Have you ever wondered whether you — or your older relative — might be taking too many medications?
You’re certainly right to ask yourself this. I consider this for all my own patients, and wish every doctor would.
In part, this is because over the years, I’ve had countless older adults express their worries and frustrations, related to their prescription drugs. These include:
- The hassle of having so many pills to take
- Worries about side-effects
- Frustration with medication costs
- Wondering whether a given medication is the “right” one for you, or for your condition
- The sneaky feeling that some of those medications don’t seem to help much
- The hassle of coordinating a long medication list among multiple doctors
Needless to say, all of this is not so good for quality of life while aging.
And unlike some things that people worry about, these concerns are all actually justified, given what geriatricians know about older adults and medications.
So if you’ve ever experienced the above worries — or if you (or your older relative) are taking more than five medications — then I want to make sure you know about a process that can improve or resolve all those problems that older adults have with their medications.
It’s called deprescribing, and it’s really essential to optimizing the health of an older person.
In this article, I’ll cover what every older adult and family caregiver should know about it:
- What is deprescribing?
- Why is deprescribing especially important for older adults?
- How does deprescribing work?
- What medications are most important for older adults to consider deprescribing?
- How can older adults and family caregivers get doctors to address deprescribing?
This way, you’ll have a better shot at what everyone wants when it comes to medication:
- To only take medications that are more likely to help than to harm
- To be taking the minimum amount of medication necessary, to optimize health and well-being
What is deprescribing?
In literal terms, deprescribing means what it sounds like: it’s the opposite of prescribing.
So instead of adding a medication to someone’s care plan, healthcare providers remove — or reduce the dosage — of one or more medications.
The Canadian Deprescribing Network has an especially nice definition here:
Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life.
Of course, there’s a little more to deprescribing. The truth is that it requires a long-needed shift in mindset and approach to health care, for doctors and patients alike.
That’s because deprescribing comes down to doctors and patients regularly asking themselves:
- Is this medication still needed?
- Does the likely benefit of this medication outweigh any risks or harms that it might cause?
- Could we manage without this drug, or could we make do with a lower dose of it?
You might think this would be the default in healthcare, but unfortunately, it isn’t. For many reasons — the influence of drug companies, the shortage of time during visits, etc. — it tends to be much easier for doctors to prescribe medication, than it is for them to deprescribe.
And once prescribed, medications tend to just…stay. And be refilled almost indefinitely.
The result of all this is that older adults are often on a lot of medications. But when we take a close look, many of these can and should be deprescribed.
Why is deprescribing especially important for older adults?
Deprescribing is especially important to address in older adults because:
- People tend to be prescribed more medications as they get older. A 2015 study found that almost 40% of older Americans take five or more prescription medications.
- Many older adults experience “inappropriate prescribing.” Studies have found that 20% to 79% of older participants were taking a potentially inappropriate medication. Despite recent efforts to educate doctors about safer medication prescribing in aging, it remains common for seniors to be prescribed medications on the “Beer’s List”, which is a regularly updated American Geriatrics Society list of “Medications that Older Adults Should Avoid or Use with Caution.”
- Many “potentially inappropriate medications” are bad for the brain, or increase the risk of falls. Falls and declines in mental abilities are two very common problems that most older adults want to avoid. Yet many of them don’t realize that they are often taking medications associated with increased risk for these problems.
- Older adults are more vulnerable to side-effects and harm from their medications. The CDC estimates that every year 177,000 older adults visit the emergency room due to medication problems.
- Most older people would like to be on fewer medications. Surveys generally find that older adults don’t like being on many medications.
- It is often possible — and usually safer — to treat many health conditions with non-pharmacological methods, such as therapy and lifestyle changes.
Geriatricians have long known that many of the prescription drugs seniors take are not strictly necessary. Some are even causing harm to those who take them.
So really, deprescribing means doing what geriatricians are very proactive about doing: eliminating medications that aren’t needed, or are more likely to harm than to help.
