A Pathway to Healthier Aging or an Illusion? A Narrative Review on Deprescribing Protocols for the Elderly

Abstract

Polypharmacy is the concurrent use of many drugs increasingly prevalent in elderly populations worldwide, with over 50% of older adults taking more than five drugs. The rise in chronic conditions such as diabetes, hypertension, and dementia largely drives this trend. However, polypharmacy poses significant risks, including adverse drug events, falls, cognitive decline, and hospitalizations, particularly due to age-related physiological changes that alter drug metabolism and clearance. Vulnerable populations, especially those with comorbidities, face heightened risks of complications associated with polypharmacy, underscoring the need for effective management strategies. Despite extensive literature on polypharmacy, gaps remain in practical, evidence-based approaches to safely reduce medication burdens. Structured deprescribing protocols are emerging as a critical intervention for reducing inappropriate medication use, improving patient outcomes, and lowering healthcare costs. These protocols involve stepwise algorithms and tools for screening to find potentially inappropriate medications and clinical decision-making frameworks to prioritize deprescribing as it can reduce fall risk, hospitalizations, and healthcare costs while enhancing quality of life. This narrative review examines evidence from trials, cohort studies, and meta-analyses on deprescribing protocols, highlighting challenges like patient resistance and withdrawal effects. It emphasizes tailored approaches, patient engagement, and shared decision-making for safe, effective, patient-centered deprescribing across healthcare settings.

Introduction

With the increase in the number of older individuals with multiple chronic conditions, there is a likelihood of complex medication regimens, raising the chances for adverse drug reactions (ADRs), and negative health outcomes. The clinical consequences of polypharmacy include hospitalizations, falls, and a general decline in quality of life (QoL); hence making the identification and reduction of potentially inappropriate medications (PIMs) a critical issue. The amelioration of these issues will be enhanced by structured deprescribing, which will, in turn, improve patient safety, improve overall health outcomes, and reduce healthcare costs. We can strive for healthier aging and improved health practices by optimizing medication use among the older population (Masnoon et al., 2017).

On the other hand, there needs to be more research on the long-term impacts of deprescribing interventions, particularly across various healthcare settings and patient populations. Most studies also lack standard protocols for deprescribing, which complicates the comparison of results and leads to questions of best-practice development. It is important to note that most research has not considered the perspectives of the patient and adherence factors, which are relevant for sustained deprescribing. Economic analyses assessing healthcare cost reductions due to deprescribing are limited. Further research is required to evaluate the financial implications of these interventions. Additionally, several questions remain regarding the feasibility and challenges of wide-scale implementation. Further data needs to be provided regarding the impact of polypharmacy in specific subgroups, such as those suffering from cognitive impairments, to tailor interventions accordingly (Hoel et al., 2021).

Polypharmacy, by definition, is the use of more than five medications to treat diseases. The use of polypharmacy is more common among geriatric patients who have multiple chronic illnesses, such as arthritis, asthma, COPD, and coronary heart disease (L. E. Davies et al., 2020). Polypharmacy is seen in around 40% to 50% of elderly patients globally, with some high-income countries seeing rates as high as 60% to 70%. In Europe, approximately 32% of people aged 65+ take five or more medications, with higher rates in Southern Europe. In the U.S. and Canada, 42% of elderly adults are affected, rising to 65% to 85% in nursing homes. In Asia, countries like Japan see 60% of elderly patients on multiple medications, while South Korea and China report 35% to 55%. Australia shows a 43% polypharmacy rate in the community-dwelling elderly, increasing to 80% in aged-care facilities (Morin et al., 2018).

Polypharmacy has considerable adverse consequences among the elderly because of the enhanced risk for ADRs, drug interactions, and overall morbidity. These patients are quite vulnerable given the changes in physiology with aging. Polypharmacy can manifest as increased hospitalization, cognitive impairment, falls, and even mortality. (Hoel et al., 2021).

