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Michael Steinman, MD
Emily Reeve, BPharm(Hons) PhD
Section Editor:
Kenneth E Schmader, MD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Apr 22, 2021.

INTRODUCTION — Deprescribing is an essential part of good prescribing and is inherently linked to related activities, such as medication reconciliation, to ensure safe and effective use of medications. This process requires attention, time, and in many cases special skills and knowledge. This includes technical knowledge, such as optimal down-titration schedules, as well as competencies in shared decision-making, communication, and managing health systems in a medical culture that historically has been more oriented toward adding medications than stopping them. A more general discussion of drug prescribing in older adults is provided separately. (See "Drug prescribing for older adults".)

Deprescribing is most commonly employed in geriatric or palliative care patients, although it can be appropriate in other patients as well. (See 'Which patients and which medications should be targets for deprescribing?' below.)

This topic will provide information on approaches to deprescribing, including common barriers and how to address them. Related issues regarding discontinuing antihypertensive and antidepressant agents are discussed in detail elsewhere. (See "Can drug therapy be discontinued in well-controlled hypertension?" and "Discontinuing antidepressant medications in adults" and "Withdrawal syndromes with antihypertensive drug therapy".)

DEFINITION — The term “deprescribing” refers to a process of medication withdrawal, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes [1]. This can encompass efforts to comprehensively review a patient’s medication list and systematically discontinue or reduce the dose of all medications with an unfavorable balance of benefits and harms, as well as efforts focused on specific types of high-risk medication. What distinguishes deprescribing from traditional approaches to pharmaceutical care is that it encourages a systematic and proactive approach. Identifying an adverse drug event and stopping the offending medication is good medical care but is also reactive to existing problems or complaints. Deprescribing focuses on being proactive to address medication-related problems that have not previously been identified or satisfactorily managed and to prevent future problems.

GOALS OF DEPRESCRIBING — The overall goal of deprescribing is to improve patient important outcomes. Patients can vary in their experience of potential benefits and harms from medication use, how they value these outcomes, and their attitudes toward medication withdrawal. Therefore, the goals of deprescribing can vary between patients. For example, for a patient who has recently suffered an injurious fall, deprescribing efforts may focus on reducing use of medications that confer increased fall risk. In another patient who is troubled by taking multiple medications dosed multiple times per day, efforts may focus on reducing medication regimen complexity and burden.

Common goals for deprescribing include reducing overall medication burden, reducing the risk of specific geriatric syndromes such as falls and cognitive impairment, and improving global health outcomes such as hospitalization and death. Ultimately, all these goals relate to improving quality of life. Specific goals can include:

Reducing medication burden – Careful medication review and aggressive discontinuation can lead to reduction in up to 39 percent of medications used [2], including reducing use of potentially inappropriate medications by up to 30 to 60 percent or more [3-5]. Reducing medication burden may improve adherence to remaining medications [6].

Reducing risk of falls – Many medications increase fall risk among older adults, including benzodiazepines and benzodiazepine receptor agonists (eg, zolpidem and zopiclone), antidepressants, antipsychotics, and strongly anticholinergic medications [7-10]. In nursing home settings, deprescribing programs using broad-based medication review have been shown to reduce fall risk by 24 percent [3]. Efforts to reduce use of psychotropic medications have also reduced the rate of falls, albeit with highly variable results across studies [11,12]. However, while deprescribing of fall-risk increasing drugs and other potentially inappropriate medications appears clinically sensible, several studies have found that interventions to deprescribe these medications have not meaningfully affected the rate of falls [5,13]. (See "Falls: Prevention in community-dwelling older persons", section on 'Medication modification' and "Falls in older persons: Risk factors and patient evaluation", section on 'Medication use' and "Falls: Prevention in nursing care facilities and the hospital setting", section on 'Medication use'.)

Improving and/or preserving cognitive function – Anticholinergic medications, sedative-hypnotics including benzodiazepines and benzodiazepine receptor agonists, and use of multiple psychotropic medications can negatively affect cognition [8]. Discontinuation of benzodiazepines has been shown to improve cognitive function in nursing home residents [14], with inconsistent or unavailable data for other drugs and settings [15].

Reduce risk of hospitalization and death – In vulnerable older adults residing in nursing homes, trials of interventions incorporating whole-regimen review and deprescribing reduced hospitalization by 36 percent and death by 26 to 38 percent [3,16]. In ambulatory settings, a systematic review found that interventions using whole-medication review had no impact on hospitalization but did reduce mortality by 26 percent [5].

In addition to these specific goals of deprescribing, medication deintensification can be framed as part of good clinical practice, since all medications are potentially harmful, cost money, and add complexity and the potential for burden. Careful medication review often identifies multiple drug-related problems such as adverse reactions, lack of effectiveness, and burdensome treatment costs, some of which can be successfully addressed through medication withdrawal [17].

WHICH PATIENTS AND WHICH MEDICATIONS SHOULD BE TARGETS FOR DEPRESCRIBING? — Medication-related problems are extremely common in the general population of adults, and especially in older adults, who take a disproportionately high share of medications [17-20]. These problems include adverse drug effects, ineffectiveness, use of medications with no indication, excessive or inadequate dosing, use of potentially inappropriate medications, and nonadherence. Thus, careful medication review and consideration of deprescribing is appropriate for most people who chronically use medications.

Although opportunities for deprescribing should be considered for all adults, certain risk factors can identify which patients are at highest risk for medication misadventures and thus may be highest priority for careful medication review and deprescribing where appropriate. Patient characteristics and medications which are good targets for deprescribing are presented in the table (table 1).

Patient characteristics — High-risk patient characteristics include:

Polypharmacy – Use of multiple medications is the strongest risk factor for medication-related problems [21-26]. In a study of older veterans, those in the highest quartile of medication use had 6 to 12 times the risk of medication-related problems compared with those in the lowest quartile of medication use [22]. There is no specific threshold number of medications above which risk increases; each incremental medication confers additional risk [22]. However, evidence suggests that use of five or more medications is a useful benchmark for identifying older adults at higher risk [27].

Multimorbidity – As the number of chronic conditions increases, the risk of drug-disease interactions (medications for one condition adversely affect a concurrent condition) also increases substantially [22,23,25].

Renal impairment – Decreased renal function increases the risk for adverse drug events, especially if there is inappropriate medication dosing [22,23].

Multiple prescribers and transitions of care – Miscommunication about medications can commonly occur when a patient has multiple prescribers or transitions from one care setting to another (eg, from hospital to a residential care facility or home). This can lead to inadvertent continuation of medications that should have been stopped either because they are causing documented harms or lack ongoing indications for use [28,29].

Medication nonadherence – Nonadherence has many causes, including dissatisfaction with medications, difficulty with medication use, and real or perceived adverse effects and/or lack of benefit. Optimizing care depends on the underlying problems and clinical scenario, but for some patients deprescribing may help them achieve the goals they value.

Limited life expectancy – Many patients with limited life expectancy prefer to reduce their medication burden. With a shift in goals of care from prolonging life to improving the quality of life, the goals of deprescribing may also shift, with different medications becoming key targets for deprescribing [30,31]. Preventative medications are often continued up until the end of life, despite changed care goals and the patient being unlikely to benefit in their remaining lifespan [32-35]. Examples of such therapies include statins, agents for aggressive control of hyperglycemia, and bisphosphonates [36-38]. In a landmark trial, discontinuation of statins in people with less than 12 months to live did not alter time to death compared with continuation, and those in the discontinuation group had better quality of life [37]. On the other hand, certain high-risk medications, such as opioids, sedatives, and anticholinergics, may be reasonable to continue because of their symptomatic benefits near the end of life and lower concerns about long-term risks.