Fortunately, since the concept of deprescribing is becoming more common in healthcare, it’s becoming easier for seniors and families to get help with this, even if they can’t see a geriatrician in person.
How does the process of deprescribing work?
Deprescribing requires doctors and other clinicians to follow these basic steps:
- Create an accurate and up-to-date list of all the drugs a person is currently taking.
- The best way to do this is to ask a person to bring in all the medications they are taking, and review the bottles.
- Clinicians should avoid relying on the medication list they have in the chart or computer. These lists are often inaccurate or out-of-date, especially if the person has been seeing multiple doctors.
- Review the reason each medication has been prescribed.
- Doctors should consider whether this use of the medication is in line with best practice guidelines, or otherwise is likely to benefit the person, based on good clinical evidence.
- Clinicians and patients together should consider whether the medication is providing symptom relief, or otherwise seems likely to be providing a meaningful benefit to the person.
- It’s important to consider whether the likely benefit is a good fit for someone’s health situation and values. For instance, if the likely benefit is a 1-in-60 chance of avoiding a heart attack over the next 10 years, this may be more worthwhile to someone in their 60s than to someone in their 90s.
- Consider whether the medication is likely to be risky, or cause harm to the person.
- For older adults, clinicians should pay special attention to medications known to be risky in seniors, such as those on the Beers List of “Medications that Older Adults Should Avoid or Use with Caution.”
- Consider whether any safer alternatives are available, for a given purpose.
- It is often possible to treat a given health concern with non-drug alternatives, or with medications that are less risky for older adults.
- Discontinue or reduce dosages of medication when possible.
- Many medications will require a tapering process, in which the dose is lowered over time.
- Make a plan to follow-up on the deprescribing plan.
- It’s essential to follow-up after medication changes, to check on related symptoms or health conditions.
Deprescribing isn’t something that you can do for yourself or a family member; you should always work with a health professional before stopping or reducing any prescription medications.
However, you can certainly get a head-start on the process by doing a little research and preparation before discussing medications with your health providers. I explain how to do this here: How to Review Medications for Safety & Appropriateness.
Which medications are the most important to consider deprescribing in older adults?
Here are some of the medications that are especially important to assess for deprescribing:
- Medications associated with falls. These include sedatives such as benzodiazepines and other sleeping pills, antidepressants, antipsychotics, anticholinergics, blood pressure medications, and also medications that lower blood sugar.
- For more on these medications, see 10 Types of Medications to Review if You’re Concerned About Falling.
- Medications associated with diminished brain function and cognitive impairment. Most of these, such as sedatives and anticholinergics, are also associated with falls.
- For more on these, see 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory.
- Non-steroidal anti-inflammatory drugs (NSAIDs). These are painkillers in the same class as ibuprofen. They are easily available over-the-counter, but are also prescribed by doctors. They are usually used to treat arthritis or other conditions related to pain and inflammation.
- In older adults, chronic use of NSAIDs can provoke internal bleeding, decreased kidney function, water retention, and other problems.
- For more on the risks of NSAIDs and finding better alternatives, see How to Choose the Safest Over-the-Counter Painkiller for Older Adults.
- Medications that lower blood sugar (for people with diabetes). Most people with diabetes take medication to keep their blood sugar from getting too high. It’s important to be careful that such medications don’t overtreat the person and cause too much low blood sugar.
- Low blood sugar (known as hypoglycemia) can provoke a fall or otherwise leave a senior feeling weak and unwell. Frequent episodes of hypoglycemia have also been associated with developing dementia and with higher mortality.
- Many experts, such as the authors of this 2016 review, recommend “moderate” blood sugar control for older adults, which means aiming for a middle ground in which blood sugar is kept not too high but also not too low.
- Proton-pump inhibitors (PPIs). This is a class of anti-acid drugs; they have been widely prescribed to treat gastroesophageal reflux disease, which can cause pain in the stomach area. They are also used to reduce stomach acid to treat other health problems.
