Deprescribing is the planned, supervised withdrawal or dose reduction of medicines where harm outweighs benefit or the medicine no longer fits the person’s goals. In frailty it is a core intervention because adverse effects, falls and delirium are more frequent and preventive benefits take years to appear. Done well, it reduces drug burden and often improves cognition and alertness without harming outcomes.

Process. List all medicines with indication and start date, identify those with no clear indication, ongoing harm or limited time to benefit, rank by harm and ease of stopping, withdraw one at a time, then monitor and document.

Shared decision. Discuss goals and fears with the person and carers. A drug stopped and later needed again is an acceptable outcome.

Medicine	Withdrawal regimen	Watch for
Benzodiazepine or zopiclone	Reduce dose by 10% to 25% every 2 to 4 weeks, slower near the end	Rebound insomnia, anxiety, seizures
SSRI or SNRI	Reduce dose by 25% to 50% every 2 to 4 weeks; venlafaxine and paroxetine need slower steps	Dizziness, irritability, relapse
Antipsychotic for dementia behaviour	After 3 months stable, reduce by 25% to 50% every 1 to 2 weeks, then stop	Return of agitation or psychosis
Proton pump inhibitor	Halve the dose for 2 to 4 weeks, then use on demand or stop	Reflux rebound; continue if ulcer, Barrett oesophagus or bleeding risk
Antihypertensive	Stop or halve one drug at a time every 2 to 4 weeks if systolic pressure is under 130 mmHg or postural hypotension is present	Blood pressure at 2 and 4 weeks
Sulphonylurea or insulin	Reduce dose when HbA1c is under 7.5% (58 mmol/mol) or hypoglycaemia has occurred	Glucose readings
Statin	Stop for primary prevention when expected survival is under 1 to 2 years	Continue for secondary prevention when life expectancy allows
Aspirin for primary prevention	Stop	None
Oral bisphosphonate	Review after 5 years; stop if low fracture risk	Fracture risk
Opioid	Reduce by 10% to 25% every 1 to 2 weeks	Pain, withdrawal
Cholinesterase inhibitor	Stop if no benefit after 3 to 6 months or in severe dementia; observe for 4 weeks	Rapid cognitive decline

Do not stop suddenly. Beta-blockers, clonidine, antiepileptics, baclofen, benzodiazepines, antidepressants and corticosteroids taken for over 3 weeks.

Special groups. In palliative care stop preventive drugs but keep symptom control. In care homes agree the plan with nursing staff and family.

Monitoring. Record symptoms, sleep, mood, behaviour, blood pressure, glucose and weight at 1 to 2 weeks after each step. Ask carers to keep a simple diary.

Dose steps. Use smaller reductions for drugs taken for years or those with narrow margins. Restart the previous dose if symptoms of the original condition return, then retry later.

Renal and hepatic. Accumulating drugs may need to be stopped sooner; reduce more slowly those with active metabolites.

Deprescribing in Frailty

Principles And Patient Context

Medicine Selection And Regimens

Dose Adjustment And Monitoring

Switching, Stopping And Escalation