Medication Safety, Polypharmacy, and Deprescribing
Polypharmacy and the Prescribing Cascade
Polypharmacy (commonly five or more medications) is not inherently harmful, but inappropriate polypharmacy is. A prescribing cascade occurs when an adverse drug effect is treated as a new disease - for example, a calcium channel blocker causing edema treated with a diuretic, or an anticholinergic causing confusion treated with an antipsychotic. Candidates must recognize these chains and interrupt them at the source.
Tools and High-Risk Classes
Use explicit criteria (Beers, STOPP/START) to flag potentially inappropriate medications and prescribing omissions. High-risk classes include benzodiazepines and Z-drugs (falls, fractures, delirium), anticholinergics (cognition, urinary retention, constipation), sulfonylureas (hypoglycemia), NSAIDs (GI, renal, cardiovascular), antipsychotics in dementia (stroke and mortality), and long-acting sedatives. The anticholinergic burden scale helps quantify cumulative risk.
Deprescribing
Deprescribing is a planned, supervised process of reducing or stopping medications when harms exceed benefits. Steps: identify candidates, confirm current indications and goals, prioritize high-risk drugs, taper rather than stop abruptly (benzodiazepines, opioids, antidepressants, beta blockers, corticosteroids, anticonvulsants), monitor for withdrawal and rebound, and document the plan. Patient and caregiver involvement improves success.
Traps
Questions may reward adding a drug to treat a side effect rather than stopping the culprit. Another trap is assuming a medication is appropriate because a specialist started it years ago; indications should be revisited.
Rule of Thumb
For every new symptom, ask "could this be a drug?" before adding therapy. When deprescribing, taper drugs with withdrawal risk and schedule a follow-up to confirm the change held.