Deprescribing is the systematic, physician-led process of reducing or discontinuing medications whose benefits for the individual patient no longer outweigh the harms, or for which the indication is no longer valid. Three elements are essential:
- Systematic: Not random or situational, but based on fixed criteria.
- Physician-led: Never carried out independently by the patient.
- Patient-centered: The goal is not reduction as an end in itself, but rather the optimization of the individual benefit-risk ratio.
The concept has evolved over the past ten years from geriatric pharmacotherapy and is now firmly established in international guidelines.
→ On the broader topic: Polypharmacy in older adults.
Several age-related changes make deprescribing particularly important in older adults:
- Altered pharmacokinetics: Decreased kidney function, liver perfusion, and body water—medications have a longer-lasting and more potent effect than in younger years.
- Increased susceptibility to side effects: The reserve capacity of many organ systems decreases.
- Risk of interactions: With five concurrent medications, there are ten possible combinations; with ten medications, there are already 45—the mathematical basis of polypharmacy problems.
- Shifting treatment goals: What was a preventive goal at age 60 (strict blood sugar control, aggressive cholesterol reduction) can become more harmful than beneficial at age 85, especially in the presence of frailty.
- Life expectancy and duration of effect: Some therapies only begin to show their benefits after several years—with limited life expectancy, this often no longer pays off.
PRISCUS List 2.0
The PRISCUS List (updated 2023) is a negative list of potentially inappropriate medications (PIMs) for older adults, developed specifically for Germany. It specifically lists:
- Benzodiazepines with a long half-life
- Z-drugs as long-term medication
- Tricyclic antidepressants
- Strongly anticholinergic medications
- Certain neuroleptics for dementia
- NSAIDs in patients with impaired renal function
- Muscle relaxants
- Older antihistamines
FORTA Classification
FORTA (Fit fOR The Aged) rates medications into four categories—from clearly appropriate (A) to generally to be avoided (D). Unlike PRISCUS, FORTA is not only negative but also positive—it identifies underprescription as an issue on par with overprescription.
STOPP/START Criteria
The international STOPP/START criteria expand the approach by two dimensions: STOPP identifies medications that should be discontinued; START identifies medications that are often incorrectly not prescribed for certain indications. This combination of deprescribing and prescribing constitutes the clinical added value.
The drug classes most frequently modified in clinical practice:
- Proton pump inhibitors (PPIs): Omeprazole, pantoprazole, and others are often taken for decades without a current indication. Long-term use increases the risk of bone fractures—which is also relevant in cases of osteoporosis in older adults—as well as pneumonia and kidney dysfunction.
- Benzodiazepines and Z-drugs: Sleep aids and sedatives that are often taken for years “for reassurance.” Risk of falls, risk of delirium, dependence.
- Antihypertensives: In frail older patients, aggressively lowering blood pressure (below 130/80) can lead to falls, collapses, and cerebral hypoperfusion.
- Diabetes medications: Strict HbA1c targets (below 7.0%) are often no longer appropriate for older patients; they increase the risk of hypoglycemia.
- Statins: Often unnecessary for primary prevention in patients with limited life expectancy. Should be evaluated on a case-by-case basis for secondary prevention.
- Anticholinergics: Tricyclic antidepressants, older antihistamines, oxybutynin—collectively, they contribute to a cumulative anticholinergic burden that can lead to delirium.
- Vitamin supplements and dietary supplements: Often taken without a clear indication. Vitamin D only in cases of proven deficiency; high-dose vitamins are frequently used without evidence.
→ How these medications contribute to falls: Falls in older adults.
→ How they can trigger delirium: Delirium in older adults.
Step 1: Complete medication assessment
Every medication—prescription, over-the-counter, herbal, or dietary supplement—is recorded. A common source of error: self-medication is not reported. Therefore, involve family members and, ideally, have them bring the home medicine cabinet.
Step 2: Review of Indications
For each individual medication: Why is it being taken? When was it prescribed? Is the indication still valid? In what context was it reviewed?
Step 3: Assessment Using PRISCUS, FORTA, STOPP/START
Systematic comparison with standard assessment tools. Every match means: review. Not every match means: discontinue.
Step 4: Benefit-Risk Assessment in Context
Taking into account frailty, life expectancy, treatment goals, and individual preferences: Which therapies are still worthwhile? Where do the harms now outweigh the benefits?
Step 5: Prioritization
Never reduce everything at once. Start with the medication with the highest risk-benefit imbalance—often benzodiazepines, anticholinergics, or PPIs.
Step 6: Implementation with Tapering
Many medications must not be discontinued abruptly. For benzodiazepines, SSRIs, beta-blockers, opioids, and corticosteroids, gradual tapering over weeks to months is standard practice. Abrupt discontinuation can be more dangerous than continuing the medication.
Step 7: Monitoring and Documentation
After each change: Monitor the patient for two to four weeks. Do the original symptoms return? Do new symptoms arise? Every change is documented in writing and forwarded to the primary care physician.
???? The key safety rule: As a patient or family member, never stop taking medication on your own. Even if you’re convinced that a medication is harmful—the proper course of action always involves consulting a doctor. Many dangerous withdrawal symptoms are not caused by the wrong medication, but by discontinuing it incorrectly.
- Keep an up-to-date medication list: all medications, dosages, and times of administration. Ideally, obtain this as a medication plan from the pharmacy or your primary care physician.
- Bring it with you to every doctor’s visit: Even when seeing specialists—otherwise, it will lead to another cascade of prescriptions.
- Disclose everything during a hospital stay: Even dietary supplements and herbal preparations can interact with anesthetics or antibiotics.
- Ask the key question: “Which medications are still necessary today—and which ones could we reduce?”
- Don’t let yourself be brushed off too quickly: If you feel that your medication is becoming a burden, a systematic review is warranted.
Not every patient on multiple medications needs to see a geriatrician. Specific reasons include:
- Ten or more long-term medications without an annual review
- A medication on the PRISCUS list as part of long-term therapy
- New episodes of falls, confusion, fatigue, or apathy of unknown cause
- After a hospital stay with new medications that were not fully taken over by the primary care physician
- Before planned surgeries in patients with multiple chronic conditions — more on this: Surgical Risk in Older Adults
- When the primary care physician and specialist prescribe different medications and no one has an overview of the patient’s entire regimen
The geriatrician complements the primary care physician—he does not replace him. The combination of continuous primary care and structured geriatric assessment is the model of care that has been proven to yield the best results.
→ How a comprehensive geriatric assessment forms the basis of every medication review: Geriatric Assessment.