A Structured Deprescribing Protocol is a systematic approach in healthcare for reducing or discontinuing medications that may no longer be necessary or beneficial, particularly for high-risk groups like elderly patients on polypharmacy (Hoel et al., 2021). The main idea behind the protocol is to minimize ADRs for better patient outcomes and to improve QoL by personalizing the regimen to the current health and goals of the patient. Deprescribing protocols review the need for each medication in terms of the potential for harm, benefits, and the patient’s goals, considering risks of comorbidities, drug interactions, and withdrawal symptoms. Some of the most relevant clinical outcomes include a reduction in the frequency of ADRs and increased satisfaction on the part of the patient. Indeed, numerous protocol tools are available in algorithm, flowchart, and table form that outline step-by-step decisions to make this process both safe and efficient for elderly patients with complex medication regimens (Page et al., 2016). However, it can be difficult to determine the exact drug that’s causing the symptoms or clinical conditions, as this could be masked by other underlying issues like the use of multiple medications or the metabolic and nutritional status of the older adult. In this case, deprescribing protocols become a useful tool to mitigate such confusion.

Screening tools help identify PIMs among the elderly, especially when patients have complicated medication lists. These tools will aid health professionals in reviewing every medication a patient takes for appropriateness, helping to minimize adverse drug reactions and improve care outcomes. One of the most commonly utilized screening tools is the STOPP/START criteria, the abbreviation for Screening Tool of Older People’s Prescriptions and Screening Tool to Alert to Right Treatment. The STOPP criteria point to potentially inappropriate medicines, including but not limited to medicines with the risk of adverse effects, drug-drug interactions, and those with no clinical benefit for the older adult. In contrast, the START criteria provide clues on medicines that may be indicated yet not prescribed, ensuring that all proper treatments are instituted to manage the conditions. Other tools put into use include the Beers Criteria, which lists the drugs potentially inappropriate for the elderly, considering the risks such as sedation, confusion, and falls. The Medication Appropriateness Index also considers every indication, effectiveness, and safety for each drug (Hoel et al., 2021).

Studies suggest that these tools are effective in improving clinical outcomes when appropriately applied in practice. Ibrahim et al. (2021) confirmed the possible reduction in potential drug reaction by deprescribing sedative and antipsychotic drugs among care home residents. Additionally, Chua et al. (2024) highlighted the importance of using validated deprescribing protocols to guide clinical decision-making, especially for older adults with cognitive impairments. Furthermore, a study by Reeve (2020) reviewed the effectiveness of various deprescribing screening tools and affirmed their role in reducing adverse drug events in the elderly. These findings emphasize that structured deprescribing protocols can significantly improve patient safety and medication management in geriatric care.

Concerning the risk estimation of ADRs, the various tools in risk scores and clinical prediction rules are particularly useful, especially for geriatric patients with chronic conditions on complicated medication. These estimation tools use patient-specific factors to arrive at a risk score that will enable clinicians to strategize interventions and individualize treatments to minimize the chances of drug-related harm. A commonly used tool is the GerontoNet ADR Risk Score, which predicts ADRs in elderly hospital-admitted patients and scores patients based on factors such as age, kidney function, the number of medications taken, and any previous history of ADRs. The higher the score, the higher the risk for ADRs; thus, clinicians will be prompted to monitor or adjust the medication regimen of a high-risk patient (Onder et al., 2010). Other examples include the Anticholinergic Risk Scale and Sedative Load Index, developed to quantify the accumulated risk of medications with anticholinergic or sedative properties, respectively. Both have been associated with higher scores, which reflect an increased risk of ADRs like cognitive impairment, falls, and functional decline (Wouters et al., 2016). Another helpful tool is the Liverpool Adverse Drug Reaction Avoidability Assessment Tool, which classifies ADRs by their avoidability and helps clinicians adjust medication regimens to minimize avoidable harm (Bracken et al., 2017).

