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For clinicians  ·  For facilities  ·  For families  ·  For staff

For facility ownership and management

For facility ownership and management

Medication burden reaches you as an operational problem long before it reaches you as a clinical one. It shows up as agitation on the night shift, as an incident log, as a family meeting, as staff turnover, and as a quality measure. The clinical version of the problem is the same problem seen from a different chair.

What DWARAA is offering, precisely

What DWARAA is, and is not

DWARAA does not prescribe, deprescribe, diagnose or treat. Those are decisions made by a patient and their own clinicians, with the whole record in front of them. What DWARAA supplies is the framework, the evidence behind it, and the shared vocabulary that lets a family, a nurse, a facility and a prescriber talk about the same medication list and mean the same thing.

So there is nothing to buy here and no service being sold. What is on offer is a framework with a stated order, an evidence base that says what it does and does not do, and material written separately for your prescribers, your staff and your residents’ families so that four groups can discuss the same medication list in the same terms.

What the evidence supports you expecting

  • A safe reduction in medication count. Across 118 randomized trials and 417,412 patients aged 65 and over, interventions to address potentially inappropriate prescribing reduced medications by roughly half a medication per patient, with no signal of harm across seven outcomes.
  • Removal of drugs treating nothing. This is the strongest single argument, and it is an operational one. In 22 Midwestern US skilled nursing facilities, 79.7% of Medicare Part A admissions were on a proton pump inhibitor and 65.3% of those had no appropriate diagnosis for it.
  • A reduction in restraint use, if the program is built the right way. See below — the distinction between kinds of program is the finding.

What the evidence does not support you promising

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.

It also does not support a mortality claim. The 2024 update of the largest meta-analysis in this field, covering 259 studies, found no significant reduction in mortality in randomized studies. We publish no savings claims and no financial projections for your facility. Where we cite cost or staffing figures they come from published research describing what care already costs, and they are not a forecast of what you would save. The published figures, with their populations and currency years.

The one finding that should shape how you implement

The 2023 Cochrane review of interventions to reduce physical restraint in long-term care — 11 studies, 19,003 participants, all including people with dementia, mean age around 85 — draws a sharp distinction between two kinds of program.

  • Organizational interventions that build a least-restraint policy into the institution — staff education plus trained low-restraint champions plus components that change institutional policy and the culture of care — probably reduce the number of residents restrained (relative risk 0.86, 95% CI 0.78 to 0.94) and probably produce a large reduction in belt restraint (relative risk 0.54, 95% CI 0.40 to 0.73). Both moderate certainty.
  • Simple educational interventions — teaching staff, changing attitudes — produced inconsistent results, and the review rates the effect as uncertain on very low-certainty evidence.

That is as close to actionable as this literature gets: training alone has not been shown to work; training embedded in a policy change has. The same shape appears in the falls literature, where tailored multifactorial programs delivered with facility staff engagement probably produce a large reduction in the rate of falls (rate ratio 0.61) while single interventions mostly do not.

The pages

Why medication burden is an ownership issue

It shows up in your incident log, your staffing, your quality measures and your relationship with families before it shows up anywhere clinical.

Adopting the framework

What changes, who does it, what it requires from you, and what the evidence says about which kind of program actually works.

Restraint-free care

Chemical and physical restraint, what the evidence shows about reducing both, and the honest limits of that evidence.

Measuring what changed

What to measure, what not to promise, and how a target becomes a hazard.

Cognitive decline and care burden

How care intensity rises as cognition declines, the three qualifications that matter, and the cascade from sedating medication to fall to hip fracture.

Common questions

What does adopting this actually require?

A policy, named people who own it, prescriber engagement, and a review that happens on a schedule and on defined triggers rather than when something goes wrong. The evidence is specific that staff education on its own has not been shown to change restraint use, while a policy change that includes education has. Adopting the framework.

Will this reduce our fall rate?

Not on its own — five independent evidence syntheses have looked and none found that deprescribing reduces falls. What does reduce falls in care facilities, on the 2025 Cochrane evidence, is sustained exercise and tailored multifactorial programs with staff engagement, which include medication optimization as one component. Deprescribing and falls.

References

  1. 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.
  2. Patterson Burdsall D, Flores HC, Krueger J, et al. Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities. Journal of the American Medical Directors Association. 2013;14(6):429–432. PMID 23583000 · DOI 10.1016/j.jamda.2013.01.021.
  3. Quek HW, Page A, Lee K, et al. The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis. British Journal of Clinical Pharmacology. 2024;90(10):2409–2482. PMID 39164070 · DOI 10.1111/bcp.16200.
  4. Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database of Systematic Reviews. 2023;7(7):CD007546. PMID 37500094 · DOI 10.1002/14651858.CD007546.pub3.
  5. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.
  6. 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.

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.