- Research suggests that long-term use (e.g. more than 8 weeks) may be linked to an increased risk of problems such as bowel infection, hip fracture, malabsorption of key vitamins, and other problems.
- Commonly used PPIs include omeprazole, esomeprazole, lansoprazole, and pantoprazole (US brand names Prilosec, Nexium, Prevacid, and Protonix, respectively).
- For more on these, see You May Be At Risk: You are currently taking a proton-pump inhibitor (PPI)
- Medications used in Alzheimer’s and other dementias to manage difficult behaviors. Antipsychotics and sedatives are often used in people with Alzheimer’s and other dementias, to try to control difficult behaviors. But these medications are often prescribed before safer alternatives have been tried, and families are not always aware of the risks.
- For more on this, see 5 Types of Medication Used to Treat Difficult Dementia Behaviors.
- Opioids and other medications prescribed for pain. Pain is common in older adults, so many are taking opioids or other prescription painkillers. Although prescription medication for pain is often needed and appropriate, it’s essential to regularly review the use of these medications.
- Per this review, it is not yet clear if overdose and misuse are as big a problem among older adults as they are in the general population.
All of these medications are frequently prescribed to older adults. Most of them are commonly — although not always — reduced or discontinued by geriatricians and others who are particularly knowledgeable about medications in older adults.
If you or your older relative are taking any of these medications, remember that this is not necessarily inappropriate. In some situations, there’s no good alternative available to continuing with the medication. Sometimes after a careful review of the situation and alternative options, we do conclude that the likely benefits of continuing a “risky” medication do outweigh the risks.
What’s most important that seniors and their doctors regularly discuss any associated risks and available alternatives. This is how you can ensure that you are only taking medication that is truly needed, or otherwise is more likely to help than to harm.
How can older adults and family caregivers get doctors to address deprescribing?
The most important thing to do is to regularly ask your doctors to review your medications with you, and ask for help with deprescribing.
Fortunately, several excellent resources online can make deprescribing easier for you, and for your doctors. The Canadian Deprescribing Network, in particular, has some of my favorite resources. They include:
- Informative brochures to help older adults request deprescribing for several types of risky drugs. These brochures have been proven, in randomized control trials, to help seniors stop certain medications. What I especially like about them is that they often include a sample schedule of how the medication can be safely reduced. Available brochures cover:
- Anti-inflammatory medications like ibuprofen(Non-steroidal anti-inflammatory drugs or NSAIDs)
- Antipsychotic medication as sleeping pills or for dementia
- Medications for allergies and itchiness (First-generation antihistamines)
- Medication for type-2 diabetes (Sulfonylurea diabetes medication)
- Sleeping pills & anti-anxiety medication(Sedative-hypnotic medication, such as Ativan, Ambien, and others)
- Stomach pills for acid reflux (Proton-pump inhibitors)
- Tips on starting a deprescribing conversation. I especially like the suggested questions you can ask, which include:
- Why am I taking this medication?
- What are the potential benefits, and potential harmful effects?
- Can it affect my memory?
- Can it cause me to fall?
- Can I stop one of my pills? Do I need to reduce the medication slowly?
- Who do I follow-up with and when?
- Deprescribing algorithms, and other useful resources for healthcare providers. These provide step-by-step guidance to doctors and other clinicians, which makes it much easier for them to work with you in reassessing the use of risky medications.
- Find these here: Tools for Your Doctor, Pharmacist, or Nurse
Remember, it will really help if you can regularly remind your doctors that your goal is to be on the minimum number of medications necessary.
To do this, you and your doctors will have to work together to regularly reassess every medication you are taking.
Again, healthcare providers are supposed to be regularly reassessing all your medications, but they are often too busy to do so unless you remind them.
So if you want to be proactive about maintaining health and well-being in aging, learn more about your medications. And then talk to your doctors about deprescribing!