Deprescribing guidelines for specific medications give targeted recommendations to safely reduce or discontinue drug classes that might pose risks, especially in elderly patients. These varied guidelines consider the unique risk of every medication type and give structured protocols to reduce unnecessary medications or harmful ones while managing withdrawal symptoms and monitoring the patient’s outcomes. For instance, benzodiazepines are commonly used in anxiety or sleep disorders but are related to significant adverse effects in older adults, such as cognitive impairment, falls, and dependence. Deprescribing guidelines favor the gradual tapering of benzodiazepines to avoid withdrawal symptoms, such as rebound anxiety or insomnia, and recommend alternative non-pharmacological therapy, such as cognitive behavioral therapy, as a much safer option for the management of these conditions. Anticholinergic medications, usually prescribed for allergies, incontinence, or depression, are frequently being deprescribed in the elderly due to associations with cognitive decline and increased risk for dementia. Recommendations suggest switching to less risky alternatives or tapering down the dose. The design of these guidelines is a balance between safety and efficacy, reducing polypharmacy risks and supporting the QoL of the patients. An emphasis on high-risk medications, coupled with gradual tapering, would help the clinician minimize adverse effects, and enhance appropriate treatment outcomes among elderly patients (Hoel et al., 2021) (Figure 1).

Figure 1.

The figure presents a Geriatric Medication Evaluation Algorithm for assessing and optimizing medication use in elderly patients, particularly those who are frail. It begins with evaluating the necessity and effectiveness of each medication. If a drug is unnecessary, tools like the Beers or STOP Criteria help identify high-risk medications for discontinuation. If necessary, medications are assessed for risks such as falls, drug interactions, or adverse effects. Safer alternatives or dosage reductions are considered, and if switching is not possible, patient education is provided. The goal is to ensure safe and effective pharmacotherapy while minimizing risks.

Deprescribing reduces the risks associated with polypharmacy in many instances; however, in practice, several other barriers impede its application. One major barrier involves patient resistance. Patients, especially those with chronic conditions, may have taken certain medications for years, and feel attached to them, whereby the medication is vital to their lives (Reeve et al., 2013). Providers may need to invest more time in educating patients about risks and benefits, which is quite challenging. Besides, there is a fear of withdrawal effects. It is reasonable that healthcare providers would be very hesitant to deprescribe medications for which abrupt discontinuation can lead to withdrawal symptoms, such as antidepressants and opioids. Additionally, perceived insufficient training and support in the deprescribing protocols might also be a barrier to healthcare provider acceptance. For example, clinicians may not be familiar with the deprescribing guidelines or might feel insecure about how to handle withdrawal symptoms, especially with complex medication regimens among the elderly (Anderson et al., 2014) (Figure 2).

Figure 2.

The figure presents a 10-Step Deprescribing Algorithm, outlining a systematic approach to evaluating and discontinuing unnecessary medications, particularly in elderly, or high-risk patients. It begins with verifying the patient’s current drug use and identifying those at risk of adverse drug reactions (ADRs). Life expectancy is assessed using clinical tools, and overall care objectives are established accordingly. Each medication is reviewed for its current indication, potential benefits, and risks, with a focus on preventive drugs in relation to life expectancy. Medications are ranked based on usefulness, and a final decision is made on which to discontinue. The process concludes with executing and monitoring the deprescribing plan under the supervision of a single clinician to ensure patient safety and effectiveness.

Methods

This narrative review examines structured deprescribing protocols in elderly patients. We comprehensively searched three major databases: PubMed, Google Scholar, and ScienceDirect. The search strategy included the following keywords and Boolean operators: “structured deprescribing protocols,” “elderly,” “patients over 60 years,” “deprescribing,” “polypharmacy,” and “adverse drug reactions.” These terms were used individually and in combination to maximize the retrieval of relevant literature from 2001 to 2024.

Inclusion criteria encompassed peer-reviewed articles, systematic reviews, RCTs, observational studies, and meta-analyses published in English. Studies on deprescribing practices, their impact on patient outcomes, and strategies to reduce polypharmacy in individuals aged 60 and above were prioritized.

