Less is more: deprescribing for safer ageing

Australia is facing a pressing challenge as the population ages — the way we manage medicines and how we prescribe for older adults must evolve.

Nearly 40% of Australians aged over 75 years take five or more medicines every day, and one in five people are prescribed a medicine that is considered potentially inappropriate and goes against general advice. Polypharmacy, a situation where several medicines are concurrently used, is becoming more common as Australians age and develop multiple chronic conditions.

Older Australians are particularly vulnerable to polypharmacy-related harm, as various physiological changes lead to altered pharmacokinetics and pharmacodynamics, including the reduced ability to metabolise and eliminate medicines, along with body composition changes that alter the distribution of medicines.

As a result, older people are more sensitive to the effects of medicines.  

Inappropriate polypharmacy is associated with poor clinical outcomes and places older Australians at an increased risk of adverse events along with a negative impact on cognition, health-related quality of life and increased mortality.

Ensuring the safe and effective use of medicines in an ageing population requires balancing the management of chronic diseases while minimising the risk of medicine-related issues.

The number of older Australians (over the age of 65) is rapidly growing — they comprised 16% of Australia’s population in 2020, up from 12% in 1995.

This risk is widespread, as most older Australians (80%) now live with one or more chronic conditions, and a quarter had three or more.

Another challenge is our culture of prescribing — Australians are reported as high consumers of medicines, including subsidised prescriptions and complementary/over-the-counter medicines. Australia’s response to the Medication without harm – WHO Global Patient Safety Challenge shows:

• more than four in ten people aged 50 years or older take five or more medicines; and
• over one in ten people aged 50 years or older take ten or more medicines.

The National Medicines Symposium (the Symposium), hosted by the Australian Commission on Safety and Quality in Health Care (the Commission) on 19 November 2024 focused on the safe and appropriate use of medicines in an ageing population.

The Symposium brought together leading experts, clinicians, consumers and policy makers for a timely discussion with a focus on the importance of deprescribing.

Assess risks versus benefits when deprescribing

Deprescribing refers to the planned, supervised and gradual withdrawal of medicines that might be causing harm or no longer provide benefit. It is an integral part of good prescribing principles, which include ongoing assessment of risks versus benefits.

The recently released Evolve Guidelines by the Royal Australasian College of Physicians (RACP) and the Australian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) emphasise the importance of withdrawing medicines that no longer provide clear benefits, or those with significant potential harm, aligning directly with deprescribing principles.

The primary goals of deprescribing include minimising overall medicine burden, lowering the risk of issues like falls, confusion and cognitive decline, and enhancing broader health outcomes such as reducing hospitalisations and mortality.

At the same time, deprescribing can improve the efficiency and financial viability of Australia’s health system, while also contributing to environmental sustainability.Sustainability in health care is increasingly critical and was one of the focuses of the 2023 National Medicines Symposium.

Engage in patient conversations

Medicines safety in an ageing population requires rethinking how we prescribe, manage and engage people in conversations about their care.

As Dr Phoebe Holdenson Kimura, Medical Advisor for the Commission and a general practitioner, highlighted in the Symposium, “Never consider prescribing as a set and forget type process. It’s always worthwhile re-evaluating, reassessing and doing that in partnership with the patient.”

Most people would prefer to take fewer medicines but often rely on the prescriber to initiate the conversation. Studies evaluating people’s attitudes towards deprescribing suggest that 84–90% are open to stopping one or more of their medicines if deemed safe by their doctor.

We can effectively address polypharmacy by initiating conversations, promoting shared decision making, and working collaboratively with a multidisciplinary team.

The focus needs to shift from quantity to quality — ensuring that every medicine prescribed serves a purpose that aligns with the person’s changing physiology, needs, preferences and goals of care.

So, what’s next?

The Symposium highlighted a strong need for systemic changes to ensure the safe and effective use of medicines in Australia’s ageing population.

Prescribers must take the lead by implementing effective strategies in their daily practice, while policy makers should focus on creating supportive frameworks.

To improve medicine safety in an ageing population, a multifaceted approach is required to:

• empower prescribers: Use training and build confidence among clinicians in initiating conversations about deprescribing and conducting timely medicines reviews.
• engage consumers: Prioritise shared decision making by educating and engaging people and their carers/families in discussions about medicines and their goals of care.
• collaborate with the multidisciplinary team: Deprescribing is a shared responsibility within the multidisciplinary team. By working collaboratively, for example through medicines review processes such as Home Medicine Reviews and Residential Medication Management Reviews, we can effectively address inappropriate polypharmacy and promote safe and quality use of medicines. 
• use research and policies: Deprescribing guidelines and de-escalation pathways should be integrated into Australian resources and health care frameworks. There is a strong need for prescribing trials that consider the ageing and frail population and multimorbid people and for deprescribing trials that focus on measuring outcomes like quality of life and potential drug withdrawal events. Pharmaco-economic research on the ongoing cost of medicines, managing adverse events and hospitalisation is crucial for shaping the future of optimal medicine use in an ageing population, as inappropriate polypharmacy has been associated with increased risk of hospitalisation, adverse events and unnecessary financial costs.

These strategies support the core prescribing principles for older patients, which are the scaffolding for best practice medication management. They include questioning the need for new medicines, continuous review of the benefits and potential harms of medicines, initiating medicines with a low dose and increasing gradually if needed and tolerated, and monitoring for adverse effects.

By consistently applying these strategies, prescribers can make a tangible difference to the quality of life and health outcomes of many older patients.

Find out more

Learn more about the National Medicines Symposium and related resources.

Ms Alaa Qassim is a pharmacist and senior project officer in medicines safety and quality, Australian Commission on Safety and Quality in Health Care.

Mr Sankit Lalseta is a pharmacist and program manager in medicines safety and quality, Australian Commission on Safety and Quality in Health Care.

Associate Professor Liz Marles is a general practitioner and clinical director, Australian Commission on Safety and Quality in Health Care, and past president of the RACGP.

Professor Jennifer Martin is a physician, clinical pharmacologist and president of the RACP.