Deprescribing Frameworks: How to Safely Reduce Medications and Cut Side Effects

More than 40% of older adults take five or more medications every day. Many of these drugs were prescribed years ago-some for conditions that no longer exist, others for symptoms that have faded. Yet they keep taking them. Why? Because no one ever asked if they still needed them. This isn’t laziness. It’s systemic. And it’s dangerous.

Every year, one in three hospital admissions among adults over 65 is linked to medication side effects. That’s not just bad luck. It’s preventable. The answer isn’t more pills. It’s fewer. And the process is called deprescribing.

What Deprescribing Really Means

Deprescribing isn’t just stopping a drug. It’s not cutting corners. It’s not ignoring symptoms. It’s a deliberate, step-by-step process to remove medicines that no longer help-or worse, hurt.

Think of it like cleaning out your closet. You keep things you wear, donate what’s outdated, and toss what’s broken. Medications work the same way. Some are still useful. Others are just taking up space-and causing problems.

According to the World Health Organization, inappropriate prescribing affects nearly half of older adults globally. That includes drugs like proton-pump inhibitors (PPIs) for heartburn that were meant for a 2-week course but taken for 10 years. Or benzodiazepines for anxiety that were prescribed after a stressful event and never reviewed since. These aren’t just leftovers. They’re risks.

Side effects from these medications can be silent. Dizziness. Confusion. Falls. Memory loss. Kidney strain. Liver stress. And in many cases, the harm outweighs the benefit. Deprescribing frameworks give doctors and pharmacists a roadmap to reverse this.

The Core Frameworks: How It’s Done

There’s no one-size-fits-all method. But there are proven systems. The most widely used are built on evidence from clinical trials and refined by researchers at deprescribing.org, launched in 2015 by Canadian experts Barbara Farrell and Cara Tannenbaum.

Five major drug classes have formal deprescribing guidelines:

• Proton-pump inhibitors (PPIs)
• Benzodiazepines and sleep aids (BZRAs)
• Antipsychotics (often used off-label for dementia)
• Antihyperglycemics (like insulin or sulfonylureas in older adults with limited life expectancy)
• Opioid analgesics

Each follows a clear structure. Take PPIs, for example. The guideline says:

1. Use STOPP/START criteria to identify patients who may not need it anymore
2. Check if the original reason still exists-like a recent ulcer or GERD diagnosis
3. Reduce the dose slowly over 4 to 8 weeks
4. Watch for return of symptoms and adjust if needed

This isn’t guesswork. It’s based on data from over 1,200 patients across multiple studies. The same approach applies to benzodiazepines: taper by 25% every two weeks, monitor for rebound anxiety or insomnia, and offer non-drug alternatives like sleep hygiene or cognitive behavioral therapy.

One validated framework, called Shed-MEDS, stands out. It’s simple: Best Possible Medication History → Evaluate → Deprescribing Recommendations → Synthesis. A 2023 JAMA Internal Medicine trial showed patients using this method lost an average of 1.8 medications after leaving a care facility-and still lost 1.6 at 90 days. No increase in hospital visits. No rise in deaths. Just fewer pills and better function.

Why Most Clinicians Don’t Do It

Despite the evidence, deprescribing is rare in practice. Why?

Time. Most primary care visits last 7 to 10 minutes. That’s not enough to review 12 medications, talk about goals of care, check for interactions, and build trust. A 2022 Canadian Medical Association Journal study found fewer than 15% of primary care doctors regularly use deprescribing frameworks.

Another problem? Fear. Doctors worry about backlash. Patients worry about withdrawal. Families worry about "giving up." But the data tells a different story.

In the same JAMA trial, 15.8% of patients in the deprescribing group had an adverse event. The control group? 16.2%. No difference. Yet the intervention group had nearly two fewer medications per person.

Then there’s the system. Electronic health records don’t help. They’re built to remind doctors to prescribe-not to stop. A 2023 survey of 450 U.S. clinicians found only 32% felt their EHR supported deprescribing. Most systems still default to "continue all meds" unless you manually override them.

And guidelines? They’re lopsided. A 2024 analysis of 3,569 clinical recommendations found only 7% addressed deprescribing. The rest? How to start more drugs.

Who Should Be Leading This?