Older age – Advanced age is not itself an independent risk factor for medication-related problems [39]. However, older adults are often at high risk of such problems due to the increased incidence of polypharmacy, multimorbidity, transitions of care, changes in pharmacokinetics and pharmacodynamics, and other risk factors [40].

Frailty and dementia – These patients may have different and changing goals of care, and there may be different opportunities to use medications safely and effectively [41]. Moreover, older adults with dementia receive potentially inappropriate medications at higher rates than the general population [42] and have high rates of central nervous system (CNS)-active polypharmacy [43]. Frailty and dementia may increase the risk of medication-related harms and change goals of care. In some cases, adverse drug effects may precipitate or worsen these syndromes (for example, due to medication-induced fatigue or cognitive changes) [8,44]. Caregivers may be engaged to be a facilitator in the deprescribing process; however, they also need support, as surrogate decision-makers may feel pressure and guilt about making deprescribing decisions [41].

Medications — Characteristics of the medication regimen which should prompt consideration of deprescribing are presented in the table (table 1) and include:

Use of potentially inappropriate medications for older adults – This term typically refers to consensus lists of medications such as the American Geriatrics Society Beers Criteria and the Screening Tool for Older Person’s Prescriptions (STOPP) criteria [8,45]. These criteria identify medications that are often problematic for older adults, with a disadvantageous balance of benefits and harms for many older adults compared with pharmacologic and nonpharmacologic alternatives.

Commonly used medications on these lists include sedative-hypnotics such as benzodiazepines and benzodiazepine receptor agonists, strongly anticholinergic medications, long-acting sulfonylureas such as glyburide, and chronic use of proton pump inhibitors (PPIs) and nonsteroidal antiinflammatory drugs (NSAIDs) in the absence of compelling indications. (See "Drug prescribing for older adults", section on 'Inappropriate medications'.)

Other high-risk medications – Examples include (but are not limited to) insulins and aspirin (table 1). Although insulin treatment is often necessary, many adults with advanced age, multimorbidity, or functional decline receive overaggressive glucose-lowering treatment that yields few benefits and substantially greater harms compared with more permissive approaches [46]. Insulins are a leading cause of severe adverse drug events, so unnecessary use of these medications is particularly problematic [47]. Aspirin can be highly beneficial for people with known coronary or cerebrovascular disease, yet the risk of serious bleeding increases substantially with older age and a landmark trial suggests that this drug causes more harm than good when used for primary prevention in older age [48,49]. (See "Aspirin in the primary prevention of cardiovascular disease and cancer", section on 'Summary and recommendations'.)

APPROACH TO DEPRESCRIBING — Deprescribing is best thought of as a multistage process, rather than simply the concrete action of stopping a medication. Multiple steps are necessary to ensure that the process is patient-centered and achieves the best possible outcomes. For example, inadequate documentation and/or communication at the end of the process can result in inappropriate medications being restarted.

Stepwise approach — We approach deprescribing in three phases, adapted from published frameworks [50-52].

Phase 1 – The first step is to engage the patient and gather relevant information. Before considering which medications to start, stop, or change, it is critical to know what a patient is actually taking, if they are having problems with any of their medications, and how medication use fits into the larger picture of their health status, goals, and preferences.

Compile a list of all regular and when required (prn) medications, including over-the-counter and complementary medications. Include the following information:

-Dose and frequency of each medication

-Duration of use


-Patient’s experience of each medication, ie, are they effective, difficult to take, or do they cause any adverse effects?


Review patient goals of care, preferences, and values.

Consider the patient’s overall susceptibility to drug-induced harms, for example, frailty, cognitive impairment, or other geriatric syndromes such as falls.

Engage the patient (and caregivers/family where appropriate) in a discussion of the deprescribing process. Connect with other health care professionals who may need to be consulted or could assist with the process.

Phase 2 – The next step is to identify and decide on drugs to deprescribe. Each medication should be evaluated for its potential to be reduced in dose or discontinued, considering the balance of current and potential future benefits and harms. Look for medications that:

Have no valid or current indication (eg, the condition has resolved or the indication doesn’t require long-term treatment, such as proton pump inhibitors [PPIs] for uncomplicated gastroesophageal reflux disease [GERD])

Are causing or contributing to a known or suspected adverse drug reaction, including geriatric syndromes which may be unrecognized adverse drug reactions (eg, reduced mobility due to muscle pain from statins, incontinence exacerbated by a diuretic)

Were started as a result of a prescribing cascade, a situation in which one medication is started to treat a side effect of another medication (eg, nonsteroidal antiinflammatory drug [NSAID] use leads to increased blood pressure which leads to prescription of a new antihypertensive medication) [53,54] (see "Drug prescribing for older adults")

Are generally high risk in the population (eg, anticholinergics in older adults) or contribute to a risk that would be more worrisome in a particular population (eg, drugs that may increase the risk of falls in someone with osteoporosis)

Are ineffective

Are used for a preventative indication in a patient with a life-limiting illness (eg, bisphosphonates in people near the end of life)

Cause unacceptable treatment burden (eg, insulin in a person with dementia who is fearful of needles)

Explicit criteria of potentially inappropriate medications such as the American Geriatrics Society Beers Criteria can be helpful, but all medications should be reviewed with assessment of the balance of benefits and risks for each individual person.

Use shared decision-making in deciding which medications to stop or reduce in order to ensure that patients’ opinions and goals are recognized. (See 'Shared decision-making' below.)

Phase 3 – The final steps involve planning, implementation, monitoring, and follow-up:

Prioritize drugs for discontinuation and plan the order of discontinuation. Medications which are causing (or have high risk of causing) harm, and those which are of greatest concern to the patient, should be stopped first.

Stopping one drug at a time is usually recommended to encourage patient willingness and enable appropriate monitoring. However, in the case of suspected adverse drug reactions or minimal risk of an adverse drug withdrawal event (ADWE; such as with vitamins), two or more drugs can be withdrawn simultaneously.

Develop a deprescribing plan with the patient and other relevant health care professionals. A few key points to discuss with the patient include:

-Deprescribing should be considered a trial, especially when it is unclear whether the medication is still providing a benefit (such as PPIs for GERD). Knowledge that deprescribing is a trial rather than an irreversible decision can reassure patients.

-Tapering is recommended where there is risk of adverse drug withdrawal reactions (ADWRs) or if there is concern that the underlying condition will return or worsen. In this setting, tapering can help identify the lowest effective dose, minimize return of symptoms if they occur, and encourage patient willingness to have a medication deprescribed.

-Patients (and their caregivers or family) should be aware of what to self-monitor for, what to do if they notice a change, and the need to attend a follow-up appointment for monitoring with a health care professional. Frequency of monitoring should be clear as well as whether it can be done via phone, email, in person, or a combination of these.

Implement and monitor the deprescribing plan.

Document the plan for deprescribing and any outcomes (eg, if a medication is restarted, note why and whether deprescribing should be re-attempted).

Ensure ongoing communication with the patient (and their caregivers or family) and relevant health care professionals.

Tapering doses — For most medications, there is limited evidence and few guideline recommendations on how to conduct withdrawal. If there is any doubt about whether a medication can be stopped abruptly, it is safer to taper the dose over weeks to months.

Tapering can reduce the chance of ADWEs, facilitate identification of the lowest effective dose in patients who are unable to stop a drug completely, and support long-term drug cessation by increasing patient comfort and willingness to try deprescribing [51]. (See 'Deprescribing specific medications' below.)

In our experience, a general rule of thumb is to reduce the dose by 50 percent every two to four weeks, with monitoring at each dose reduction and at two to four weeks after cessation. Stepping down through available dose formulations is another approach.

