Abstract

Deprescribing, defined as the planned and supervised process of dose reduction or cessation of medications that may no longer be beneficial or could be causing harm, represents an increasingly vital component of comprehensive geriatric care. (fhea.com) This detailed review delves into the contemporary landscape of deprescribing practices specifically tailored for older adults. It meticulously examines its profound significance in an aging global demographic, elaborates on the diverse methodologies employed, identifies the multifaceted challenges encountered during its implementation, and highlights the indispensable roles played by interdisciplinary healthcare teams in fostering its success. Furthermore, this report scrutinizes the far-reaching impact of deprescribing on critical patient outcomes, including enhanced patient safety, significant improvements in quality of life, and tangible reductions in healthcare expenditures. By exploring both the pronounced benefits and inherent limitations, this analysis provides a nuanced and comprehensive understanding of deprescribing as a pivotal strategy for optimizing pharmacotherapy and promoting healthier aging trajectories.

1. Introduction

The profound demographic shift towards an aging global population is one of the defining features of the 21st century. This seismic change has ushered in an era where a growing number of older adults contend with multimorbidity—the coexistence of multiple chronic health conditions. (pubmed.ncbi.nlm.nih.gov) This increasing complexity in patient health status invariably leads to a corresponding escalation in the reliance on pharmaceutical interventions, culminating in the widespread phenomenon of polypharmacy. Polypharmacy, typically defined as the concurrent use of five or more medications, but sometimes more broadly as the use of more medications than are clinically indicated, poses substantial and often insidious risks to older individuals. These risks encompass a spectrum of adverse outcomes, including an elevated propensity for adverse drug events (ADEs), clinically significant drug-drug and drug-disease interactions, diminished adherence to essential therapies, and a profound deterioration in overall quality of life. (ce.pharmacy.wisc.edu)

In response to this pressing public health challenge, deprescribing has emerged as a scientifically grounded and ethically imperative strategic approach. It involves a systematic and evidence-informed process of reviewing and discontinuing or reducing the dose of medications that are either no longer necessary, potentially harmful, or incongruent with the patient’s current care goals and life expectancy. (en.wikipedia.org) The foundational premise of deprescribing is to optimize pharmacotherapy, simplify medication regimens, and ultimately improve patient outcomes by reducing medication burden and associated risks. While the potential benefits of judicious deprescribing are substantial and well-documented, its widespread implementation continues to be hampered by a formidable array of challenges. These include a reluctance from both patients and healthcare providers, the notable absence of universally standardized protocols and comprehensive clinical guidelines for all medication classes, and often, insufficient patient education regarding the risks of polypharmacy and the merits of medication reduction. (australianprescriber.tg.org.au) This report aims to dissect these intricacies, offering a deep dive into the theoretical underpinnings, practical methodologies, persistent hurdles, and the collaborative strategies required to effectively integrate deprescribing into routine geriatric care.

2. The Significance of Deprescribing in Older Adults

Deprescribing transcends a mere clinical intervention; it represents a fundamental paradigm shift in pharmacotherapy for older adults, moving beyond the traditional focus on adding medications to address new symptoms, towards a holistic approach that prioritizes overall patient well-being and medication appropriateness. Its significance is underscored by the pervasive issues of polypharmacy, potentially inappropriate medications (PIMs), and the insidious prescribing cascade.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2.1 Polypharmacy and Its Multifaceted Implications

Polypharmacy, commonly defined as the regular use of five or more prescription medications, is a ubiquitous phenomenon among older adults, with prevalence estimates varying geographically but consistently high across developed nations. Studies in the United States, for instance, indicate that a substantial proportion, often approaching 40%, of older Americans regularly consume five or more prescription medications, and a significant subset utilizes ten or more. (ormondmanor.com) While some instances of polypharmacy may be clinically appropriate for managing complex multimorbidity, a considerable proportion is considered inappropriate or problematic, contributing to a cascade of negative health outcomes.

The implications of problematic polypharmacy are extensive and profoundly impact older adults. Foremost among these are Adverse Drug Events (ADEs), which are defined as any unintended and undesired effect of a drug that occurs at doses used in humans for prophylaxis, diagnosis, or therapy. Older adults are disproportionately susceptible to ADEs due to age-related physiological changes that affect pharmacokinetics (drug absorption, distribution, metabolism, and excretion) and pharmacodynamics (how drugs affect the body). For example, reduced renal and hepatic function can lead to drug accumulation and heightened toxicity. Furthermore, polypharmacy significantly increases the likelihood of deleterious drug-drug interactions, where the effects of one drug are altered by the presence of another. These interactions can manifest as increased toxicity or reduced therapeutic efficacy, often leading to a need for further medication to manage the new symptoms or interactions.