Pharmacists are the unsung heroes of deprescribing. Studies show when pharmacists lead medication reviews, success rates jump 35-40%. Why? They have the time. They’re trained in drug interactions. They don’t have to rush to the next patient.

Take Sarah Chen, a pharmacist in Ohio. She used deprescribing.org’s benzodiazepine algorithm to taper 18 of 22 elderly patients over six months. Only two had mild withdrawal. No hospitalizations. No crises. Just relief.

Nurse practitioners and care coordinators are also key. They build relationships. They ask the right questions: "What do you want your life to look like in the next year?" "Are you taking all these pills because you think they’re helping-or because you’ve always done it?"

Doctors can’t do this alone. It takes a team. And that team needs training. Pharmacists need at least 150 hours of specialized medication therapy management education. Nurses need to recognize withdrawal signs. Primary care providers need to shift from "prescribe and forget" to "review and reassess."

What Patients Say

When patients are included in the decision, they respond well.

A 2022 qualitative study found 65% of older adults felt better after reducing medications. Less confusion. More energy. Fewer trips to the bathroom at night from diuretics. Less drowsiness from antihistamines they didn’t need.

But 22% felt anxious. "I’ve been taking this pill for 15 years," one woman said. "What if I get sick without it?" That fear is real. And it’s why education matters.

Deprescribing isn’t abandonment. It’s reevaluation. It’s saying: "We’re not giving up on you. We’re making sure your treatment fits your life now-not your life 10 years ago."

Patients need clear explanations. Written plans. Follow-up calls. A trusted person to call if symptoms return. Without that, even the best framework fails.

What’s Changing Now

Change is coming. Fast.

In June 2024, the American Medical Association issued its first official policy: physicians should routinely assess the continuing appropriateness of all medications. That’s huge. It’s not optional anymore.

Starting in 2026, Medicare will start measuring deprescribing as part of physician performance bonuses under the Merit-Based Incentive Payment System. Hospitals and clinics will be paid more for reducing inappropriate meds.

The FDA has funded $8.7 million in deprescribing research since 2020. The EU’s Pharmaceutical Strategy calls it a priority. Canada has a national program called DIGE that’s been running since 2018. In Canada, 63% of primary care practices have formal deprescribing protocols. In the U.S.? Just 28%.

And AI is stepping in. Researchers are building algorithms that scan EHRs and flag drugs that might be candidates for deprescribing-like an antipsychotic prescribed for insomnia in a patient with dementia. These tools will soon nudge doctors before they write the next script.

Where the Gaps Still Are

But it’s not perfect. We still lack formal guidelines for 500+ medication combinations. What about someone on blood thinners, antidepressants, beta-blockers, and a statin? There’s no clear algorithm. No step-by-step plan.

And for patients with advanced dementia? Some medications-like antipsychotics-are used to calm agitation. Stopping them too fast can cause distress. The American Geriatrics Society warns against indiscriminate deprescribing. Goals matter. Quality of life matters.

That’s why every decision must be personalized. Not based on age. Not based on charts. Based on the person.

"Deprescribing is not simply stopping medications," says Dr. Amy Gravely, lead author of the 2024 Langford study. "It’s a structured clinical process that requires the same rigor as initiating therapy."

How to Start Today

If you’re a patient or caregiver:

• Ask your doctor: "Which of my medications are still necessary?"
• Bring a full list-every pill, supplement, and OTC drug.
• Ask: "What happens if I stop this?" and "What would happen if I keep it?"
• Request a pharmacist consult if your clinic offers one.

If you’re a clinician:

• Use deprescribing.org’s free algorithms. They’re downloadable and printable.
• Start with one drug class-PPIs or benzodiazepines are good entry points.
• Use STOPP/START version 3 criteria to screen for inappropriate meds.
• Partner with your pharmacy team. They’re your best ally.
• Document every decision. Not just what you stopped-but why.

It doesn’t take a revolution. It takes one conversation. One review. One decision to ask, "Do we still need this?"

What’s Next

By 2030, experts predict deprescribing checks will be as routine as blood pressure screenings. The numbers don’t lie: aging populations, rising drug costs, and mounting evidence of harm are pushing this forward.

The goal isn’t to eliminate all medications. It’s to eliminate the ones that don’t belong. To replace fear with clarity. To replace clutter with control.

Medications aren’t trophies. They’re tools. And like any tool, they should be used only when they help-and removed when they don’t.