In some cases, a more nuanced approach to the rate of taper can be informed by the pharmacologic properties of the drug, including half-life, whether use of the medication causes up- or down-regulation of receptors that require time to re-equilibrate, and the likelihood of an adverse drug withdrawal event [55].

Preventing adverse drug withdrawal events — An adverse drug withdrawal event (ADWE) is a clinically significant negative outcome caused by drug discontinuation [56,57]. ADWEs may encompass unwelcome symptoms, the return of the medical condition that the drug had been used to treat, or a physiological withdrawal reaction (eg, rebound phenomena). The latter, a subset of the broader category of ADWEs, is often referred to as an adverse drug withdrawal reaction (ADWR) [58]. These typically occur when a medication is withdrawn too quickly.

A number of drug classes have been associated with ADWRs, for example, beta blockers, corticosteroids, and benzodiazepines [59]. A list of drug classes associated with ADWRs and their associated symptoms is provided in the table (table 2).

A slow taper can in most, but not all, cases prevent ADWRs [60-68] (see 'Deprescribing specific medications' below). When deprescribing a medication that is associated with an ADWR, closer monitoring, including informing the patient what to self-monitor for, is important, particularly in the first week following discontinuation [55,69-71].

Practical strategies — Some practical tips for successful deprescribing include:

Set aside separate visit(s) to focus on medication review and deprescribing. Reimbursement/billing codes can include the diagnosis that the medication is intended to treat or general wellness/annual health visits.

Use the expertise and services of pharmacists, nurses, and other health care professionals, either to lead the process, to complete time intensive tasks, or as part of a multidisciplinary team [72-77]. Programs that engage such professionals include Medicare Part D Medication Therapy Management (MTM) programs in the United States [78] and Home Medicines Reviews in Australia [79].

Start the process; deprescribing doesn’t need to be conducted all in one visit.

Use patient educational materials (PEMs) when possible. (See 'Communication with patients and families' below.)

References that describe other stepped approaches to deprescribing are also available [50-52,80-83].

DEPRESCRIBING SPECIFIC MEDICATIONS — Information regarding deprescribing of certain commonly prescribed medication classes is provided below. Online resources to assist with deprescribing of particular medications are available. (See 'Resources to support deprescribing' below.)

Benzodiazepines and benzodiazepine receptor agonists — Because both psychological and physiologic dependence can occur with these medications, closely engaging patients, offering alternate nonpharmacologic or pharmacologic therapies, and obtaining buy-in before and during discontinuation attempts is essential [60,84]. (See "Overview of the treatment of insomnia in adults".)

Very slow tapers are often needed, aiming for approximately 25 percent dose reduction every two weeks, and if possible 12.5 percent reductions near the end of the taper and/or drug-free days [60,61].

If dosage forms do not permit such small incremental reductions, consider a 50 percent dosage reduction initially and then drug-free days during the final parts of the taper [61].

A useful tapering schedule and patient education materials (PEMs) used in the EMPOWER and D-PRESCRIBE trials are available [4,85].

Withdrawal symptoms (eg, insomnia, anxiety, irritability, gastrointestinal symptoms) often occur, especially once doses have been reduced to approximately 25 percent of the original dose [60].

If such symptoms appear, patients should be reassured that they are usually mild and subside in days to several weeks.

Maintain the current dose for one to two weeks and then resume the taper [61].

For patients who have previously failed attempts at deprescribing, understanding reasons for failure (eg, overly rapid tapering) can be used to formulate new discontinuation plans with greater likelihood of success and provide reassurance. With proper intervention and support, up to 60 to 80 percent of benzodiazepine users have been able to stop using these medications [60].

Proton pump inhibitors — We have a low threshold for targeting proton pump inhibitors (PPIs) for deprescribing, as they are commonly overused and often continued indefinitely rather than for the discrete duration appropriate for the indication [86]. Harms of treatment include increased risk of Clostridioides difficile colitis, hip fractures, and impaired vitamin B12 absorption.

Before deprescribing, ensure that the patient does not have a compelling reason for ongoing treatment, such as Barrett’s esophagus, chronic nonsteroidal antiinflammatory (NSAID) use with bleeding risk, severe esophagitis, history of bleeding upper gastrointestinal ulceration, and in some cases older age with chronic anticoagulant or corticosteroid use [87,88].

Although evidence about optimal deprescribing strategies is limited, gradual dose reduction is likely more effective than abrupt discontinuation given risk of rebound hyperacidemia with the latter [62,63,89]. One reasonable approach is as follows:

Halve the dose for two to four weeks, then stop; for people already on the lowest dose, alternate-day therapy may be useful [63].

Monitor at 4 and 12 weeks for symptom recurrence (eg, heartburn, dyspepsia, regurgitation, or among non-verbal people anorexia or agitation).

Occasional symptoms may be managed with on-demand therapy (antacids, H2 receptor antagonists, or PPIs) or with daily H2 receptor antagonist use. On-demand therapy with PPIs has been recommended as a form of minimizing total use and is associated with high patient satisfaction [63], although the drug’s mechanism of action may not be conductive to irregular use [90]. H2 receptor antagonists may also be substituted for PPIs, although with higher risk of symptom return than with ongoing use of lower-dose PPIs [88].

If symptoms persist and interfere with normal activity, consider testing for Helicobacter pylori and returning to the lowest effective PPI dose. H. pylori treatment is discussed elsewhere. (See "Treatment regimens for Helicobacter pylori in adults".)

Antipsychotics for behavioral and psychological symptoms of dementia or for insomnia — Since antipsychotics confer increased risk of mortality in older adults with dementia, trials of discontinuation are warranted for patients whose behavioral and psychological symptoms have stabilized or who did not improve on antipsychotic therapy (while recognizing that such symptoms often fluctuate or change over time even without intervention) [8,64]. Withdrawal of antipsychotics in people with dementia may not significantly affect behavioral and psychological symptoms [91,92]. Treatment of neuropsychiatric symptoms in patients with dementia, including the use of antipsychotic medications, is discussed elsewhere. (See "Management of neuropsychiatric symptoms of dementia".)

Although there is little clinical evidence to support one particular tapering scheme [93], a recommended strategy is as follows:

Reduce the dose by 25 percent, then 50 percent, then 75 percent every one to two weeks, then stop [64,65].

At each step, there should be close follow-up for potential adverse drug withdrawal events (ADWEs) such as worsening psychosis, aggression, or hallucinations.

Behavioral and environmental strategies for symptom control, the mainstay of treatment, should be continued throughout. (See "Treatment of Alzheimer disease", section on 'Nonpharmacologic therapy and supportive care'.)

Relapse of symptoms may be managed by nonpharmacologic means or restarting drug therapy at the lowest possible dose with regular review and consideration for a retrial of deprescribing.

In the setting of insomnia treatment with low-dose antipsychotics, tapering may not be necessary, and persistent symptoms should ideally be managed with behavioral approaches [65]. Expert consultation is advised before considering deprescribing for other indications, such as schizophrenia or adjunctive treatment for major depression.

Glucose-lowering medications — Deprescribing glucose-lowering medications may be warranted in patients for whom potential risks are likely to exceed benefits [94]. Such patients include those with multiple chronic conditions, renal impairment, dementia, limited life expectancy, history of hypoglycemia, impaired ability to sense or respond to hypoglycemia (eg, concurrent use of beta blockers, cognitive impairment), or use of agents most likely to precipitate hypoglycemia (insulins, sulfonylureas).

Careful communication and shared decision-making is essential, since patients who have been told for decades about the importance of tight glycemic control may have difficulty accepting a new message that tight control can now cause them more harm than good, or they may hold values and understandings that run counter to guidelines [95-97]. It is also critical to communicate and coordinate care with other clinicians involved, especially any endocrine specialists.