Beyond direct drug-related harm, polypharmacy is a recognized independent risk factor for falls, a leading cause of injury and mortality in older adults. Medications affecting the central nervous system, such as benzodiazepines, opioids, and certain antidepressants, are particularly implicated due to their sedative and psychoactive properties that impair balance and cognitive function. Cognitive impairment, including delirium and dementia exacerbation, is another critical consequence, with anticholinergic medications being a notable culprit. Additionally, polypharmacy can lead to a reduced quality of life through symptoms such as fatigue, gastrointestinal disturbances, and sexual dysfunction, which are often overlooked or misattributed to aging or other comorbidities. The sheer burden of managing multiple medications—remembering doses, navigating complex regimens, and affording co-pays—can also lead to decreased medication adherence for essential therapies, financial strain, and considerable psychological stress, further compromising health outcomes. (ce.pharmacy.wisc.edu)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2.2 Potentially Inappropriate Medications (PIMs)

Central to the discussion of problematic polypharmacy is the concept of Potentially Inappropriate Medications (PIMs). These are drugs that, for various reasons, should generally be avoided in older adults or used with caution, either because their risks outweigh their benefits in this population, or because safer and equally effective alternatives are available. The identification and avoidance of PIMs are cornerstones of geriatric pharmacotherapy and a primary target for deprescribing interventions.

The most widely recognized and frequently updated set of explicit criteria for identifying PIMs is the Beers Criteria, developed by the American Geriatrics Society (AGS). (en.wikipedia.org) First published in 1991, the Beers Criteria list medications that are potentially inappropriate for older adults due to high risk profiles, regardless of diagnosis or condition, or due to drug-disease or drug-syndrome interactions that exacerbate existing conditions. Examples of PIMs often found on the Beers Criteria include first-generation antihistamines (e.g., diphenhydramine) due to their anticholinergic effects, certain benzodiazepines (e.g., long-acting lorazepam) due to increased risk of falls and cognitive impairment, and nonsteroidal anti-inflammatory drugs (NSAIDs) for long-term use in patients with hypertension or heart failure due to renal and cardiovascular risks. Regular review and deprescribing of PIMs are not merely advisable but essential practices for optimizing patient safety and enhancing the overall quality of geriatric care.

Beyond the Beers Criteria, other tools have been developed to address the nuances of PIMs in various contexts. The ‘Screening Tool of Older Person’s Potentially Inappropriate Prescriptions’ (STOPP) and ‘Screening Tool to Alert doctors to Right Treatment’ (START) criteria are another pair of explicit criteria developed in Europe. STOPP identifies common instances of potentially inappropriate prescribing, while START identifies common instances of potential prescribing omissions. Other criteria, such as the PRISCUS list (Germany) and the NORGEP criteria (Norway), also offer region-specific guidance. These tools, while sharing a common objective, differ in their comprehensiveness, specific drug lists, and emphasis, reflecting varied healthcare systems and populations. The proliferation of such criteria underscores the complexity and global recognition of PIMs as a major clinical concern in older adult care.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2.3 The Prescribing Cascade

A critical factor contributing to both polypharmacy and the presence of PIMs is the ‘prescribing cascade.’ This phenomenon occurs when an adverse drug event (ADE) is misinterpreted as a new medical condition, leading to the prescription of an additional medication to treat this ‘new’ condition. This new medication, in turn, may cause its own set of side effects, prompting yet another prescription, thereby creating a spiraling chain of medication additions. A classic example involves a patient prescribed a calcium channel blocker for hypertension, who then develops peripheral edema (a known side effect). If this edema is misdiagnosed as heart failure, a diuretic might be prescribed, which could lead to electrolyte imbalances or renal dysfunction, necessitating further interventions. This cascade not only increases medication burden but also obscures the true underlying issue, leading to diagnostic confusion and potentially harmful polypharmacy. Recognising and interrupting the prescribing cascade is a core principle of deprescribing, requiring vigilant assessment of new symptoms and considering medication-induced causes before adding new therapies.

3. Methodologies of Deprescribing

Effective deprescribing requires a systematic, evidence-based, and patient-centered approach. It is not a haphazard process of simply stopping medications, but rather a carefully considered clinical strategy that integrates robust assessment tools with individualized patient preferences and goals.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.1 Systematic Review and Comprehensive Medication Reconciliation

The cornerstone of any successful deprescribing initiative is a thorough and systematic review of all medications a patient is currently taking. This process, often referred to as a Comprehensive Medication Review (CMR), extends beyond prescription drugs to include over-the-counter (OTC) medications, herbal remedies, dietary supplements, and even recreational substances, as all can contribute to drug interactions or adverse effects. The initial step involves gathering a complete and accurate medication list, a process known as medication reconciliation. This is particularly crucial during transitions of care (e.g., hospital admission, discharge, transfer between care settings), where discrepancies and omissions are common and can lead to significant patient harm. Patients, their caregivers, pharmacy records, and electronic health records (EHRs) are all critical sources for this reconciliation process.

