Polypharmacy in Older Adults

The information provided in this article is for educational and informational purposes only and is not intended as medical advice, diagnosis, or treatment.

Polypharmacy means taking five or more medicines at once. In older adults the side effects stack, and the result often looks like aging instead of a drug problem.

This is common. Johns Hopkins Medicine reported in 2024 that, according to a CDC report, about a third of American adults in their 60s and 70s use five or more prescription drugs regularly. Each of those medicines was prescribed for a good reason. The trouble starts when nobody looks at the whole shelf at the same time.

As a geriatric doctor who sees patients at home in Scottsdale, Paradise Valley, Fountain Hills, Chandler and the East Valley, I open a lot of medicine cabinets. What I find there is usually the fastest answer to a question a family has been asking for months.

A close-up, warmly sunlit composition with a shallow depth of field, focusing on an older person's hands resting on a wooden counter. Soft natural light illuminates a daily pill organizer displaying visible day abbreviations like 'M', 'T', 'W', and 'TH', positioned next to a piece of paper covered in illegible cursive scribbles. The background fades into a bright, airy kitchen setting with gently blurred, glowing amber bottles.

What Is Polypharmacy, and When Do Five Medications Become a Risk?

Polypharmacy is the regular use of five or more medicines by one person, and the risk grows with each one added. The number itself is not the problem. The problem is that every new medicine can interact with the ones already there, and nobody feels all of those interactions the same way.

Older bodies also handle medicine differently. The U.S. Food and Drug Administration notes that as we age, the liver and kidneys may not work as well as they once did, which affects how a drug breaks down and leaves the body. The same dose that was fine at 60 can behave differently at 80, even though nothing about the prescription changed.

Counting matters more than most people expect. Prescription medicines, over-the-counter pills, eye drops, patches, vitamins and herbal supplements all belong on the list. Families often count only what came from a pharmacy, then wonder why the total looks smaller than it is.

Why Do Medication Side Effects Hit Older Adults Harder?

Side effects in older adults tend to arrive quietly, as tiredness or unsteadiness rather than an obvious reaction. Johns Hopkins Medicine lists reduced alertness, confusion or cognitive problems, falls and accidents, weakness and dizziness, and loss of appetite among the possible complications of taking many medicines at once.

Symptoms That Get Mistaken for Aging

Read that list again and you will notice how much of it sounds like ordinary old age. That overlap is exactly why the cause gets missed. The FDA puts it plainly: some medications can cause side effects that mimic other health problems, such as memory difficulties, dizziness and sleepiness, and it advises asking whether any new problem could be coming from a medicine.

Geriatrics teaches the habit of thinking medications first when a new symptom shows up, as Dr. Ariel Green of Johns Hopkins describes in Polypharmacy in Adults 60 and Older. It costs nothing to ask the question, and it sometimes saves a family a year of worry about memory loss that is not dementia at all.

When a Medicine Follows You Into the Next Day

Sedating medicines are a good example, because the effect does not stop when the person wakes up. Grogginess, slower reactions and poor balance can carry into the morning, which puts steadiness and fall prevention squarely in the conversation. Families usually describe this as a parent who has become unsteady, rather than as a medicine that is still working at breakfast.

Sleep is worth treating on its own terms before adding anything. A practical walkthrough of the non-drug options is available in Insomnia: Why Sleep Goes Wrong and How It Is Treated, which covers cognitive behavioral therapy for insomnia as the first-line approach.

Which Medications Are Riskiest for Older Adults?

There is a published list, and it is worth knowing by name. The Beers Criteria identify medicines that often carry more risk than benefit in people over 65, and clinicians use it as a prompt to re-examine a prescription rather than as a ban.

What the Beers Criteria List Actually Is

The American Geriatrics Society maintains the list and revises it every three years, as Cleveland Clinic explains, and there are close to 100 medications or medication classes on it. The current version dates from 2023. It is written for clinicians, but the general idea is simple enough for any family to hold onto: age changes the math on some medicines.