When deprescribing in patients taking multiple glucose-lowering medications, it is typically preferable to focus first on discontinuing or reducing the dose of agents at highest risk of causing hypoglycemia (eg, insulins, sulfonylureas). While there is little evidence to support a specific approach to deprescribing [98,99], reasonable strategies include gradual dose lowering every one to four weeks, switching to a safer medication, or, when severe hyperglycemia is not anticipated, abrupt cessation. For patients switching from complex to simpler insulin regimens, the American Diabetes Association guidelines offer an algorithm [100].

After a change is made, instruct the patient to monitor daily for one to two weeks for signs of severe hyperglycemia; these can be assessed by symptoms such as fatigue or excessive thirst or urination and typically do not require regular fingerstick blood glucose measurements for patients not already taking such measurements. Changes in hemoglobin A1c levels may not occur for several months [98,101]. Limited evidence suggests that deprescribing often does not worsen glycemic control [99,102].

Cholinesterase inhibitors and memantine — Decisions about deprescribing cholinesterase inhibitors and memantine can be very challenging due to uncertainty about whether these medications are providing benefit to any given patient. Deprescribing should be considered in patients who do not have an evidence-supported indication (eg, mild cognitive impairment), in patients who have been taking the medication long term with substantial interval worsening of their cognition and/or function or with lack of benefit from treatment, and in patients with severe and end-stage dementia [103]. Other reasons to pursue deprescribing include adverse effects (eg, syncope, gastrointestinal distress, or weight loss with cholinesterase inhibitors) and possibly severe agitation (given some evidence that cholinesterase inhibitors can worsen this symptom, although limited and inconsistent studies suggest that discontinuation may result in worse neuropsychiatric symptoms in the short to medium term) [104,105]. Randomized trials have found that people who discontinue cholinesterase inhibitors have, on average, a likely clinically meaningful worsening of cognitive function and possibly neuropsychiatric symptoms compared with those continuing the medication, although with no differences between groups in global assessment of change or quality of life [103,104,106]. These trials may not be generalizable to all people with dementia, particularly those who are older, are in residential care facilities, or have multiple comorbidities. Decisions about deprescribing of cholinesterase inhibitors and memantine should be conducted via shared decision-making with the patient, caregivers, and family members.

The use of cholinesterase inhibitors, including decisions to discontinue therapy, is discussed in detail separately. (See "Cholinesterase inhibitors in the treatment of dementia", section on 'Duration of therapy'.)

Once the decision to deprescribe has been made, there is little information to inform stopping strategies. However, we suggest the following:

Tapering of dose and close monitoring for cognitive, functional, and neuropsychiatric symptoms are strongly advisable, as case reports suggest that severe adverse drug withdrawal reactions (ADWRs) can occur from abrupt discontinuation of cholinesterase inhibitors and memantine [66,107]. Tapering should involve halving the dose every four weeks to the lowest available dose, then stopping; for medications where the dose formulation cannot easily be halved, stepwise reduction through the available dose formulations is reasonable [66].

A reasonable follow-up monitoring interval is four weeks after each dose reduction, or one to two weeks for patients at higher risk of ADWRs [66,103].

If substantial neuropsychiatric changes occur in the first week after a dose reduction or discontinuation, (eg, agitation, aggression, hallucinations, or reduced consciousness) this may indicate an ADWR, and the previous dose should be promptly restarted. After stabilization, it is reasonable to attempt deprescribing again with a more gradual taper.

If cognitive, behavioral, or psychological symptoms emerge in roughly two to six weeks, this may indicate that the drug was providing benefit, and restarting at the previous dose should be considered (unless there is an apparent other cause of these symptoms, for example urinary tract infection or initiation of another psychotropic medication).

If such symptoms emerge between 6 and 12 weeks, this may indicate either the above or progression of the underlying condition [66,103,108].

Antidepressants — Indications for discontinuation of antidepressants are discussed in detail elsewhere (See "Discontinuing antidepressant medications in adults".)

Withdrawal symptoms from antidepressant discontinuation are common and include insomnia, increased anxiety, and flu-like symptoms [109]. Although withdrawal symptoms often resolve within one to two weeks, they can persist for weeks to months [109], and care should be taken to distinguish between withdrawal symptoms and relapse of the underlying condition the antidepressants were used to treat [67]. The incidence of withdrawal symptoms can be reduced by tapering doses gradually over a period of weeks [67,68]. Some have argued for even longer tapers, with progressively smaller dose decrements over several months [110]. However, there is limited evidence as to which dose-reduction schedules work best [67,68].

Antihypertensive medications — Blood pressure targets for older adults are controversial and continue to evolve [111,112]. Discontinuation of antihypertensives may be considered when blood pressure is below targets, as well as in the setting of adverse drug events, drug-drug interactions, and patient preference [113,114]. In a systematic review, rates of adverse events attributed to drug withdrawal remained low, and some metabolic derangements improved once therapy was withdrawn, although a substantial proportion of study subjects were restarted on therapy due to elevated blood pressures [113].

In many cases, antihypertensives may be discontinued abruptly. Important exceptions include beta blockers and clonidine, which should be tapered: abrupt discontinuation of clonidine can result in severe rebound hypertension, and abrupt discontinuation of beta blockers can lead to rebound hypertension, tachycardia, and symptoms of myocardial ischemia even in people without known cardiac disease. (See "Can drug therapy be discontinued in well-controlled hypertension?" and "Withdrawal syndromes with antihypertensive drug therapy".)


Communication with patients and families — Effective communication with patients about goals and preferences and experiences with their medications is essential to identify medications which are suitable for deprescribing (table 3) (see 'Approach to deprescribing' above). It also helps to engage the patient in the deprescribing process, including using patient education materials (PEMs) as needed, to prime them for further discussion [115,116].

Points to consider when communicating with patients and families or other decision makers include:

Determine their preferences for involvement in the decision-making process. Some patients may prefer to defer to their healthcare professional for decision-making; this does not negate the need for good communication and shared decision-making, but it can help clinicians tailor the discussion to the individual [117-119].

Discuss patient goals and preferences and elicit patient’s experiences with their medications in order to identify medications suitable for deprescribing.

Discuss the “why” (why should the medicine be stopped?) and “how” (how will the withdrawal and monitoring be done?) of deprescribing [95,120-123]

Discussion of the risk of side effects as a rationale for deprescribing is generally preferred by older adults [124].

Frame deprescribing as a trial, with reassurance that the medication(s) can be restarted if necessary.

Frame deprescribing as “not giving up on you” or taking something of value away, but as optimizing care. Discuss what alternative strategies are being taken to manage the symptom or disease the deprescribed medication was intended to treat.

Elicit and address concerns and fears about deprescribing:

Patients may be reluctant to stop a medication if they think it is still necessary and may experience cognitive dissonance from being told to stop a medicine that for years they were urged to take or was described as “lifelong treatment.” Other concerns may include fear of their condition returning, fear of a withdrawal reaction, or a nonspecific fear of change [95,122,123]. Such emotions about deprescribing can easily overtake logic. Unless there is imminent risk of harm from a medication, addressing emotions about medication use before implementing a deprescribing plan can maintain therapeutic alignment between the clinician and patient and increase chances of long-term success from deprescribing attempts.

If the patient is against medication withdrawal, the reasons for this should be explored (eg, fear or belief the medication is necessary). If they are well-informed about the likely risks and benefits and place a greater value on the potential benefit than the likely harm of continuation, then deprescribing may not be appropriate (unless there is a clear and present risk of harm) [125]. However, the conversation can be revisited at regular intervals, particularly when there are changes in the patient’s condition or new evidence to inform deprescribing.

