Official Journal of the Society of Hospital Pharmacists of Australia

G E R I AT R I C T H E R A P E U T I C S R E V I E W
EDITED BY ROHAN A. ELLIOTT, BPHARM, BPHARMSC (HONS), MCLINPHARM, PHD, BCGP, FSHP

Deprescribing tools: a review of the types of tools available to aid

deprescribing in clinical practice
Emily Reeve, BPharm(Hons), PhD1,2,3*
1
Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia,
Adelaide, Australia
2
Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
3
College of Pharmacy, Dalhousie University, Halifax, Canada

Abstract
The importance of deprescribing, which is the process of withdrawing an inappropriate medication, supervised by a healthcare pro-
fessional with the goal of managing polypharmacy and improving outcomes, is increasingly recognised as part of good clinical care.
With this, a number of tools have been developed with the purpose of aiding health professionals to deprescribe in regular practice.
The types of tools vary significantly in their form and include tools to aid in the overall process of deprescribing (such as generic
frameworks and drug-specific deprescribing guidelines) as well as tools that may assist in a specific part of the process (such as
identifying inappropriate medications or engaging the patient). While many tools are available, most provide little (if any) informa-
tion on how they were developed, and limited implementation research has been conducted. This paper provides an overview of
the types of available tools and how they might be used in clinical practice.

Keywords: clinical tools, deprescriptions, geriatric medicine, health personnel, inappropriate prescribing, older adults, pharmacists.

INTRODUCTION Many barriers to deprescribing from health profession-

In Australia and internationally there is an increasing
number of older adults and an increasing prevalence of
polypharmacy. Polypharmacy (use of multiple medica-
tions, often defined as five or more regular medications),
has been associated with a number of harms including
adverse drug reactions, falls, frailty, hospitalisation and
mortality.1 With more medications also comes increased
likelihood of taking an inappropriate medication, that is,
one where the potential harms outweigh the benefits in
the individual.1 Deprescribing is the process of with-
drawing an inappropriate medication, supervised by a
health professional with the goal of managing polyphar-
macy and improving outcomes.2
Deprescribing is part of good prescribing and medica-
tion management. There is emerging evidence that
deprescribing is safe and may be beneficial, however,
enacting deprescribing in practice can be difficult.1
*Address for correspondence: Emily Reeve, School of Pharmacy &
Medical Sciences, University of South Australia, City East Campus,
Frome Road, Adelaide, South Australia, Australia.
Email: Emily.reeve@unisa.edu.au
als’ and patients’ perspectives have been described,
including a lack of resources to support deprescribing.3,4
Many resources, guidelines and other tools have thus
been developed to assist clinicians to enact deprescrib-
ing.
The purpose of this narrative review is to describe the
different types of tools available, with examples, and dis-
cuss their potential use and limitations in practice. It was
informed by a non-systematic search of academic data-
bases (PubMed and Google Scholar) and grey literature
(Google) as well as the author’s personal library. While
no strict inclusion and exclusion criteria were applied,
tools were generally published in peer-reviewed journals
or hosted on government, healthcare organisation or uni-
versity websites. This article does not provide an exhaus-
tive list of all deprescribing tools, instead it aims to
provide an overview of the different types of tools that
are available and provide examples (Table 1). No assess-
ment of quality of the tools was conducted.
Deprescribing tools can be broadly classified as those
that aid in the overall process of deprescribing and
those that assist with a specific part of the process.

Journal of Pharmacy Practice and Research (2020) 50, 98–107

© 2020 The Society of Hospital Pharmacists of Australia doi: 10.1002/jppr.1626
Deprescribing tools 99

