Take your mother’s medication chart and count the lines. More than five is average. More than ten and you are in a situation with a precise medical name — polypharmacy — and it is itself a risk factor, in the same way smoking or high blood pressure is.
The way people get there is almost always the same, and nobody in particular is at fault. She moved in on eight medicines. Then one restless night, and something was added to help her sleep. Then hip pain and an anti-inflammatory. Then a stomach protector to cover the anti-inflammatory. The cardiologist adds, the orthopaedic surgeon adds, the emergency department adds after a fall. Every single prescription is reasonable on its own. Nobody has the job of looking at the whole list and taking things off it.
This article explains how to ask for that review, who to ask, what to bring, and the words that make it actually happen.
The prescribing cascade, or how one tablet becomes two
There is a phenomenon worth knowing about, because once you have seen it you cannot unsee it: the prescribing cascade.
It works like this. A blood pressure medicine causes swollen ankles. The swelling is read as a new problem, so a diuretic is added. The diuretic has her up three times a night. The night-time trips lead to a fall. After the fall a sedative is added «to settle her». The sedative increases confusion and the risk of falling again.
Four medicines, three of which exist only to treat the effects of the first. It is more common than it sounds, and spotting it is half the work: whenever a new symptom appears, the first question should be «could this be a medicine?», not «which medicine do we add?».
The signs that say «let us look at the medicines»
Before putting everything down to age or dementia, ask yourself whether something new has appeared in recent months:
- confusion or disorientation that appeared or worsened relatively quickly
- daytime drowsiness, head nodding, difficulty staying awake after lunch
- falls, or that unsteady walk families describe as «she has been walking badly for a while»
- loss of appetite, dry mouth, stubborn constipation
- dizziness on standing
- a decline that began after a hospital admission — the moment when medicines are most often changed
None of these signs *proves* the medicines are to blame. But every one of them justifies a question.
The review you can ask for by name: the RMMR
This is the most useful thing to know in Australia. A permanent resident of an aged care home is eligible for a Residential Medication Management Review — an RMMR. The GP refers, an accredited pharmacist reviews the entire medication list including interactions and appropriateness, and the findings go back to the GP, who then agrees a plan with the resident and family.
It is funded through Medicare. It costs the family nothing. And most families have never heard of it.
Ask for it by name: «Can we arrange an RMMR?» is a request a GP and a facility recognise and can act on. «Is she on too many tablets?» is not.
If your parent is still living at home, the equivalent is a Home Medicines Review — an HMR — with the same structure: GP referral, accredited pharmacist, written findings.
There is a second Australian lever worth knowing. Aged care homes must report polypharmacy — the proportion of residents taking nine or more medicines — and antipsychotic use, every quarter, under the national mandatory quality indicator program. It is a fair question to ask a home before your parent moves in, and a fair question to ask afterwards.
The document to ask for, and the column that reveals everything
Ask in writing for the complete, current medicines list: drug name, dose, timing, what it is for, the date it was started, and who prescribed it.
It is that date column that reveals everything. Something started «for a few days» to help her sleep in March two years ago and never revisited is the single most common line of all, and the easiest to put right.
Ask as well who is responsible for the medicines: the home cannot change a prescription — that is the GP’s job — but it is responsible for flagging concerns and requesting a review. Each side often assumes the other is reviewing, and in between nobody reviews.
The medicines that deserve the most attention in older people
This is not a list of things to stop — only a doctor decides that. It is the list of things worth asking about, because the geriatric literature flags them as the most problematic after seventy-five:
- Benzodiazepines and sleeping tablets: they increase the risk of falls and worsen memory and alertness. They are also the hardest to come off, and any reduction must be gradual, never abrupt.
- Antipsychotics in dementia: prescribed for agitation or aggression, but in dementia they raise the risk of stroke and death. Australian guidance treats them as a last resort, for short periods, with review — not «for months, because she was agitated». Their use in residential care is a reported quality indicator for exactly this reason.
- Anticholinergic medicines: many antihistamines, some older antidepressants, treatments for an overactive bladder. Taken together they add up to an «anticholinergic burden» that causes confusion, dry mouth and constipation.
- Anti-inflammatories (NSAIDs) taken continuously: hard on the kidneys, the stomach and blood pressure, and in older people the kidneys already work less well.
- Proton pump inhibitors (stomach protectors) continued for years without a current reason: very often started to cover another medicine, and never stopped when that medicine ended.
