Polypharmacy review should identify which treatment is helping, which may be causing harm and which change can be made safely. The aim is not the smallest possible medicine list. In an older adult with falls, a recently added sedating product may be more immediately relevant than a long-standing medicine with a clear preventive indication.
For ABFM, the useful reasoning connects the patient's symptoms, actual use, treatment goals and clinical findings. A potentially inappropriate medicine list supports that process; it does not replace it. The case and medication chart below are fictional educational material, with no prescribing doses.
Reconstruct what the patient actually takes
Start with the medicines brought from home, the prescribing record, pharmacy information and the patient's account. Include over-the-counter sleep remedies, antihistamines, supplements and medicines borrowed from another person. A prescription marked active is not proof that it is being taken, and an item absent from the record may still be clinically important.
Ask about timing, recent starts or changes, missed medicines and the reason each product is used. Clarify who manages the medicines and whether vision, dexterity, cognition, cost or complicated instructions create difficulties. A medication review can fail before any pharmacology is considered if the underlying list is wrong.
The CDC STEADI clinical resources, checked on 27 September 2026, include medication review and orthostatic blood-pressure assessment within a broader falls approach. That framing is useful: medicines are part of the assessment, not the only possible cause of falling.
Identify the pattern of falls before choosing a culprit
Distinguish a trip from collapse, dizziness on standing, daytime sedation, hypoglycaemic symptoms or a new neurological problem. Ask about injuries and head impact, circumstances, warning symptoms and recovery. A significant injury or acute illness needs its own assessment rather than waiting for a routine medicines appointment.
Review gait, balance, vision, footwear, environment and other relevant contributors. The same medicine list can have different implications in a patient who trips over a rug and one who repeatedly becomes light-headed after standing.
The CDC medicines-and-falls fact sheet, still linked through STEADI when checked in September 2026, highlights sedation, confusion, blurred vision and postural hypotension as mechanisms to investigate. It also emphasises monitoring after medication changes rather than treating discontinuation as a completed intervention.
Use Beers Criteria as a prompt, not a verdict
The 2023 AGS Beers Criteria, reviewed on 27 September 2026, are designed principally for US adults aged 65 or older, outside hospice and end-of-life settings. They identify medicines that are potentially inappropriate in many circumstances or particular clinical situations. The authors explicitly place their use within shared clinical decision-making.
The distinction matters. A medicine may have a justified specialist indication despite appearing in a caution category. Conversely, a product can contribute to harm through duplication or interactions even when the learner does not remember seeing its name on a list.
The AGS alternatives resource announced in July 2025 adds a useful second question: what can address the original problem more appropriately? Removing a treatment without attending to the symptom it was intended to manage can leave the patient unsupported.
The fictional medication chart
A 79-year-old reports two recent falls, increased daytime sleepiness, dry mouth and constipation. They want to remain independent and are particularly concerned about poor sleep. The initial assessment does not identify an acute injury or new focal neurological deficit, but further evaluation remains necessary.
| Medicine or product | Stated reason | Timeline in this fictional case | Review question |
|---|---|---|---|
| Diphenhydramine bought over the counter | Sleep | Started shortly before daytime sleepiness worsened | Does its current burden outweigh a limited perceived benefit? |
| Oxybutynin | Urinary urgency | Long-standing; benefit uncertain | Is anticholinergic burden contributing, and what alternatives address symptoms? |
| Lorazepam | Anxiety and sleep | Taken regularly for several years | Is there physical dependence, and what would a safe review or taper require? |
| Amlodipine | Hypertension | Established treatment | Does blood pressure or the symptom pattern suggest a relevant adverse effect? |
| Apixaban | Atrial fibrillation with an established indication | Established treatment | Assess bleeding and indication separately from the causes of falls |
The chart deliberately does not imply that every medicine is inappropriate. The task is to decide what information is missing and which changes have the clearest rationale, not to remove the greatest number of rows.
Connect anticholinergic and sedating effects to the timeline
The combination of a newly added sedating antihistamine and existing anticholinergic treatment deserves attention. Dry mouth, constipation and daytime sleepiness provide a coherent hypothesis, though they do not prove that medicines explain all symptoms.
The AGS Beers Criteria identify first-generation antihistamines such as diphenhydramine as strongly anticholinergic and advise consideration of cumulative burden. They also discuss benzodiazepine-associated risks in older adults. The appropriate lesson is to examine the combination and its indications, not to assume that changing one item will necessarily prevent every future fall.
In this fictional case, a clinician and patient could agree to remove the recently introduced non-essential sleep product while addressing insomnia and monitoring symptoms. The decision is supported by timing and an unclear benefit, rather than by age alone. Review the urinary symptoms and the role of oxybutynin separately, including whether the patient considers it helpful.
