Tackling deprescribing in older adults

During a routine checkup, a 78-year-old patient tells her physician that she's concerned about her memory. She's been forgetting things more often, and with her increasing age, she fears it's the early signs of dementia.

This common scenario with older patients should prompt a thorough review of their medications, said Cynthia Boyd, MD, MPH, FACP, a professor of medicine specializing in geriatrics and gerontology at Johns Hopkins School of Medicine in Baltimore. In fact, she and other experts said, regular medication reviews are essential in older patients, given the growing risks of polypharmacy.

Defined as taking five or more prescription drugs, polypharmacy is becoming more common as the population ages, affecting approximately 42% of adults ages 60 or older, according to the CDC's National Center for Health Statistics. However, recent research suggests that patient-centered deprescribing interventions can safely and effectively reduce medication burdens while improving patients' overall quality of life.

“When the balance shifts toward more harm than good, that's our cue to start talking about tapering, while giving the patient time to adjust and offering support along the way,” Dr. Boyd said.

Understanding the risks

“Polypharmacy increases the risk for poor outcomes, such as cognitive decline, delirium, falls, and functional decline—things that dramatically affect quality of life for older adults,” said ACP Member Amanda S. Mixon, MD, MS, MSPH, associate professor at Vanderbilt University Medical Center in Nashville, Tenn. “And while many of these medications are prescribed with the best intentions, they often continue long after they are no longer necessary, leading to a heavier burden of care.”

Polypharmacy is particularly prevalent among older adults with multiple chronic conditions, note the authors of the 2023 Shed-MEDS study, published in JAMA Internal Medicine. The problem is compounded by age-related changes in drug metabolism, making older adults more vulnerable to harmful interactions.

An earlier Vanderbilt-led analysis, cited in a 2019 BMC Health Services Research study, found that 83% of 904 Medicare patients discharged from the hospital to skilled nursing facilities (SNFs) left on 10 or more prescriptions, so-called “hyper-polypharmacy,” which sharply raises the risk of drug-drug interactions and delirium.

“When you're juggling that many agents, even a perfectly indicated drug can tip the balance toward harm,” including falls, said Scott Bragg, PharmD, a medication safety pharmacist at the Medical University of South Carolina in Charleston.

The risks are particularly pronounced when medications like benzodiazepines and opioids, often prescribed for anxiety, insomnia, and chronic pain, are used over extended periods. “The risk of cognitive decline or confusion due to these medications rises substantially as people age,” Dr. Bragg said. “While they are effective for their intended purposes, the long-term consequences are significant.”

Common medications used to manage hypertension and diabetes can also pose significant risks by triggering dangerous side effects, like hypotension or hypoglycemia. “These drugs can lead to a cascade of problems if they aren't carefully monitored, especially when used in combination with other medications,” said Dr. Mixon.

Medications with anticholinergic properties, including some antihistamines and antidepressants, are another major concern. These drugs can contribute to cognitive decline and increase the risk of falls, particularly when combined with other medications.

“The prescriptions we flag most often are sleep aids and benzodiazepines that can cloud cognition,” said Matthew Clark, MD, chair of the National Pharmacy and Therapeutics Committee for the Indian Health Service in Anchorage, Alaska. “The risk of adverse drug events rises substantially with increasing numbers of concurrent medications.”

Strategies for deprescribing

Formal frameworks can help physicians whittle down medication lists. Tools such as the STOPP/START criteria, the 2023 American Geriatrics Society Beers Update, and disease-specific algorithms hosted by the US Deprescribing Research Network offer quick, point-of-care checks on what to taper, stop, or switch.

“Begin with a thorough medication review, then risk-stratify,” said George Hennawi, MD, FACP, physician executive director of geriatrics and senior services at MedStar Health in Baltimore. “Target the highest-risk drugs first and walk patients through why each change makes sense.”

A pharmacist- or nurse-led protocol can also be effective, as demonstrated in the 2023 Shed-MEDS study, where the Vanderbilt team was able to cut total drug counts by 14% after an acute discharge without increasing adverse events. The intervention pairs a best possible medication history with real-time chart review and weekly check-ins at SNFs, giving prescribers a road map to taper and monitor progress.