The use of PEMs may aid in communication and shared decision-making around deprescribing [116]. PEMs are available about deprescribing in general as well as for specific medications such as antidepressants, psychotropics, and proton pump inhibitors (PPIs) [126]. Although there is scarce information on the development, implementation, and outcomes of use of most tools, PEMS can be a strong trigger for deprescribing [116]. For example, in a trial of older adults, the EMPOWER brochure, a PEM designed to induce cognitive dissonance about sedative-hypnotic use and provide user-friendly guidance on how to deprescribe, led to a 27 percent reduction in use of benzodiazepines [85].

Communication with other health care professionals — Clinicians may be hesitant to stop a medication that was started by a specialist or while the patient was in the hospital. This may be because they do not feel that they are responsible for that medication, because of professional hierarchy, or because they do not wish to affect the patient’s relationship with this other professional [96,98]. However, these clinician barriers can be addressed.

Direct communication between health care professionals (such as specialists and primary care clinicians) when deprescribing is being considered can be invaluable to resolve uncertainties, prevent conflicting instructions to patients, and ensure alignment of the therapeutic plan [127-129]. However, if communication is not forthcoming, clinicians should not hesitate to take the initiative in stopping a medication that is clearly inappropriate or causing more harm than benefit.

Empowering patients to advocate for clear instructions when a medication is started or stopped can enhance communication between all parties. The patient may be primed to act as a conduit between the primary care clinician and specialist, for example “next time you see your cardiologist, make sure to tell them about this symptom you are having, and ask if it’s safe to stop this medication.”

When a non-prescribing clinician (such as a pharmacist) is making recommendations to a primary care clinician, having clear information on why the medication should be deprescribed (with supporting evidence where possible) as well as how to conduct deprescribing will likely increase the uptake of the recommendations. Templates for communication of deprescribing recommendations between pharmacists and clinicians (“pharmaceutical opinions”) have been developed and trialed in Canada with favorable results [130,131].


Patient and/or family reluctance — Patients and/or families may be reluctant to engage in deprescribing. However, clinicians may perceive reluctance, based on past experience, even if patients have not specifically expressed such concerns [72,96,132].

Most strategies for overcoming real or perceived reluctance relate to good communication. (See 'Communication with patients and families' above.)

It is often helpful to engage with patients and/or family early in the process, to communicate the “why” and “how” of deprescribing, and to address specific fears (table 3).

While deprescribing may not be familiar to patients, studies have shown that approximately 90 percent of older adults and caregivers say that they would be willing to stop one or more of their medicines if their doctor said it was possible [120,121]

The use of existing patient educational materials (PEMs) may be helpful [116].

Lack of evidence — There is a relative lack of evidence and guidelines to inform deprescribing (compared with initiation of medications). This, coupled with uncertainly over whether the medication is beneficial to the individual, can mean that there is limited objective impetus to deprescribe and fear about the outcomes of deprescribing [96,125,128,133]. Strategies to reduce uncertainty include:

For medications used to treat symptoms or whose effectiveness can be measured by a biomarker (eg, blood pressure), considering a deprescribing trial with monitoring for symptoms and/or worsening or return of condition.

Weighing the lack of evidence for the benefits of continuing a medicine (particularly among older adults with polypharmacy and multimorbidity), not only the lack of evidence for deprescribing.

Prioritize a patient-centered approach, focusing on the patients’ preferences with knowledge of their unique circumstances [133].

Limited time — Deprescribing is a complex process, which in the majority of cases requires considerable time to undertake. As such, the ability to deprescribe within a single clinical encounter may be limited [96,134]. Health care professionals can overcome time limitations by utilizing practical strategies. (See 'Practical strategies' above.)

Care shared among multiple providers — When medications are prescribed or recommended by another clinician such as a specialist, primary care clinicians may feel like it’s not their role to manage the medications (devolving of responsibility) or may not wish to make changes due to professional hierarchies [133-137]. Additionally, they may be concerned about damaging the patient’s relationship with this other professional by providing contradictory advice. However, it is helpful to not assume that specialists are resistant to deprescribing, and to communicate clearly. (See 'Communication with other health care professionals' above.)

Challenges in recognizing problematic medications — A lack of recognition of inappropriate medication use in individual patients has been identified as a barrier to deprescribing [96]. This may be addressed through:

Using electronic prescribing support and audit and feedback services where available to enable proactive deprescribing.

Realigning expectations of benefits and harms of medication use (both patients and clinicians tend to overestimate the benefits of medication use and underestimate the harms) [138,139].

Considering adverse drug reactions in the differential diagnosis of new symptoms or a change in condition [140,141].

Medical culture and clinical inertia — Medical culture has been highlighted as a barrier to deprescribing, including a historically clinician-centric culture where prescribing is a central part of professional identity [137,142,143]. Additionally, starting a medication is familiar and considered a positive action (ie, doing something to help the patient), while deprescribing is less familiar and may be considered a lower priority or as withdrawing care. Clinical inertia (continuation along a path of treatment without re-evaluation or staying with the “status quo”) is also common in medical culture and can discourage deprescribing [128,134,144]. Strategies to combat clinical inertia and cultural norms and increase the normality of deprescribing include:

Equally considering the benefits and harms of continuation against the benefits and harms of discontinuation [125].

Attending deprescribing-related continuing education opportunities and advocating for greater undergraduate teaching of deprescribing.

Discussing deprescribing activities with colleagues, including success stories [133].


Hospitalized patients — Hospitalization is a potentially opportune time for deprescribing as there is often a complete medication history and reconciliation performed on admission, access to a multidisciplinary team (including specialists), and the ability for close short-term monitoring. However, there are also limitations: duration of admission may be considered too short to complete a deprescribing process, working patterns may limit capacity to support deprescribing, deprescribing is likely to be lower priority than the acute reason for hospital admission, and inpatient clinicians may not be aware of the complete history and context of a patient’s medication use [132,145]. Communication with the primary care clinician about potential deprescribing targets is generally advisable before changing long-term medications [129,146]; if such communication is not forthcoming, caution should be taken with changing treatment for chronic conditions not related to the reason for hospitalization, although it is reasonable to make changes where a medication is clearly harmful or inappropriate. Despite these challenges, interventions are being trialed in hospitals to enhance deprescribing, particularly use of electronic clinical decision support systems.

Medications are commonly added during hospitalization and continued after discharge even when no longer needed, for example, medications used for stress ulcer prophylaxis and those used to treat constipation, insomnia, or elevated blood sugar or blood pressure that occur during inpatient stays. These medications may be continued indefinitely unless the watchful clinician identifies and stops them. Post-hospitalization visits, for example to primary care clinicians, should thus be used to review all medications changed during the hospital stay and stop those which are no longer needed.

People nearing the end of life — As life expectancy shortens, people often prioritize controlling symptoms over life-preserving therapy and there is less opportunity to benefit from therapies designed to prevent disease over the long term, for example, anticoagulants, cholesterol-lowering therapies, and anti-resorptive therapies for osteoporosis [36-38,147] (see 'Patient characteristics' above). Several research groups have compiled lists of medications that are often inappropriate near the end of life [36,148-150]. Such medications can thus often be useful to deprescribe, although good communication remains paramount. Conversely, some medications such as benzodiazepines, which may otherwise be frequent targets of deprescribing efforts in older adults, can be useful in palliative care. The attitudes held by patients nearing the end of life and their caregivers towards deprescribing can vary and, as with the general population, conversations need to be tailored to the individual [151].

Children — There is little published literature on deprescribing in children and adolescents. While polypharmacy is commonly associated with ageing and older adults, it can occur at any age. Possibly because of the lack of evidence-based guidelines for children, a culture of “trialing” medications often occurs. While deprescribing may be more complex in children due to a lack of evidence for both prescribing and deprescribing, it may be easier to establish indications due to the use of electronic health records and close involvement of parents/caregivers [152]. There is a need for further investigation and development of interventions and support tools in this area, particularly in pediatric psychiatry [153,154].