Structured Frameworks for Deprescribing

Deprescribing is believed to be a complex process by many physicians. Despite most clinicians reporting that they feel comfortable in deprescribing, fewer engage in this process regularly. Various frameworks have been developed to ease the process. These structured protocols comprehensively assess each medication’s risks and benefits. Evidence proves that the Good Palliative-Geriatric Algorithm and the confirm, estimate, assess, sort, eliminate (CEASE) guide are the two most effective methods with high physician acceptability. These algorithms guide the physician to efficient decision-making through sequential steps that consider all relevant factors. For example, the CEASE protocol takes into consideration the Confirmation of current medications, Estimating the potential for harm considering risk factors like age, medications with high risk like benzodiazepines, and substance abuse, etc, Assessing each medicine for its usefulness with risk, Sort while considering patient preferences and then Eliminate (Scott et al., 2016).

Outcomes of Deprescribing in Older Adults

This section explores the impact of deprescribing on key health outcomes in elderly patients. It examines how reducing potentially inappropriate medications (PIMs) can enhance the QoL by lowering risks such as cognitive decline, falls, and adverse drug interactions. The discussion also covers the effect of deprescribing on adverse drug events (ADEs), drug-related side effects, hospitalization, and emergency department visits, assessing whether structured medication reviews reduce hospital readmissions and adverse drug reactions (ADRs). By reviewing recent studies, this section provides insight into the safety and effectiveness of deprescribing in geriatric care.

Impact on QoL Among Elderly Patients After Implementing Deprescribing Protocols

Identifying and managing PIMs is vital for safeguarding older adults’ health and safety while improving their overall QoL. PIMs can aggravate existing medical conditions, increase the risk of falls, impair cognitive function, and trigger adverse drug interactions. Such complications can lead to hospitalizations and negatively affect the QoL for elderly individuals (Beck et al., 2022). Therefore, the importance of reducing the impact of PIMs in geriatric medicine is quite evident.

Anticholinergic and sedative medications are linked to increased risks of falls, higher mortality rates, hip fractures, frailty, and diminished QoL (Jamieson et al., 2018; Ruxton et al., 2015; Wilson et al., 2011). Thus, minimizing unnecessary anticholinergic use is crucial for maintaining the QoL in older adults, especially considering the adverse effects associated with these drugs (Wouters et al., 2020).

In a study by Veronese et al. (2024), systematic reviews revealed findings concerning 276 frail older adults. One RCT demonstrated a marked decline in the number of prescribed PIMs, while another trial noted a reduction in the overall quantity of PIMs. Additionally, in a separate systematic review, only one out of nine RCTs indicated that deprescribing improved the QoL compared to standard care practices. The GRADE assessment performed by Cole et al. (2023) showed low certainty of evidence when QoL was assessed, with six studies reporting some improvement in QoL while 10 studies found no significant difference in QoL post-intervention.

Bülow et al. (2023) conducted a comprehensive review, and the analysis indicated that medication reviews might exert little to no influence on mortality rates (RR 0.96, 95% CI [0.87, 1.05]; 18 trials, 10,108 participants; low-certainty evidence). Regarding health-related QoL, the evidence remains inconclusive, with findings displaying substantial uncertainty (SMD 0.10, 95% CI [–0.10, 0.30]; four trials, 392 participants; very low-certainty evidence). According to a study by Ibrahim et al. (2021), their review also did not find any significant effect of deprescribing on the QoL in frail older individuals, which aligns with previous literature concerning the elderly in general (Eckert et al., 2013; Iyer et al., 2008; Pruskowski et al., 2019; Rankin et al., 2018).

Impact on ADEs Among Elderly Patients After Implementing Deprescribing Protocols

Adverse drug events (ADEs) describe any harm that occurs when a patient is exposed to a particular medication, regardless of whether it stems from the drug’s direct effects. This includes harm arising from the inappropriate or incorrect use of the drug.

