Reducing Medication Burden
Minimize the use of medications that may cause adverse side effects, especially in older adults with dementia, to enhance quality of life and prevent drug interactions.
Burden is not the same as count
Reducing a list from eleven drugs to nine is not automatically progress. What matters is which two, what they were doing, and what the resident’s day looks like afterwards. The relevant questions are whether a drug is still treating something, whether its time to benefit is shorter than the resident’s expected remaining life, whether it is treating a side effect of another drug, and whether it is sedating someone who is then judged to be declining.
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 it is only visible if someone reads the list as a whole in date order rather than as a set of individually reasonable decisions.
What the review checks
- Medications reviewed regularly to avoid overmedication or inappropriate use of sedatives.
- Reduction or deprescribing of unnecessary psychotropic medications considered.
- Work with healthcare providers to manage behavior without chemical restraints.
- Monitoring for side effects or negative interactions with current medications.
Medication Review & Management, category 31 of 54.
DWARAA is six steps. Back to the overview.
The four questions worth asking about each drug
- What is it treating, and is that still happening? A surprising share of long-term care prescriptions treat a condition that resolved, or one that was never confirmed.
- 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.
- How long does it take to help, and does the resident 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 a resident with a two-year outlook.
- Is it sedating, and is the sedation being read as decline? The most consequential question on the list.
Anticholinergic load
Individual drugs can each look harmless while their combined anticholinergic effect produces confusion, constipation, urinary retention and falls. Bladder medications, some antihistamines, some antidepressants and some antipsychotics all contribute. The burden is a property of the list, not of any one line in it.
What withdrawal has to look like
Deliberately, one change at a time, with an observation window and someone writing down what happened. Reducing four drugs in a week makes the outcome uninterpretable — and if the resident deteriorates, everything gets restarted, including whatever was doing the harm.