Once a complete list is obtained, the systematic review proceeds through several key stages:

1. Indication Assessment: For each medication, the original indication is reviewed. Has the condition resolved? Is the medication still needed? For example, a proton pump inhibitor (PPI) prescribed for an acute ulcer may be continued indefinitely without re-evaluation, despite no ongoing indication.
2. Efficacy and Safety Review: The efficacy of the medication for its current indication is assessed. Is it working? Are the benefits outweighing the risks? Are there any adverse effects that could be mitigated by discontinuing or reducing the dose? This involves a careful consideration of the drug’s therapeutic window and potential for side effects in the older adult population.
3. Appropriateness in Context: Each medication’s appropriateness is evaluated in the context of the patient’s current health status, comorbidities, life expectancy, and overall care goals. A medication that was appropriate for a younger, healthier individual might be inappropriate for a frail older adult with multiple chronic conditions and a limited life expectancy.
4. Drug-Drug and Drug-Disease Interactions: A meticulous review for potential interactions is performed. This often requires specialized pharmaceutical knowledge and access to robust drug interaction databases. Identifying potential interactions that could lead to adverse events is a primary driver for deprescribing.
5. Duplication and Redundancy: Checking for therapeutic duplication, where two or more medications from the same class or with similar mechanisms of action are prescribed unnecessarily (e.g., two different benzodiazepines, or multiple drugs causing constipation).

This comprehensive review provides the foundational data upon which deprescribing decisions are made, enabling healthcare professionals to identify candidates for dose reduction or cessation with a robust evidence base. (aafp.org)

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.2 Deprescribing Algorithms and Clinical Decision Support Tools

To facilitate the identification of medications suitable for deprescribing, various algorithms, explicit criteria, and clinical decision support tools have been developed. These tools serve to standardize the review process, reduce reliance on subjective judgment, and provide evidence-based guidance to healthcare providers.

• Explicit Criteria: These tools provide clear, predefined lists of medications or prescribing patterns to be avoided or considered for deprescribing. The Beers Criteria (AGS Beers Criteria®) and STOPP/START criteria are the most prominent examples. As discussed, the Beers Criteria focus on PIMs across various categories, while STOPP identifies potentially inappropriate prescriptions and START highlights common prescribing omissions. These criteria are highly valuable for initial screening and raising red flags for specific drugs or drug classes. They are relatively easy to apply and can be integrated into electronic prescribing systems.

• Implicit Criteria: These tools require clinical judgment and a more in-depth, patient-specific assessment. The Medication Appropriateness Index (MAI) is a well-known implicit tool. It involves evaluating each medication against ten criteria (e.g., indication, effectiveness, dose, duration, cost, drug interactions, practical considerations) to determine its appropriateness for the individual patient. While more time-consuming, implicit criteria allow for a nuanced assessment that considers the patient’s unique clinical context, making them particularly useful for complex cases.

• Disease-Specific Deprescribing Guidelines: Recognizing that broad criteria might not always address specific clinical scenarios, guidelines for deprescribing particular drug classes have emerged. Examples include guidelines for deprescribing proton pump inhibitors (PPIs), benzodiazepines and Z-drugs, opioids, antipsychotics, and medications for diabetes or hypertension. These guidelines often provide step-by-step instructions for dose tapering, monitoring for withdrawal symptoms, and managing potential rebound effects. (en.wikipedia.org)

• Digital Tools and Algorithms: With advancements in health information technology, some deprescribing algorithms are being integrated into electronic health records (EHRs) or specialized software. These tools can flag potential PIMs, identify polypharmacy thresholds, and provide alerts or suggestions to prescribers, thereby streamlining the process and reducing cognitive load.

While these tools are invaluable, they are not a substitute for clinical judgment and patient-centered communication. They serve as aids to guide decision-making, prompting healthcare providers to critically evaluate pharmacotherapy rather than dictating actions.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.3 Patient-Centered Approach and Shared Decision-Making

Engaging the patient as an active partner is paramount to successful and sustainable deprescribing. A purely top-down, provider-driven approach is likely to encounter resistance and lead to poor adherence or anxiety. Instead, a patient-centered approach, grounded in the principles of shared decision-making (SDM), is essential. SDM involves a collaborative conversation between the patient (and often their caregivers) and the healthcare provider, where both parties contribute their unique expertise. The provider offers clinical knowledge about risks, benefits, and alternatives, while the patient contributes their values, preferences, life goals, and experiences with medications.

