What are the recommended strategies for safely deprescribing medications in older adults?

Safe deprescribing of medications in older adults involves a patient-centred, gradual, and closely monitored approach to minimise withdrawal symptoms and adverse effects while maximising clinical benefit. Key strategies include:

• Shared decision-making: Engage the older adult in discussions about the benefits and risks of continuing, adjusting, or stopping medications, considering their preferences and clinical context. Reassure them about dependence as a common effect and address any anxieties sensitively. Agree and document a management plan, ensuring the patient knows who to contact with concerns NICE NG222,NICE NG215.
• Gradual dose reduction: Taper medications slowly in a step-wise fashion, often reducing by 25-50% of the previous dose, with smaller decrements as doses become lower. Use liquid formulations if needed to achieve finer dose adjustments. The pace of tapering should be led by the patient’s tolerance and withdrawal symptom resolution, recognising that withdrawal may take weeks to months NICE NG222,NICE NG215.
• Monitoring and review: Provide frequent and flexible reviews during deprescribing to monitor withdrawal symptoms, recurrence of the original condition, and any adverse effects. Adjust the tapering schedule accordingly. Extra unscheduled reviews should be offered if the patient reports problems or changes in health or social circumstances NICE NG222,NICE NG215.
• Managing withdrawal symptoms: Reassure patients that withdrawal symptoms are common and not necessarily relapse of the underlying condition. If symptoms are severe, consider temporarily reinstating the previous dose and then tapering more slowly NICE NG222.
• Clinical context considerations: Take into account the pharmacokinetics of the medication (e.g., half-life), the duration of treatment, and the potential benefits of more rapid withdrawal if serious side effects occur. For example, antidepressants with short half-lives require slower tapering NICE NG222.
• Addressing unsuccessful tapering: If dose reduction is not tolerated, aim to prevent dose escalation, document the rationale for continuation, and plan to attempt reduction again later NICE NG215.
• System-level support: Emergency department and primary care programs that focus on medication safety can support deprescribing efforts in older adults by providing structured reviews and interventions to reduce polypharmacy and medication-related harm Skains et al. 2025.

Overall, deprescribing in older adults should be a flexible, patient-led process with multidisciplinary support, balancing the risks of continued medication use against the risks of withdrawal and disease recurrence NICE NG222,NICE NG215 Skains et al. 2025.