Deprescribing medications in older adults: What the data reveals about safer care

HN Summary

• Older adults in Canada face growing risks from polypharmacy, with many taking 10 or more medications annually and higher exposure to high-risk drugs in long-term care settings. 

• A Canadian Medical Protective Association review found many complaints about deprescribing stemmed from poor communication or misunderstanding, even when clinical care was appropriate. 

• Researchers say safer deprescribing depends on clear patient-centred communication, strong follow-up, multidisciplinary care and better guidance on how to deprescribe medications safely.

Medication safety in older adults remains an evolving concern.

Medication-related patient safety events are disproportionately represented in older adults, particularly because the number of people 65 years or older living in Canada continues to increase year over year in a climate of primary care physician shortage.  In 2021, the Canadian Institute for Health Information reported that up to 1 in 4 older adults in Canada were taking 10 or more different classes of medication annually.  The risks are even greater in long-term care facilities, where older adults are three to eight times more likely to be prescribed high-risk medications such as benzodiazepines and antipsychotics.

Discussions around deprescribing medication are not easy, especially when establishing a new physician-patient relationship. How can a physician proceed in a way that gives the patient a full understanding of the reasons for deprescribing? It is reasonable for patients to think that stopping medication means stopping treatment and so have concerns that their health needs will go unaddressed. Therefore, it is important that the physician helps the patient understand the “why,” which then can reduce miscommunication that may otherwise arise during care or may result in medico-legal complaints.

Improving medication use and deprescribing

To better understand where deprescribing care can be strengthened, CMPA analyzed medico-legal cases involving older adults over a five-year period (2018-2022). This research, recently published in BMC Geriatrics in the study Lessons learned from Canadian family physicians deprescribing medications in older adults – a five-year retrospective review of medico-legal cases, highlights areas where deprescribing in older adults can be improved. 

The study underscores opportunities to improve how deprescribing is planned, communicated, and monitored in clinical practice through case examples. Composite situations included a physician weaning a patient off medications with a substitute decision-maker; and a physician having concerns regarding medication safety following their patient’s stay in hospital. The scenarios summarize expert opinions on real cases, ranging from supportive to critical of the care provided, reflecting the complexity of deprescribing decisions in real-world practice. 

Where physicians were most often criticized

Across the cases reviewed, experts most frequently identified concerns associated with decision-making for and documentation of treatment plans, monitoring and follow-up, communication with patients, substitute decision-makers, and other healthcare professionals. Importantly, complaints were often not associated with the quality of care.

So, if care was done well, then why did a complaint still occur? The patient-physician relationship is complex, and complaints can occur even when physicians are safely deprescribing. Past research has indicated that complaints are often driven by patient or substitute decision-maker perceptions. Analysis of complaints in this study demonstrated a frequent reason for complaints was a belief that a medication should not have been deprescribed or that the way deprescribing occurred was incorrect. Only one-third of complaints aligned with expert opinion. 

These findings underscore an important reality: even clinically sound deprescribing decisions can create tension if patients or families do not fully understand the rationale behind them. 

The importance of explaining the “why”

One of the clearest lessons from the study was the importance of patient-centred communication. When physicians explain why deprescribing is being considered and acknowledge patients’ fears and uncertainty, it could improve patient care and reduce a physician’s risk of receiving a complaint. 

Communication extends beyond informed consent. It includes active listening, clarifying patient goals, using accessible language, and ensuring substitute decision-makers are meaningfully involved in discussions when appropriate.

Current tools focus on “what” — not “how”

Canadian-led organizations and networks are making strides in providing tools and promoting research to support the practice of deprescribing, including the Institute for Safe Medication Practices Canada, Deprescribing.org, the Canadian Medication Appropriateness and Deprescribing Network, and Choosing Wisely Canada.

However, a recent study published in the British Medical Journal found that while many guidelines address “what,” “when,” or “why” to deprescribe, only 58% of the guidelines reviewed included guidance on “how” to deprescribe safely.

Lessons learned from complaint data

In summarizing expert opinion from complaints, researchers identified several practices that can support safer deprescribing care, including conducting comprehensive assessments before deprescribing, using multidisciplinary approaches to develop tapering plans, ensuring appropriate monitoring and follow-up, communicating clearly with patients and substitute decision-makers, and thoroughly documenting the clinical rationale for decisions. 

Ultimately, deprescribing is not simply about stopping medications. It is a collaborative process that depends on clinical judgment, continuity of care, and strong patient relationships.

Turning medico-legal data into safer care 

In supporting physicians from across the country, CMPA collects and maintains medico-legal data, the largest collection of its kind in the world. These data, coded and anonymized, uniquely position CMPA to identify patterns and inform research to foster system change and improve patient safety. 

Empowering better healthcare – About CMPA

As Canada’s largest physician organization and with the support of our 119,000+ physician members, CMPA collaborates, advocates, and effects positive change on important medico-legal issues. CMPA empowers better healthcare by delivering efficient, high-quality physician-to-physician advice, guidance, and assistance to physicians in medico-legal matters. On behalf of our members, CMPA also provides appropriate compensation to patients proven to be injured by negligent medical care. Through our peer-reviewed research results in evidence-based products and services, CMPA works to enhance patient safety and reduce patient harm.

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