Key elements of a patient-centered deprescribing conversation include:

1. Eliciting Patient Concerns and Beliefs: Understanding what medications mean to the patient (e.g., ‘feeling safe,’ ‘preventing illness,’ ‘doctor knows best’) and their fears (e.g., ‘my condition will worsen,’ ‘withdrawal symptoms,’ ‘doctor giving up on me’) is crucial. Motivational interviewing techniques can be highly effective in exploring these perspectives.
2. Communicating Risks and Benefits Clearly: Explaining the potential harms of continued medication (e.g., falls, cognitive decline, financial burden) and the anticipated benefits of deprescribing (e.g., improved cognition, reduced side effects, simpler regimen, increased autonomy) in plain, understandable language. Using visual aids or analogies can be helpful.
3. Setting Realistic Expectations: Informing the patient about the process, potential temporary discomforts during tapering, and the importance of monitoring. Emphasizing that deprescribing is a trial and adjustments can be made reassures patients.
4. Aligning with Patient Goals: Discussing how deprescribing aligns with their personal goals (e.g., ‘I want to be able to walk without fear of falling,’ ‘I want to feel less drowsy,’ ‘I want to reduce the number of pills I take daily’). When deprescribing is framed as a means to achieve patient-valued outcomes, engagement significantly increases. Studies consistently demonstrate that patients are often willing to discontinue medications if they fully comprehend the potential risks and benefits, and if they feel involved and respected in the decision-making process. (australianprescriber.tg.org.au)
5. Developing a Deprescribing Plan: Collaboratively creating a clear, actionable plan that specifies which medication to reduce/stop, the tapering schedule (if applicable), how to monitor for changes or withdrawal, and clear instructions on who to contact if concerns arise. This empowers the patient and fosters a sense of control.

By ensuring that deprescribing aligns with the patient’s values, preferences, and current priorities for their health and well-being, the likelihood of successful and sustained medication reduction is significantly enhanced. This approach respects patient autonomy and promotes a collaborative therapeutic alliance.

4. Challenges in Deprescribing

Despite the clear rationale and substantial benefits, the widespread adoption of deprescribing in routine clinical practice faces significant hurdles. These challenges are multifaceted, stemming from psychological, systemic, educational, and evidentiary domains, creating a complex environment that often favors continued prescribing over strategic reduction.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.1 Patient and Healthcare Provider Resistance

Resistance to deprescribing is a pervasive and well-documented barrier, often arising from a confluence of factors on both the patient and provider sides.

Patient Resistance:

• Fear of Worsening Health or Symptom Recurrence: Patients may have a deep-seated belief that their medications are essential for maintaining their health or preventing symptom exacerbation. They might fear the return of symptoms or a decline in their condition if a medication is stopped, even if the original indication is no longer present or the medication offers marginal benefit. This fear is often rooted in past experiences or the perception that ‘more medication equals better health.’
• Withdrawal Symptoms: Many medications, particularly those affecting the central nervous system (e.g., benzodiazepines, antidepressants, opioids), can cause uncomfortable or even dangerous withdrawal symptoms if discontinued abruptly. Patients may have experienced this previously or fear it, making them hesitant to attempt deprescribing.
• Perceived Loss of Control/Feeling Abandoned: Some patients may interpret a suggestion to stop medication as a sign that their doctor is ‘giving up’ on them or that their condition is not being taken seriously. They might feel a sense of security from their medication regimen, even if it is burdensome.
• Trust in Medications: Decades of public health messaging and direct-to-consumer advertising have often instilled a belief in the efficacy and necessity of pharmaceutical solutions for every ailment, leading to a ‘pill for every ill’ mentality.
• Social and Cultural Factors: Family members or caregivers may also exhibit resistance, concerned that changes to medication might jeopardize the patient’s stability or lead to increased care burden.

Healthcare Provider Resistance:

• Fear of Adverse Outcomes and Medicolegal Concerns: Providers often worry about the potential for adverse events following medication discontinuation, such as symptom rebound, withdrawal syndromes, or even the recurrence of the original condition. This fear is compounded by medicolegal anxieties about being held responsible if a patient’s condition deteriorates after deprescribing. The dictum ‘first, do no harm’ can sometimes be interpreted as ‘never stop a drug,’ even when it is causing harm.
• Lack of Time and Resources: Deprescribing is a time-intensive process that requires comprehensive medication review, in-depth patient discussions, careful monitoring, and follow-up. In busy clinical settings with limited appointment times and inadequate reimbursement for such complex consultations, providers often prioritize new prescriptions over the laborious process of deprescribing.
• Diagnostic Uncertainty and Risk Aversion: When facing complex older patients with multimorbidity, providers may be uncertain about the precise indication for each medication, especially if they did not initiate it. It can feel safer to continue a medication rather than risk destabilizing a patient. There is often a greater perceived risk in stopping a medication than in starting one, even if the latter carries its own set of risks.
• Lack of Training and Confidence: Many healthcare professionals receive extensive training in prescribing but less emphasis on deprescribing methodologies, communication strategies, and managing withdrawal symptoms. This lack of specific expertise can lead to a lack of confidence in initiating and managing the deprescribing process. (australianprescriber.tg.org.au)
• Inertia and Habit: Prescribing habits are deeply ingrained. It is often easier to ‘renew’ an existing prescription than to critically evaluate and potentially discontinue it, especially when faced with large patient panels and administrative burdens.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.2 Lack of Standardized Protocols and Insufficient Evidence

