A nonprofit division of Sevadar Foundation Inc.

For clinicians  ·  For facilities  ·  For families  ·  For staff

Read the medication list in date order

A pharmacist in a white uniform hands medication to a customer across the counter.

Written by

Dwaraa

in

Sort the medication list by start date. That is the whole technique, and it takes about five minutes.

Why sort order changes what you can see

A list sorted alphabetically, or grouped by drug class, is optimized for finding a drug you already have in mind. A list sorted by the date it was started is optimized for finding a pattern — and the two most consequential patterns in a long medication list are both patterns in time.

The prescribing cascade

A drug causes a symptom. The symptom is read as a new condition. The new condition is treated. Every step is defensible; nobody made an error; and the sequence is invisible unless somebody looks at the order.

What you are looking for is a medication started within weeks to a few months of another, treating a recognized effect of the earlier one, with no note recording that the earlier drug was reconsidered first. That last part is the diagnostic bit. “Reviewed X, symptom persisted, adding Y” is not a cascade. Silence is.

The substitution

The other pattern is a drug appearing as another one is reduced. It is easy to miss because it looks like success on the class you were watching.

The clearest documented example: among Ontario nursing home residents dispensed an opioid between 2009 and 2020, concurrent benzodiazepine use fell by 53.2% in relative terms while concurrent gabapentinoid use rose by 505.4%. In US nursing homes in 2021, gabapentin was the agent most frequently involved in central nervous system polypharmacy. A class was reduced and the burden reappeared under a different heading.

The exercise

For every drug started in the past two years, ask what happened in the eight weeks before it. That is it. It is the highest-yield five minutes available in a medication review, and it requires no tool.

Read more: Prescribing cascades · The medication review.

References

  1. Hogan DB, Campitelli MA, Bronskill SE, et al. Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents. Journal of the American Geriatrics Society. 2023;71(8):2462–2475. PMID 36942992 · DOI 10.1111/jgs.18320.
  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.

Bibliographic records in this note 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.

More posts