The Kitchen Counter Test
How the Prescribing Cascade Starts — and How to Stop It
Do this right now.
Go to your parent’s home—or call up the picture in your mind if you know it well enough. Walk to the bathroom cabinet. The nightstand. The kitchen drawer where the pills migrate. Gather every bottle.
Lay them on the counter.
Count them.
Research says most of you will count somewhere between eight and fifteen. Some of you will count more than twenty. And as you stand there looking at this chemical inventory of your parent’s life, you will ask the question that brought you here:
Is all of this really necessary?
The honest, peer-reviewed, evidence-based answer is probably no.
For most older adults taking ten or more medications, at least three to five are unnecessary, harmful, or treating the side effect of another drug. Not maybe. Statistically. Documented in the literature. Known by every geriatrician who has ever done a proper medication review.
Here is what the system will not tell you: there is no financial incentive to remove a pill. There is only a financial incentive to add one.
That is not an accusation. It is arithmetic. And once you understand that arithmetic, everything about your parent’s overcrowded pill organizer begins to make a different kind of sense.
The Trap That Looks Like Medicine
It starts simply.
Your parent begins one medication for blood pressure. A side effect causes dizziness. The dizziness gets attributed to a balance problem. A second medication is prescribed. That medication causes dry mouth and confusion. The confusion gets attributed to early dementia. A third medication is added for dementia.
This is called the Prescribing Cascade—first described by researchers Rochon and Gurwitz (1997), and now documented in hundreds of peer-reviewed studies. A side effect of Drug A is misread as a new medical condition. Drug B is prescribed to treat it. Drug B has its own side effects. Drug C follows. The cascade continues.
Each step makes clinical sense in isolation. Taken together, they are making your parent sicker.
And at every step, someone is getting paid.
The cardiologist who prescribed the blood pressure pill. The urologist who prescribed the bladder medication. The pharmacy that filled both. The insurance system that processed both. The lab that ran the bloodwork that led to the third prescription.
This is not a conspiracy. It is a structure. The healthcare system is not designed to look at your parent as a whole person holding fifteen bottles. It is designed to see one complaint, in one appointment, and respond. The response is almost always a prescription. The response is almost never, “Let’s remove something.”
That removal—that careful, evidence-based unwinding of an unnecessary medication—is called deprescribing. It requires time, clinical judgment, and a pharmacist who has reviewed the whole list. It is the most underused intervention in geriatric medicine. It is also the one that most often changes lives.
The Man Who Got His Father Back
John was a retired librarian. He was sharp and fiercely independent. The kind of man who had read more books than most people have ever owned.
Over three months, he became acutely, frighteningly confused. Not gradually forgetful—dramatically altered. He stopped tracking conversations. He shuffled when he walked. He fell twice. His daughter Sarah watched her father disappear in front of her.
John’s doctor saw him for eight minutes and wrote: Early cognitive decline. Recommend memory-enhancing medication.
The thing is, dementia generally is not dramatic; it’s slow. Sarah did not accept this.
She asked the question the system never pays for and actually costs the system money: What if this isn’t dementia? What if it’s the pills?
She brought John’s complete medication list—every prescription, every supplement, every over-the-counter remedy—to a clinical pharmacist for a full review. They found it immediately. John’s confusion had started within weeks of beginning a bladder medication prescribed by a specialist who had never seen his full medication list. That medication was an anticholinergic drug—a class of medications known to block the brain chemicals essential for memory and clear thinking. The new memory-enhancing medication his doctor had just added was about to pour gasoline on a chemical fire.
They stopped the bladder medication. They held the new prescription. Within weeks, the fog lifted. John was alert, oriented, and back at his books.
His brain had not been failing.
It had been overloaded by a system that never looked at the whole picture.
The confusion wasn’t dementia. It was five medications yelling at each other in John’s brain. And no one was listening.
What Medication Overload Actually Looks Like
The system will call these things normal aging. They are not.
I hear it all the time: “She had a dramatic decline after the fall.” Maybe—or maybe it was a medication that caused the fall and is still contributing to what everyone thinks is “decline.” Maybe it’s not decline. Maybe it’s too many medications.
Sudden confusion or increased forgetfulness. Especially if it appeared or worsened after a new medication was started. This is the single most important pattern to recognize. Anticholinergic medications—found in bladder drugs, antihistamines, sleep aids, and over-the-counter PM formulas—directly block the brain chemicals needed for clear thinking.
Gait changes and new falls. Many medications cause blood pressure to drop suddenly when your parent stands up. The medication is the fall risk, not the aging. This is documented, predictable, and frequently missed.
New behavioral changes. Unexpected anxiety, depression, or lethargy that seems out of character. These are often medication signatures, not personality shifts. The system tends to add another prescription. The right move is to audit the existing ones.
The specialist coordination gap. Your parent sees a cardiologist, a urologist, and a rheumatologist. None of them know what the others have prescribed. None of them have reviewed the full list. This is not negligence—it is a fractured healthcare system. The system does not build a whole picture because systems don’t talk to each other. You have to build the whole picture.
Five Moves That Change Everything
Here is exactly what to do.
