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geriatrics.deprescribing.core.v1PRODUCTION
geriatrics.deprescribing.core.v1

Deprescribing in older adults

general_internal_medicinechronicgeriatricadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Scope: older adult on polypharmacy where systematic medication optimization is indicated; deprescribing is iterative and patient-centred, NOT nihilistic withdrawal of all drugs (Scott JAMA Intern Med 2015)

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Patient confirmed as a structured-medication-review / deprescribing candidate (NICE NG5 medicines optimisation)

Patient inputs (12)

Full reconciled list incl OTC/supplements/PRN/topicals is the substrate for every deprescribing decision (Scott JAMA Intern Med 2015)

OTC NSAIDs, antihistamines, PPIs, herbals/supplements are commonly omitted yet high-yield deprescribing targets (Reeve Br J Clin Pharmacol 2014)

Each drug must be mapped to an active indication; no-longer-indicated / indication-lapsed drugs are first-priority targets (Scott JAMA Intern Med 2015)

Active essential indications protect a drug from deprescribing; comorbidity burden shapes benefit-risk (O'Mahony Age Ageing 2023)

Patient/caregiver goals + life-expectancy estimate drive time-to-benefit vs time-to-harm weighting and palliative deprescribing (Scott JAMA Intern Med 2015)

Deprescribing prioritization is age- and life-expectancy-anchored; Beers/STOPP age-stratified (AGS Beers 2023)

eGFR re-checks renally-cleared drug appropriateness and is the primary post-deprescribing safety lab (O'Mahony Age Ageing 2023)

Flags drugs that must NOT be stopped abruptly (benzodiazepine, opioid, beta-blocker, clonidine, corticosteroid, SSRI/SNRI, gabapentinoid, levodopa, PPI rebound) (Reeve Br J Clin Pharmacol 2014)

Frailty/ADL trajectory modifies benefit horizon (statin/antihyperglycemic/antihypertensive targets relax) (O'Mahony Age Ageing 2023)

Anticholinergic/sedative burden vs cognition; affects self-management capacity and caregiver involvement (Boustani Aging Ment Health 2008)

Orthostasis / supine-standing delta is the key antihypertensive-deprescribing signal (O'Mahony Age Ageing 2023)

Relax glycemic target in frailty/limited life expectancy; over-tight HbA1c on sulfonylurea/insulin = hypoglycemia harm (AGS Beers 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningabrupt_withdrawal_high_risk_drug
    High-withdrawal-risk drug (benzodiazepine, opioid, beta-blocker, clonidine, corticosteroid, SSRI/SNRI, gabapentinoid, levodopa) stopped abruptly rather than tapered (Reeve Br J Clin Pharmacol 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredisease_destabilization_after_deprescribing
    Original disease destabilizes after a drug was stopped (e.g. HF decompensation after diuretic stop, angina after beta-blocker stop, hyperglycemic crisis after antihyperglycemic stop) (Scott JAMA Intern Med 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebenzodiazepine_or_opioid_withdrawal
    Benzodiazepine withdrawal (tremor, autonomic instability, seizure) or opioid withdrawal (agitation, autonomic, GI) emerging during a taper (AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremedication_induced_delirium_or_fall
    Acute delirium or fall with injury attributable to anticholinergic / sedative / opioid / antihypertensive burden in an older adult (AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategoals_of_care_end_of_life_deprescribing
    Goals of care shift to comfort / end-of-life — preventive and long-time-to-benefit drugs (statin, antihyperglycemic, bisphosphonate, antihypertensive, DAPT) now net burden (Scott JAMA Intern Med 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Deprescribing — Scott/Reeve 5-step (reconcile → identify PIM → benefit-risk-in-context → prioritize+SDM → class-specific taper → iterate)
axis: deprescribing_5stepstep 1 - Step 1 — Comprehensive medication reconciliation
Selected step "Step 1 — Comprehensive medication reconciliation" — Every patient entering the pathway
  • best_possible_medication_history
    first line
    med_reconciliation_action
    triggers: polypharmacy, care_transition, new_review
    Reconcile ALL prescribed + OTC + supplement + PRN + topical + inhaled drugs with dose/duration/prescriber/adherence and the active indication for each (Scott JAMA Intern Med 2015)
  • capture_otc_and_supplements
    first line
    med_reconciliation_action
    triggers: self_medication_likely
    OTC NSAIDs, sedating antihistamines, PPIs, and herbals/vitamins are routinely omitted yet high-yield targets (Reeve Br J Clin Pharmacol 2014)

outpatient playbook — drug actions (5)