Cleveland Clinic’s summary is useful for families because it names the effect, not just the drug. Antipsychotics of any kind are flagged for stroke, cognitive decline and delirium. Antihistamines are flagged for confusion, cognitive impairment and delirium. Those are the symptoms that send families looking for a neurologist.

Seeing a familiar medicine on the list is not a reason to stop it. Plenty of people take a listed medicine safely because the benefit is clear and the alternative is worse. It is a reason to ask the prescriber what the plan is.

Antipsychotics and Dementia: The Risk Worth Naming

This one deserves its own paragraph because families are often given no warning at all when the prescription is written. A 2024 population-based study in The BMJ followed 173,910 adults with dementia in a matched cohort design, comparing 35,339 people who newly started an antipsychotic with up to 15 non-users each.

Current use was associated with higher risks of pneumonia (hazard ratio 2.19), acute kidney injury (1.72), venous thromboembolism (1.62), stroke (1.61), fracture (1.43), myocardial infarction (1.28) and heart failure (1.27). In the 90 days after starting, pneumonia occurred in 4.48 percent of users compared with 1.49 percent of non-users. The authors noted the highest risks came soon after treatment began.

Behavior changes in dementia are real and exhausting, and sometimes medicine is the right call for a family that has run out of other options. What should not happen is the prescription arriving without that conversation. Ask what is being treated, what improvement would look like, and when the decision gets reviewed again.

What Are the STOPP and START Criteria?

STOPP and START are a second review tool, built as two matching lists: one for medicines to consider stopping, one for beneficial medicines that may be missing. Version 3 was published in European Geriatric Medicine in 2023 and contains 190 validated criteria in total, 133 STOPP criteria and 57 START criteria, agreed by a panel of physicians from eight European countries.

The second half of that tool surprises people. Undertreatment is a real problem too, and a good review can end with a medicine being added rather than removed. The authors describe the criteria as support for deprescribing and for introducing beneficial medicine as part of routine medication review in older people living with several conditions at once.

The table below sets the two tools side by side, since families often hear both names in the same appointment and assume they compete with each other. They do not. A thorough review will usually draw on both, and on the judgment of whoever knows the patient best.

Review tool	What it is used for
AGS Beers Criteria (2023)	Flags medicines that often carry more risk than benefit in adults over 65, with close to 100 medications or medication classes listed
STOPP criteria (version 3, 2023)	133 criteria pointing to medicines that may be worth stopping in older people with several conditions
START criteria (version 3, 2023)	57 criteria pointing to beneficial medicines that may be missing from the list
How a doctor uses them	As a prompt for a conversation about each medicine, not as an automatic instruction to stop or start anything

What Is Deprescribing, and Why Does It Happen So Rarely?

Deprescribing is the planned, supervised reduction or stopping of a medicine that is no longer helping. It is the quieter half of prescribing, and it happens far less often than starting a medicine does, even in patients whose list everyone agrees has grown too long.

The reasons are practical rather than mysterious. Starting a medicine takes one visit, while stopping one takes monitoring, follow-up appointments and a prescriber willing to revisit a colleague’s decision. Nobody wants to be the person who removed something that later turned out to matter.

What the Research Says About Stopping Safely

The evidence is reassuring on the main worry. An Agency for Healthcare Research and Quality review published in 2024 found that deprescribing generally decreased the number of medications or potentially inappropriate medications, and that few adverse drug withdrawal events resulted from deprescribing interventions. The same review points to what makes it work: agreement by both the patient and the clinician, a standardized process, and an interprofessional team.

Clinical outcomes in that review were more variable, which is worth repeating rather than glossing over. Cutting the number of pills is a means, and the goal is a person who feels steadier and clearer than they did before. If a reduction does not deliver that, the honest answer is to say so and reconsider, not to keep cutting.

How to Ask for a Medication Review

Ask for it directly, and ask for a time when it is the only item on the agenda. A medication review squeezed into the last three minutes of a visit about something else will not go anywhere, because the prescriber has no room to think and the family has no room to ask follow-up questions. Booking it as its own appointment changes the whole conversation.

