Why deprescribing matters now

For older adults, medicines are both lifeline and liability. By age 65, nearly half of adults are taking five or more regular medicines, and close to 60% are exposed to at least one potentially inappropriate medication (PIM). Each prescription might once have been justified — for blood pressure, sleep, mood, or bone health — but the body changes with age. Drug clearance slows, the brain becomes more sensitive to sedatives, and interactions multiply.

The result? Falls, delirium, cognitive decline, hospital admissions, and avoidable costs. Polypharmacy itself is now recognized as a patient safety hazard.

That is why deprescribing — the systematic process of identifying and discontinuing drugs when harms outweigh benefits — has become a core element of safer prescribing for the elderly.

What the evidence says

The latest AHRQ Making Healthcare Safer IV review examined 15 systematic reviews and 7 original studies published since 2019. Findings were clear on some points and more nuanced on others:

• Medication outcomes: Deprescribing consistently reduces the number of drugs and the number of PIMs.

• Safety: Serious withdrawal harms are rare when deprescribing is structured and supervised.

• Clinical outcomes: Evidence is mixed. Some trials showed fewer falls, better quality of life, or even reduced mortality; others showed no significant change.

• Costs: Pharmacy costs almost always fell, though effects on overall healthcare spending were harder to prove.

The conclusion: deprescribing is safe, lowers drug burden, and may improve patient outcomes — but results vary depending on the drugs targeted, the setting, and how well the intervention is delivered.

Criteria for deprescribing

So how do clinicians decide what to stop? Several well-validated criteria guide the process:

1. No current indication — e.g., a proton pump inhibitor continued long after reflux symptoms resolved.

2. Risk outweighs benefit — benzodiazepines for sleep may increase falls and confusion more than they improve rest.

3. Ineffectiveness — medicines that have not achieved their intended effect.

4. Therapeutic duplication — two drugs from the same class where one would suffice.

5. PIMs flagged by Beers or STOPP criteria — such as strong anticholinergics, long-acting sulfonylureas, first-generation antipsychotics.

6. Cumulative burden — the additive effect of multiple CNS depressants or anticholinergic agents.

7. Patient preference or prognosis — if quality of life is prioritized over prevention, certain long-term preventive medicines (e.g., statins, bisphosphonates) may be deprescribed.

How to deprescribe safely

Stopping medicine is rarely as simple as binning the pack. Many drugs — particularly psychotropics — require careful tapering to avoid withdrawal. The Maudsley Deprescribing Guidelines recommend hyperbolic tapering: making progressively smaller reductions as doses get lower, rather than cutting in big jumps.

Examples:

• Antidepressants: taper slowly over weeks to months, monitor for withdrawal (which can mimic relapse).

• Benzodiazepines: reduce by 5–10% every 2–4 weeks; abrupt cessation risks seizures.

• Z-drugs and gabapentinoids: taper gradually, support sleep or pain management during withdrawal.

Every deprescribing plan should include:

• A complete medication reconciliation.

• Shared decision-making with the patient and family.

• A written tapering schedule.

• Clear monitoring and follow-up.

Barriers and facilitators

If the evidence is strong, why don’t we deprescribe more often? Common barriers include:

• Fear of destabilizing disease.

• Misinterpreting withdrawal as relapse.

• Fragmented care between multiple prescribers.

• Clinician time constraints.

Facilitators that help:

• Involving pharmacists in medication reviews.

• Clinical decision support nudges in electronic health records.

• Educational materials for patients and families.

• A predefined deprescribing process (including reassurance that medicines can be restarted if needed).

The bigger picture

Deprescribing is not about neglect. It is active, structured care, as much a part of good medicine as prescribing itself. Done well, it reduces avoidable harms and restores focus to what matters most to the patient: function, clarity, dignity, and safety.

In the words of the AHRQ review, deprescribing is still a young practice, with more to learn about long-term outcomes. But the balance of evidence is reassuring: few harms, definite reduction in drug burden, and the potential for real quality-of-life gains.

Key takeaway

For older adults, safe prescribing is not only about what to start — it’s about knowing when and how to stop.

Dr. Srinivas Rajkumar T, MD (Psychiatry)
Consultant Psychiatrist, Apollo Clinic Velachery, Chennai
 8595155808