Getting patients off inappropriate medications is one of the most important and difficult tasks to get right in clinical practice.
Here’s the step-by-step approach I follow—an approach recently updated because of a new clinical trial.
Let’s start with some sobering statistics.
Over 40% of adults over 75 are prescribed 5 or more medications [1].
And as I explain to my patients, while those medications may have given you a benefit when you were younger, as we get older, the risks from those medications can start to outweigh the benefits—and they can turn into poison.
In one study of nursing home residents, efforts to reduce unnecessary prescriptions slashed mortality risk by 26% and fall risks by 24% [2].
But this raises an important set of questions. When does it make sense to stop medications? Which medications should be stopped? And how can we get this process right?
Let’s take a closer look.
Table of Contents
- How Are Too Many Prescriptions a Problem?
- Case Study 1: Managing Polypharmacy in a Healthy Patient
- Case Study 2: Falls, Frailty, and the Dangers of Hyponatremia
- A Clinician’s Framework for Deprescribing
- Case Study 3: Diabetes, Heart Failure, and the Danger of Over-Treatment
- Final Thoughts
- References
How Are Too Many Prescriptions a Problem?
Taking too many medications—known as polypharmacy—has been consistently linked with poor outcomes in older adults. These include falls, hospitalizations, and even death.
Deprescribing—thoughtful reduction of unnecessary medications—has emerged as an important clinical intervention to reduce these risks.
Let’s walk through some real-world case studies to see how this works in practice.
Case Study 1: Managing Polypharmacy in a Healthy Patient
The first patient was in his early 80s, exercised regularly, and had solid health metrics: blood pressure of 126/84 and LDL-c of 54 mg/dL.
He was taking:
- Candesartan 16mg
- Aspirin
- Omeprazole 40mg
- Pravastatin 20mg nocte
-
Ezetimibe 10mg
That’s five medications. When working with a new patient like this, we carefully evaluate each drug’s necessity.
Step 1: Omeprazole
This was for acid reflux. But the patient hadn’t experienced reflux symptoms in years. A recent endoscopy had shown no damage.
So we halved the dose from 40mg to 20mg, with plans to reduce again in 3 months to 10mg, and then taper off completely. We avoid stopping all at once to prevent rebound reflux, which can occur if the body doesn’t have time to adjust after long-term use.
Step 2: Aspirin
Aspirin is often prescribed to reduce clot-related risks like heart attacks and strokes. In those without a prior heart attack, studies show an 11% lower risk of cardiovascular events with aspirin [3].
However, the same study showed a 43% increased risk of major bleeding, particularly in older adults [3]. Bleeding can occur in the digestive tract or in the brain, both of which carry serious risks.
Additionally, aspirin can contribute to anemia and iron deficiency, especially in older adults [4].
Because of these risks, guidelines now recommend against routine aspirin use in older adults without prior cardiovascular events [4].
So in this patient’s case, we stopped aspirin.
Remaining Meds
Candesartan (for blood pressure), Pravastatin, and Ezetimibe (for cholesterol) were continued, given his fitness and lack of side effects.
Key Takeaways:
- Omeprazole and aspirin are often continued long past their useful life.
- Patients may remain on meds prescribed decades ago without reevaluation.
Case Study 2: Falls, Frailty, and the Dangers of Hyponatremia
The second patient was a woman in her late 60s, frail, and using a walker. Her sodium level was low at 130. She was on:
- Amitriptyline 25mg
- Zopiclone 7.5mg
- Candesartan 32mg
- Bendroflumethazide 5mg
- Sertraline 100mg
All five medications are classified as fall risk-increasing drugs (FRIDs) [5].
Step 1: Sleep Medications
Zopiclone is a sedative. It impairs balance, coordination, and alertness—dangerous for someone frail who wakes up at night to use the bathroom. That’s a recipe for disaster. We planned to taper her off this medication slowly.
To help with sleep, we considered sustained-release melatonin, which has been shown to reduce time to fall asleep [6] and improve sleep quality [7].
We also discussed sleep hygiene—non-drug strategies to improve sleep quality. In our clinic, patients can work with a health improvement practitioner to optimize this area without medication.
Once off zopiclone, our next goal was to reduce and ideally stop amitriptyline, which is also sedating and sometimes used to help with sleep.
Step 2: Antidepressant and Blood Pressure Meds
She was also taking sertraline, candesartan, and bendroflumethazide. This combination was likely causing her low sodium levels (hyponatremia).
Even mild hyponatremia significantly increases fall risk [8], and is associated with double the in-hospital mortality rate after trauma in older adults [9].
