Medication review brief · for the pharmacist
Rajesh Kowalski
70 · male · Hypertension, Type 2 diabetes, Enlarged prostate (BPH), Depression, Anxiety
Prepared by Domino · Oct 1, 2026
Summary
5 likely prescribing cascade links. If Metformin were reviewed, up to 1 downstream medicine might no longer be needed (10 → 8). Anticholinergic burden is 4.
Question 1
Could the diarrhoea be from metformin? An extended-release form or dose change may help.
- Metformin (Jan 9, 2023) → diarrhoea → Loperamide (Jan 18, 2023) · likely 0.88 · label
- Metformin (Jan 9, 2023) → nausea → Metoclopramide (Nov 9, 2023) · possible 0.26 · graph-inferred
If reviewed: Loperamide; medicines 10 → 8; anticholinergic burden 4 → 3; fall-risk drugs 7 → 7.
Question 2
Could the dizziness be from the alpha blocker (often on standing)? Vestibular sedatives are strongly anticholinergic and add fall risk.
- Tamsulosin (Aug 11, 2023) → dizziness or spinning → Dimenhydrinate (Sep 13, 2023) · likely 0.99 · consensus
- Dimenhydrinate (Sep 13, 2023) → confusion or memory problems → Rivastigmine (Oct 26, 2023) · likely 0.59 · graph-inferred
- Rivastigmine (Oct 26, 2023) → nausea → Metoclopramide (Nov 9, 2023) · likely 0.96 · graph-inferred
If reviewed: Dimenhydrinate; medicines 10 → 8; anticholinergic burden 4 → 1; fall-risk drugs 7 → 5.
Question 3
Could the memory problems be from the benzodiazepine? Benzodiazepines impair memory and attention in older adults.
- Lorazepam (May 8, 2023) → confusion or memory problems → Rivastigmine (Oct 26, 2023) · likely 0.84 · consensus
- Rivastigmine (Oct 26, 2023) → nausea → Metoclopramide (Nov 9, 2023) · likely 0.96 · graph-inferred
If reviewed: no downstream change; medicines 10 → 9; anticholinergic burden 4 → 4; fall-risk drugs 7 → 6.
Do not stop abruptly
- Lorazepam: Taper slowly if changed: stopping suddenly can cause withdrawal, including seizures.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Metformin as prescribed Dr. J. Martin (family doctor) | Jan 9, 2023 | Type 2 diabetes | Root of a cascade |
| Loperamide as prescribed Dr. R. Ahmed (walk-in clinic) | Jan 18, 2023 | Diarrhoea | Possibly treating a side effect ACB +1 |
| Lorazepam as prescribed Dr. J. Martin (family doctor) | May 8, 2023 | Anxiety | Root of a cascade Beers-listed |
| Tamsulosin as prescribed Dr. J. Martin (family doctor) | Aug 11, 2023 | Enlarged prostate (BPH) | Root of a cascade |
| Dimenhydrinate as prescribed Dr. R. Ahmed (walk-in clinic) | Sep 13, 2023 | Dizziness / vertigo | Possibly treating a side effect ACB +3 Beers-listed |
Evidence
- Product monographs and prescribing information (adverse reaction sections), curated by hand for this prototype. Frequencies are approximate bands, not exact rates.
- 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.
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.