone to stop. The obstacles it lists are human and logistical: patients are afraid to stop, communication breaks down, multiple clinicians have to coordinate, doses sometimes need tapering, withdrawal symptoms happen, and the stop order has to reach the pharmacy so the refills end.
The panel adds two points that cut against the usual assumption. The goal is not simply to swap a riskier drug for a safer one, because sometimes a non-drug approach or no treatment at all is better. And cost is a real complication, since the safer alternative is sometimes the expensive one. AGS says so directly and calls on insurers and policymakers to stop making the safer option the unaffordable one.
Which leads to the sentence this article exists to deliver.
Stopping a prescribed medicine on your own can be more dangerous than taking it. Some drugs cause withdrawal effects. Some cause rebound, where the condition returns harder than before. Some are holding back a problem you cannot feel, like high blood pressure, right up until the day you can. If a medicine is bothering you, that is a reason to make an appointment, not a reason to skip tomorrow’s dose.
When to call, and which number
For a suspected poisoning or overdose, including a double dose or the wrong pill, call Poison Help at 1-800-222-1222. It is available 24/7 in over 100 languages, anywhere in the United States and many territories, and it connects you to your local poison center. You do not have to be certain anything is wrong to call.
For an emergency, call 911. That includes trouble breathing, chest pain, a seizure, fainting, sudden confusion, or anyone you cannot wake.
Short of an emergency, some changes are worth a same-week call to your clinician or pharmacist instead of waiting. New dizziness or unsteadiness, especially on standing. Confusion or memory trouble that arrived over weeks rather than years. Unusual bruising, bleeding gums, nosebleeds, blood in urine, or black or tarry stools. New swelling in the ankles or face. A rash after starting something new. New daytime drowsiness. Any of these can have ordinary explanations. They can also be medication effects, and medication effects are the kind that get fixed.
One habit helps in the meantime. FDA advises checking active ingredients on over-the-counter products so you do not take too much of the same ingredient across several of them. Acetaminophen turns up in cold medicines, sleep aids and prescription combinations alike, which makes doubling up easy.
The one thing to do this week
Get a paper grocery bag. Walk the house: medicine cabinet, kitchen counter, nightstand, purse, glove compartment, the drawer you keep meaning to clean out. Put every bottle, box, tube and jar in it. Then call your pharmacy for a medication review appointment, and ask your Part D plan whether you qualify for a comprehensive one at no charge.
That is the whole assignment. Not a decision, not a change, not a single pill skipped. Just getting everything you take in front of one trained person at one time, which may never have happened in your life.
Sources
- American Geriatrics Society. “American Geriatrics Society Beers Criteria Update Expert Panel. "American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults." Journal of the American Geriatrics Society, 2023;71(7):2052-2081. PubMed. DOI: 10.1111/jgs.18372.” doi.org
- Agency for Healthcare Research and Quality, PSNet. “American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” psnet.ahrq.gov
- Journal of the American Geriatrics Society. “McCarthy LM, Visentin JD, Rochon PA. "Assessing the Scope and Appropriateness of Prescribing Cascades." Journal of the American Geriatrics Society, 2019;67(5):1023-1026. PubMed. DOI: 10.1111/jgs.15800.” doi.org
- JAMA Internal Medicine. “Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. "Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011." JAMA Internal Medicine, 2016;176(4):473-482. PubMed. DOI: 10.1001/jamainternmed.2015.8581.” doi.org
- Journal of Clinical Anesthesia. “Elvir Lazo OL, White PF, Lee C, et al. "Use of herbal medication in the perioperative period: Potential adverse drug interactions." Journal of Clinical Anesthesia, 2024;95:111473. PubMed. DOI: 10.1016/j.jclinane.2024.111473.” doi.org
- Current Pharmaceutical Design. “Akman C, Erdem AB, Ersan E, et al. "Clinical Utilization of Beers Criteria and STOPP-START Algorithm in Elderly Patients: Emphasis on Neuropsychiatric Medications." Current Pharmaceutical Design, 2026. PubMed. DOI: 10.2174/0113816128486528260611091824.” doi.org
- National Center for Complementary and Integrative Health. “St. John's Wort.” nccih.nih.gov
- NIH Office of Dietary Supplements. “Vitamin K: Fact Sheet for Consumers.” ods.od.nih.gov
- NIH Office of Dietary Supplements. “Dietary Supplements: What You Need to Know.” ods.od.nih.gov
- U.S. Food and Drug Administration. “Questions and Answers on Dietary Supplements.” fda.gov
- U.S. Food and Drug Administration. “Drug Interactions: What You Should Know.” fda.gov
- Centers for Medicare & Medicaid Services. “Medication Therapy Management.” cms.gov
- Health Resources and Services Administration. “Poison Help.” poisonhelp.hrsa.gov
- Centers for Disease Control and Prevention. “Preventing Older Adult Falls.” cdc.gov