Updated October 2025
Geriatrics | Medication Safety
Polypharmacy and Deprescribing in Older Adults
Polypharmacy is common in older adults and drives adverse drug events, functional decline, and hospitalizations. Structured deprescribing—anchored in goals-of-care, medication review, and use of explicit criteria—reduces potentially inappropriate medications (PIMs), adverse drug reactions, and medication burden, with emerging evidence of benefit for function, falls, and mortality in selected settings.
Clinical question
In older adults with multimorbidity and polypharmacy, what deprescribing strategies safely reduce medication burden and improve clinical outcomes?
PolypharmacyDeprescribingGeriatricsMedication SafetyPIMsADR PreventionNursing HomesMedication Review
Key points
Why it matters
Polypharmacy is linked to adverse drug events, cognitive/functional impairment, and higher costs [4], [5]. More than one-third of community-dwelling older adults take at least one PIM [1].
What works
Multicomponent deprescribing (goal-concordant review, explicit criteria, pharmacist–physician collaboration) reduces PIMs and ADRs and improves appropriateness; strongest data in institutional settings [2], [3], [1], [6].
Safety
When deprescribing follows a structured process with monitoring, serious harms are uncommon and medication-related problems decrease [2], [3], [1].
Clinical outcomes
Evidence suggests improvements in function, falls, QoL, hospitalizations, and mortality in some studies, though effects are heterogeneous and context-dependent [1], [6].
Implementation
Apply explicit tools (e.g., STOPP/START, Beers), reconcile high-risk classes (anticholinergics, sedatives, antihypertensives, sulfonylureas, PPIs), and titrate with close follow-up [4], [2], [1], [7], [8].
Evidence highlights
≈33% [1]
Prevalence of ≥1 PIM in community-dwelling older adults
Reduced PIM prevalence; significant in pooled analyses [2], [1]
Effect of deprescribing interventions on PIM use
Nursing homes; medication review–directed deprescribing beneficial [3]
Setting with strongest outcome signal
Practical Deprescribing Algorithm
A concise, reproducible sequence to identify and reduce low-value medications while aligning with patient goals.
1
Elicit goals, prognosis, and priorities
Clarify life expectancy, functional goals, symptom priorities, and treatment time-to-benefit vs time-to-harm. Align every medication with goals of care [4], [7].
2
Assemble the complete medication list
Include OTCs, supplements, PRNs, and transdermals. Identify therapeutic duplication, adherence barriers, and recent changes that increased risk [4], [8].
3
Screen for PIMs and PPOs
Apply Beers/STOPP (PIMs) and START (PPOs) to flag candidates for discontinuation or substitution. Prioritize agents with high anticholinergic burden, sedatives, hypoglycemics with high hypoglycemia risk, and PPIs without indication [4], [2], [1], [7].
4
Risk–benefit stratification
Estimate absolute benefit vs harm considering frailty, falls risk, cognition, renal/hepatic function, and drug–drug interactions. Prefer deprescribing where NNT >> NNH in the patient’s context [4], [1], [7].
5
Plan tapering and monitoring
Use shared plans with explicit tapers (e.g., benzodiazepines, PPIs, beta-blockers), withdrawal/relapse checkpoints, and contingency actions. Schedule follow-up within 2–4 weeks, then at 3 months [4], [2], [1].
6
Document and communicate
Record rationale, expected benefits, and monitoring parameters. Communicate changes to pharmacies, caregivers, and all prescribers to prevent medication re-initiation drift [1], [8].
High-Yield Targets and Enablers
Medication classes to prioritize and system-level supports that increase deprescribing success.
High-risk classes to reassess first
Anticholinergics (cumulative burden → delirium, falls, constipation, urinary retention) [4], [1], [7]
Benzodiazepines/Z-drugs (falls, fractures, cognitive effects) — taper slowly [4], [1]
Antipsychotics for BPSD without severe distress/psychosis — attempt reduction after stabilization [4], [1]
Sulfonylureas/insulin with tight targets — deintensify to avoid hypoglycemia; align A1c with frailty [4], [1], [7]
Opioids for chronic non-cancer pain — assess function, consider multimodal reductions [4], [1]
PPIs without a sustained indication — step-down/stop with rescue antacids [4], [1]
Antihypertensives with orthostasis/falls — consider dose reduction or agent removal [4], [1]
Interventions with strongest evidence
Pharmacist-physician medication review in nursing homes: improves appropriateness and outcomes [3]
Structured deprescribing programs: reduce PIMs and ADRs in pooled analyses [2], [1]
Goal-concordant deprescribing in limited life expectancy: improves appropriateness, potential QoL gains [6]
Implementation enablers
Use explicit criteria (Beers, STOPP/START) embedded in EHR decision support [4], [1], [8]
Team-based reviews with pharmacists; reconcile at transitions of care [3], [8]
Patient education scripts about expected withdrawal/relapse and monitoring plan [1]
Track process metrics (PIM count, anticholinergic burden) and outcomes (falls, ED visits) [2], [1]
Adherence and patient factors
Address health literacy and regimen complexity to enhance adherence to deprescribing plans [9], [8]
Simplify dosing schedules; align refills; employ blister packs or pill organizers [9]
Screen for frailty, cognition, depression; tailor follow-up intensity accordingly [1], [9]
References
Source material
Primary literature that informs this article.
How “age‐friendly” are deprescribing interventions? A ...
onlinelibrary.wiley.com
Review Article Deprescribing Interventions for Older Patients
www.sciencedirect.com
Health Outcomes of Deprescribing Interventions Among ...
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Deprescribing in older adults with polypharmacy
www.bmj.com
Deprescribing in older adults with polypharmacy
pubmed.ncbi.nlm.nih.gov
Outcomes of deprescribing interventions in older patients ...
www.uptodate.com
Polypharmacy and Deprescribing in Older Adults
pubmed.ncbi.nlm.nih.gov
Medication management in older adults
pubmed.ncbi.nlm.nih.gov
Barriers and Facilitators to Medication Adherence among ...
pmc.ncbi.nlm.nih.gov
Polypharmacy and deprescribing among geriatric patients
www.sciencedirect.com