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Reducing medication burden

R — the fourth step

Reducing a list from eleven drugs to nine is not automatically progress. What matters is which two, what they were doing, and what the person’s day looks like afterward. Burden is not count.

Before you read on

Never stop or change a prescribed medication without speaking to your own prescriber. Several of the classes described on this site rebound, or cause a withdrawal syndrome, when they are stopped abruptly, and some have to be reduced gradually over weeks or months under supervision. Nothing here is advice about your own medication, and nothing here is a reason to change anything on your own.

Four questions worth asking about each drug

  1. What is it treating, and is that still happening? A meaningful share of long-term care prescriptions treat a condition that resolved, or one that was never confirmed in the first place.
  2. Is it treating a side effect of something else on this list? That is the prescribing cascade, and it is only visible when the list is read in date order.
  3. How long does it take to help, and does this person have that long? This is what the STOPPFrail criteria exist for. A preventive medication with a five-year time to benefit is a different proposition in someone with a two-year outlook. Time to benefit.
  4. Is it sedating, and is the sedation being read as decline? The most consequential question on the list, because getting it wrong produces a diagnosis.

The prescribing cascade

A drug causes a symptom. The symptom is treated as a new condition. The second drug causes a symptom of its own. It is one of the most common ways a long-term care medication list gets long, and every individual step in it was defensible. It is only visible if someone reads the list as a whole, in the order the drugs were started, rather than as a set of independently reasonable decisions. Prescribing cascades.

What “burden” actually means

Three different things get called medication burden and they need separating.

  • Count. How many drugs. The easiest to measure and the least informative. It is also, as it happens, the outcome most deprescribing trials use as their primary endpoint — which is a fact about the trials, not about the patients.
  • Pharmacologic load. Anticholinergic and sedative exposure, which is what the Drug Burden Index was built to capture. In a cohort of 3,075 community-dwelling adults aged 70 to 79, a one-unit increase in that index was associated with a deficit in physical function more than three times the size of the deficit associated with a single additional comorbid illness.
  • Lived burden. Doses at four times a day, tablets that are hard to swallow, a medication that has to be taken standing, dietary restrictions, monitoring appointments, and the sheer administrative weight of a regimen on the person and whoever helps them. Nobody scores this and it is often what the patient means.

Central nervous system polypharmacy

One specific combination has its own threshold. The Beers Criteria flag concurrent use of three or more central-nervous-system-active medications — antidepressants, antiseizure medications, antipsychotics, benzodiazepines, Z-drugs, opioids and skeletal muscle relaxants. A 2026 cross-sectional study of 211,783 long-stay US nursing home residents aged 65 and over with fee-for-service Medicare, using 2021 assessment data linked to Part D, found that 23.2% met that threshold, defined as three or more concurrent CNS-active medications for more than 30 days of continuous exposure. Gabapentin was the agent most frequently involved.

That figure is worth stating carefully: it describes long-stay residents in US nursing homes with that specific insurance status, in that year, by that criterion. It is not a statement about older adults generally. Polypharmacy in long-term care.

A correction worth carrying

The most quoted number in this field is that adverse drug events cause roughly 100,000 emergency hospitalizations a year among older Americans. The estimate is real — 99,628 per year (95% CI 55,531 to 143,724) from national surveillance data for adults aged 65 and over. But the same study found that four drugs or classes accounted for 67% of them: warfarin, insulins, oral antiplatelets and oral hypoglycemics. Medications typically designated high-risk or inappropriate were implicated in 1.2%.

The consequence for practice is direct. The drugs actually causing most drug-related emergency admissions in older adults are mostly drugs that should not be stopped. They need better dosing and better monitoring. Pairing the 100,000 figure with an argument for cutting Beers-list medications misuses the study that produced it.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

What withdrawal has to look like

Deliberately, one change at a time, with a stated expectation and a defined window for monitoring, and with a way back if the reduction turns out to have been wrong. The classes that require a taper get one. Tapering principles covers the method.

Common questions

Is there a number of medications that is too many?

No, and thresholds like “five or more” are counting conventions used in research, not clinical limits. A person on nine drugs each of which is treating something active is in a different position from a person on six where three are treating the side effects of the other three. The question is always which drugs and doing what. How polypharmacy is defined and measured.

Does a shorter medication list mean better health?

It means less pill burden, which is worth having on its own terms and which the randomized evidence supports. It has not been shown to reduce falls, hospitalizations or mortality. Anyone promising those outcomes from a shorter list is going beyond what the trials found. What deprescribing trials measure.

DWARAA is six steps. Back to the framework overview.

References

  1. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Archives of Internal Medicine. 2007;167(8):781–787. PMID 17452540 · DOI 10.1001/archinte.167.8.781.
  2. Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
  3. By the 2023 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. PMID 37139824 · DOI 10.1111/jgs.18372.
  4. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. The New England Journal of Medicine. 2011;365(21):2002–2012. PMID 22111719 · DOI 10.1056/NEJMsa1103053.
  5. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115–2125. PMID 27893129 · DOI 10.1001/jama.2016.16201.
  6. Curtin D, Gallagher P, O’Mahony D. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age and Ageing. 2021;50(2):465–471. PMID 32997135 · DOI 10.1093/ageing/afaa159.
  7. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.