RESOURCES TO SUPPORT DEPRESCRIBING — There are a large variety of resources and tools that have been developed to support health care professionals to deprescribe, such as generic frameworks and drug-specific deprescribing guidelines. These tools have been developed using different methods such as expert consensus, structured and unstructured literature reviews, external review, or following internationally recognized standards (such as guideline development) [155].

Evidence-based guidelines for deprescribing have been developed by a Canadian consortium for an expanding number of medication classes, with easy-to-use algorithms and other resources available for online review and download. Trial-tested patient handouts that are designed to address the educational, psychological, and behavioral needs of the patient can also be helpful.

Other online resources for deprescribing of specific medications are also available from the NSW Therapeutic Advisory Group, the Canadian Deprescribing Network, Primary Health Tasmania, the Australian Deprescribing Network, and the US Deprescribing Research Network. Additional information on patient education materials are presented above. (See 'Communication with patients and families' above.)

Individual health systems may have additional resources such as pharmacist consultation services or deprescribing clinics such as the IMPROVE polypharmacy project. Independent consultant pharmacists can be found through the American Society of Consultant Pharmacists website [156] and can provide valuable services.


The term “deprescribing” refers to a process of medication withdrawal, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes [1]. This can encompass efforts to comprehensively review a patient’s medication list and systematically discontinue or reduce the dose of all medications with an unfavorable balance of benefits and harms, as well as efforts focused on specific high-risk medications. (See 'Definition' above.)

Common goals for deprescribing include reducing overall medication burden, reducing the risk of specific geriatric syndromes such as falls and cognitive impairment, and improving global health outcomes such as hospitalization and death. (See 'Goals of deprescribing' above.)

Patient characteristics which are good targets for deprescribing efforts include polypharmacy, multimorbidity, renal impairment, transitions of care, medication nonadherence, limited life expectancy, older age, frailty, and dementia. (See 'Patient characteristics' above.)

Commonly overused and high-risk medications are good targets for deprescribing. These include potentially inappropriate medications for older adults such as sedative-hypnotics, strongly anticholinergic medications, long-acting sulfonylureas such as glyburide, and chronic use of proton pump inhibitors (PPIs) and nonsteroidal antiinflammatory drugs (NSAIDs) in the absence of compelling indications. In certain situations, insulins and aspirin may also be appropriate for deprescribing. Other such medications are presented in the table (table 1). (See 'Medications' above.)

Deprescribing is best accomplished in a stepwise approach which includes engaging the patient and gathering information, identifying and deciding on medications to deprescribe, and implementing a deprescribing plan with monitoring and follow-up (table 3). (See 'Stepwise approach' above.)

Tapering is a good strategy for many medications. It can reduce the chance of adverse drug withdrawal events (ADWEs), facilitate identification of the lowest effective dose in patients who are unable to stop a drug completely, and support long-term drug cessation by increasing patient comfort and willingness to try deprescribing. Certain medications are more likely to cause adverse drug withdrawal reactions (ADWRs) if stopped abruptly (table 2). (See 'Tapering doses' above.)

Several practical strategies can aid the clinician in deprescribing. (See 'Practical strategies' above.)

Specific information regarding deprescribing of certain commonly prescribed medication classes is available, including benzodiazepines and benzodiazepine receptor agonists, PPIs, antipsychotics, glucose-lowering medications, cholinesterase inhibitors and memantine, antidepressants, and antihypertensive medications. (See 'Deprescribing specific medications' above.)

Shared decision-making is essential to successful deprescribing and should include alignment of patient goals and preferences. Effective communication is needed not only between patients and clinicians but also between health care professionals (table 3). (See 'Shared decision-making' above.)

Several common barriers to deprescribing such as patient reluctance, care shared between multiple providers, challenges in recognizing appropriate medications, and clinical inertia can be addressed through communication, education, and other strategies. (See 'Common barriers to deprescribing and strategies for overcoming them' above.)

Patients in certain medical settings such as those who are hospitalized or near the end of life may have unique opportunities and challenges to deprescribing. (See 'Special populations and settings' above.)

There are a large variety of resources and tools that have been developed to support health care professionals to deprescribe, such as generic frameworks and drug-specific deprescribing guidelines. (See 'Resources to support deprescribing' above.)

