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Deprescribing for health optimization

D — the first step

Deprescribing is the planned, supervised reduction or withdrawal of a medication that is no longer helping, or whose harm has come to outweigh its benefit. It is a formal discipline with named tools, not an improvisation, and it is the first step of DWARAA because everything after it is measured through a person whose baseline is being altered by what they take.

Before you read on

Never stop or change a prescribed medication without speaking to your own prescriber. Several of the classes described on this site rebound, or cause a withdrawal syndrome, when they are stopped abruptly, and some have to be reduced gradually over weeks or months under supervision. Nothing here is advice about your own medication, and nothing here is a reason to change anything on your own.

Why the list is where this starts

A resident arriving from a hospital, from home, and from a previous facility has accumulated three prescribers’ decisions, none of whom saw the whole list. A drug started for a transient problem in an acute ward becomes a standing prescription. A side effect gets read as a new condition and treated as one. Nobody set out to build an eleven-drug regimen; it assembled itself, and each step was locally reasonable.

That is why deprescribing is a review of the list, in date order, as one object — not a series of judgments about individual prescriptions made in isolation, which is how the list got long in the first place.

The named tools

The AGS Beers Criteria

The American Geriatrics Society Beers Criteria is the US reference list of medications generally best avoided in adults aged 65 and older. The current edition is the 2023 update; there is no 2026 edition, and pages circulating under that name are not AGS publications. The criteria are written for ambulatory, acute and institutional care and explicitly exclude hospice and end-of-life settings. In 2025 the AGS added a companion list of alternatives to the medications the criteria flag.

The Society is unusually clear about how the list should be used. In its own words, the criteria “should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.” It is a prompt to think, not a prohibition. More on the Beers Criteria.

STOPP/START

The European counterpart, now at version 3 (2023), is two lists rather than one. STOPP identifies potentially inappropriate medications; START identifies prescribing omissions — treatments a patient should be on and is not. That second half matters and is usually left out of the conversation, because undertreatment in older adults is as real as overtreatment.

It is also worth knowing that version 3’s own evidence base has been formally audited and found uneven: high-level evidence supported 43% of the STOPP criteria against 88% of the START criteria, and a small number of STOPP criteria were found to lack an appropriate supporting reference altogether. The tool is useful. It is not scripture. More on STOPP/START.

STOPPFrail

STOPPFrail, now at version 2, covers older adults with limited life expectancy who are approaching the end of life — the situation where a preventive medication’s time to benefit can exceed the time available to benefit from it. It supplies 25 criteria and a method for identifying that population, and it foregrounds shared decision-making rather than a rule. More on time to benefit.

What deprescribing has been shown to do

The most useful summary comes from a 2025 systematic review and meta-analysis of 118 randomized trials covering 417,412 patients aged 65 and over in community and long-term care settings. Interventions to address potentially inappropriate prescribing reduced the number of medications prescribed — a standardized mean difference of −0.25 (95% CI −0.38 to −0.13), which the authors describe as roughly half a medication per patient — with no substantial difference in non-serious adverse drug reactions, quality of life, medical visits, emergency department admissions, hospitalizations or all-cause mortality.

That is a modest and honest result, and it is the one worth acting on: reviewing and reducing inappropriate prescribing is safe, and it works for the thing it directly measures. Claims beyond that need to be checked against what the trials found.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

The mortality claim, and why it was retired

A 2016 meta-analysis of deprescribing studies reported a mortality reduction, and that finding traveled widely. The same research group published an updated review in 2024 covering 259 studies, and it did not hold: no significant reduction in mortality in randomized studies (odds ratio 0.96, 95% CI 0.84 to 1.09). Subgroup signals remain for adults aged 65 to 79 and for patient-specific interventions, but the main effect is null. A page that still cites the 2016 headline is citing a superseded result.

Two harms that deprescribing addresses directly

Antihypertensive dose and falls

An over-tight blood-pressure dose can produce orthostatic hypotension, which produces dizziness and syncope on standing, which produces falls, fractures and head injuries — morbidity that has nothing to do with blood pressure. Beers and STOPP/START both single out centrally acting antihypertensives and alpha-blockers as not recommended for routine hypertension treatment in older adults.