While various deprescribing guidelines and criteria exist (e.g., Beers, STOPP/START), there remains a notable absence of universally accepted, comprehensive, and detailed standardized protocols that cover all scenarios, all medication classes, and all patient populations. This lack of prescriptive guidance can complicate implementation, as clinicians are often left to navigate complex decisions with limited clear direction. For instance, while guidelines exist for deprescribing specific drug classes like PPIs or benzodiazepines, integrating these into a cohesive strategy for a patient on 10+ medications requires significant clinical judgment and often a lack of an overarching framework.

Furthermore, the evidence base supporting deprescribing, while growing, still has gaps. Many studies are observational or focus on specific drug classes. There is a need for more robust, large-scale randomized controlled trials (RCTs) demonstrating the long-term benefits and safety of deprescribing across a broader range of medications and patient groups, particularly concerning hard outcomes like mortality, functional status, and institutionalization. The absence of definitive ‘gold standard’ evidence can make providers hesitant to deviate from established prescribing patterns.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.3 Insufficient Patient and Public Education

A significant barrier is the widespread lack of awareness among patients, their families, and the general public about the risks associated with polypharmacy and the potential benefits of deprescribing. Many individuals hold the implicit belief that more medications equate to better health or that all prescribed drugs are unequivocally beneficial. This perception is often reinforced by societal norms and marketing. Without a foundational understanding of the potential harms of unnecessary medications and the proactive nature of deprescribing, patients are less likely to engage in the process willingly. Educational initiatives are therefore critical to empower patients to ask questions, voice concerns, and actively participate in shared decision-making regarding their medication regimens. This includes educating them about the difference between appropriate and inappropriate polypharmacy and the concept of ‘less is more’ in certain contexts.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.4 Systemic and Structural Barriers

Beyond individual resistance, systemic factors within healthcare systems also impede deprescribing efforts:

• Fragmented Care: Patients often see multiple specialists who may not communicate effectively or have a complete overview of all medications prescribed by others. This fragmentation creates silos of prescribing, making comprehensive medication review difficult.
• Electronic Health Record (EHR) Limitations: While EHRs can assist, many are not optimally designed to facilitate deprescribing. They may lack integrated decision support tools, comprehensive medication histories that include OTCs, or easy-to-use interfaces for tracking deprescribing attempts and outcomes.
• Reimbursement Models: Current reimbursement models often prioritize brief patient visits and procedural interventions over the time-intensive cognitive work required for comprehensive medication reviews and deprescribing discussions. This creates a disincentive for providers to engage in these vital activities.
• Lack of Training in Medical Education: Deprescribing is often not a central component of medical, nursing, or pharmacy school curricula, leading to a workforce inadequately prepared to champion these efforts.

Overcoming these challenges necessitates a multi-pronged approach that addresses individual attitudes, enhances the evidence base, improves public health literacy, and reforms healthcare systems to better support deprescribing as an integral part of high-quality care for older adults.

5. The Role of Interdisciplinary Teams

Effective deprescribing, particularly in the context of older adults with multimorbidity and polypharmacy, is rarely a solitary endeavor. It thrives within a collaborative, interdisciplinary team framework, where the unique expertise of various healthcare professionals converges to provide holistic, patient-centered care. This team-based approach ensures a comprehensive evaluation of the patient’s medication regimen, clinical status, functional capacity, and personal preferences, leading to more informed and safer deprescribing decisions.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.1 Collaborative Care Models

Collaborative care models are foundational to successful deprescribing. These models facilitate regular communication and shared decision-making among various healthcare professionals, enabling a more thorough and coordinated approach to medication management. In such models, the patient is at the center, surrounded by a team that includes primary care physicians, pharmacists, nurses, specialists (e.g., geriatricians, cardiologists), and often other allied health professionals like dietitians, social workers, and physical or occupational therapists. The synergy created by these teams ensures that all aspects of a patient’s health are considered when evaluating medication appropriateness.