When to Ask

Johns Hopkins describes high-quality care as reviewing all of a patient’s medications at least once a year, and after any fall, hospitalization or emergency department visit. Those three events are the ones families tend to treat as over once the person is home, and they are exactly when the list has usually changed.

Bring the Whole List, Every Time

The FDA advises writing down all medicines taken, including over-the-counter drugs, vitamins and dietary supplements, keeping the list current, and showing it to every health care professional involved. Bringing the actual bottles works even better, because labels catch duplicates that memory does not.

Add what you have noticed at home: when the tiredness started, which days are worse, whether anything changed around the time a new prescription began. That timeline is often the single most useful thing in the room, and nobody but the family has it.

Never Stop a Medicine on Your Own

This is the one firm rule in the whole article. The Harvard Health Publishing is direct about it: do not skip doses or stop taking a prescribed medication without first consulting your health care professional. Some medicines need a gradual taper, and stopping abruptly can cause real harm.

Bring the concern instead of the decision. A prescriber who hears that the afternoons have become unmanageable, or that the dizziness started in July, has something concrete to work with. A prescriber who finds out three weeks later that a medicine was quietly dropped is left guessing about what caused what, and that guesswork can lead somewhere worse.

Where a Home Visit Fits In

A medication review works better in the room where the medicines actually live. Every cabinet, drawer and nightstand comes into view, along with the expired bottles at the back, the duplicates sitting under two different names, and the supplements nobody thought to mention because they came from a health food store rather than a pharmacy.

That is a large part of why I visit patients at home across the Phoenix East Valley. The same visit shows how someone moves through their own kitchen, whether the lighting is adequate, and whether the routine described in the office matches the one that happens at six in the evening. Other early signals turn up the same way, from a urinary tract infection presenting as confusion to the quieter signs that a parent needs more help.

If the medicine list in your family has grown past the point where anyone can explain every item on it, that is a reasonable thing to sit down and go through. You can book an appointment and start with the bottles.

Sources Used

Beers Criteria – Cleveland Clinic (2023)

Deprescribing To Reduce Medication Harms in Older Adults – Agency for Healthcare Research and Quality (2024)

Insomnia: Why Sleep Goes Wrong and How It Is Treated – Dr. Cleo Williams (2026)

Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study – The BMJ (2024)

Polypharmacy in Adults 60 and Older – Johns Hopkins Medicine (2024)

STOPP/START criteria for potentially inappropriate prescribing in older people: version 3 – European Geriatric Medicine (2023)

5 Medication Safety Tips for Older Adults – U.S. Food and Drug Administration (2024)

Stopping a medication? Check first, quit safer – Harvard Health(2023)

Frequently Asked Questions

Does taking exactly five medicines mean something is wrong?

No. Five is the number researchers use to define polypharmacy, not a threshold where harm begins. Some people need eight medicines and do well on all of them, while others feel worse on three. The number is a signal to review, not a verdict.

Who should run the medication review if several specialists are prescribing?

Usually the primary care clinician or geriatrician, because that is the person with a view of the whole list. Specialists manage their own piece well, and the gaps tend to appear between them. Tell each specialist who is coordinating.

Do vitamins and supplements really need to be on the list?

Yes. The FDA specifically includes over-the-counter drugs, vitamins and dietary supplements in the list it recommends keeping. Several common supplements interact with prescription medicines, and a prescriber cannot account for what they do not know about.

How long does it take to notice a difference after a medicine is reduced?

It varies by medicine, from a few days to several weeks, and some changes need a slow taper before anything is noticeable. This is why deprescribing includes follow-up rather than a single decision. Ask what to watch for and when to report back.

What if my parents refuse to give up a medicine they have taken for years?

That reaction is common and usually reasonable, since the medicine has been part of a routine that feels safe. Ask the prescriber to explain the specific benefit today, not when it was started. Familiarity is not the same as a current indication, and hearing that from the doctor lands differently than hearing it from family.

Is a pharmacist able to help with this?

Pharmacists are often the most accessible people for questions about interactions and timing, and many will go through a full list. They cannot change a prescription on their own, so anything they flag still goes back to the prescriber.

Polypharmacy in Older Adults: When Too Many Medications Becomes a Risk