  1. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol 2015; 80:1254.
  2. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J 2007; 9:430.
  3. Kua CH, Mak VSL, Huey Lee SW. Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2019; 20:362.
  4. Martin P, Tamblyn R, Benedetti A, et al. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA 2018; 320:1889.
  5. Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:3323.
  6. Ulley J, Harrop D, Ali A, et al. Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review. BMC Geriatr 2019; 19:15.
  7. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169:1952.
  8. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2019; 67:674.
  9. Wilson NM, Hilmer SN, March LM, et al. Associations between drug burden index and falls in older people in residential aged care. J Am Geriatr Soc 2011; 59:875.
  10. Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing 2021; 50:1189.
  11. Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem. Drugs Aging 2012; 29:15.
  12. van der Cammen TJ, Rajkumar C, Onder G, et al. Drug cessation in complex older adults: time for action. Age Ageing 2014; 43:20.
  13. Lee J, Negm A, Peters R, et al. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open 2021; 11:e035978.
  14. Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging 2008; 25:1021.
  15. Dills H, Shah K, Messinger-Rapport B, et al. Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials. J Am Med Dir Assoc 2018; 19:923.
  16. Page AT, Clifford RM, Potter K, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol 2016; 82:583.
  17. O'Connell MB, Chang F, Tocco A, et al. Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review. J Am Geriatr Soc 2015; 63:1900.
  18. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003; 289:1107.
  19. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: "There's got to be a happy medium". JAMA 2010; 304:1592.
  20. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487.
  21. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006; 54:1516.
  22. Steinman MA, Miao Y, Boscardin WJ, et al. Prescribing quality in older veterans: a multifocal approach. J Gen Intern Med 2014; 29:1379.
  23. Onder G, Petrovic M, Tangiisuran B, et al. Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older: the GerontoNet ADR risk score. Arch Intern Med 2010; 170:1142.
  24. Zhan C, Correa-de-Araujo R, Bierman AS, et al. Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations. J Am Geriatr Soc 2005; 53:262.
  25. Lindblad CI, Artz MB, Pieper CF, et al. Potential drug-disease interactions in frail, hospitalized elderly veterans. Ann Pharmacother 2005; 39:412.
  26. Carey IM, De Wilde S, Harris T, et al. What factors predict potentially inappropriate primary care prescribing in older people? Analysis of UK primary care patient record database. Drugs Aging 2008; 25:693.
  27. Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol 2012; 65:989.
  28. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004; 164:545.
  29. Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother 2007; 5:31.
  30. Todd A, Holmes HM. Recommendations to support deprescribing medications late in life. Int J Clin Pharm 2015; 37:678.
  31. Shrestha S, Poudel A, Steadman K, Nissen L. Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review. Br J Clin Pharmacol 2020; 86:1931.
  32. Paque K, De Schreye R, Elseviers M, et al. Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases. Br J Clin Pharmacol 2019; 85:827.
  33. Morin L, Todd A, Barclay S, et al. Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing? Cancer 2019; 125:2309.
  34. Geijteman ECT, Huisman BAA, Dees MK, et al. Medication Discontinuation at the End of Life: A Questionnaire Study on Physicians' Experiences and Opinions. J Palliat Med 2018; 21:1166.
  35. Todd A, Husband A, Andrew I, et al. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care 2017; 7:113.
  36. Holmes HM, Sachs GA, Shega JW, et al. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc 2008; 56:1306.
  37. Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015; 175:691.
  38. Lipska KJ, Krumholz H, Soones T, Lee SJ. Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes. JAMA 2016; 315:1034.
  39. Gurwitz JH, Avorn J. The ambiguous relation between aging and adverse drug reactions. Ann Intern Med 1991; 114:956.
  40. Maher D, Ailabouni N, Mangoni AA, et al. Alterations in drug disposition in older adults: a focus on geriatric syndromes. Expert Opin Drug Metab Toxicol 2021; 17:41.
  41. Reeve E, Bell JS, Hilmer SN. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. Curr Clin Pharmacol 2015; 10:168.
  42. Delgado J, Jones L, Bradley MC, et al. Potentially inappropriate prescribing in dementia, multi-morbidity and incidence of adverse health outcomes. Age Ageing 2021; 50:457.
  43. Maust DT, Strominger J, Kim HM, et al. Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US. JAMA 2021; 325:952.
  44. Reeve E, Trenaman SC, Rockwood K, Hilmer SN. Pharmacokinetic and pharmacodynamic alterations in older people with dementia. Expert Opin Drug Metab Toxicol 2017; 13:651.
  45. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44:213.
  46. Lipska KJ, Ross JS, Miao Y, et al. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med 2015; 175:356.
  47. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007; 147:755.
  48. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018; 379:1519.
  49. Whitlock EP, Burda BU, Williams SB, et al. Bleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164:826.
  50. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015; 175:827.
  51. Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol 2014; 78:738.
  52. Scott I, Anderson K, Freeman C. Review of structured guides for deprescribing. Eur J Hosp Pharm 2017; 24:51.
  53. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ 1997; 315:1096.
  54. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet 2017; 389:1778.
  55. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56:1946.
  56. Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med 1997; 157:2205.
  57. Kennedy JM, van Rij AM, Spears GF, et al. Polypharmacy in a general surgical unit and consequences of drug withdrawal. Br J Clin Pharmacol 2000; 49:353.
  58. Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. Expert Opin Drug Saf 2018; 17:39.
  59. Hanlon JT, Tjia J. Avoiding Adverse Drug Withdrawal Events When Stopping Unnecessary Medications According to the STOPPFrail Criteria. Sr Care Pharm 2021; 36:136.
  60. Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Can Fam Physician 2018; 64:339.
  61. Benzodiazepine and Z-Drug (BZRA) deprescribing algorithm. 2019. (Accessed on July 15, 2019).
  62. Haastrup P, Paulsen MS, Begtrup LM, et al. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014; 31:625.
  63. Kim J, Blackett JW, Jodorkovsky D. Strategies for Effective Discontinuation of Proton Pump Inhibitors. Curr Gastroenterol Rep 2018; 20:27.
  64. Antipsychotic (AP) deprescribing algorithm. 2018. (Accessed on July 15, 2019).
  65. Bjerre LM, Farrell B, Hogel M, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Can Fam Physician 2018; 64:17.
  66. Reeve E, Farrell B, Thompson W, et al. Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary. Med J Aust 2019; 210:174.
  67. Maund E, Stuart B, Moore M, et al. Managing Antidepressant Discontinuation: A Systematic Review. Ann Fam Med 2019; 17:52.
  68. Gelenberg AJ, Freeman MP, Markowitz JC, et al. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd ed, American Psychiatric Association, 2010. (Accessed on September 15, 2019).
  69. Gerety MB, Cornell JE, Plichta DT, Eimer M. Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc 1993; 41:1326.
  70. Coulson J, Routledge PA. Adverse reactions to drug withdrawal. Adverse Drug React Bull 2008; 252:967.
  71. Marcum ZA, Pugh MJ, Amuan ME, et al. Prevalence of potentially preventable unplanned hospitalizations caused by therapeutic failures and adverse drug withdrawal events among older veterans. J Gerontol A Biol Sci Med Sci 2012; 67:867.
  72. Paque K, Vander Stichele R, Elseviers M, et al. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37.
  73. Steinman MA, Handler SM, Gurwitz JH, et al. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc 2011; 59:1513.
  74. Hazen ACM, Zwart DLM, Poldervaart JM, et al. Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care. Fam Pract 2019; 36:544.
  75. Tjia J, DeSanto-Madeya S, Mazor KM, et al. Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing. J Hosp Palliat Nurs 2019; 21:312.
  76. Bregnhøj L, Thirstrup S, Kristensen MB, et al. Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care. Eur J Clin Pharmacol 2009; 65:199.
  77. Korenvain C, MacKeigan LD, Dainty KN, et al. Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel. Res Social Adm Pharm 2020; 16:1746.
  78. Brandt NJ, Cooke CE. Centers for Medicare and Medicaid Services Support for Medication Therapy Management (Enhanced Medication Therapy Management): Testing Strategies for Improving Medication Use Among Beneficiaries Enrolled in Medicare Part D. Clin Geriatr Med 2017; 33:153.
  79. Jokanovic N, Tan EC, van den Bosch D, et al. Clinical medication review in Australia: A systematic review. Res Social Adm Pharm 2016; 12:384.
  80. McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised older patients receiving multiple medications. Intern Med J 2016; 46:35.
  81. Reeve E, Andrews JM, Wiese MD, et al. Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors. Ann Pharmacother 2015; 49:29.
  82. Cross AJ, George J, Woodward MC, et al. Deprescribing potentially inappropriate medications in memory clinic patients (DePIMM): A feasibility study. Res Social Adm Pharm 2020; 16:1392.
  83. Michiels-Corsten M, Gerlach N, Schleef T, et al. Generic instruments for drug discontinuation in primary care: A systematic review. Br J Clin Pharmacol 2020; 86:1251.