A study by Hanlon and Gray (2022) reviewed findings from McDonald et al.’s (2022) research and noted that deprescribing was observed more frequently in the intervention group than in the control. Nevertheless, rates of adverse drug events (ADEs) within 30 days post-discharge were nearly identical between groups, with an adjusted risk difference (aRD) of −0.8% (95% CI [−2.9, 1.3]; p > .05). The intervention group also saw no increase in adverse drug withdrawal events (ADWEs) compared to the control, showing an aRD of −0.1% (95% CI [−1.2, 1.0]; p > .05). In total, 49 ADWEs were recorded, accounting for 19.7% of the 249 ADEs observed. A randomized trial reported a significant reduction in the total number of ADEs upon the implementation of FORTA (Fit fOR The Aged; Wehling et al., 2016).

A study by Quek et al. (2024) indicated that there were no notable changes in ADEs or exacerbations for individual medications or drug classes, except in the case of antipsychotics, where deprescribing led to a higher likelihood of exacerbation. Conversely, a separate investigation into deprescribing non-steroidal anti-inflammatory drugs (NSAIDs) reported a significant decrease in the likelihood of pain exacerbation.

A study conducted by Veronese et al. (2024) highlighted that in hospital environments, particularly in end-of-life scenarios, deprescribing demonstrated comparable effectiveness to standard care in terms of reducing inappropriate medication use, and minimizing adverse events. The systematic reviews indicated that both approaches were similarly effective in managing drug cessation.

Impact on Falls Among Elderly Patients After Implementing Deprescribing Protocols

Falls among older adults have become a significant public health issue, contributing to serious consequences like increased injury rates, deaths, and heavy healthcare expenses. Among seniors aged 65 and above who live independently, about one-third experience a fall annually (Berry & Miller, 2008). Medications classified as fall-risk-increasing drugs (FRIDs) are widely acknowledged as a leading cause of falls in older adults (De Vries et al., 2018). In those who experience fall-related injuries, FRID usage rates are strikingly high, with studies showing a prevalence ranging from 65% to 93%. This high proportion highlights the strong association between these medications and fall-related incidents in older populations (Hart et al., 2020). Elderly individuals who are frail face a heightened risk of both falls and serious injury if they do fall. Frailty implies a diminished physiological reserve in aging individuals, making them more susceptible to sudden health declines (Joseph et al., 2014). This population, especially those with cognitive challenges, is at a pronounced risk for falls, and negative medication effects. Consequently, medication assessments—including evaluations of fall-risk-increasing drugs—should ideally occur every 6 months for those who are frail (NICE, 2015). In contrast, older adults who aren’t frail may benefit from annual medication reviews (Department of Health, 2001).

A study by Earl et al. (2020) reported that discontinuing multiple medications simultaneously was notably linked to decreased fall occurrences and frailty scores among older individuals. The study also assessed medication reviews with general practitioners for patients aged 65 and above. It found a significant drop in the drug burden index by 0.34 (p < .001) and a reduction in falls and frailty by 1.35 (p < .05) on the Edmonton Frailty Scale (Ailabouni et al., 2019).

However, a systematic review and meta-analysis by Lee et al. (2021) found that deprescribing FRIDs did not significantly affect fall-related outcomes. Similarly, a study by Cameron et al. (2018) concluded that conducting routine medication reviews appears to have minimal or no effect on fall frequency or risk within long-term care settings. Additionally, two most recent studies (Quek et al., 2024; Veronese et al., 2024), found that efforts to reduce polypharmacy through deprescribing did not lead to notable decreases in fall or fracture occurrences.

It’s essential to understand that falls result from a combination of factors, particularly among frail individuals. Merely adjusting medications without incorporating other strategies may not significantly lower the likelihood of falls. A broader approach is likely necessary to mitigate fall risks in this vulnerable population effectively (Veronese et al., 2024).