Table 1 Types of tools available to aid deprescribing

Type Examples

1. General A practical guide to stopping medicines in older people. Best Practice Journal 2010; 27: 10–23. Available from:
deprescribing https://bpac.org.nz/bpj/2010/april/stopguide.aspx
guidance Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: Making it safe and sound. London;
2013. Available from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/polypharmac
y-and-medicines-optimisation-kingsfund-nov13.pdf
Howard C. Polypharmacy: Getting our medicines right UK: Royal Pharmaceutical Society; 2019. Available from:
https://www.rpharms.com/recognition/setting-professional-standards/polypharmacy-getting-our-medicines-
right
Scottish Government Effective Prescribing and Therapeutics Division and the Digital Health and Care Division.
Polypharmacy Guidance - Medicines Review: NHS Scotland; 2019. Available from: http://www.polypharmacy.
scot.nhs.uk/polypharmacy-guidance-medicines-review/for-healthcare-professionals/
Starkey V, Omorinoye e, Railton D, Aslam S, Jones N, Goodwin T, et al. Deprescribing: A Practical Guide: NHS
North Derbyshire CCG, NHS Erewash CCG, NHS Hardwick CCG, NHS South Derbyshire CCG; 2017.
Available from: http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/clinical_
guidelines_front_page/Deprescribing.pdf
Therapeutics Initiative. Reducing polypharmacy: A logical approach. Therapeutics Letter 2014; Sept 2. Available
from: https://www.ti.ubc.ca/2014/09/02/reducing-polypharmacy-a-logical-approach/
Scott IA, Hilmer SN, Reeve E, Potter K, Couteur DL, Rigby D, et al. Reducing inappropriate polypharmacy: The
process of deprescribing. JAMA Intern Med 2015; 175: 827–34
Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE:
National Institute for Health and Care Excellence; 2015. Available from: https://www.nice.org.uk/guidance/
ng5/chapter/1-Recommendations#clinical-decision-support
Bruy
ere Continuing Care polypharmacy and deprescribing educational module.13 Available from: https://
www.bruyere.org/en/polypharmacy-deprescribing

2. Generic (non-drug 5-Step deprescribing framework (also known as the CEASE deprescribing framework)11,14,20,72
specific) Patient-centred deprescribing process15,19
deprescribing The Deprescribing Rainbow16 (focus is more on the patient context than the process, may be used in
frameworks conjunction with another framework)
Decision Making for Older Adults With Multiple Chronic Conditions17,18 (not strictly for deprescribing,
however provides steps to assist clinicians when faced with uncertainty in older adults with multimorbidity)

3. Drug-specific Bruy
ere Deprescribing Guidelines in the Elderly Project21–27: Benzodiazepines, proton pump inhibitors (PPIs),
deprescribing antihyperglycemic, antipsychotics, cholinesterase inhibitors and memantine (in collaboration with the
guidelines/guides University of Sydney, Australia). Available from: https://deprescribing.org/
NSW Therapeutic Advisory Committee (TAG) Deprescribing guides35: Benzodiazepines and Z-drugs,
antipsychotics, selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors, tricyclic
antidepressants, anticholinergic drugs for Parkinsonism, anticholinergic drugs for urinary incontinence
(antimuscarinics), sedating antihistamines, opioids, PPIs. Available from: http://www.nswtag.org.au/depresc
ribing-tools/
Primary Health Tasmania deprescribing resources34: Allopurinol, antihyperglycaemics, antihypertensives,
antipsychotics, aspirin, benzodiazepines, bisphosphonates, cholinesterase inhibitors, glaucoma eye drops, non-
steroidal anti-inflammatory drugs, opioids, PPIs, statins, vitamin D and calcium. Available from: https://www.
primaryhealthtas.com.au/resources/deprescribing-resources/

4. Electronic Clinical MedStopper37 Available from: https://medstopper.com/

Decision Support Goal-directed Medication review Electronic Decision Support System (G-MEDSS)39,40
Systems TaperMD41
MedSafer42

5. Tools for identifying See recent systematic review of tools and criteria to identify inappropriate medications46
potentially Explicit tools (criteria-based, lists of PIMs): e.g. Beers criteria,43 Screening Tool for Older Peoples Prescriptions
inappropriate (STOPP)44
medications (PIMs) Implicit tools (guidance which requires clinical judgement): e.g. Good Palliative-Geriatric Practice (GP-GP)
algorithm,50 Medication Appropriateness Index (MAI)73

© 2020 The Society of Hospital Pharmacists of Australia Journal of Pharmacy Practice and Research (2020) 50, 98–107
100 E. Reeve

Table 1 (continued)

