One of the biggest contributors to polypharmacy isn’t the number of diagnoses a patient has—it’s our mindset around medications that fail to deliver benefit. Everyone knows we need to reduce meds in geriatrics, but how do we do that? Too often, when a drug doesn’t work, we add something new instead of stopping what’s ineffective. Over time, this creates unnecessary complexity, a higher risk of adverse effects, and confusion for patients and caregivers.
A key clinical skill—especially for pharmacists, nurses, and prescribers—is learning to ask a simple but powerful question: “Is this medication actually helping?” If the answer is no, continuing it rarely makes sense.
I provide a couple of examples of ways to reduce meds that I encountered recently in practice.
Scheduled Tums + PPI Example
Consider a patient who is scheduled on calcium carbonate (Tums) three times daily for reflux symptoms. Despite this, the patient continues to report heartburn. Instead of reassessing the effectiveness of the antacid, a proton pump inhibitor (PPI) is added.
At face value, this might seem reasonable. However, a deeper look reveals a common problem:
- The scheduled antacid is not adequately controlling symptoms
- The PPI is intended to replace, not supplement, frequent antacid use
- Tums remains scheduled indefinitely without reassessment
Now the patient is taking two acid-related therapies, one of which was already shown to be ineffective. This increases pill burden, calcium exposure, constipation risk, and medication administration complexity—especially in older adults or long-term care settings.
A better approach would be:
- Initiate the PPI
- Reassess symptom control
- Discontinue scheduled Tums if symptoms improve
PRN antacids may still have a role, but scheduled therapy that doesn’t work should not be carried forward by default.
The Sleep Cascade: Trazodone Plus Melatonin
Sleep medications are another area where ineffective therapy often lingers.
A common scenario:
- Trazodone is started for insomnia
- The patient reports little to no improvement
- Instead of stopping trazodone, melatonin is added
Now the patient is taking two agents for sleep, despite the first one failing. Trazodone continues indefinitely, exposing the patient to risks such as orthostasis, daytime sedation, and falls—particularly concerning in older adults.
Melatonin may or may not help, but the core issue remains: the ineffective medication was never stopped.
A cleaner strategy would be:
- Trial trazodone with a defined evaluation period
- Discontinue if ineffective
- Consider melatonin or non-pharmacologic sleep strategies next
Each medication should earn its place on the list.
If you are looking for more on polypharmacy, the prescribing cascade, and how to reduce meds, my book, Perils of Polypharmacy is an excellent resource for countless examples.
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