We stopped bendroflumethazide, a diuretic known to have the largest sodium-lowering effect among her meds. But doing so could raise blood pressure.
A recent study showed that reducing the number of antihypertensive medications did not lead to increased mortality in frail older adults [10]. That gave us confidence in adjusting her regimen.
We decided we’d tolerate a systolic BP up to 140. If it rises higher, we could introduce a low-dose calcium channel blocker or beta blocker, both of which don’t reduce sodium as much. It’s also preferable to use multiple low-dose medications rather than a single high-dose one to minimize side effects while effectively lowering BP.
We also reduced sertraline from 100mg to 50mg. But we made sure her mental health support continued through community connection and practitioner follow-up.
Key Takeaways:
- Many older adults are on sedatives that increase fall risk.
- Blood pressure and antidepressant medications often cause hyponatremia in frail patients.
- Adjustments require careful monitoring and a flexible plan.
A Clinician’s Framework for Deprescribing
If you or someone you care about is on multiple medications, what should you do?
Ideally, you work with your doctor through a structured process. Here’s the 3-phase approach I use, based on the UpToDate framework.
Phase 1: Gather Information
- What is the full list of medications?
- Are there problematic adverse effects?
-
What is the patient’s current health status and personal goals?
Phase 2: Identify Medications to Consider Stopping
- This is a shared decision-making process.
- I educate patients on potential benefits and harms.
- The patient considers their goals, values, and risk tolerance.
Phase 3: Implement and Monitor a Plan
- Together, we decide what to stop or reduce.
- We create a concrete tapering plan.
- We monitor for any rebound symptoms or side effects, adjusting as necessary.
Higher-risk groups for inappropriate medications:
- Those with multiple health problems
- Older adults
- Patients with frailty or dementia
- Those with limited life expectancy
- Patients who’ve had several care transitions with different prescribers
-
Patients struggling to follow medication instructions
Also, certain medication classes—like sedatives and long-term PPIs—are flagged by the American Geriatrics Society as high-risk in older adults.
Case Study 3: Diabetes, Heart Failure, and the Danger of Over-Treatment
Our third patient was a man in his mid-70s with frailty, type 2 diabetes, and heart failure. His HbA1c was 6.7%.
He was taking:
- Lantus 50u
- Gliclazide 80mg
- Aspirin
- A beta blocker
Step 1: Aspirin
He had no history of heart attack. So again, the bleeding risks outweighed the modest potential benefit. We stopped aspirin.
Step 2: Blood Sugar Targets
For older, frail patients, clinical guidelines recommend an HbA1c target of <8%, not <7% [11].
Trying to achieve aggressive blood sugar control in this group increases the risk of hypoglycemia, which in turn increases fall risk [11].
We cut Lantus (insulin) in half and stopped Gliclazide.
Instead, we added Empagliflozin 10mg, an SGLT2 inhibitor. This class of drug is specifically indicated for patients with type 2 diabetes and heart failure and carries a lower risk of falls or hypoglycemia.
Step 3: Beta Blocker
This was kept, as it’s important for managing heart failure. But beta blockers can interact with insulin-lowering medications, increasing the risk of dangerously low blood sugar. Reducing insulin and stopping Gliclazide helped mitigate this.
Key Lessons:
- Frail older adults shouldn’t be treated to the same targets as younger people.
- Deprescribing doesn't mean anti-medicine—it means appropriate medicine.
- Sometimes, adding a better alternative—like an SGLT2i—is the right move.
Final Thoughts
Deprescribing is one of the most powerful yet underutilized tools in modern medicine—especially for older adults. As we age, the balance between benefits and harms of medications can shift dramatically. By regularly reviewing and thoughtfully reducing unnecessary prescriptions, we can lower the risk of side effects, falls, hospitalizations, and even mortality. This isn’t about being anti-medication—it’s about using the right medication, at the right dose, for the right patient, at the right time.
References
1. https://pmc.ncbi.nlm.nih.gov/articles/PMC11182547/
2. https://pubmed.ncbi.nlm.nih.gov/30581126/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC6439678/
5. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-024-05557-2
6. https://www.sciencedirect.com/science/article/abs/pii/S0022395619309872?via%3Dihub
7. https://pubmed.ncbi.nlm.nih.gov/33417003/
8. https://www.sciencedirect.com/science/article/abs/pii/S016749432300393X
9. https://tsaco.bmj.com/content/10/1/e001562
10. https://www.nejm.org/doi/full/10.1056/NEJMoa2508157
11. https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