Note what the evidence does not yet show. The 2025 Cochrane review of antihypertensive withdrawal in older people pooled six randomized trials and 1,073 participants, and reported plainly that no included study measured falls at all. It also found blood pressure rose after withdrawal, by about 9.75 mmHg systolic. Reducing a dose that is causing symptomatic hypotension is a specific clinical judgment about a specific person, not a general policy with a proven falls benefit. More on antihypertensives.

Statins and glycemia

The FDA added a class-wide label change for statins in February 2012 warning of increased HbA1c and fasting glucose. This is a documented trade-off to weigh with a prescriber against a patient’s cardiovascular risk — it is not a reason for anyone to stop a statin on their own. More on statins in the very old.

What withdrawal has to look like

  1. One change at a time, so that if something happens you know what caused it.
  2. A stated reason recorded before the change, and a stated expectation of what should improve.
  3. A taper where a taper is required. Several classes rebound or produce a withdrawal syndrome. The FDA’s benzodiazepine labeling is explicit that stopping abruptly or reducing too quickly can cause withdrawal reactions including seizures, and that there is no standard schedule suitable for all patients.
  4. Monitoring, with a defined window. Someone has to be looking, and they have to know what they are looking for.
  5. A way back. A reduction that turns out to have been wrong is information, not a failure — provided restarting is a planned option rather than an admission.
  6. Agreement. A taper the patient did not agree to is a different intervention with different outcomes.

Common questions

Is deprescribing the same as stopping medication?

No. Deprescribing is a supervised process that may end in a lower dose, a different drug, or no change at all. Stopping is one possible outcome of it, not the goal. A review that concludes everything on the list is still earning its place is a successful review. What a medication review involves.

Does deprescribing make people live longer?

The current best evidence says no. A 2024 update of the largest meta-analysis in this field, covering 259 studies, found no significant reduction in mortality in randomized studies. An earlier 2016 version of the same review did report one, and that superseded figure is still widely quoted. What deprescribing does show is that it safely reduces pill burden. What deprescribing trials measure.

Who decides?

The prescriber, with the patient, and with whoever holds the rest of the picture — a pharmacist, the nursing staff who see the person daily, and often a family member who knows what changed and when. DWARAA does not prescribe, deprescribe, diagnose or treat, and no page on this site is advice about an individual’s medication. What a medication review looks like.

DWARAA is six steps. Back to the framework overview.

References

  1. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
  2. By the 2025 AGS Alternative Treatments Panel. Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria. Journal of the American Geriatrics Society. 2025;73(9):2657–2677. PMID 40697073 · DOI 10.1111/jgs.19500.
  3. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. PMID 37256475 · DOI 10.1007/s41999-023-00777-y. See also the published correction, Eur Geriatr Med. 2023;14(4):633, PMID 37326916.
  4. Boland B, Sibille FX, Mouzon A, et al. Appraisal of the references supporting the STOPP/START.version 3 criteria. European Geriatric Medicine. 2026;17(3):1193–1200 (published online 2025-12-26). PMID 41452533 · DOI 10.1007/s41999-025-01386-7.
  5. Curtin D, Gallagher P, O’Mahony D. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age and Ageing. 2021;50(2):465–471. PMID 32997135 · DOI 10.1093/ageing/afaa159.
  6. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.
  7. Quek HW, Page A, Lee K, et al. The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis. British Journal of Clinical Pharmacology. 2024;90(10):2409–2482. PMID 39164070 · DOI 10.1111/bcp.16200.
  8. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. British Journal of Clinical Pharmacology. 2016;82(3):583–623. PMID 27077231 · DOI 10.1111/bcp.12975.
  9. Gnjidic D, Langford AV, Jordan V, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database of Systematic Reviews. 2025;3(3):CD012572. PMID 40162571 · DOI 10.1002/14651858.CD012572.pub3.
  10. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  11. U.S. Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety Communication, September 23, 2020. fda.gov. 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.