Type Examples

6. Tools for engaging See recent review of patient educational materials for deprescribing53
patients Decision aids and option grids (PPIs, antidepressants, antipsychotics):
• https://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOCHWID=zx3018
• http://optiongrid.org/pdf/grid/grids/64/64.en_us.1.pdf
• https://deprescribing.org/resources/deprescribing-patient-decision-aids/55
EMPOWER brochures (antipsychotics, first generation antihistamines, NSAIDs, Opioids for chronic non-cancer
pain, PPIs, sedative hypnotic medications, sulfonylurea diabetes medication). Available from: https://
www.deprescribingnetwork.ca/patient-handouts
5 Questions to Ask About Your Medications. Available from: https://www.ismp-canada.org/download/MedRec/
MedSafety_5_questions_to_ask_poster.pdf
Questionnaires to capture how patients feel about deprescribing:
• Patients’ Attitudes Towards Deprescribing (PATD) questionnaire (revised in 2016, versions for older
adults, caregivers and people with cognitive impairment)74,75
• Patient Perceptions of Deprescribing (PPoD) survey76

7. Other Pharmaceutical opinions: Templates to aid in communication between pharmacists and physicians about
deprescribing recommendations.56,57 Available from: https://www.deprescribingnetwork.ca/pharmaceutical-
opinions

No assessment of quality, robustness or validity of the tools has been conducted by the author of this manuscript. Inclusion or non-inclu-
sion in this table does not indicate endorsement by author or affiliated organisations.
NSAID = non-steroidal anti-inflammatory drug; PIM = potentially inappropriate medication; PPI = proton pump inhibitor.

TOOLS TO AID THE OVERALL PROCESS OF
DEPRESCRIBING
General Deprescribing Guidance
There are a number of resources available internation-
ally which provide general (non-drug specific) advice
for health professionals about deprescribing.5–12 Some of
these were published in peer-reviewed journals while
others are available publicly on government or other
organisation websites. These resources tend to provide
background information about the need to deprescribe,
principles of how to identify medications suitable for
deprescribing and some include a framework or process
for how to deprescribe. Several include recommenda-
tions about specific drugs.5,8,9
These general guidance documents may not be useful
during clinician-patient interactions due to their length
and generic nature, however, they are a rich educational
source for clinicians. To aid with education of health
professionals about deprescribing, Bruy
ere Continuing
Care developed a polypharmacy and deprescribing
module. In this module, users work through a fictional
case to learn about an approach to deprescribing in
practice.13
Generic Deprescribing Frameworks
Many generic (non-drug specific) deprescribing frame-
works have been published.14,15 These often provide a
stepped approach to deprescribing, highlighting that it
is a process (rather than a simple one-off interaction).
Generally, the steps include taking a medication history,
identifying inappropriate medications (where the poten-
tial harms outweigh the potential benefits), recognising
the need to stop medications, planning and conducting
the withdrawal of the medication and monitoring out-
comes during and after withdrawal.14,15
A 5-step deprescribing framework by Scott and col-
leagues was developed in Australia, informed by previ-
ously developed deprescribing processes.11 The steps
are:
1. Ascertain all drugs the patient is currently taking
and the reasons for each
2. Consider overall risk of drug-induced harm in
determining the required intensity of deprescrib-
ing intervention
3. Assess each drug for its eligibility to be discontin-
ued
4. Prioritise drugs for discontinuation
5. Implement and monitor discontinuation regimen
The different frameworks available generally include
the same steps, however they differ regarding the detail
and relative emphasis on each step.15 Many frameworks
provide significant detail on how to identify medications
for deprescribing, while others focus more on the depre-
scribing process. For example, the ‘patient-centred depre-
scribing process’15 doesn’t provide specific guidance on