Key features of collaborative care models in deprescribing include:

• Shared Responsibility: No single professional bears the entire burden of deprescribing decisions. Each team member contributes their expertise, leading to more robust decision-making and shared accountability.
• Structured Communication: Regular team meetings, case conferences, and integrated electronic health records facilitate efficient information exchange and ensure that all team members are aware of the patient’s current medication plan and any changes made.
• Holistic Patient Assessment: The team collaboratively assesses not only pharmacological aspects but also the patient’s functional status, cognitive abilities, social support, nutritional needs, and psychosocial well-being, which all influence medication effectiveness and patient safety.
• Continuity of Care: Collaborative models can ensure smoother transitions of care, reducing the likelihood of medication discrepancies and promoting consistent deprescribing efforts across different settings (e.g., hospital to home, primary care to specialty care).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.2 Pharmacists’ Contribution

Pharmacists are indispensable members of the deprescribing team, bringing specialized knowledge of pharmacokinetics, pharmacodynamics, drug interactions, and adverse drug reactions. Their training positions them uniquely to identify PIMs and drug-related problems. (aafp.org) Their specific contributions include:

• Comprehensive Medication Reviews: Pharmacists excel at conducting thorough medication reconciliations and identifying potential drug-drug interactions, drug-disease interactions, therapeutic duplications, and inappropriate dosing for older adults, considering age-related physiological changes.
• Identification of Deprescribing Candidates: Utilizing tools like the Beers Criteria and STOPP/START, pharmacists can pinpoint medications that are potentially inappropriate or lack clear indications, presenting evidence-based recommendations to the physician.
• Patient Counseling and Education: Pharmacists are experts in medication counseling. They can explain the rationale for deprescribing, potential withdrawal symptoms, and monitoring plans to patients and caregivers in an understandable manner, addressing concerns and fostering adherence to the deprescribing plan. This role is crucial in overcoming patient resistance.
• Monitoring and Follow-up: They can assist in monitoring patients for adverse events or symptom recurrence during and after deprescribing, adjusting tapering schedules as needed, and communicating findings back to the prescribing physician.
• Drug Information and Alternative Therapies: Pharmacists can provide evidence-based information on alternative non-pharmacological or safer pharmacological options if a medication is discontinued.
• Medication Management in Various Settings: Whether in hospitals, community pharmacies, or aged care facilities, pharmacists are positioned to intervene at critical junctures to optimize medication regimens.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.3 Nurses’ and Physicians’ Contributions

While pharmacists provide specialized medication expertise, nurses and physicians play equally crucial and distinct roles in the interdisciplinary deprescribing effort.

Nurses’ Contribution:

Nurses, as the healthcare professionals with the most direct and continuous patient contact, are pivotal in the deprescribing process. Their roles include:

• Patient Assessment and Monitoring: Nurses are often the first to observe and document symptoms, functional changes, and adverse effects (including withdrawal symptoms) in patients, which are critical for identifying deprescribing opportunities and monitoring progress. They can assess a patient’s understanding and compliance with medication regimens.
• Medication History and Reconciliation: They assist in gathering accurate medication histories, including OTCs and supplements, and reconciling medication lists across care settings, identifying discrepancies that need addressing.
• Patient Education and Support: Nurses serve as vital educators, reinforcing information provided by physicians and pharmacists, explaining the deprescribing plan, and empowering patients and families to manage medication changes. They provide emotional support and reassurance, helping to alleviate fears and build confidence.
• Communication Bridge: Nurses often act as the primary liaison between the patient, family, and the rest of the healthcare team, ensuring that concerns are communicated and care plans are understood and adhered to.
• Advocacy: They can advocate for patients, raising concerns about problematic polypharmacy and potential PIMs to the physician or pharmacist based on their close observations.

Physicians’ Contribution:

Physicians, particularly primary care physicians and geriatricians, hold the ultimate responsibility for overall patient care and leading the clinical decision-making process in deprescribing. Their contributions are central:

• Diagnosis and Holistic Patient Management: Physicians have a comprehensive understanding of the patient’s medical history, diagnoses, and overall care plan, which is essential for determining the ongoing need and appropriateness of each medication in the context of the patient’s total health status.
• Initiating and Authorizing Deprescribing: They are typically the ones to initiate the formal deprescribing discussion with patients and legally authorize medication changes, including dose reductions or cessations.
• Risk-Benefit Analysis and Goal Alignment: Physicians weigh the clinical risks and benefits of continuing versus stopping each medication, aligning decisions with the patient’s values, preferences, and current care goals (e.g., ‘comfort care’ versus ‘aggressive disease management’).
• Managing Complex Comorbidities: In older adults with multimorbidity, physicians navigate the complex interplay of conditions and medications, ensuring that deprescribing for one condition does not adversely affect another.
• Leadership and Coordination: The physician often serves as the orchestrator of the interdisciplinary team, synthesizing input from pharmacists, nurses, and specialists to create a coherent and safe deprescribing plan.
• Follow-up and Adjustment: They oversee the long-term follow-up of patients undergoing deprescribing, making adjustments to the plan based on clinical response, side effects, or symptom recurrence.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.4 Other Healthcare Professionals