Impact on Hospitalizations and Emergency Department Visits

Deprescribing can lead to fewer hospitalizations post-intervention as compared to pre-intervention, which is supported by the research conducted by Taylor et al. (2003) and Syafhan et al. (2021). However, a systematic review reported that only 2 out of 14 studies showed a decline in hospital admissions, while the other 12 showed little or no difference between the intervention and control groups. (Cole et al., 2023)

In a comprehensive review that examined studies from 2008 to 2018, Earl et al. (2020) underscored findings from Ocampo et al. (2015). This study revealed that an 18-month medication review initiative led by pharmacists within community pharmacies successfully identified 408 prescription-related problems and resolved 393. This proactive approach was linked to a significant decline in hospitalizations (p = .039) and emergency department visits (p = .001; Earl et al., 2020).

A study by Bülow et al. (2023) suggests medication reviews may help lower hospital readmission rates in hospitalized adults (RR 0.93, 95% CI [0.89, 0.98]; I² = 0%; moderate-certainty evidence). The analysis indicates a 7% relative risk reduction, with one readmission prevented for every 22 high-risk patients treated (95% CI [14, 77]) and every 29 in a slightly lower-risk group (95% CI [18, 100]) over a median 6-month follow-up. Similarly, medication reviews in hospitalized adults might help lower emergency department visits (RR 0.84, 95% CI [0.68, 1.03]; I² = 31%). However, the evidence remains of low certainty, indicating that while a reduction is possible, the findings are inconclusive.

A study conducted by Carollo et al. (2024) found that regardless of the time analyzed, reviewing and deprescribing medications resulted in a modest but statistically significant reduction of 8% in hospital readmission rates among older patients (HR 0.92, 95% CI [0.85, 0.99]). However, the effects of these changes on mortality rates remain unclear (HR 0.98, 95% CI [0.96, 1.00]). Furthermore, they found that reviewing and deprescribing medications can significantly lower hospital readmission rates for older patients. This benefit is particularly linked to the decrease in PIMs. Implementing comprehensive medication reviews and deprescribing strategies in hospital environments could enhance patient outcomes after discharge and help reduce overall healthcare expenses.

Impact on Drug-Related Side Effects

Adverse drug reactions (ADRs) encompass any harmful, undesirable, or unintended effects resulting from a therapeutic agent, regardless of whether these effects were anticipated (Aronson & Ferner, 2005). These reactions frequently result in unplanned hospital admissions, particularly among older adults who often take multiple medications to manage various health issues (multimorbidity; E. A. Davies & O’Mahony, 2015).

Hospitalized individuals face a greater risk of adverse drug reactions (ADRs) due to the increased number of new medications they are prescribed compared to those living in the community. Moreover, this increased risk necessitates healthcare providers to meticulously monitor and assess the effects of ADRs in hospitalized patients (McGettigan et al., 2024).

Frailty is another common aspect of aging that can increase the likelihood of ADRs in older adults. Research by Cullinan et al. (2015) revealed that patients with a frailty index (FI) of 0.16 or higher were twice as likely to experience one or more ADRs during their hospital stay and to receive potentially inappropriate prescriptions according to the STOPP criteria, in comparison to those with a lower frailty index (O’Mahony et al., 2023).

In a study, Earl et al. (2020) noted a reduction in ADRs by 4.24 (p < .05) after 6 months (Ailabouni et al., 2019). The high rates of adverse drug reactions (ADRs) among older adults are primarily attributed to polypharmacy, a consequence of treating multiple chronic conditions simultaneously (Aggarwal et al., 2020).

Healthcare Costs Comparison: Deprescribing versus Standard Care

A significant number of RCTs demonstrated a reduced financial load with deprescribing. Some studies are worth mentioning, such as one that included seniors 65 years of age and older from four nursing facilities across Singapore, and the results demonstrated a daily saving of US$5.42 (Kua et al., 2020). The other studies also showed a decline in monthly medication expenses in the intervention group compared to the control group (Curtin et al., 2019; Jódar-Sánchez et al., 2015; Williams et al., 2003). Overall, it was found to be a cost-effective approach. However, minimal to nonexistent reductions in hospitalizations were seen with the prescription of medicines that didn’t contribute to reduced costs of deprescribing (Campins et al., 2016; Olesen et al., 2013; Zermansky et al., 2001).