Journal of Pharmacy Practice and Research (2020) 50, 98–107 © 2020 The Society of Hospital Pharmacists of Australia
Deprescribing tools
how to identify inappropriate medications, instead
focusing on the process surrounding deprescribing (e.g.
planning, tapering, monitoring and documentation).
Todd et al.16 described a conceptual framework for
deprescribing which highlights the importance of patient
context. Their ‘deprescribing rainbow’ includes clinical,
psychological, social, financial and physical considera-
tions when deprescribing. The authors noted that the
deprescribing rainbow may be helpful when used in
conjunction with a generic deprescribing framework like
those discussed above.
The American Geriatrics Society has published Guid-
ing Principles on the Care of Older Adults With Multi-
morbidity.17,18 These action steps were designed to assist
clinicians to make patient-centred treatment decisions
when faced with uncertainty, which is often the case
when caring for older adults with multimorbidity. While
not deprescribing-specific, their principles may be useful
for guiding deprescribing decisions. The steps are:
1. Identify and communicate patients’ health priori-
ties and health trajectory;
2. Stop, start, or continue care based on health prior-
ities, potential benefit vs harm and burden, and
health trajectory;
3. Align decisions and care among patients, care-
givers, and other clinicians with patients’ health
priorities and health trajectory.
The guiding principle also provides suggested tools,
tips and example scripts to assist with carrying out
these actions.18
Generic deprescribing frameworks are likely to be
useful when considering deprescribing interventions
whether as quality improvement or as part of a research
study. Additionally, clinician knowledge of the steps
required for deprescribing is likely to be helpful in opti-
mising medication use in practice. The 5-step frame-
work11 and the patient-centred deprescribing process15
have both been shown to be feasible and possibly bene-
ficial in practice.19,20 The success and outcomes of larger
implementation of such frameworks is not yet known.
Drug-Specific Deprescribing Guidelines and
Guides
Drug-specific deprescribing guidelines and guides pro-
vide specific advice on when (or in whom) it is suitable
to trial deprescribing a specific medication, or a class of
medication. They also provide guidance on other parts
of the process, such as how to withdraw the medica-
tions (tapering) and what monitoring is required.
The Bruy
ere Deprescribing Guidelines in the Elderly
project (Canada) has developed four drug-specific
© 2020 The Society of Hospital Pharmacists of Australia
101
deprescribing guidelines, and a fifth was developed in
conjunction with the University of Sydney (Australia).21–
27
Their method of developing guidelines28 is based on
the Grading of Recommendations Assessment, Develop-
ment and Evaluation (GRADE) process,29 Guideline 2.0
checklist,30 and Appraisal of Guidelines for REsearch and
Evaluation (AGREE) II.31 The fifth guideline also under-
went the process required for Australian National Health
and Medical Research Council (NHMRC) approval,
demonstrating that deprescribing guidelines could be
developed to the same robust standards as clinical treat-
ment guidelines as assessed by an external body. Key to
implementation of these guidelines, is the development of
a 2-page algorithm for clinicians. The first page contains a
flow chart that takes the clinician through a decision-
making process to determine whether to deprescribe the
medication and how to deprescribe. The second page con-
tains supportive information such as the dose and brands
available, engaging with the patient, monitoring and non-
pharmacological support. A study examining implemen-
tation of the proton pump inhibitor (PPI) deprescribing
guideline in a long-term care home found an initial reduc-
tion in use after implementation (increased deprescrib-
ing), but this was not sustained, with an increase towards
baseline after six months. There was, however, a signifi-
cant reduction in the average cost of PPI prescriptions.32
Additionally, these deprescribing guidelines may increase
clinicians’ self-efficacy for deprescribing.33
In Australia, deprescribing guides have been pub-
lished by Primary Health Tasmania34 and the New
South Wales Therapeutic Advisory Group (NSW TAG)35
(Table 1). Primary Health Tasmania have a large number
of drug-specific guidelines, however, there is limited
information on the development method.34 The depre-
scribing tools developed by NSW TAG were developed
for use in hospitals, and research into implementation
and outcomes is currently underway.35
Electronic Clinical Decision Support Systems
Given the increasing uptake of electronic prescribing
and medical records, potential exists for electronic clini-
cal decision support systems (CDSSs) to enhance depre-
scribing at the point of care. A recent narrative review
identified 20 studies investigating the use of CDSSs to
reduce inappropriate medication use.36 While the evi-
dence suggests a benefit of these types of systems, par-
ticularly in the hospital setting, there is limited robust
work on the development and implementation of such
tools. Several CDSSs have been specifically developed to
enhance and guide deprescribing activities.
