What is the systematic approach to deprescribing medications in an older adult patient?

Systematic Approach to Deprescribing in Older Adults

Use validated explicit tools (Beers Criteria or STOPP/START) combined with a structured medication review process to identify potentially inappropriate medications, then systematically discontinue drugs where harms outweigh benefits while considering individual patient factors including care goals, functioning, and life expectancy 1, 2.

Core Framework for Deprescribing

The deprescribing process follows a stepwise algorithmic approach that prioritizes patient safety while reducing medication burden 2:

Step 1: Medication Reconciliation and Assessment

Begin by creating an accurate medication list of what the patient actually takes (not just what's prescribed). This reveals:

• Discontinued medications still being taken
• Missing prescribed medications
• Medications taken incorrectly
• Duplicate therapies

Assess adherence barriers using validated tools like the Morisky Medication Adherence Scale to identify complexity issues (multiple daily dosing), cost barriers, or side effects driving non-adherence 2.

Step 2: Identify Drug Therapy Problems

Screen systematically for 2:

High-risk medications using explicit criteria:

• Apply Beers Criteria or STOPP/START criteria to flag potentially inappropriate medications
• These validated tools identify medications with high adverse drug event (ADE) risk in older adults
• Focus on: sedative/hypnotics, opioids, anticholinergics, benzodiazepines, sulfonylureas

Drug-drug interactions:

• Screen for QT prolongation risks
• Anticoagulant combinations increasing bleeding
• Serotonin syndrome risks
• NSAIDs with anticoagulants

Drug-disease interactions:

• NSAIDs in heart failure, chronic kidney disease, hypertension
• Sulfonylureas in renal impairment
• Anticholinergics in dementia

Overtreatment and duplications:

• Identify duplicate therapies
• Medications with additive side effects
• Excessive doses for age/renal function

Step 3: Prioritize Medications for Deprescribing

Target these high-priority categories first 2:

Hypoglycemic agents causing episodic hypoglycemia:

• Sulfonylureas are highest risk
• Short-acting insulin
• Relax glycemic targets (hemoglobin A1c goals) in older adults

Strong anticholinergic medications:

• Diphenhydramine (older antihistamines)
• Cyclobenzaprine (muscle relaxants)
• Oxybutynin (overactive bladder agents)
• These cause "anticholinergic burden" affecting cognition and function

Medications no longer providing benefit:

• Preventive medications in patients with limited life expectancy (<1 year)
• Statins for primary prevention in frail elderly
• Medications where indication has resolved

Unnecessary supplements:

• Multiple vitamins without clear indication
• Herbal supplements causing interactions
• Exception: vitamin D remains appropriate

Step 4: Implement Deprescribing Using "Stop Slow, Go Low"

The withdrawal strategy matters 3:

• Taper gradually rather than abrupt cessation for most medications
• Monitor closely for adverse drug withdrawal events
• One medication at a time when possible to identify causality if problems arise
• Adjust doses for renal/hepatic function before complete discontinuation when appropriate

Step 5: Patient-Centered Communication

Engage patients and caregivers in the deprescribing plan 1, 2:

• Explain why medications are being stopped (harms outweigh benefits)
• Address patient concerns about stopping medications
• Align with patient's care goals and preferences
• Obtain explicit agreement before implementing changes

Step 6: Monitor Outcomes

Track both benefits and harms 2:

• Reduction in medication burden (number of daily doses)
• Adverse drug withdrawal events
• Disease control maintenance
• Functional status
• Cognitive function
• Cost savings

Evidence Quality and Tool Selection

95 validated tools exist for deprescribing, with 83.2% developed specifically for older adults 1. However, critical limitations exist:

• Only 25% of medications in these tools have high-quality evidence supporting their classification
• The same medication may be classified as inappropriate in some tools and appropriate in others
• Tools for patients with limited life expectancy have particularly weak evidence bases

Despite these limitations, use explicit criteria tools (Beers or STOPP/START) as they have validation data demonstrating reduction in ADEs, hospitalizations, and mortality 2, 4.

Common Pitfalls to Avoid

Don't deprescribe beneficial medications: The STOPP/START criteria include a "START" component identifying undertreated conditions (e.g., missing statin in coronary artery disease, missing antiplatelet after stenting) 2.

Avoid abrupt cessation of high-risk medications: Benzodiazepines, opioids, and some cardiovascular medications require tapering to prevent withdrawal syndromes 3.

Don't ignore patient preferences: Deprescribing without patient buy-in leads to non-adherence and confusion 1.

Monitor for disease recurrence: Some conditions may worsen after medication discontinuation, requiring reinitiation 5.

Team-Based Approach

Clinical pharmacists are ideally positioned to perform comprehensive medication reviews, identify drug therapy problems, and propose optimization plans. In VA studies, pharmacist-led interventions reduced potentially inappropriate medications by 36.4% 2.

The evidence consistently demonstrates that deprescribing interventions reduce polypharmacy and potentially inappropriate medication use 4, 5. While evidence for improved clinical outcomes (mortality, hospitalizations) is mixed, the reduction in medication burden, cost, and complexity represents meaningful benefit for older adults with polypharmacy 1, 5.