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

Why So Many Older Adults Are Taking Too Many Pills

Imagine waking up every morning to a tray of 10 or more pills. Some for blood pressure. Some for cholesterol. One for sleep, another for acid reflux, maybe a painkiller, a diabetes pill, and a vitamin you’ve been told to take "just in case." Now imagine doing this every single day for years. Sounds exhausting? That’s because it is. And it’s more common than you think.

In the U.S. and Europe, about 40% of adults over 65 are taking five or more medications regularly. That’s called polypharmacy. And while some of these drugs are essential, many aren’t. In fact, research shows that up to 30% of hospital visits for older adults are linked to medication side effects-not the disease they’re trying to treat. Stomach bleeds from NSAIDs. Confusion from sleeping pills. Falls from blood pressure drugs that drop too low. These aren’t rare mistakes. They’re systemic.

This isn’t about being careless. It’s about how medicine works. Doctors often add medications to manage side effects of other medications. A statin causes muscle pain? Add a painkiller. The painkiller causes stomach upset? Add a proton-pump inhibitor. The PPI increases infection risk? Add an antibiotic. It’s a cascade. And no one ever steps back to ask: "Do we still need all of this?"

What Is Deprescribing? It’s Not Just Stopping Pills

Deprescribing isn’t about cutting pills just because you can. It’s not a quick fix. It’s a structured, evidence-based process of reviewing every medication to see if the risks still outweigh the benefits-especially as people age, their health changes, or their goals shift.

Think of it like this: when you start a new medication, you weigh the upside (lower blood pressure, less pain) against the downside (dizziness, nausea, interactions). Deprescribing does the same thing-but in reverse. You ask: "Is this drug still helping?" "Is it causing more harm than good?" "Would my life be better without it?"

The concept was formalized around 2012 by researchers in Canada, especially Barbara Farrell and Cara Tannenbaum. They built the first real frameworks to guide doctors, pharmacists, and patients through this process. Today, deprescribing.org is the global hub for these tools. And it’s not just theory. A 2023 JAMA study showed that when deprescribing was done properly, patients dropped an average of 1.8 medications-with no increase in hospital visits or deaths.

The Five Key Medication Classes That Need the Most Attention

Not all drugs are equal when it comes to deprescribing. Some are far more likely to cause harm than others. Five classes stand out as top targets:

• Proton-pump inhibitors (PPIs) like omeprazole: Often prescribed for heartburn, but many people stay on them for years-even when they no longer need them. Long-term use raises risk of bone fractures, kidney damage, and infections like C. diff.
• Benzodiazepines and sleep aids like lorazepam or zolpidem: These can cause drowsiness, memory loss, and falls. They’re often prescribed for insomnia, but studies show they lose effectiveness after just a few weeks. And yet, many people take them for decades.
• Antipsychotics like risperidone: Sometimes used off-label for agitation in dementia. But they increase stroke risk and can make confusion worse. The American Geriatrics Society says they should be avoided unless absolutely necessary.
• Antihyperglycemics like sulfonylureas: These lower blood sugar, but in older adults with limited life expectancy, overly strict control can lead to dangerous lows-sometimes fatal.
• Opioid painkillers: Chronic pain is real, but long-term opioids often do more harm than good. They cause constipation, dizziness, dependence, and respiratory issues. Tapering off safely can improve mobility and mental clarity.

Each of these has a clear, step-by-step deprescribing guideline. For example, with PPIs, the process is: 1) Check if you still have symptoms that justify the drug, 2) Try reducing the dose, 3) Switch to as-needed use instead of daily, 4) Stop completely if no symptoms return after 4-8 weeks.

How It’s Done: The Shed-MEDS Framework

One of the most proven methods is called Shed-MEDS. It’s simple, practical, and designed for real-world clinics.

1. Best Possible Medication History: Get a full list of everything the patient is taking-prescription, over-the-counter, supplements. Many patients forget or don’t realize something counts.
2. Evaluate: Use tools like STOPP/START criteria or the Beers Criteria to flag potentially inappropriate drugs. Ask: Is this drug still helping? Is it causing harm? Is it aligned with the patient’s goals?
3. Deprescribing Recommendations: Decide which drugs can be reduced or stopped. Prioritize those with the highest risk and lowest benefit.
4. Synthesis: Create a clear plan with the patient. When will we start cutting? How slowly? What symptoms should we watch for?

