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What a medication review looks like

For families of residents

A medication review is not a dramatic event and does not usually happen in a room you are in. Knowing its shape lets you tell whether one has actually taken place.

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.

What happens

  1. Somebody assembles the whole list — everything, including things bought over the counter, in the order they were started. That sounds trivial and is often the hardest step, because the list lives in more than one place.
  2. Each medicine is asked what it is for, and whether that is still happening.
  3. The list is looked at as a whole for combinations: how much of it is sedating, how much has anticholinergic side effects, whether one drug is treating another drug’s effect.
  4. What is missing is considered. A good review adds as well as subtracts. Undertreatment is real — among US adults aged 65 and over with heart failure, fewer than half were receiving the combination of medicines recommended for it.
  5. A small number of changes are proposed — ideally one at a time, so that if something happens everyone knows what caused it.
  6. A plan is written: what should improve, by when, what would mean the change was wrong, who is watching, and that restarting is an option.

What you should be told

  • That a review is happening, before it happens.
  • What is being changed and why, in a sentence you can repeat.
  • What to watch for over the following weeks.
  • Who to tell if you notice something.
  • That a change can be reversed.

Being told after a change is the most common failure and the most damaging one. A family who learns about a medication change by noticing a difference in their parent has been given a reason to distrust everything else they are told.

How long it takes to see anything

Weeks, usually, not days — and for a gradual reduction, longer. A sedative being reduced slowly may take months to come down, and the improvement, if there is one, appears gradually: more alert in the afternoon, more talkative, steadier, more interested. Those are the things to watch for, and you are better placed to notice them than anyone else.

What “gradual” means, and why

Several kinds of medicine cannot be stopped suddenly. The FDA warns that stopping a benzodiazepine abruptly or reducing it too quickly can cause withdrawal reactions including seizures. Opioid labeling warns that rapid reduction or abrupt discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain and suicide. Some blood pressure medicines rebound. Anti-seizure medicines are not stopped abruptly.

So a slow reduction is not hesitancy. It is the correct method, and the regulators are explicit that there is no single schedule that suits everybody.

What a review is not

  • Not a target. There is no correct number of medications, and a review that concludes everything is still needed is a successful review.
  • Not something done to your parent. Their agreement, or yours where you hold that role, is part of it. In one trial, patients or their family agreed with 63% of the recommendations made — the obstacle is usually that the conversation does not happen.
  • Not a falls prevention program.

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.

If a review has not happened

Ask for one, in those words, and ask when. A reasonable trigger list is: after any hospital stay, after a fall, after any new medicine is started, after a new or worsening behavior, and otherwise on a regular schedule. Hospital returns matter most, because that is when medication lists change most and when nobody has yet reconciled them.

Back to the family track.

References

  1. Pan S, Li S, Jiang S, et al. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011–2020. The Journals of Gerontology Series A. 2024;79(7):glae108. PMID 38644631 · DOI 10.1093/gerona/glae108.
  2. U.S. Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety Communication, September 23, 2020. fda.gov. 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class.
  3. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
  4. Kim JL, Lewallen KM, Hollingsworth EK, Shah AS, Simmons SF, Vasilevskis EE. Patient-Reported Barriers and Enablers to Deprescribing Recommendations During a Clinical Trial (Shed-MEDS). The Gerontologist. 2023;63(3):523–533. PMID 35881109 · DOI 10.1093/geront/gnac100.
  5. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  6. 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.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

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.