Rosa Alvarez

88 · female · Dementia, Anxiety, Osteoporosis

A four-drug chain that started with an anxiety pill.

Pharmacist brief Check a new prescription Export FHIR

Medicines

Likely cascade links

Could be avoidable

Anticholinergic burden

Drugs toward falls

Dangerous combos

Root drug · likely · score 0.76

Lorazepam → 3 downstream

Lorazepam

Benzodiazepine

Risperidone

Antipsychotic

Carbidopa-levodopa

Antiparkinsonian

Quetiapine

Antipsychotic

Root drug · likely · score 0.88

Alendronate → 1 downstream

Alendronate

Bisphosphonate

Pantoprazole

Proton pump inhibitor

Feedback loop

Donepezil can cause insomnia, which Lorazepam treats; Lorazepam can cause cognitive impairment, which Donepezil treats. Each drug can feed the problem the other is treating.

Risperidone can cause parkinsonism (eps), which Carbidopa-levodopa treats; Carbidopa-levodopa can cause hallucinations, which Risperidone treats. Each drug can feed the problem the other is treating.

Why Domino thinks so

Lorazepam → agitation, restlessness or delirium → Risperidone

Lorazepam started May 30, 2024 · Risperidone started Jun 20, 2024

0.60

likely

How often it causes this×0.4Agitation / delirium is uncommon with Lorazepam.

Timing×1Risperidone started 3 weeks after Lorazepam, inside the usual window for agitation / delirium (1 to 45 days).

Other reasons×1.25Risperidone was charted for agitation / delirium.

Published evidence×1.2Matches a documented cascade backed by expert consensus (ThinkCascades).

Benzodiazepine → agitation or delirium → antipsychotic

Evidence: expert consensus

Real-world signal: adjusted sequence ratio 1.15 (95% CI 1.08–1.21), found in 3.2% of Ireland, 533,464 adults aged 65+.

Question for the pharmacist: Could the agitation be a paradoxical reaction or delirium from the benzodiazepine, rather than a new behavioural problem?

Teach Domino. Your decision becomes memory every future review respects.

Checked and set aside

Analysis: 10 FalkorDB queries, run in parallel, 23 ms