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The medication review

For prescribing clinicians

The difference between a medication review and a medication list is that a review reads the list as one object, in the order it was written, and asks a question of each line that has an answer.

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.

Read it in date order

This is the single change that reveals most. A list sorted alphabetically or by class hides the thing you most need to see: what was started after what. A prescribing cascade is invisible in an alphabetical list and obvious in a chronological one. Prescribing cascades.

The four questions

  1. What is it treating, and is that still happening? Not what class it is — what problem, in this person, now. A drug started in a hospital for a transient issue, a condition that resolved, or a diagnosis that was never confirmed.
  2. Is it treating a side effect of something else on this list?
  3. How long does it take to help, and does this person have that long? Applies to preventive medications, not to symptom control. Time to benefit.
  4. Is it sedating, and is the sedation being read as decline?

What to add up rather than read line by line

  • Anticholinergic burden. A property of the list, not of any one drug. Name the scale used, since the scales disagree — one systematic review of seven expert-based scales found quetiapine rated high anticholinergic activity by one, moderate by another and low by two others. Anticholinergic burden.
  • Central nervous system polypharmacy. Three or more concurrent CNS-active medications is a Beers threshold, met by 23.2% of long-stay US nursing home residents aged 65 and over in 2021 data, with gabapentin the most frequently involved agent.
  • Sedative and anticholinergic load together. The Drug Burden Index captures both on a dose-response basis. In 3,075 community-dwelling adults aged 70 to 79, a one-unit increase was associated with a physical-function deficit more than three times that associated with a single comorbid illness.

The omissions half

A review that only subtracts is doing half the job. START exists because undertreatment is as real: in 6,336 US community-dwelling adults aged 65 and over, only 44.3% of those with heart failure were on an ACE inhibitor or ARB plus a beta blocker, and only 54.0% of those with albuminuria were on an ACE inhibitor or ARB. And the criteria audit found high-level evidence behind 88% of START criteria against 43% of STOPP criteria — the evidence for adding is stronger than the evidence for removing.

What makes a review actually change anything

The two randomized trials with the largest effects in this field share a design feature: they engage the patient and the prescriber in parallel rather than one through the other.

  • EMPOWER mailed a deprescribing booklet and tapering protocol directly to 303 community-dwelling long-term benzodiazepine users aged 65 to 95. At six months 27% had discontinued against 5% of controls, number needed to treat 4 — and 62% of recipients started the conversation themselves.
  • D-PRESCRIBE sent the patient an educational brochure and the physician an evidence-based pharmaceutical opinion at the same time. 43% of the intervention group no longer filled the inappropriate prescription at six months against 12% of controls.
  • OPTIMIZE, by contrast, mailed a brochure and notified clinicians without the paired opinion, across 3,012 patients — and was null on both primary outcomes.

And what to write down before changing anything

  1. The reason for the change, in one sentence.
  2. What should improve, and by when.
  3. What would indicate the change was wrong.
  4. Who is monitoring, and over what window.
  5. That restarting is a planned option, not a failure.

That last item is what makes the difference between a reduction people are willing to try and one they resist. Tapering principles.

Back to the clinician track.

References

  1. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatrics. 2015;15:31. PMID 25879993 · DOI 10.1186/s12877-015-0029-9.
  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. 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.
  4. 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.
  5. Boland B, Sibille FX, Mouzon A, et al. Appraisal of the references supporting the STOPP/START.version 3 criteria. European Geriatric Medicine. 2026;17(3):1193–1200 (published online 2025-12-26). PMID 41452533 · DOI 10.1007/s41999-025-01386-7.
  6. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Internal Medicine. 2014;174(6):890–898. PMID 24733354 · DOI 10.1001/jamainternmed.2014.949.
  7. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889–1898. PMID 30422193 · DOI 10.1001/jama.2018.16131.
  8. Bayliss EA, Shetterly SM, Drace ML, et al. Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial. JAMA Internal Medicine. 2022;182(5):534–542. PMID 35343999 · DOI 10.1001/jamainternmed.2022.0502.
  9. 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.
  10. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. PMID 37256475 · DOI 10.1007/s41999-023-00777-y. See also the published correction, Eur Geriatr Med. 2023;14(4):633, PMID 37326916.

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.