“What made Shed-MEDS stick was the handoff loop. We didn't just write an order and hope,” said Dr. Mixon, a co-investigator on the study. “Pharmacists called the SNF nurse, clarified the titration plan, and followed up every week until the patient went home.”

Patient education is also important. In a 2025 Journal of General Internal Medicine study of more than 1,300 Veterans Affairs patients, mailing medication-specific brochures two weeks before a patient's primary care appointment more than doubled the odds that deprescribing would be discussed during the visit.

The brochures clearly explained each medication's purpose and risk-benefit profile and provided short worksheets on dosage, side effects, and questions to take to patients' next appointments. Veterans who completed the worksheets were especially likely to raise the topic themselves, encouraging shared decision making.

Giving patients the opportunity to digest information in advance paves the way for an informed dialogue about medication burden, which often doesn't happen naturally, said Scott Pilla, MD, MHS, a general internal medicine physician and assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. “Patients rarely report any side effects or problems, and doctors don't always ask,” he said. “You have to make medication review a priority, or it never gets done.”

Experts recommend doing a full medication reconciliation at every care transition—hospital discharge, specialty consult, ED visit—and at least annually in stable outpatients. High-risk drugs that affect cognition, blood pressure, or glucose should be reviewed even more frequently.

“Think of deprescribing as chronic disease management in reverse,” Dr. Mixon said. “We escalate thoughtfully; we should de-escalate with the same rigor.”

Communication, shared decision making

Before deprescribing can begin, physicians need a clear view of everything a patient is actually swallowing, experts said. Dr. Boyd asks older patients to bring all their prescriptions and over-the-counter products into the office at least once a year, while Dr. Clark prefers checking medications at every visit if the list is long.

Each medication becomes an entry point for a conversation about goals, side effects, and alternatives.

“I ask patients to bring in every single pill bottle, plus an informant who knows their routine,” said Dr. Hennawi. “I've seen people arrive with 60 bottles, half of them duplicates or expired. When the family sees that spread out on the table, it opens their eyes, and we can start fixing the list together.”

Communication style, not just content, shapes success, said Dr. Boyd. She advised opening with the patient's goals—”What worries you most right now?”—and then tying each proposed change to that priority.

“When people hear you're trying to reduce fall risk so they can stay independent, they're far more willing to taper a medication,” she said. “When someone tells me their memory is slipping, I can say, ‘Some of your medicines may be working against that goal. Let's see which ones we can safely reduce.’” The reframing turns deprescribing into partnership, she said.

If a patient still seems reluctant to move forward, Dr. Mixon suggests a reversible trial: Taper one agent for four weeks with clear stop criteria. “It lowers the stakes,” she said. “If blood pressure or pain worsens, we simply restart.” Documenting that plan in the EHR, and messaging subspecialists, avoids mixed signals and reassures patients that their care team is working together.

Follow-up must be proactive, especially after hospitalization, said Dr. Hennawi, who schedules a phone call within three days of discharge and an in-person visit within a week. “Those first seven days are when home meds, hospital meds, and confusion collide,” he said. “A quick touchpoint prevents a lot of unnecessary readmissions.”

With multiple subspecialists often influencing an older adult's regimen, primary care clinicians are uniquely positioned to see the whole picture and keep medication lists under continuous monitoring. They can reconcile hospital discharge summaries, flag duplications in the EHR, and decide when the benefit of a drug no longer outweighs its risk, experts said.

While resources and frameworks can help, their effectiveness relies on a willing quarterback.

“At the end of the day, the primary care doctor is the anchor,” said Dr. Hennawi. “If we don't initiate the conversation and coordinate the plan, nobody else will, and our most vulnerable patients will keep carrying a pill burden that works against the very health we're trying to protect.”

Time pressure is real, acknowledged Dr. Mixon, but deprescribing needn't be all or nothing.

“You don't have to tackle the entire list in one visit,” she said. “Pick the highest-risk drug or the medicine the patient already dislikes, document the taper plan, and circle back in four weeks. Small wins accumulate—and they build trust.”