• Geriatricians: These specialists possess deep expertise in the complex physiology and pathology of aging, uniquely positioning them to identify PIMs and guide deprescribing in complex older adults.
• Occupational and Physical Therapists: These professionals assess functional status, mobility, and fall risk. Medications that impair balance or cognition directly impact their therapy goals, making their input valuable in identifying drugs for deprescribing.
• Social Workers: They can identify social determinants of health, financial barriers to medication adherence, and provide support systems that may reduce the need for certain medications (e.g., for anxiety related to social isolation).
• Dietitians: They assess nutritional status and can identify drug-nutrient interactions or medication-induced changes in appetite or digestion, offering non-pharmacological strategies where appropriate.

In essence, the interdisciplinary team functions as a safety net, ensuring that all facets of medication management are rigorously addressed, thereby maximizing the safety, efficacy, and patient-centeredness of deprescribing efforts.

6. Impact of Deprescribing on Patient Outcomes

The ultimate justification for the challenging yet rewarding endeavor of deprescribing lies in its tangible and far-reaching positive impact on patient outcomes. By carefully and systematically reducing medication burden, deprescribing initiatives consistently demonstrate improvements across several critical domains: patient safety, quality of life, functional status, and healthcare costs.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.1 Patient Safety

One of the most compelling and immediate benefits of deprescribing is the enhancement of patient safety. Polypharmacy and the use of PIMs are directly linked to an elevated risk of adverse drug events (ADEs), which can range from bothersome side effects to life-threatening complications. Deprescribing directly addresses this by reducing exposure to unnecessary or harmful medications.

• Reduction in Adverse Drug Events (ADEs): By discontinuing medications with high toxicity profiles or those prone to interactions, the absolute number of ADEs decreases. This includes a reduction in gastrointestinal bleeds from NSAIDs, delirium from anticholinergic drugs, and electrolyte imbalances from diuretics. (ce.pharmacy.wisc.edu)
• Decreased Fall Risk: Medications affecting the central nervous system (e.g., benzodiazepines, Z-drugs, opioids, certain antidepressants) are major contributors to falls in older adults due to their sedative, hypotensive, and psychomotor impairing effects. Deprescribing these agents has been consistently associated with a significant reduction in fall rates, leading to fewer fractures, head injuries, and hospitalizations.
• Reduced Hospitalizations and Emergency Department Visits: A substantial proportion of hospital admissions among older adults are attributable to ADEs. By mitigating these events through deprescribing, there is a measurable decrease in unplanned hospitalizations and emergency department presentations, which not only improves patient well-being but also alleviates strain on healthcare systems.
• Improved Organ Function: Deprescribing nephrotoxic or hepatotoxic medications, or those that worsen conditions like heart failure, can lead to improvements in renal, hepatic, and cardiovascular function, respectively. For instance, reducing the dose or discontinuing certain antihypertensives can prevent episodes of symptomatic hypotension.
• Lower Risk of Antimicrobial Resistance: While not the primary focus, judicious deprescribing, especially of inappropriate antibiotics, contributes to broader public health goals by reducing the selective pressure for antimicrobial resistance.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.2 Quality of Life and Functional Status

Beyond merely preventing harm, deprescribing actively contributes to a better quality of life and improved functional independence for older adults.

• Enhanced Cognitive Function: Many PIMs, particularly those with anticholinergic properties or strong sedative effects, can induce or exacerbate cognitive impairment. Deprescribing these medications can lead to improvements in memory, attention, and overall cognitive clarity, reducing the burden of ‘medication-induced brain fog.’
• Reduced Sedation and Fatigue: Patients on multiple medications often experience chronic fatigue, lethargy, and excessive sedation. Reducing or discontinuing these drugs can restore alertness and energy levels, allowing patients to participate more actively in their daily lives and social activities.
• Improved Mobility and Balance: As mentioned, reduced fall risk directly translates to improved confidence in mobility. Patients may feel more stable, increasing their willingness to engage in physical activity and maintain independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as walking, dressing, cooking, and managing finances.
• Alleviated Burden of Medication Management: A simpler medication regimen with fewer pills to remember, fewer complicated dosing schedules, and less frequent refills can significantly reduce the daily burden and stress associated with polypharmacy. This simplicity can also improve adherence to the truly essential medications.
• Greater Sense of Autonomy and Well-being: Patients often report a greater sense of control over their health and a feeling of ‘lightness’ or empowerment when they are able to reduce their medication load. This psychological benefit contributes significantly to overall well-being and life satisfaction.
• Fewer bothersome Side Effects: Many patients live with chronic, sub-threshold medication side effects that subtly erode their quality of life (e.g., constipation, dry mouth, blurred vision, dizziness). Deprescribing can alleviate these chronic nuisances, leading to a noticeable improvement in comfort and general well-being.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.3 Healthcare Costs