I also hope you’ll listen to this related podcast episode featuring deprescribing expert Dr. Cara Tannenbaum: Deprescribing & Reducing Risky Medications in Aging.
This article was last reviewed & received minor updates in July 2024.
Dave deBronkart says
Me again 🙂 … there’s no end to the usefulness of the things you talk about.
Telling a friend about deprescribing just now, googling led me to http://deprescribing.org, which now has an app. Do you know about it / have you tried it / got any opinions?
Leslie Kernisan, MD MPH says
hi Dave, as always I’m glad you find the info here useful. Yes I know of deprescribing.org. Didn’t know of their app but just tried it. It is for clinicians and honestly I’m not finding it very user friendly. I think it’s easier to work with the info at the Canadian Deprescribing site here https://www.deprescribingnetwork.ca/.
Barbara says
Thank you for highlighting this site for both patients and health providers. Well-organized with links to many resources. In Ontario, pharmacists are compensated by our provincial health plan (OHIP) for carrying an annual MedsCheck (voluntary) interview with patients taking 3 or more prescription medications (plus vitamins and other supplements).
P.S. On my monitor the print in the reply box is very pale–would be difficult for someone with impaired vision.
Nicole Didyk, MD says
I’m so glad you enjoyed the article. My practice is in Ontario (the land of OHIP). Another Canadian Deprescribing website you might be interested in is Deprescribing.org from the Bruyere centre in Ottawa. It’s a great resource for health professionals, but also has a lot of valuable information for non-pros as well.
Thanks for the tip about the ease of reading the comments. I’m not sure if we can change the font or size of text, but I know I have my screen set to make the print bigger for my aging eyes. Especially on my phone, that helps a lot!
Heila Janse van Rensburg says
I am 74 and read you newsletters with great interest. I am suffering from occipital neuralgia as a result of a whiplash accident. I have seen many neurologists, physiotherapists, etc. and tried many treatments.The neurologist prescirbed pills such as Trepelyne, Lyrica. Epilepten, etc. All these meds made me extremely sick. My house dr then prescribed ativan for my pain. I gradually went up to 3mg per day. When that was no longer helping, I decided to reduce my dosage after I had read on the internet how terribly addictive these pills can be. I am now taking 1,5mg per day and using cannabis oil on my neck. I find I cannot ingest it. It also makes me ill. However, I am still suffering a lot. Do you perhaps have any suggestion that might help me.
Leslie Kernisan, MD MPH says
I’m sorry for your whiplash and resulting pain, chronic neuropathic pain can be very difficult. Unfortunately, I cannot offer any specific suggestions for you. Generally treating chronic pain requires working closely with a skilled and attentive clinician (or team of clinicians), and also a multipronged approach. My main suggestion would be to try to find a chronic pain provider or clinic that offers more than just pills. Some people also find it very helpful to enroll in a program on living with chronic pain, such as this one: Chronic Pain Self-Management Program.
I will also say that tapering off Ativan can cause discomfort or worse. A slower taper is often more tolerable. Good luck!
Ted says
several comments have been about too little time to review meds with the doctor.
You can do an annual wellness visit with your GP….Medicare pays for it and even sent me a bonus $25 for doing it. Provided a great opportunity to review meds.
Leslie Kernisan, MD MPH says
Thanks for this suggestion. My experience has been that providers differ in how they handle the Annual Wellness Visit, but I agree that it can be a good opportunity to get some extra time and attention from the doctor. As far as I know, fee-for-service Medicare does not pay patients a bonus for getting the wellness visit. So I am guessing you are in a Medicare Advantage plan (also known as a Medicare HMO).
