Over 40% of adults over 75 are prescribed 5 or more medications [1]. While those medications may have been appropriate at prescription, the risk–benefit balance shifts as the body ages—and drugs that once helped can start causing more harm than good.
In one study of nursing home residents, efforts to reduce unnecessary prescriptions slashed mortality risk by 26% and fall risks by 24% [2].
This raises an important set of questions. When does it make sense to stop medications? Which medications should be stopped? And how can clinicians get this process right?
This guide walks through three real-world case studies and a structured clinical framework for deprescribing—updated in light of a new clinical trial.
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. The case studies below show 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. Each drug's necessity was carefully evaluated.
Step 1: Omeprazole
This was prescribed for acid reflux. The patient hadn't experienced reflux symptoms in years, and a recent endoscopy had shown no damage.
The dose was halved from 40mg to 20mg, with plans to reduce again in 3 months to 10mg and then taper off completely. Stopping abruptly is avoided 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].
In this patient's case, aspirin was stopped.
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 medications 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. A gradual taper was planned.
To support sleep, sustained-release melatonin was considered as an alternative. Clinical research has shown that melatonin can reduce time to fall asleep [6] and improve sleep quality [7]—without the sedative-related fall risk of zopiclone.
Non-drug strategies—collectively called sleep hygiene—were also discussed, including consistent sleep schedules, limiting evening light exposure, and working with a health practitioner on behavioural supports.
Once off zopiclone, the clinical goal was to reduce and ideally stop amitriptyline, which is also sedating and sometimes used to help with sleep.
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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].
Bendroflumethazide was stopped—a diuretic known to have the largest sodium-lowering effect among her medications. Stopping it risked raising blood pressure.
A recent study showed that reducing the number of antihypertensive medications did not lead to increased mortality in frail older adults [10]. This evidence provided confidence in adjusting the regimen.
A systolic BP target up to 140 was accepted. If it rose higher, a low-dose calcium channel blocker or beta blocker could be introduced—both of which don't reduce sodium as much. It is generally preferable to use multiple low-dose medications rather than a single high-dose one, to minimise side effects while effectively lowering BP.
Sertraline was also reduced from 100mg to 50mg, with community connection and practitioner follow-up maintained to support mental health.
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 a patient or their carer is concerned about multiple medications, the recommended approach is to work with a doctor through a structured process. Here is a 3-phase framework, based on the UpToDate deprescribing guidance.
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.
- The patient is educated on potential benefits and harms of each medication.
- The patient considers their goals, values, and risk tolerance.
Phase 3: Implement and Monitor a Plan
- A shared decision is made on what to stop or reduce.
- A concrete tapering plan is created.
- Rebound symptoms or side effects are monitored and the plan is adjusted 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 have had several care transitions with different prescribers
- Patients struggling to follow medication instructions
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
The 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. The bleeding risks outweighed the modest potential benefit. Aspirin was stopped.
Step 2: Blood Sugar Targets
For older, frail patients, clinical guidelines recommend an HbA1c target of <8%, not <7% [11].
Aggressive blood sugar control in this group increases the risk of hypoglycemia, which in turn increases fall risk [11].
Lantus (insulin) was cut in half and Gliclazide was stopped.
Instead, Empagliflozin 10mg was added—an SGLT2 inhibitor specifically indicated for patients with type 2 diabetes and heart failure, and carrying a lower risk of falls or hypoglycemia.
Step 3: Beta Blocker
The beta blocker was kept, as it is important for managing heart failure. Beta blockers can interact with insulin-lowering medications, increasing the risk of dangerously low blood sugar. Reducing insulin and stopping Gliclazide helped mitigate this interaction.
Key Lessons:
- Frail older adults should not 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 SGLT2 inhibitor—is the right move.
Final Thoughts
Deprescribing is one of the most powerful yet underutilized tools in modern medicine—especially for older adults. As the body ages, the balance between benefits and harms of medications can shift dramatically. By regularly reviewing and thoughtfully reducing unnecessary prescriptions, the risk of side effects, falls, hospitalizations, and mortality can all be lowered. 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
