Every night around the same time, Joshua Niznik’s grandmother, like many older adults, would sit down with a glass of water and a plastic organizer brimming with pills. She was in her late 70s, living with dementia, and taking almost a dozen medications. Some of them were meant to ease her confusion; others might have been making it worse.“I remember thinking, Are all these prescriptions actually beneficial?” Niznik recalls.
That quiet question sparked a research career now shaping the way Niznik thinks about aging, medicine, and what it means to live well, especially toward the end of life.
Within the UNC School of Medicine and Eshelman School of Pharmacy, Niznik studies medication use in older adults. Specifically, he focuses on deprescribing: the supervised process of reducing or discontinuing drugs that may no longer be necessary — or may be doing more harm than good. In a health care system that often adds more pills than it subtracts, his work asks a deceptively simple question: What if less is more?
Before he was a researcher, Niznik was just a curious kid growing up in Pennsylvania. He liked chemistry class and lived across the street from a woman who worked as a pharmacist. For a career project in eighth grade, he decided to shadow her and was struck by the unique way pharmacists combined science and real-world impact.
Upon entering pharmacy school at the University of Pittsburgh, he imagined himself working in clinical settings, helping patients manage their prescriptions. But as he moved through his coursework, he found himself drawn to the bigger picture: Why are certain medications prescribed in the first place? How do decisions made in clinical settings affect people long after they’ve left the doctor’s office?
Impact Report
Nearly 20% of North Carolinians are over the age of 65 — a number that continues to grow as the state’s population ages. Many live in rural or medically underserved areas where access to geriatric care is limited, making thoughtful care critical.
Joshua Niznik’s research is funded by the National Institute on Aging, part of the National Institutes of Health. This federal support enables high-impact studies using Medicare and Veterans Affairs data, helping to inform guidelines for safer, more personalized care in older adults.
He eventually pivoted to research in pharmaceutical outcomes and policy, driven by a deeper desire to understand — not just treat.
Decoding deprescribing
If prescribing is an action — something a doctor does — then deprescribing is more of a question. It asks: Is this still the right medication for this person at this stage of their life?
Deprescribing doesn’t mean cutting corners or taking people off meds just for the sake of it. It means zooming out, seeing the full picture of someone’s health, and reconsidering the long list of prescriptions that may have accumulated over years, even decades. It means choosing quality over quantity. Relief over routine.
“The ultimate goal is to reduce the number of pills someone takes, making it easier for them to manage their prescriptions,” Niznik explains. “I mean, it’s a lot to take 10 pills. It’s more about personalizing the goals of each of the treatments that they’re receiving so that it’s more aligned with maximizing safety and minimizing risk.”
Take diabetes, for example. For younger adults, the focus is often strict blood sugar control and keeping glucose levels in a tight range. But for an 85-year-old with a history of falls, memory issues, or other chronic conditions, the risks of that aggressive control — like low blood sugar or dizziness — can outweigh the benefits. In that case, backing off the medication can actually be the safer choice.
And then there are over-the-counter drugs, like Benadryl. It’s easy to grab from a pharmacy shelf, but for older adults, the active ingredient — diphenhydramine — can cause confusion and memory problems.
“As we age, we get more vulnerable to the negative side effects of medications,” Niznik says. “Our bodies don’t process or eliminate medications as well. And so what would be a normal dose for a younger, healthier person can end up being a really high systemic exposure.”
And older adults are vastly underrepresented in research. Although he is no longer a practicing clinical pharmacist, Niznik is driven to encourage a sense of agency and purpose in patients as they age, with support from their caregivers and providers.
Purposeful pills
Niznik’s research may be driven by patient stories and interactions, but that is only part of the work he does. He interviews patients, caregivers, and health care providers to gather insights that don’t always show up in lab results or charts. These conversations often reveal the emotional terrain of deprescribing, like the fear of change.
The other side of his work is rooted in data — and lots of it. Niznik analyzes enormous health care datasets like Medicare records, electronic health records, and databases from the Veterans Health Administration.
Thanks to Carolina’s robust hospital system, access to this information is much easier. Niznik uses their anonymous data to look for patterns over time, like who is on what prescriptions, when their medications get discontinued, and what happens after. He hopes to connect the dots between medication use and real-world health outcomes, especially for older adults with complex needs.
“I try to identify groups of people who would be targets for deprescribing,” he clarifies. “So often it’s people with dementia or with a prognosis of less than six months, and people who are near end-of-life. We look at their prescription refill records and basically try to piece it together like a daily diary.”
In one study, Niznik found that people who take 10 or more medications are less likely to discontinue or have doctors deprescribe any of their prescriptions. While these patients seem like logical candidates for deprescribing, Niznik and his team realized they need a more nuanced approach for identifying candidates for medication reduction.
Even though this research might start with interviews and spreadsheets, it is helping reshape how health care systems think about prescribing in older adults.
Niznik is also using data from electronic health care records to compare documents that list patient goals with their medications and determine if those two factors are aligned. For example, if a patient prioritizes staying mentally sharp enough to play with their grandkids, that value should guide how doctors approach drugs that might impact cognition.
“Patient awareness and engagement are what our field needs to drive deprescribing,” Niznik says. “Patients have access to more information, they can ask more questions, and they should ask questions. They should feel empowered to check the decisions that are being made.”