Deprescribing offers compelling economic benefits, leading to substantial cost savings for patients, healthcare systems, and society at large. These savings accrue from various sources:

• Reduced Medication Expenditures: The most direct saving comes from no longer purchasing unnecessary or inappropriate medications. While individual drug costs may seem small, cumulatively, across a population with polypharmacy, these savings can be substantial. A study highlighted that deprescribing in residential aged care facilities in Australia could save up to $16 million annually, primarily from reduced medication acquisition costs. (en.wikipedia.org)
• Fewer Hospitalizations and Emergency Department Visits: As discussed, preventing ADEs and falls directly reduces the need for costly acute care services. Hospitalizations are among the most expensive healthcare events, and avoiding them through proactive deprescribing translates into significant savings.
• Decreased Outpatient and Diagnostic Service Utilization: Fewer ADEs mean fewer follow-up appointments with specialists to manage side effects, fewer diagnostic tests (e.g., blood tests, imaging) to investigate symptoms that are actually medication-induced, and less need for additional prescriptions to counteract drug side effects (interrupting the prescribing cascade).
• Reduced Long-term Care Costs: By improving functional status and reducing the risk of falls and cognitive decline, deprescribing can help older adults maintain independence for longer, potentially delaying or preventing transitions to more expensive institutional care settings, such as nursing homes.
• Improved Productivity and Caregiver Burden: Although harder to quantify, improved patient health and reduced need for intensive medical management can lessen the burden on informal caregivers, potentially enabling them to maintain employment or improve their own well-being.

While the initial investment in time and resources for comprehensive medication reviews and patient counseling may seem significant, the long-term benefits in terms of improved patient outcomes and reduced healthcare expenditures make deprescribing a highly cost-effective and ethically imperative strategy.

7. Conclusion

Deprescribing is unequivocally a vital and increasingly indispensable component of contemporary geriatric care. It provides a structured and evidence-based pathway not only to mitigate the inherent risks associated with polypharmacy and potentially inappropriate medications but also to actively enhance patient safety, significantly improve the quality of life, and realize substantial reductions in healthcare costs. The imperative for deprescribing stems from a rapidly aging global population grappling with rising multimorbidity and the concomitant challenges of complex medication regimens.

Successfully integrating deprescribing into routine clinical practice, however, requires a concerted and multifaceted effort to overcome the persistent challenges it faces. These challenges range from deeply ingrained patient and healthcare provider resistance, fueled by fears of adverse outcomes and medicolegal concerns, to systemic barriers such as time constraints, fragmented care models, and a lack of standardized, universally accepted protocols. Furthermore, a crucial gap remains in widespread public and professional education regarding the risks of excessive medication and the profound benefits of judicious reduction.

The path forward demands a collaborative, patient-centered approach, leveraging the diverse expertise of interdisciplinary healthcare teams—including physicians, pharmacists, nurses, and allied health professionals—working in concert. By fostering open communication, employing shared decision-making strategies that honor patient values and preferences, and utilizing a growing array of evidence-based tools and guidelines, deprescribing can be more effectively implemented. Continued research is essential to further strengthen the evidence base for deprescribing specific drug classes and to develop more refined clinical decision support systems. Policy reforms are also needed to incentivize and support the time-intensive work of comprehensive medication reviews and patient counseling.

Ultimately, by embracing deprescribing as a proactive and essential element of person-centered care, healthcare systems can move beyond a reactive model of disease management to one that prioritizes optimal health, functional independence, and overall well-being for older adults, thereby leading to better health outcomes and a more sustainable healthcare future.

References

• fhea.com – What NPs Should Know About Deprescribing in Older Adults
• pubmed.ncbi.nlm.nih.gov – Defining and measuring multimorbidity: a systematic review of systematic reviews
• ce.pharmacy.wisc.edu – Deprescribing in the Older Adult
• en.wikipedia.org – Deprescribing
• australianprescriber.tg.org.au – Deprescribing in older people
• ormondmanor.com – Deprescribing: How To Take Less Medication For Healthier Aging
• en.wikipedia.org – Beers criteria
• aafp.org – How to Deprescribe Safely: A Step-by-Step Guide