  1. 1. medication reconciliation
    best-possible history incl OTC/supplements • review • at visit
    trigger: Polypharmacy / PIM / goals shift
    Step 1 — substrate for every decision
  2. 2. STOPP/START v3 + Beers + ACB screen
    explicit-tool screen • review • at visit
    trigger: Age >=65
    Step 2 — identify PIM / no-longer-indicated / harm>benefit
  3. 3. benefit-risk-in-context per drug
    time-to-benefit vs life expectancy + frailty + goals • review • at visit
    trigger: Candidate list ready
    Step 3 — net benefit in THIS patient
  4. 4. prioritize + shared decision
    highest harm/lowest benefit first; agree order with patient/caregiver • review • at visit
    trigger: Per-drug decisions assigned
    Step 4 — SDM is central; one change at a time
  5. 5. class-specific taper
    PPI step-down / benzo ~25% q2wk / antipsychotic withdrawal / opioid slow taper / relax glycemic + BP targets / stop primary-prevention statin / bisphosphonate holiday / antidepressant taper • taper • over weeks per class
    trigger: Plan agreed
    Step 5 — taper with monitoring + contingency

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: >=5 chronic medications — polypharmacy / medication-optimization trigger (O'Mahony Age Ageing 2023); Beers-listed / STOPP-flagged / high-anticholinergic medication on review (AGS Beers 2023); Limited life expectancy / advanced frailty / goals-of-care shift — time-to-benefit reassessment (Scott JAMA Intern Med 2015).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Deprescribing in older adults** (geriatrics.deprescribing.core.v1).
Phenotype framing: Step 3 — assess each candidate drug's ongoing benefit vs risk in THIS patient: active vs lapsed indication, time-to-benefit vs estimated life expectancy, time-to-harm, frailty, goals of care; classify each as continue / dose-reduce / substitute-lower-risk / taper-and-stop / stop-now (Scott JAMA Intern Med 2015)
Scope: Scope: older adult on polypharmacy where systematic medication optimization is indicated; deprescribing is iterative and patient-centred, NOT nihilistic withdrawal of all drugs (Scott JAMA Intern Med 2015)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Deprescribing — Scott/Reeve 5-step (reconcile → identify PIM → benefit-risk-in-context → prioritize+SDM → class-specific taper → iterate)** — step "Step 1 — Comprehensive medication reconciliation".
1. best_possible_medication_history (med_reconciliation_action, first line) — Reconcile ALL prescribed + OTC + supplement + PRN + topical + inhaled drugs with dose/duration/prescriber/adherence and the active indication for each (Scott JAMA Intern Med 2015)
2. capture_otc_and_supplements (med_reconciliation_action, first line) — OTC NSAIDs, sedating antihistamines, PPIs, and herbals/vitamins are routinely omitted yet high-yield targets (Reeve Br J Clin Pharmacol 2014)

Setting playbook (outpatient) — Structured medication review: reconcile → identify PIM → benefit-risk-in-context → prioritize with shared decision-making → implement class-specific taper one change at a time with a monitoring + re-prescribe plan
3. medication reconciliation best-possible history incl OTC/supplements review at visit — Polypharmacy / PIM / goals shift (Step 1 — substrate for every decision)
4. STOPP/START v3 + Beers + ACB screen explicit-tool screen review at visit — Age >=65 (Step 2 — identify PIM / no-longer-indicated / harm>benefit)
5. benefit-risk-in-context per drug time-to-benefit vs life expectancy + frailty + goals review at visit — Candidate list ready (Step 3 — net benefit in THIS patient)
6. prioritize + shared decision highest harm/lowest benefit first; agree order with patient/caregiver review at visit — Per-drug decisions assigned (Step 4 — SDM is central; one change at a time)
7. class-specific taper PPI step-down / benzo ~25% q2wk / antipsychotic withdrawal / opioid slow taper / relax glycemic + BP targets / stop primary-prevention statin / bisphosphonate holiday / antidepressant taper taper over weeks per class — Plan agreed (Step 5 — taper with monitoring + contingency)

Non-pharmacologic actions:
- CBT-I as benzodiazepine/Z-drug substitution
- Non-pharmacologic behavioural plan as antipsychotic-withdrawal contingency
- Pharmacist-led collaborative structured medication review
- Patient/caregiver plain-language deprescribing communication + updated medication list
- Schedule next structured medication review

AVOID / contraindication checks:
- Never_abruptly_stop_benzodiazepine_seizure_withdrawal (AGS Beers 2023)
- Never_abruptly_stop_opioid_withdrawal_syndrome (CDC opioid 2022; AGS Beers 2023)
- Never_abruptly_stop_beta_blocker_rebound_HTN_ischemia (O'Mahony Age Ageing 2023)
- Never_abruptly_stop_clonidine_rebound_hypertensive_crisis (O'Mahony Age Ageing 2023)
- Never_abruptly_stop_corticosteroid_adrenal_crisis (O'Mahony Age Ageing 2023)
- Never_abruptly_stop_SSRI_SNRI_discontinuation_syndrome (Reeve Br J Clin Pharmacol 2014)
- Never_abruptly_stop_gabapentinoid_withdrawal (AGS Beers 2023)
- Never_abruptly_stop_levodopa_parkinsonism_hyperpyrexia (O'Mahony Age Ageing 2023)
- Taper_not_abrupt_for_PPI_rebound_acid_hypersecretion (O'Mahony Age Ageing 2023)
- Do_not_deprescribe_drug_treating_active_essential_indication (Scott JAMA Intern Med 2015)
- Watch_disease_destabilization_after_each_single_change (Scott JAMA Intern Med 2015)

