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

Every year, millions of older adults take more medications than they need. Some of these drugs were prescribed years ago for conditions that have changed-or even disappeared. Yet they keep taking them, often because no one ever asked if they still needed them. This isn’t laziness or neglect. It’s a system that rewards adding pills, not removing them. The result? Higher risk of dizziness, falls, confusion, kidney damage, and hospital stays-all linked to medication side effects. The good news? There’s a proven way to fix this: deprescribing.

What Deprescribing Really Means

Deprescribing isn’t just stopping pills. It’s not a quick fix or a shortcut. It’s a careful, step-by-step process where doctors and patients work together to identify which medications might be doing more harm than good. The goal? Reduce unnecessary drugs without risking health. This approach is especially important for people over 65, who on average take five or more medications daily. That’s called polypharmacy-and it’s a silent crisis. According to the World Health Organization, about 40% of older adults globally are on potentially inappropriate medications.

The idea took shape around 2010, led by researchers in Canada like Barbara Farrell and Cara Tannenbaum. They didn’t just say, “Stop the drugs.” They built tools-frameworks-that guide clinicians through the decision-making process. Today, deprescribing.org is the go-to resource for evidence-based protocols. These aren’t guesses. They’re based on clinical trials, expert reviews, and real patient outcomes.

Which Medications Are Most Often Reduced?

Not all drugs are equal when it comes to deprescribing. Some have clear, well-studied risks. Five classes stand out as top targets:

• Proton-pump inhibitors (PPIs) like omeprazole: Often prescribed for heartburn, but many people take them for years without a clear reason. Long-term use raises risk of bone fractures, kidney disease, and infections.
• Benzodiazepines and sleep aids like lorazepam or zolpidem: These can cause drowsiness, memory problems, and increase fall risk. Studies show many older adults can safely taper off these drugs over weeks.
• Antipsychotics used for behavioral issues in dementia: These are often prescribed off-label and carry a black-box warning for increased death risk in elderly patients with dementia.
• Antihyperglycemics like sulfonylureas: In older adults with limited life expectancy, aggressive blood sugar control can lead to dangerous low blood sugar episodes.
• Opioid painkillers: Many are prescribed long-term for chronic pain, even when benefits fade and risks climb. Tapering reduces addiction risk and improves alertness.

Each of these has a published deprescribing guideline. For example, the PPI protocol follows four steps: check if the original reason still exists, assess how strong the indication is, slowly lower the dose over 4-8 weeks, then monitor for return of symptoms. It’s not about stopping cold turkey. It’s about smart, slow, monitored reduction.

How It Works: The Shed-MEDS Framework

One of the most validated approaches is called Shed-MEDS. It stands for:

1. Best Possible Medication History-gather every drug the patient is taking, including over-the-counter and supplements.
2. Evaluate-use tools like STOPP/START criteria or the Beers Criteria to flag potentially inappropriate meds.
3. Deprescribing Recommendations-prioritize which drugs to cut first based on risk, benefit, and patient goals.
4. Synthesis-create a clear plan with the patient, including tapering schedule and follow-up.

A 2023 JAMA Internal Medicine trial tested this with 372 older adults in post-acute care. The group using Shed-MEDS had an average reduction of 1.8 medications at discharge-and still had 1.6 fewer meds 90 days later. And here’s the kicker: their rate of adverse events was nearly identical to the control group. No increase in hospitalizations. No rise in deaths. Just fewer pills and better function.

Why It’s Hard to Do-And How to Make It Work

You’d think this would be easy. But it’s not. Most doctors have 7-10 minutes per visit. Asking, “Which of these 12 pills can we take away?” takes time. It requires trust. It means having hard conversations.

Patients often feel anxious. One woman in a 2022 study said, “I’ve been taking this pill for 20 years. What if I get sick without it?” That fear is real. And it’s why patient education is part of every good deprescribing plan. Nurses and pharmacists play a huge role here. In settings where pharmacists lead the process, success rates jump 35-40%.

Electronic health records (EHRs) can help-but most don’t. Some systems now include alerts that say, “This patient is on a benzodiazepine. Consider deprescribing.” But only 32% of clinicians say their EHR actually supports this work. The rest are left to do it manually, with paper lists and memory.

Successful programs require more than good intent. They need:

• Pharmacists trained in medication therapy management (150+ hours of specialized training)
• Physician champions who model the behavior
• Nurses who monitor for withdrawal symptoms
• Time built into schedules-not squeezed in between other tasks

In Canada, where the Deprescribing Guidelines in the Elderly (DIGE) program is nationally supported, adoption is 63%. In the U.S., it’s only 28%. The difference? Structure. Leadership. Funding.

The Numbers Don’t Lie

Let’s talk about what this saves-not just in pills, but in money and lives.

A 2023 Canadian study found that for every dollar spent on deprescribing programs, healthcare systems saved $3.20. How? Fewer hospital visits. Fewer emergency trips. Fewer falls. Fewer drug interactions.

And it’s not just older adults. People with dementia, heart failure, or advanced cancer often get medications that don’t match their goals. A 2022 editorial in JAMA Internal Medicine warned that indiscriminate deprescribing can backfire-if done without understanding what matters to the patient. For someone with late-stage dementia, a pill that reduces agitation might improve quality of life, even if it doesn’t cure anything. Deprescribing isn’t about removing all drugs. It’s about removing the wrong ones.

The American Geriatrics Society’s 2023 Beers Criteria lists 34 potentially inappropriate medications for seniors. But only 12 of them have formal deprescribing guidelines. That’s a big gap. Researchers are now working on protocols for antidepressants, anticoagulants, and other common drugs. By 2030, experts predict deprescribing checks will be as routine as checking blood pressure.

What You Can Do

If you or a loved one is on five or more medications, ask:

• “Is this still needed?”
• “What happens if we stop it?”
• “Is there a safer alternative?”
• “Can we try reducing the dose slowly?”

Bring your complete medication list to every appointment-including vitamins, supplements, and over-the-counter drugs. Don’t assume your doctor knows what’s in your medicine cabinet.

Talk to your pharmacist. They’re trained to spot interactions and unnecessary meds. Many offer free med reviews.

And if your doctor says, “It’s fine as is,” ask for a second opinion. You have the right to question every pill.

What’s Next?

The tide is turning. In June 2024, the American Medical Association issued its first policy urging physicians to routinely assess whether all medications are still appropriate. Starting in 2026, Medicare will start measuring deprescribing as part of doctor performance ratings.

AI tools are being developed to scan EHRs and flag patients who might benefit from deprescribing. New guidelines are coming for antidepressants, blood thinners, and more. The goal isn’t to eliminate all medications-it’s to make sure every one you take is truly helping you.

Deprescribing isn’t about cutting corners. It’s about cutting clutter. It’s about giving people back their energy, their balance, their peace of mind. One pill at a time.