Bonnie says
I am very fortunate to have a lovely doctor who listens and takes time with me. Before I go I always write down on a little note pad the topics I wish to cover. I go back in my file and see what we went over the last time and if I have had any tests etc. I make a note to ask about them. ie. blood work, x-rays, etc. I also take copies of any reports that I’ve had since the last time at other doctors. I take a current list of my medications and allergies also. All of this saves a lot of time for the doctor I think. I know they are very busy and I want to get the most for my money. I do this for my husband also, who has dementia, and cannot answer her questions very well. So, I go in with him, and help him answer.
Leslie Kernisan, MD MPH says
These are wonderful suggestions, thank you for sharing. I’m glad you are being so proactive.
Angela G. Gentile says
Excellent article, Leslie! You should write a book.
Warm regards,
Angela.
Leslie Kernisan, MD MPH says
Thank you, I’m so glad you found it helpful!
I’d love to write a book, maybe some day I’ll find the time…
Alexa Gregory says
And she now has.
Nicole Didyk, MD says
It’s exciting isn’t it? Have you picked up your copy yet? If not, you can get more information here: /education-and-support/when-your-aging-parent-needs-help/
Madeline Longnion says
“Thanks for sharing this, Leslie. What I’ve observed is that some seniors are too hopelessly dependent of
medicinal drugs. I can give you my uncle’s example, who believes that quitting anxiety pills will cause his
brain to burst. I’ve tried several times to explain it to him that this is all in his head, but he wouldn’t
listen. So how would deprescribing work for him, and several other older adults like him?”
Leslie Kernisan, MD MPH says
Well, nobody likes to hear that one of their concerns is “all in their head.” When an older person is resisting sensible suggestions, then it’s important to try to back off and try a different approach. Start with a lot of listening and validating of their concerns and experience. Frame any suggestions as a way to help them reach their goals. Propose small steps.
Also, it often helps to get someone else, such as a professional with good communication skills, to help out. I have some more suggestions here: 4 Things to Do When an Older Person Resists Help.
Good luck!
Helena says
Hi..I couldn’t really understand how to place a new comment, so i’ll post it here since it is similar to what i wanted to say. I am 58 yrs old and take most meds for anxiety, and sleep: xanax and Lunesta. That’s all i take. I have no problem with my doctor to continue prescribing them as long as i’m taking them correclty and i do. No one is going to deprescribe this meds that work so well for me and doctor agrees. Why should i walk a\round anxious as a rat and not sleep? with my meds i feel no anxiety, and sleep like an 8 hr baby. Why, please tell me, why should i fix something that’s not broken? This whole article really didn’t make me feel confident in your profession.
Nicole Didyk, MD says
I’m glad that you have a good therapeutic relationship with your doctor and thanks for sharing your experience.
As Geriatricians, Dr. K and I mostly work with adults over the age of 60. We use some general principles about physiologic changes that are a natural part of aging to give advice about medications that might be more likely to cause side effects and should be avoided. These principles are scientifically based, and of course information gets updated as new research comes out, but the data we have right now shows that sleeping pills can increase the risk of falls and other dangerous outcomes.
Here’s an article that reviews the risks of medications like lunesta in older adults that you might find interesting: https://pubmed.ncbi.nlm.nih.gov/33258763/
Virginia Gaines says
This is coming a long time after your original post here, but I am struck by what seems to me a hostile tone. No one has said that you, or anyone else, SHOULD or MUST do anything. Dr. Kernesan or other doctors on this website have not told you to change anything. You use the words “Why should I …” What I’ve observed, In my 85 years of life, is that usually this means fearful defiance– “I am not going to do …” whatever the person fears they are going to be somehow forced to do.
Elizabeth Shewchuk says
It is so difficult when you have to almost make a specific appointment with doctors since most doctors will only give you two issues to discuss during your visit. Doctors are busy waiting rooms are full and quite honestly, it’s a difficult situation. What also may work is having a good rapport with your pharmacist and I know that some pharmacies offer an evaluation of medications.