Move 1: The Total Sweep. Every prescription bottle. Every over-the-counter remedy. Every supplement. Vitamin D from the bathroom, ibuprofen from the kitchen, the herbal sleep aid from Amazon. Gather everything. Your parent probably cannot account for half of what they are taking. This pile is your starting point.
Move 2: The Medication List. Create a single-page document—drug name, dose, instructions, prescribing physician, and most importantly: the reason it was prescribed. If neither you nor your parent knows why a medication is on the list, circle it. That is your first question for the doctor. See our recent newsletter for assistance with The Medication List.
Move 3: The Brown Bag Consult. Do not try to have this conversation at a busy pharmacy counter during the lunch rush. Call ahead. Ask for a dedicated fifteen-minute consultation—most pharmacists know exactly what a Brown Bag Review is and will make time for it. Bring the physical bottles. This is where interactions, duplications, and prescribing cascades get spotted. This is also where you use your pharmacist the way they were trained to be used—as a clinical partner, not a dispenser.
Move 4: Prepare for the Eight-Minute Appointment. Your parent’s physician has approximately eight minutes. The RVU system that governs physician reimbursement rewards procedures and prescriptions, not the thirty minutes it takes to properly review a complex medication list. There is no billing code for “talked about how each medication fits with this patient’s goals of care.”
Arrive with a plan. I recommend the One-Page Briefing in the MyRxPro Caregivers Toolkit. Your One-Page Briefing will help you include your top three concerns, your master medication list, and specific observations with dates. “She has been dizzy every morning since starting the new blood pressure pill—Tuesday, Thursday, and Saturday this week, each time within an hour of her morning dose.” That is clinical data. That gets action by the doctor. See our recent newsletter for assistance with One-Page Briefing.
Move 5: Strategic Patience.
Safe deprescribing is methodical. Some medications require careful tapering — stopping a benzodiazepine abruptly is dangerous; stopping certain blood pressure medications can cause rebound hypertension. Work with the clinical team. This is not a sprint. It is a careful, collaborative unwinding — and it is worth every step.
The Caregivers Toolkit includes the Medication List Template and the One-Page Briefing.
A Word on Safety
Deprescribing must always be done under clinical supervision. Never stop a medication on your own.
But asking whether a medication is still necessary? Questioning a new prescription that appeared after a side effect from the last one? Requesting a full medication review from a pharmacist before the next appointment?
That is always safe.
The system added these pills one at a time, in separate decisions, by separate specialists, over years of care, with no one looking at the whole picture. To stop the cascade, what should you ask?
Five Questions to Ask to Limit the Prescribing Cascade
If the doctor’s answer is another prescription, be sure you understand why and that you have a plan for if, and when, to stop the medication in the future. How do you know what to ask? CLICK HERE to watch our short video for 5 questions to ask before you leave the doctor’s office.
Go Back to the Counter
Now you have something you did not have when you started. You have a name for what you are looking at—the prescribing cascade. You have a name for what it produces—polypharmacy. You have a name for what reverses it—deprescribing. And you have five moves to begin.
The system will not sweep those bottles into a bag and ask hard questions about each one. The cardiologist will not call the urologist. The eight-minute appointment will not stretch to thirty. None of that will change before your parent’s next refill.
But you will be in the room. You will have the list. You will know what questions to ask and why they matter. You will be the one person in your parent’s care who sees the whole picture—because you are the only one who has been there long enough to know what the picture looked like before.
You needed one question and the courage to ask it.
What if it’s the pills?
You already have the question. The 5 Moves is your place to start.
Peace and wellness,
David Lee, PharmD, PhD Founder, MyRxPro
Want the full playbook?
Fewer Pills, More Paws gives you the complete system — the scripts, the checklists, the pharmacist’s triage, and the One-Page Briefing template that makes the eight-minute appointment work for you.
The paperback is available now for pre-order:
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Have you seen our latest YouTube videos?
Narrow Therapeutic Index (NTI) drugs are medications on a tight rope.
Too little and it’s like not taking it at all. A little too much could be toxic. The problem: Older adults often have a narrower homeostatic range; in other words, the tightrope has narrowed even more. How do you know if you or a loved one is taking an NTI drug?
This video gives you 5 signs to look out for. CLICK HERE to see the video now!
You don’t have to look at that kitchen counter alone.
If you are staring at a jumble of amber bottles and suspect your aging parent is caught in a prescribing cascade, you do not have to fight the modern medical maze by yourself. The system is built for speed, but you can choose precision.
As a geriatric clinical pharmacist, I look at the whole picture to help you step confidently onto the podium as the Conductor of your family’s care.
Book a Free 15-Minute Medication Consultation with me this week, and we will:
Audit the List: Identify potential high-risk medications, duplications, and hidden interactions.
Goals of Care: We’ll discuss your goals of care and how each medication is helping or hurting you realize those goals.
Uncover the Cascades: Look for instances where a pill is only there to treat a side effect of another drug.
Build Your Script: Create a targeted strategy for your next 8-minute doctor’s appointment so you get real action.
No strings attached. No systemic pressure. Just a quiet, expert look at the board so you can keep your parent safe, alert, and independent.
References:
Rochon, P. A., & Gurwitz, J. H. (1997). Optimising drug treatment for elderly people: the prescribing cascade. BMJ, 315(7115), 1096–1099. https://doi.org/10.1136/bmj.315.7115.1096