- Diabetes and blood pressure medicines aimed too tightly: in a ninety-year-old, «perfect» readings can do more harm than good. This is the principle behind deprescribing: when age and condition change, the treatment target changes too.
There are well-known international lists of medicines to use with caution in older people. Quoting them is not the point: asking for a structured review and a date is.
The best moment to ask
After a hospital admission. On the way back the medicines have almost always changed, often without anyone comparing the new list with the old one. Ask explicitly for medicines reconciliation between the pre-admission list and the discharge list, and ask in writing: this is where duplicates accumulate.
Other useful moments: after a fall, after an episode of confusion, after weight loss, and at every care plan review.
Who to ask, in order
1. The GP. They are the one who can change a prescription and the one who refers for an RMMR. Everything starts here.
2. The accredited pharmacist, through that referral. This is the person whose actual job is to look at the whole list.
3. The community pharmacy. They can check interactions across everything she takes, which no single specialist does, because each one only sees their own prescriptions.
4. A geriatrician. The only specialty trained to look at the whole picture rather than one organ. In a complex situation, one geriatric consult is worth three separate specialist appointments.
How to ask, in practice
The difference between a request that lands and one that drifts is entirely in the framing. Do not ask «isn’t she on too many tablets?» — that is an opinion, and opinions can be waved away.
Ask for a dedicated appointment and bring three things: the complete list (including supplements, drops, eye drops and anything bought over the counter, which are almost always missing from official lists), the list of new symptoms with dates, and this question:
> «I would like a full review of her medicines. For each one: why is she on it, since when, and is there still a reason to continue it today?»
That is a question a clinician can answer, and it is framed as a clinical request rather than a suspicion. The second useful sentence:
> «Could any of these symptoms be side effects? Could we try stopping one and see what happens?»
And the third, which closes it:
> «Can we set a date to go through the medicines together?»
As with any request in an aged care home, put it in writing. A ten-line email with the list and the dates exists; a question asked in the corridor does not.
What to ask for, in writing
- A full medication review, with a written outcome: what stays, what is reduced, what is stopped, and with what monitoring.
- A review date for every medicine started «for a few days».
- The reason for every sedative or antipsychotic, with the date of the next review.
- That changes are communicated to you if you hold an enduring power of attorney or guardianship, or are the named family contact. You only need to put that in writing once.
The three things never to do
Never stop anything yourself. Some medicines — benzodiazepines, steroids, anti-epileptics, antidepressants, beta-blockers — cause withdrawal reactions, sometimes serious ones, if stopped abruptly. Reduction is gradual and must be supervised.
Do not expect everything to be taken away. A good review stops one or two medicines and adjusts the doses of others. If it stops only one, but that one is the benzodiazepine that was causing the falls, it was an excellent review.
Do not turn it into an accusation. «You are giving her too many tablets» closes the conversation. «I would like to understand whether any of these could come off» opens it.
If nothing happens
Write to the facility manager with a date by which you expect a reply, and copy the GP. If nothing comes, the Aged Care Quality and Safety Commission takes complaints, and the Older Persons Advocacy Network provides free, independent advocacy if you would rather not do it alone. And talk to the GP: a review request coming from the doctor carries more weight than ten requests from the family.
Why it is worth it
A proper review is not an administrative detail: in very old people, removing unnecessary medicines often means fewer falls, less confusion, more appetite and more lucid hours in the day.
Many families describe the same scene a few weeks later: «she started talking again», «she woke up». It was not the dementia advancing. It was the tablets.
In short
- Polypharmacy accumulates because every specialist adds and nobody has the job of taking away.
- Recognise the prescribing cascade: faced with a new symptom, first ask «could this be a medicine?».
- Ask the GP for an RMMR by name — Medicare-funded, done by an accredited pharmacist, free to the family.
- Ask for the complete list with the start date next to every line.
- The best moment is after a hospital admission: ask for medicines reconciliation.
- Never stop anything on your own.
Looking for an aged care home that actually keeps on top of medicines? Not every home has the same level of clinical oversight, and it is not something you will find on their websites. With Curalune Care Help (A$109, one-off) we read your father’s or mother’s situation — conditions, medicines, needs — and within 24 business hours we send you 3 to 5 suitable homes in your area, with contacts, links and a ready-to-send message you can put to all of them at once. Start here.
*Prescribing arrangements, reporting duties and regulatory responsibilities depend on national rules and on how each home is run, and are updated regularly. Never stop or change medicines on your own initiative: speak to the GP and to the home. This article is general information and is not a substitute for medical or legal advice. Curalune does not allocate places and cannot guarantee availability.*