Deprescribing in Varied Healthcare Settings

The execution of deprescribing after a thorough medication review must be customized to meet the unique requirements and difficulties of different healthcare settings. This section delves into the observations reported by research studies in various healthcare settings like primary care, hospitals, and nursing homes regarding the assessment of medications and execution of deprescribing.

Deprescribing in the Primary Care Setting

Primary care is one of the best frameworks for conducting drug evaluations and initiating deprescribing programs. An RCT conducted in a primary care setting showed that 21.5% of prescriptions were modified (9.1% cessation, 6.9% dosage adjustment, 3.2% substitution, and 2.2% new prescription), while 26.5% were deemed potentially unsuitable (Campins et al., 2016). Given the ease of access and periodic evaluation, this could be possible only in a primary care setting.

Deprescribing and Hospitals

Hospitalization provides a great opportunity to examine and manage polypharmacy while taking the patient’s morbidities and treatment objectives into consideration. One of the RCTs spanning over 4 years in a hospital setting showed 142 intervention group participants consuming a mean of 14% fewer medications. In addition, the intervention decreased patients’ exposure to possibly undesirable medications and the Drug Burden Index (Vasilevskis et al., 2023). One of the meta-analyses showed a 41% decrease in mortality rate with deprescription in hospitalized patients at the end of their lives (Veronese et al., 2024).

Importance of Deprescribing in Nursing Homes

In nursing homes, where a substantial number of patients are on polypharmacy and potentially inappropriate medications are frequently prescribed, the implementation of medication review, and deprescribing is of particular importance. A meta-analysis that considered the nursing home setting revealed that deprescribing was associated with substantially lower PIMs than standard care (OR = 0.41; 95% CI [0.19, 0.88]) (Veronese et al., 2024).

Importance of Engaging Patients and Caregivers in the Process of Deprescribing

A collaborative approach that includes the patient and caretaker can lead to successful deprescribing, as consideration of the patient’s needs and opinions leads to better drug adherence and eventually improved health outcomes. In addition, better patient-doctor communication can reduce potentially harmful consequences. The caregiver can suggest what the patient would want if they could decide, help weigh out the pros and cons, or help the patient identify their goals (Alrawiai, 2023; Chock et al., 2021).

A systematic review conducted on 21 studies identified the “fear” of cessation as a barrier and the “dislike” of medications as an enabler (Reeve et al., 2013). Incorporating a monthly program of home medical consultations whose sole purpose would be clinical checkup and emotional support, as social interaction prevents loneliness and isolation. This serves to increase both life expectancy and QoL.

Consideration of Patient Characteristics in Deprescribing Protocols

A medication that was necessary, effective, and safe in the past may no longer be. As healthcare goals and priorities can change over time to better the QoL and comfort. This calls for the timely tailoring of treatment regimens accordingly. Factors that may shift the balance between the benefits and drawbacks of medications include increased susceptibility to adverse effects, multiple comorbidities, functional impairment, dementia, and so on.

Potential Risks and Unintended Consequences of Deprescribing

• Withdrawal Syndromes and Symptom Recurrence: When stopping or reducing the dosage of certain medications, caution should be taken as it can lead to withdrawal symptoms. For example, the discontinuation of benzodiazepines leads to tremors, tachycardia, hypertension, agitation, etc. Other examples of medications that can lead to symptom recurrence with discontinuation include antidepressants, antipsychotics, opioids, beta-blockers, etc. (Ie et al., 2021). One study went on to show a resumption of 12.0%, 15.9%, and 17.3% of drugs at 3, 6, and 12 months follow-up, respectively (Campins et al., 2016).

• Represcribing: Certain deprescribed medications can be resumed again due to symptom recurrence or patient preference.