Leslie Kernisan, MD MPH says
Agree that it can be hard to work around how busy doctors often seem to be. As a patient I’ve been told when I walk in the room “we have time to discuss 1-2 things, what do you want to discuss,” and I find it rather off-putting (even though I understand why the doc is doing this).
Talking to a pharmacist first, or finding other ways to get the process going, is a good idea.
Anonymous says
Deprescribing less medication as you mention is a very good practice for the doctors but how many will do that, hardly anyone I met so far. There is always not enough time to examine, ask and answer questions in 20 mins. for each patient so why not have the schedule more flexible. Kaiser is in that
category. For seniors they show less patience to communicate.
I feel desperate as each visit is $35 or above out of pocket and yet not getting problems solved or alleviated. I feel sorry. Some of my friends feel the same too.
Leslie Kernisan, MD MPH says
Thank you for bring up this important issue. Yes, families do tell me that sometimes they find it hard to get the doctors to address deprescribing. Here are a few things that can help:
– Tell the doctor ahead of time that you want to address deprescribing. Send your request in writing or by secure message if possible, because then your request will definitely be in the record. It may be better to schedule a visit specifically for this purpose.
– Ask if it might be possible to do a preliminary consultation with a pharmacist, followed by another visit with the doctor. This might make the deprescribing process easier for the doctor to manage.
– Politely express your concerns to the clinic management, if you feel the doctor isn’t getting around to addressing your medication concerns or alleviating the problems. Again, in writing is more likely to generate some changes. Tell them you’d like to know what you can do to help them address this more effectively.
All of this means more work for you, of course, and I’m sorry for that, because it really shouldn’t be so hard for patients to get the right care. But yes…when things aren’t happening as they should, one has to ramp up the persisting and insisting. Good luck!
Sue G says
We have Kaiser and my husband is on quite a number of medications (for pain and heart issues) which are quite necessary. He was offered (received a letter in the mail) a phone consultation with a pharmacist to go over each and every medication and its appropriateness. This was very reassuring and I’d bet anyone could request this of their Kaiser doctor.
Nicole Didyk, MD says
Professional advice about medication can be very helpful, even if no medication changes are suggested. You might be interested in this podcast about inappropriate medications in older adults.
Judy Stanhope says
Medicare limits my doctor visits to 15 minutes. By the time she gets thru her agenda and I get thru my questions, that time is up. Very frustrating!
Nicole Didyk, MD says
That does sound frustrating.
It sounds like you’re well prepared for your medical visits, and that can be helpful. Dr. K has a good article on how to talk to a new doctor: /10-types-medical-information-for-new-doctor-or-phr/. Many of the tips are applicable to seeing your regular doctor too.
Donna says
Hi Leslie. I agree when someone says,”So many people spend their health gaining wealth, and then have to spend their wealth to regain their health”.I have read an article somewhere that Experts have found that the drug Gabapentin stay in the body for 5-7 hours.Do you agree?
Leslie Kernisan, MD MPH says
There are pharmacological reference materials, such as Micromedex, which describe the “pharmacokinetics” of medications. Micromedex says that the half-life of gabapentin is 5-7 hours, so this means it takes 5-7 hours for the concentration of the drug in the bloodstream to go down by 50%.
You can usually find information on a drug’s half-life by searching Google.
However, since gabapentin is mostly removed from the body by the kidneys, it will stay in the body longer if a person has decreased kidney function. Most people’s kidney do work less well as they get older, so that means gabapentin is likely to last longer in older adults.
Stephen Simac says
This could save billions in health care costs. The book Save Trillions with Universal Health Care reports on many other ways to reduce medical costs through individual and social transformation.
Leslie Kernisan, MD MPH says
Reducing the use of unnecessary medications could certainly save money, and ultimately our care system needs to be financially sustainable for everyone.
However, I think saving money should be a secondary goal when it comes to deprescribing, or any other approach that prunes back medical care that doesn’t help much. What is most important is making sure people get more of the healthcare (and other care) that they need, and less of what they don’t need.