Monitoring

Regimen monitoring:
- ppi rebound acid symptom check 2-4wk post taper (O'Mahony Age Ageing 2023)
- benzodiazepine opioid withdrawal watch during taper (AGS Beers 2023)
- beta blocker clonidine rebound BP HR 2-4wk (O'Mahony Age Ageing 2023)
- antipsychotic BPSD recurrence weekly x4 post withdrawal (AGS Beers 2023)
- antidepressant discontinuation syndrome and mood relapse 4-8wk (Reeve Br J Clin Pharmacol 2014)
- glycemic and orthostatic BP drift after de-intensification q3mo (AGS Beers 2023)
- creatinine electrolytes after renally relevant changes (O'Mahony Age Ageing 2023)
- re-prescribe trigger if original indication re-emerges (Scott JAMA Intern Med 2015)
- medication count and pill burden reassessment q3-6mo (NICE NG5 medicines optimisation)

Setting (outpatient) monitoring:
- Per-class withdrawal/rebound/symptom-recurrence check 2-4 wk after each single change (Scott JAMA Intern Med 2015)
- eGFR/electrolytes after renally relevant changes (O'Mahony Age Ageing 2023)
- Frailty/ADL trajectory + medication count q3-6 mo (NICE NG5 medicines optimisation)

Follow-up plan: Iterative re-review at every visit and care transition; update advance care planning / goals of care; palliative deprescribing at end of life; caregiver communication tools + updated medication list; schedule next structured medication review (NICE NG5 medicines optimisation)
- Close-out criterion: Re-prescribe-or-continue decisions logged; next medication review scheduled; goals-of-care/ACP refreshed (NICE NG5 medicines optimisation)

Monitoring phase: Per-class withdrawal / rebound / symptom-recurrence surveillance after each single change: PPI rebound hyperacidity 2-4 wk, benzodiazepine/opioid withdrawal, beta-blocker rebound HTN/angina, antipsychotic BPSD recurrence, antidepressant discontinuation syndrome, glycemic/BP drift; re-prescribe if the original indication re-emerges (deprescribing is iterative) (Reeve Br J Clin Pharmacol 2014)

Disposition

Current setting: outpatient — Structured medication review: reconcile → identify PIM → benefit-risk-in-context → prioritize with shared decision-making → implement class-specific taper one change at a time with a monitoring + re-prescribe plan

Disposition criteria:
- Stable on revised regimen with documented rationale and a scheduled re-review (NICE NG5 medicines optimisation)
- Refer palliative care when goals shift to comfort — palliative deprescribing (Scott JAMA Intern Med 2015)

Escalation triggers (move to higher acuity):
- Abrupt-withdrawal symptoms (benzodiazepine/opioid/beta-blocker/clonidine) → restart lowest effective dose, restart taper, escalate setting if unstable (AGS Beers 2023)
- Disease destabilization after deprescribing → re-prescribe, reassess indication (Scott JAMA Intern Med 2015)
- Drug-related delirium / fall with injury / severe hypoglycemia → urgent assessment, hold offending agents (AGS Beers 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] High-withdrawal-risk drug (benzodiazepine, opioid, beta-blocker, clonidine, corticosteroid, SSRI/SNRI, gabapentinoid, levodopa) stopped abruptly rather than tapered (Reeve Br J Clin Pharmacol 2014)
- [SEVERE] Original disease destabilizes after a drug was stopped (e.g. HF decompensation after diuretic stop, angina after beta-blocker stop, hyperglycemic crisis after antihyperglycemic stop) (Scott JAMA Intern Med 2015)
- [SEVERE] Benzodiazepine withdrawal (tremor, autonomic instability, seizure) or opioid withdrawal (agitation, autonomic, GI) emerging during a taper (AGS Beers 2023)

Citations

- US Deprescribing Research Network / Scott JAMA Intern Med 2015 5-step + STOPP/START v3 (O'Mahony 2023) + AGS Beers 2023 + NICE medicines optimisation [PMID:25798731](https://pubmed.ncbi.nlm.nih.gov/25798731/)
- Cited evidence (PMID 24428595) [PMID:24428595](https://pubmed.ncbi.nlm.nih.gov/24428595/)
- Cited evidence (PMID 37347666) [PMID:37347666](https://pubmed.ncbi.nlm.nih.gov/37347666/)
- Cited evidence (PMID 37139824) [PMID:37139824](https://pubmed.ncbi.nlm.nih.gov/37139824/)
- Cited evidence (PMID 16129869) [PMID:16129869](https://pubmed.ncbi.nlm.nih.gov/16129869/)

Last reconciled with current guidelines: 2026-05-16.
References
  • US Deprescribing Research Network / Scott JAMA Intern Med 2015 5-step + STOPP/START v3 (O'Mahony 2023) + AGS Beers 2023 + NICE medicines optimisation — PMID:25798731
  • Cited evidence (PMID 24428595) — PMID:24428595
  • Cited evidence (PMID 37347666) — PMID:37347666
  • Cited evidence (PMID 37139824) — PMID:37139824
  • Cited evidence (PMID 16129869) — PMID:16129869