A 2023 trial with 372 older adults showed that using Shed-MEDS led to a 1.6-pill reduction even 90 days after discharge. And here’s the kicker: the group that had medications reduced had no more side effects than the group that didn’t.

Why Pharmacists Are the Secret Weapon

Doctors are busy. Nurses are stretched thin. But pharmacists? They’re trained to know every drug interaction, every side effect, every alternative.

Studies show that when pharmacists lead deprescribing efforts, success rates jump by 35-40%. Why? Because they spend time with patients. They explain why a drug might be unnecessary. They help design slow tapering plans. They track symptoms.

One pharmacist in Ontario reduced benzodiazepine use in 18 out of 22 elderly patients over six months. Only two had mild withdrawal-easily managed with support.

But here’s the problem: most primary care clinics don’t have pharmacists on staff. Or if they do, they’re not involved in medication reviews. That’s changing slowly. In Canada, where pharmacists are integrated into care teams, deprescribing adoption is 63%. In the U.S., it’s just 28%.

The Real Barrier: Time, Not Will

Most clinicians agree deprescribing is the right thing to do. A 2023 survey found 78% of doctors and pharmacists believe it improves patient outcomes. But only 32% feel their electronic health records support it.

Imagine this: you have a 7.2-minute appointment. The patient has three chronic conditions. They’re on 11 medications. You need to check blood pressure, review lab results, refill a prescription, and now-somehow-have a 20-minute conversation about stopping five drugs?

It’s impossible without systems. That’s why successful deprescribing programs include:

• EHR alerts that flag high-risk medications
• Pre-visit questionnaires asking patients: "Which meds are you willing to try cutting?"
• Team-based care: pharmacist reviews meds before the doctor sees the patient
• Follow-up calls after tapering

One U.S. health system saved $3.20 for every $1 spent on deprescribing staff-because fewer patients ended up in the hospital. That’s not just good care. It’s smart economics.

What Patients Really Think

Patients aren’t resistant because they’re stubborn. They’re scared.

A 2022 study found 65% of older adults were relieved to take fewer pills. But 22% were anxious. "I’ve been on this medicine since my husband died," one woman said. "What if I get sick again? What if I forget how to feel normal without it?"

That’s why communication matters more than algorithms. You can’t just hand someone a tapering schedule. You have to listen. You have to validate their fears. You have to say: "It’s okay to be nervous. We’ll go slow. We’ll watch. We’ll stop if you need to."

One man in his 80s stopped his sleeping pill after a six-week taper. He said: "I didn’t realize how groggy I was all day. Now I can read the newspaper without falling asleep. I feel like myself again."

What’s Next? AI, Policy, and the Future of Care

The tide is turning. In June 2024, the American Medical Association officially urged doctors to regularly review all medications. In 2026, Medicare will start paying hospitals and clinics based on how well they reduce inappropriate prescribing.

Researchers are now building AI tools that scan electronic records and flag drugs that might be safe to stop. The NIH has funded projects to create deprescribing guidelines for antidepressants, anticoagulants, and other classes that still lack clear protocols.

By 2030, experts predict deprescribing checks will be as routine as checking blood pressure. That’s not a fantasy-it’s a necessity. With 1 in 6 people globally expected to be over 65 by then, we can’t keep adding pills without asking if they’re still helping.

What You Can Do Today

If you or someone you care about is on five or more medications:

• Ask your doctor: "Which of these drugs are still necessary?"
• Ask your pharmacist: "Is there a safer or simpler way to manage this?"
• Keep a written list of every pill, vitamin, and supplement-and bring it to every appointment.
• Don’t be afraid to say: "I’d like to try going off this one. Can we taper slowly?"
• Watch for changes: more energy? Better sleep? Less dizziness? These are signs it might be working.

Deprescribing isn’t about taking away care. It’s about restoring it. Less clutter. Fewer side effects. More life.