Medication review brief · for the pharmacist
Pierre Patel
83 · male · Dementia, Hypertension, Depression
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Escitalopram were reviewed, up to 1 downstream medicine might no longer be needed (6 → 4). Anticholinergic burden is 4.
Question 1
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Escitalopram (May 12, 2024) → trouble sleeping → Zopiclone (Jun 28, 2024) · likely 0.99 · consensus
If reviewed: Zopiclone; medicines 6 → 4; anticholinergic burden 4 → 4; fall-risk drugs 6 → 4.
Do not stop abruptly
- Escitalopram: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Zopiclone: Taper if changed: stopping suddenly can cause rebound insomnia.
Question 2
Could the ankle swelling be from the calcium channel blocker? CCB edema does not respond well to diuretics; a dose change or a different antihypertensive may help instead.
- Amlodipine (Mar 19, 2023) → ankle and leg swelling → Furosemide (Apr 17, 2023) · likely 0.84 · consensus
If reviewed: Furosemide; medicines 6 → 4; anticholinergic burden 4 → 3; fall-risk drugs 6 → 4.
Question 3
Could dizziness or spinning be from Memantine?
- Memantine (Oct 16, 2024) → dizziness or spinning → Meclizine (Nov 11, 2024) · likely 0.74 · graph-inferred
If reviewed: Meclizine; medicines 6 → 4; anticholinergic burden 4 → 1; fall-risk drugs 6 → 4.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Amlodipine as prescribed Dr. J. Martin (family doctor) | Mar 19, 2023 | — | Root of a cascade |
| Furosemide as prescribed Dr. T. Nguyen (walk-in clinic) | Apr 17, 2023 | — | Possibly treating a side effect ACB +1 Beers-listed |
| Escitalopram as prescribed Dr. J. Martin (family doctor) | May 12, 2024 | Depression | Root of a cascade Beers-listed |
| Zopiclone as prescribed Dr. T. Nguyen (walk-in clinic) | Jun 28, 2024 | Insomnia | Possibly treating a side effect Beers-listed |
| Memantine as prescribed Dr. J. Martin (family doctor) | Oct 16, 2024 | Dementia | Root of a cascade |
| Meclizine |
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.
- Savage RD, et al. Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA Intern Med. 2020;180(5):643-651.
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.