• Adherence to Deprescribing Protocols: There can be non-adherence from the patient’s side due to a multitude of factors. Common misconceptions include the idea that deprescribing will aggravate medical conditions and cause disease recurrence, which can further contribute to decreased adherence. According to some medical professionals, drug dependence, a lack of understanding of the implications of aging, and concerns about drug safety may make patients reluctant to deprescribe. These problems are exacerbated by low health literacy and communication barriers (Robinson et al., 2024). Though non-adherence remains a potential risk while deprescribing, a systematic review by Cole et al. (2023) reported that medication adherence was noted across nine studies, while four studies revealed little to no difference between intervention and control groups’ medication adherence scores.

Discussion

The challenges of polypharmacy in elderly patients are related to serious health risks such as an elevated chance of falls, greater hospitalizations, and death (Hoel et al., 2021). The introduction of systematic deprescribing measures will mitigate these risks while improving health status (Masnoon et al., 2017). Instruments like the Beers Criteria (L. E. Davies et al., 2020) and STOPP/START (Cullinan et al., 2016) help identify potentially inappropriate medications. Still, discrepancies remain: some studies suggest a reduction in falls (Linsky et al., 2024), whereas other studies have limited net benefits (van Dam et al., 2022). It expresses the need for a more comprehensive solution where one size does not fit all.

Beyond medication reduction, deprescribing should focus on necessity—whether drugs genuinely benefit the patient’s QoL (Veronese et al., 2024). It requires healthcare providers to consider medical and sociocultural complexities, aligning decisions with patient goals. More high-quality studies are needed to assess long-term deprescribing effects (van Dam et al., 2022), and compare outcomes over extended periods (Linsky et al., 2024).

Advances in technology, such as EHRs and clinical decision support systems, can streamline deprescribing by tracking medication history, and risk factors more effectively (Veronese et al., 2024). Future research should focus on individualized deprescribing strategies that not only discontinue unnecessary medications but also promote overall well-being in older adults (O’Donnell et al., 2020).

Controversial results are inevitable when studying the health-disease process, particularly in the context of aging and the systematic social isolation that many older adults experience in modern societies. However, our findings emphasize that advancing deprescribing requires a shift away from depersonalized care. Additionally, long-term randomized trials are needed to assess the impact of deprescribing across diverse older adult populations. It is also crucial to acknowledge that the origins of many health conditions in this population are deeply rooted in social determinants.

Despite the increasing conviction that deprescribing can be a suitable method for improving medication use, its practice is not widely accepted due to the limitations of the reviewing studies, including ours. Here, we will address some of these limitations.

One limitation is that the existing studies we reviewed have had a wide range of differences concerning the methods, patients included, protocols, and outcomes tracked. Most current evidence is based on observational data and not RCTs. Campins et al. (2016), estimated deprescribing success rates over 3, 6, and 12 months, but the study design does not seem to consider long-term patient compliance or other factors that may interfere during patients reusing the medications.

There is a shortage of data concerning the clinical outcomes of deprescribing in elderly patients with frailty, particularly regarding its long-term effects. Several studies examine short-term effects such as symptom reoccurrence, but more serious effects on mortality, hospitalization, and QoL are not analyzed.

Another concern is the possibility of bias. Most deprescribing studies occur in controlled settings with supervision, unlike real practice, and may have selection bias from health-conscious participants.

Finally, many studies ignore mental factors such as health literacy, culture, and people’s ability to make choices. For instance, Robinson et al. (2024) explain how negative attitudes toward deprescribing, dependency on drugs, and concerns about safety restrain effective processes. Yet, these are often not incorporated into deprescribing trial designs.

Conclusion

Deprescribing helps mitigate the adverse effects of polypharmacy for older patients with multiple comorbidities. A universal approach is inadequate—deprescribing must be patient-centered, culturally sensitive, and aligned with individual health goals.

To advance deprescribing, rigorous long-term RCTs are needed to compare outcomes with usual care. Avoiding depersonalized care is crucial. Future research should focus on individualized deprescribing strategies tailored to patients with complex health conditions and treatment objectives.