  84. Ng BJ, Le Couteur DG, Hilmer SN. Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 2018; 35:493.
  85. Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014; 174:890.
  86. Bykov K, Yoshida K, Weisskopf MG, Gagne JJ. Confounding of the association between statins and Parkinson disease: systematic review and meta-analysis. Pharmacoepidemiol Drug Saf 2017; 26:294.
  87. Proton pump inhibitor (PPI) deprescribing algorithm. 2018. (Accessed on July 15, 2019).
  88. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician 2017; 63:354.
  89. Wiens E, Kovaltchouk U, Koomson A, Targownik LE. The Clinician's Guide to Proton-Pump Inhibitor Discontinuation. J Clin Gastroenterol 2019; 53:553.
  90. Boghossian TA, Rashid FJ, Thompson W, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev 2017; 3:CD011969.
  91. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2018; 3:CD007726.
  92. Ballard C, Creese B, Corbett A, Aarsland D. Atypical antipsychotics for the treatment of behavioral and psychological symptoms in dementia, with a particular focus on longer term outcomes and mortality. Expert Opin Drug Saf 2011; 10:35.
  93. Tjia J, Reidenberg MM, Hunnicutt JN, et al. Approaches to Gradual Dose Reduction of Chronic Off-Label Antipsychotics Used for Behavioral and Psychological Symptoms of Dementia. Consult Pharm 2015; 30:599.
  94. Oktora MP, Kerr KP, Hak E, Denig P. Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review. Diabet Med 2021; 38:e14408.
  95. Reeve E, To J, Hendrix I, et al. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013; 30:793.
  96. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open 2014; 4:e006544.
  97. Schoenborn NL, Crossnohere NL, Bridges JFP, et al. Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets. JAMA Intern Med 2019; 179:1642.
  98. Antihyperglycemics deprescribing algorithm. 2018. (Accessed on July 15, 2019).
  99. Seidu S, Kunutsor SK, Topsever P, et al. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 2019; 21:1668.
  100. American Diabetes Association. 12. Older Adults: Standards of Medical Care in Diabetes-2021. Diabetes Care 2021; 44:S168.
  101. Farrell B, Black C, Thompson W, et al. Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline. Can Fam Physician 2017; 63:832.
  102. Abdelhafiz AH, Sinclair AJ. Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications 2018; 32:444.
  103. Reeve E, Farrell B, Thompson W, et al. Evidence-based clinical practice guideline for deprescribing cholinesterase inhibitors and memantine. The University of Sydney 2018. (Accessed on September 15, 2019).
  104. Parsons C, Lim WY, Loy C, et al. Withdrawal or continuation of cholinesterase inhibitors or memantine or both, in people with dementia. Cochrane Database Syst Rev 2021.
  105. Niznik JD, Zhao X, He M, et al. Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing. Alzheimers Dement 2020; 16:630.
  106. O'Regan J, Lanctôt KL, Mazereeuw G, Herrmann N. Cholinesterase inhibitor discontinuation in patients with Alzheimer's disease: a meta-analysis of randomized controlled trials. J Clin Psychiatry 2015; 76:e1424.
  107. Singh S, Dudley C. Discontinuation syndrome following donepezil cessation. Int J Geriatr Psychiatry 2003; 18:282.
  108. Cholinesterase inhibitor (ChEI) and memantine deprescribing algorithm. 2018. (Accessed on July 15, 2019).
  109. Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav 2019; 97:111.
  110. Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry 2019; 6:538.
  111. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315:2673.
  112. Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database Syst Rev 2020; 12:CD004349.
  113. Reeve E, Jordan V, Thompson W, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database Syst Rev 2020; 6:CD012572.
  114. Sheppard JP, Burt J, Lown M, et al. Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial. JAMA 2020; 323:2039.
  115. Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ 2016; 353:i2893.
  116. Fajardo MA, Weir KR, Bonner C, et al. Availability and readability of patient education materials for deprescribing: An environmental scan. Br J Clin Pharmacol 2019; 85:1396.
  117. Weir KR. Preferences around communication and decision‐making in deprescribing. J Pharm Pract Res 2020; 50:524.
  118. Weir K, Nickel B, Naganathan V, et al. Decision-Making Preferences and Deprescribing: Perspectives of Older Adults and Companions About Their Medicines. J Gerontol B Psychol Sci Soc Sci 2018; 73:e98.
  119. Thompson W, Jacobsen IT, Jarbøl DE, et al. Nursing Home Residents' Thoughts on Discussing Deprescribing of Preventive Medications. Drugs Aging 2020; 37:187.
  120. Reeve E, Wolff JL, Skehan M, et al. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med 2018; 178:1673.
  121. Reeve E, Low LF, Hilmer SN. Attitudes of Older Adults and Caregivers in Australia toward Deprescribing. J Am Geriatr Soc 2019; 67:1204.
  122. Reeve E, Low LF, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study. Br J Gen Pract 2016; 66:e552.
  123. Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns 2015; 98:220.
  124. Green AR, Aschmann H, Boyd CM, Schoenborn N. Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults. JAMA Netw Open 2021; 4:e212633.
  125. Reeve E, Denig P, Hilmer SN, Ter Meulen R. The Ethics of Deprescribing in Older Adults. J Bioeth Inq 2016; 13:581.
  126. Nguyen-Soenen J, Rat C, Fournier JP. Suitability of patient education materials on proton-pump inhibitors deprescribing: a focused review. Eur J Clin Pharmacol 2020; 76:17.
  127. Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in Older Adults With Cardiovascular Disease. J Am Coll Cardiol 2019; 73:2584.
  128. Anderson K, Foster M, Freeman C, et al. Negotiating "Unmeasurable Harm and Benefit": Perspectives of General Practitioners and Consultant Pharmacists on Deprescribing in the Primary Care Setting. Qual Health Res 2017; 27:1936.
  129. Duong MH, McLachlan AJ, Bennett AA, et al. Iterative Development of Clinician Guides to Support Deprescribing Decisions and Communication for Older Patients in Hospital: A Novel Methodology. Drugs Aging 2021; 38:75.
  130. Martin P, Tannenbaum C. A prototype for evidence-based pharmaceutical opinions to promote physician-pharmacist communication around deprescribing. Can Pharm J (Ott) 2018; 151:133.
  131. (Accessed on July 17, 2019).
  132. Scott S, Twigg MJ, Clark A, et al. Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists. Age Ageing 2019; 49:102.
  133. Damarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC Fam Pract 2020; 21:131.
  134. Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians' Views on Deprescribing in Everyday Practice. Ann Fam Med 2017; 15:341.
  135. Kouladjian L, Gnjidic D, Reeve E, et al. Health Care Practitioners' Perspectives on Deprescribing Anticholinergic and Sedative Medications in Older Adults. Ann Pharmacother 2016; 50:625.
  136. Schmidt-Mende K, Hasselström J, Wettermark B, et al. General practitioners' and nurses' views on medication reviews and potentially inappropriate medicines in elderly patients - a qualitative study of reports by educating pharmacists. Scand J Prim Health Care 2018; 36:329.
  137. Doherty AJ, Boland P, Reed J, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open 2020; 4.
  138. Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med 2015; 175:274.
  139. Hoffmann TC, Del Mar C. Clinicians' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med 2017; 177:407.
  140. Klopotowska JE, Wierenga PC, Smorenburg SM, et al. Recognition of adverse drug events in older hospitalized medical patients. Eur J Clin Pharmacol 2013; 69:75.
  141. Tangiisuran B, Wright J, Van der Cammen T, Rajkumar C. Adverse drug reactions in elderly: challenges in identification and improving preventative strategies. Age Ageing 2009; 38:358.
  142. Jordan S, Logan PA, Panes G, et al. Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles. Pharmacy (Basel) 2018; 6.
  143. Ferris R, Blaum C, Kiwak E, et al. Perspectives of Patients, Clinicians, and Health System Leaders on Changes Needed to Improve the Health Care and Outcomes of Older Adults With Multiple Chronic Conditions. J Aging Health 2018; 30:778.
  144. Reeve E, Shakib S, Hendrix I, et al. The benefits and harms of deprescribing. Med J Aust 2014; 201:386.
  145. Should Hospital Admission Be Used as an Opportunity for Deprescribing in Older Adults? Can J Hosp Pharm 2020; 73:294.
  146. Nguyen AD, Baysari MT, Duong M, et al. Communicating deprescribing decisions made in hospital with general practitioners in the community. Intern Med J 2021; 51:1473.
  147. Shah SJ, Singer DE, Fang MC, et al. Net Clinical Benefit of Oral Anticoagulation Among Older Adults With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2019; 12:e006212.
  148. Thompson W, Lundby C, Graabaek T, et al. Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc 2019; 67:172.
  149. Zueger PM, Holmes HM, Calip GS, et al. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission. J Gen Intern Med 2019; 34:2029.
  150. Curtin D, Gallagher P, O'Mahony D. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age Ageing 2021; 50:465.
  151. Burghle A, Lundby C, Ryg J, et al. Attitudes Towards Deprescribing Among Older Adults with Limited Life Expectancy and Their Relatives: A Systematic Review. Drugs Aging 2020; 37:503.
  152. Begum R, Tomlin S. Deprescribing in paediatrics. Eur J Hosp Pharm 2017; 24:70.
  153. Coughlin M, Goldie CL, Tregunno D, et al. Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics. Int J Ment Health Nurs 2018; 27:1188.
  154. Barnett ER, Trepman AZ, Fuson HA, et al. Deprescribing psychotropic medications in children: results of a national qualitative study. BMJ Qual Saf 2020; 29:655.
  155. Reeve E. Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice. J Pharm Pract Res 2020; 50:98.
  156. American Society of Consultant Pharmacists. Available at: (Accessed on December 10, 2019).
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