Medication review brief · for the pharmacist
Rosa Alvarez
88 · female · Dementia, Anxiety, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
4 likely prescribing cascade links. If Lorazepam were reviewed, up to 3 downstream medicines might no longer be needed (8 → 4). Anticholinergic burden is 4.
Question 1
Could the agitation be a paradoxical reaction or delirium from the benzodiazepine, rather than a new behavioural problem?
- Lorazepam (May 30, 2024) → agitation, restlessness or delirium → Risperidone (Jun 20, 2024) · likely 0.60 · consensus
- Risperidone (Jun 20, 2024) → stiffness, tremor, shuffling → Carbidopa-levodopa (Aug 24, 2024) · likely 0.99 · consensus
- Carbidopa-levodopa (Aug 24, 2024) → seeing or hearing things → Quetiapine (Feb 6, 2025) · likely 0.88 · label
If reviewed: Risperidone, Carbidopa-levodopa, Quetiapine; medicines 8 → 4; anticholinergic burden 4 → 0; fall-risk drugs 5 → 1.
Do not stop abruptly
- Lorazepam: Taper slowly if changed: stopping suddenly can cause withdrawal, including seizures.
- Risperidone: Taper if changed: stopping suddenly can cause withdrawal symptoms or relapse.
- Carbidopa-levodopa: Never stop suddenly: abrupt withdrawal of levodopa can cause a dangerous reaction with fever and rigidity.
- Quetiapine: Taper if changed: stopping suddenly can cause withdrawal symptoms or relapse.
Question 2
Could the indigestion be from the bisphosphonate (and how it is taken)?
- Alendronate (Sep 3, 2023) → heartburn or indigestion → Pantoprazole (Oct 7, 2023) · likely 0.88 · label
If reviewed: Pantoprazole; medicines 8 → 6; anticholinergic burden 4 → 4; fall-risk drugs 5 → 5.
Do not stop abruptly
- Pantoprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Donepezil 10 mg at bedtime Dr. L. Romero (geriatrics) | Mar 27, 2023 | Dementia | |
| Alendronate 70 mg weekly Dr. A. Patel (family doctor) | Sep 3, 2023 | Osteoporosis | Root of a cascade |
| Calcium + vitamin D 500 mg + 800 IU daily Dr. A. Patel (family doctor) | Sep 3, 2023 | Osteoporosis | |
| Pantoprazole 40 mg daily Dr. T. Nguyen (walk-in clinic) | Oct 7, 2023 | Reflux / indigestion | Possibly treating a side effect Beers-listed |
| Lorazepam 0.5 mg twice daily Dr. T. Nguyen (walk-in clinic) | May 30, 2024 | Anxiety | Root of a cascade Beers-listed |
| Risperidone 0.5 mg twice daily Dr. L. Romero (geriatrics) |
Evidence
- McCarthy LM, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840.
- Doherty AS, Lund LC, Moriarty F, et al. Prescribing Cascades Among Older Community-Dwelling Adults: Application of Prescription Sequence Symmetry Analysis to a National Database in Ireland. Ann Fam Med. 2025;23(4):315-324.
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
Decision support only. Domino flags patterns in a synthetic record for a clinician to review; it does not diagnose, and it never recommends stopping or changing a medicine. Synthetic data; no real patient.