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 since changed-or disappeared. But no one ever stopped them. The result? A growing pile of pills, each with its own risks, each adding to the chance of dizziness, falls, confusion, or hospital visits. This isn’t laziness. It’s a system designed to start treatments, not stop them. That’s where deprescribing comes in.

What Deprescribing Really Means

Deprescribing isn’t just stopping pills. It’s not cutting corners or ignoring doctors’ orders. It’s a careful, step-by-step process of reviewing every medication a person takes and asking: Is this still helping? Or is it hurting more than it helps? The goal is simple: reduce harm, not just pills.

The term became official around 2012, thanks to researchers in Canada who saw how often older adults were stuck on drugs that no longer made sense. One of those researchers, Dr. Cara Tannenbaum, helped build the first real framework for doing this safely. Today, deprescribing.org is the go-to resource for clinicians worldwide. And the data shows it works.

A 2023 study in JAMA Internal Medicine followed 372 older adults in post-acute care. Those who went through a structured deprescribing process ended up taking 1.8 fewer medications on average. And here’s the surprise: their risk of falls, confusion, or hospital stays didn’t go up. It stayed the same. That means you can cut back-and stay just as safe, if not safer.

Which Medications Are Most Often Stopped

Not all drugs are created equal when it comes to deprescribing. Some are high-risk, low-reward. Five classes stand out as the most common targets:

• Proton-pump inhibitors (PPIs) - These are heartburn drugs like omeprazole. Many people take them for years, even though they were only meant for short-term use. Long-term use raises the risk of bone fractures, kidney problems, and infections.
• Benzodiazepines and sleep aids - Drugs like diazepam or zolpidem. These increase fall risk by 50% in people over 65. They also cause memory fog and can lead to dependence.
• Antipsychotics - Often prescribed for dementia-related agitation, even though they’re not approved for that use. These drugs can cause tremors, stiffness, and even sudden death in older adults.
• Antihyperglycemics - Diabetes medications like sulfonylureas. In frail older adults, low blood sugar can be deadly. Tight control isn’t always better.
• Opioid painkillers - Long-term use for chronic pain rarely improves function. But it increases the risk of addiction, constipation, and respiratory depression.

Each of these has a clear, evidence-based deprescribing pathway. For example, the PPI guideline says: check the original reason for the prescription, assess if it still applies, then slowly lower the dose over 4 to 8 weeks while watching for return of symptoms. No sudden stops. No guesswork.

The Shed-MEDS Framework: How It Works

One of the most validated tools is called Shed-MEDS. It’s a four-step process used in hospitals and clinics across North America:

1. Best Possible Medication History - Get the full list. Not what the patient remembers. Not what the chart says. What they’re actually taking, including over-the-counter pills and supplements.
2. Evaluate - Use tools like STOPP/START criteria or the Beers Criteria to flag drugs that are inappropriate for age or condition.
3. Deprescribing Recommendations - Prioritize which drugs to stop first. Start with the ones with the highest risk and lowest benefit.
4. Synthesis - Talk to the patient. Explain why you’re suggesting a change. Get their input. Build a plan together.

This isn’t a checklist for a nurse to tick off. It’s a conversation. And it works. In the same 2023 trial, patients who went through Shed-MEDS kept their medication reductions at 90 days. That’s not a fluke. That’s sustainability.

Why Most Clinicians Struggle to Do It

You’d think with all this evidence, deprescribing would be routine. But it’s not.

A 2022 study in the Canadian Medical Association Journal found fewer than 15% of primary care doctors regularly use deprescribing frameworks. Why? Time. The average visit lasts 7.2 minutes. That’s not enough to review 10 medications, check for interactions, explain risks, and answer fears.

Another problem? EHRs. Most electronic health records are built to remind doctors to add medications. They rarely prompt: “Have you considered stopping this?”

And then there’s fear. Patients have been on these pills for 10, 15, even 20 years. They believe the pill is keeping them alive. Stopping it feels like giving up. One 2022 study found 22% of older adults felt anxious about stopping even a single medication.

Pharmacists, on the other hand, are leading the charge. When pharmacists are part of the team, deprescribing success rates jump 35-40%. Why? They’re trained in medication therapy management. They have the time. They’re not rushing between patients.

What Happens When You Don’t Deprescribe

The cost of doing nothing is staggering.

The World Health Organization reports that 40% of older adults globally are on five or more medications - a condition called polypharmacy. In the U.S., medication-related problems cause 30% of hospital admissions in people over 65. Many of those admissions are preventable.

A 2024 analysis of 80 clinical guidelines found that only 7% included any deprescribing advice. Meanwhile, 93% focused on when to start a drug. That imbalance is dangerous. We’ve spent decades teaching doctors how to prescribe. We’ve barely started teaching them how to stop.

And it’s not just hospitals. It’s families. It’s caregivers. It’s the elderly woman who takes 12 pills a day and can’t remember which ones are for her blood pressure, which for sleep, which for pain she doesn’t even feel anymore.

How to Start Deprescribing - Even If You’re Not a Doctor

You don’t need to be a specialist to help. If you’re caring for an older adult, here’s what you can do:

• Make a complete list - Write down every pill, patch, cream, vitamin, and supplement. Include doses and how often they’re taken. Bring this to every appointment.
• Ask the big question - “Why was this prescribed? Is it still needed?” Don’t be afraid to ask twice.
• Look for red flags - Dizziness, confusion, falls, constipation, extreme fatigue. These aren’t just “part of aging.” They might be side effects.
• Use free tools - Go to deprescribing.org. Download the STOPP/START criteria or the Beers Criteria. They’re free, updated yearly, and designed for non-experts.
• Push for pharmacist involvement - Ask if your clinic has a medication therapy management program. If not, request one.

The Future Is Here - But It’s Not Everywhere

Change is coming. The American Medical Association passed its first deprescribing policy in June 2024, saying doctors must regularly assess whether all medications are still appropriate. The Centers for Medicare & Medicaid Services will start tying payments to deprescribing performance in 2026.

In Canada, the DIGE program has been nationally adopted since 2018. In the U.S., only 28% of primary care practices have formal deprescribing protocols. That gap is closing - slowly.

AI tools are being developed to scan EHRs and flag potential deprescribing candidates. The NIH has invested $8.7 million since 2020 to expand guidelines to cover antidepressants, anticoagulants, and other high-risk classes.

By 2030, experts predict deprescribing assessments will be as routine as checking blood pressure. But until then, progress depends on patients, families, and frontline clinicians speaking up.

What to Do Next

If you’re a patient or caregiver: gather your medication list. Pick one drug you’re unsure about. Ask your doctor: “Could this be stopped?”

If you’re a clinician: start with one class - PPIs or sleep aids. Use deprescribing.org’s free algorithms. Involve your pharmacist. Track your results.

If you’re a health system leader: build deprescribing into your EHR. Train your staff. Reward it.

This isn’t about taking away care. It’s about restoring it. Fewer pills. Fewer side effects. More clarity. More life.