Do not solve one risk by creating withdrawal
Long-standing regular benzodiazepine use requires a different approach from a recently started over-the-counter product. Physical dependence can occur during prescribed use and is not synonymous with a substance use disorder.
The 2025 Joint Clinical Practice Guideline on Benzodiazepine Tapering, checked on 27 September 2026, advises against abrupt discontinuation in patients likely to be physically dependent. It supports individualised, supervised tapering when risks outweigh benefits, with adjustment according to the patient's response.
Therefore, "stop all sedatives today" is not a defensible answer to the medication chart. It ignores exposure duration, withdrawal risk and the condition being treated. A safer plan assesses the indication, explains the concern, agrees a supported approach and defines monitoring. This article does not specify a taper schedule.
Separate a medicine's harms from its benefits
A fall history should trigger assessment of bleeding and injury in a patient taking an anticoagulant. It should not produce an unexamined decision to remove all treatment with a potential adverse effect. Review the indication, individual risks, other medicines and the circumstances of the fall with the appropriate clinician.
Similarly, blood-pressure treatment should be assessed against measured blood pressure, postural symptoms and the patient's overall condition. Do not stop a long-standing antihypertensive solely because another patient became dizzy while taking one. The list is a starting point for hypotheses; the examination and trajectory test them.
The AGS criteria stress treatment context and shared decisions. A medication count cannot quantify the benefit lost when a necessary treatment is withdrawn, nor can it identify the cause of a fall without clinical evidence.
Follow the patient across three encounters
Encounter one: reconciliation and the initial change. The newly added diphenhydramine is identified only when the patient brings the packet. The clinician discusses stopping that non-essential product, reviews sleep habits and makes a monitoring plan. The long-term lorazepam is not abruptly withdrawn. Falls assessment continues rather than ending with the discovery of a plausible medicine effect.
Encounter two: an informative partial response. At review, daytime sleepiness has improved, but dizziness on standing remains. The original medicine hypothesis explained part of the problem, not all of it. Reassess blood pressure, hydration, illness and other contributors. Do not call the review unsuccessful merely because more than one mechanism exists.
Encounter three: a negotiated longer-term plan. The patient now agrees that daytime function matters more than immediate sedation at bedtime. The clinician reviews the long-standing benzodiazepine with appropriate support and explores treatment for the original anxiety and sleep problem. Urinary symptoms are reviewed before changing oxybutynin, so that the patient is not left with a new burden they consider unacceptable.
These encounters are illustrative rather than a universal sequence. Acute danger or serious adverse effects can require several coordinated changes at once. When clinically feasible, a clear rationale and documented sequence make subsequent effects easier to interpret.
Compare the tempting answers
| Proposed answer | Why it is incomplete | Better question |
|---|---|---|
| Stop every medicine linked to falls immediately | Ignores withdrawal and established indications | Which harm is most plausible, and how can change be made safely? |
| Keep everything because it was prescribed previously | Ignores changed physiology, new products and current goals | Does the original benefit still outweigh the present burden? |
| Stop the anticoagulant because falling is dangerous | Does not balance its indication or examine causes and injury | What are the patient's actual bleeding, thrombotic and falls circumstances? |
| Add another medicine for each adverse symptom | May create a prescribing cascade | Could an existing product be contributing? |
| Count the remaining prescriptions as the outcome | Misses function, symptoms and patient experience | Has the patient become safer and better able to do what matters? |
Document a review that another clinician can continue
Record the reconciled list, indication, suspected problem, agreed change, monitoring and responsible clinician. State which medicines were deliberately retained and why. Explain what symptoms should prompt earlier contact and what the patient should do if the plan is difficult to follow.
For ABFM revision, use an indication-benefit-harm-withdrawal framework before selecting an answer. Per iatroX product information, September 2026, its question-linked Tutor can help explore why a tempting deprescribing option is unsafe. A learning record documents reflection; it does not establish that a medicine change was appropriate for an unassessed real patient.
Frequently asked questions
Is the aim of deprescribing to achieve the fewest medicines possible?
No. The aim is an appropriate treatment plan that balances benefit, harm, practical burden and the patient's priorities.
Should a long-term benzodiazepine be stopped abruptly because an older adult has fallen?
Not when physical dependence is likely. Review the risks and benefits and use an individualised supervised approach rather than creating avoidable withdrawal.
Does improvement after one medicine change prove that every fall was medicine-related?
No. A partial response supports a hypothesis but does not remove the need to assess remaining symptoms and other causes.