MedStopper is a web-based system that provides
information about a medication’s benefits and risks and
Journal of Pharmacy Practice and Research (2020) 50, 98–107
102
provides recommendations about tapering and possible
withdrawal symptoms.37,38 This information also feeds
into a recommended order of stopping list. MedStopper
was developed by a team of experts in gerontology,
polypharmacy, pharmacology, pharmacy, patient advo-
cacy and family medicine and tested by physicians and
polypharmacy leaders.37 This resource is publicly avail-
able and free to use, with a note that it is a ‘beta’ ver-
sion and still a work in progress.37,38
The Goal-directed Medication review Electronic Deci-
sion Support System (G-MEDSS),39,40 TaperMD41 and
MedSafer42 are other examples of CDSSs designed to
support and increase deprescribing. MedSafer uses the
Beers’ criteria,43 Screening Tool for Older Peoples Pre-
scriptions (STOPP)44 and Canadian Choosing Wisely
recommendations to highlight medications for potential
deprescribing.42 Use of MedSafer in hospital was
recently evaluated in a nonrandomised controlled
before-and-after study. It led to an increase in the pro-
portion of patients who had at least one potentially
inappropriate medication (PIM) deprescribed during
admission, however the effect was modest (increase
from 46.9% to 54.7%) and the study was not powered to
capture whether this influenced clinical outcomes.42 G-
MEDSS and TaperMD also incorporate previously vali-
dated and/or robust tools and guidelines and research is
currently being undertaken in Australia and Canada to
investigate implementation and outcomes.39–41
Despite the potential for CDSSs to enhance depre-
scribing, limitations of IT platforms, such as their ability
to extract and interpret routinely entered clinical data
may impede the incorporation of tools into electronic
prescribing systems. Additionally, without considered
and robust development and implementation evalua-
tion, these systems run the risk of causing ‘alert fatigue’
and may not actually result in improved care.45
TOOLS TO AID IN SPECIFIC PARTS OF THE
DEPRESCRIBING PROCESS
Tools for Identifying Potentially Inappropriate
Medications for Deprescribing
Masnoon et al.46 conducted a systematic review of the
tools and criteria available for assessing appropriateness
of prescribing and reviewed whether they had been val-
idated with external clinical outcomes. They identified
42 prescribing assessment tools and 33 of these pro-
vided guidance around identifying inappropriate medi-
cations. Both explicit (criteria based) and implicit
(requires clinical judgement or assessment) tools exist.
Eleven tools provided suggestions on safer alternative
treatment options, which may be useful in aiding
Journal of Pharmacy Practice and Research (2020) 50, 98–107
E. Reeve
deprescribing as lack of acceptable alternatives has been
noted as a barrier to deprescribing.3 However, less than
half of the tools had evidence of association with clinical
outcomes (that is, association between taking one or
more inappropriate medications identified by the tool
and adverse clinical outcomes in observational studies),
limiting the known external validity of the tools.46
Commonly used explicit tools for identifying inappro-
priate medications include the Beers criteria43 and
STOPP.44 Both of these tools have been associated with
clinical outcomes,46 and may be effective as part of
interventions to reduce the use of inappropriate medica-
tions.47,48 However, overall, there are potential limita-
tions to all the tools available for identifying
inappropriate medications in relation to their utility in
deprescribing. For example, most of the tools lack con-
sideration of dose as well as renal function and other
patient characteristics and many have only been vali-
dated or tested in certain populations. Explicit PIMs lists
do not take into account the individual patient’s situa-
tion and as such a significant proportion of medications
identified using these tools may be ‘appropriate’ and
not suitable for deprescribing.49 Additionally, they gen-
erally do not provide guidance on what to do once a
potentially inappropriate medication has been identified
or how to prioritise clinical decisions.46
The Good Palliative-Geriatric Practice (GP-GP) algo-
rithm is an implicit tool, designed to guide clinicians
through determining appropriateness of a medication
and provide advice on whether to stop the medication,
reduce the dose, continue the medication or switch to
an alternative.50 Its stepped process contains questions
such as whether the indication for the medication is
valid and relevant given the patient’s age and condition.
The GP-GP algorithm has been used in a cohort study
in Israel and a randomised controlled trial in Australian
aged care facilities and was found to reduce number of
medications and may also improve global health.50,51
An Australian study found moderate to substantial
inter-rater agreement between pharmacists and physi-
cians using the GP-GP algorithm to identify medications
for deprescribing.52 An algorithm described by Scott
et al.11 also provides a stepped process for considering
which medications should be stopped, and guidance on
whether to continue or discontinue the medication and
if tapering is required.
Tools for Engaging and Empowering Patients and
Shared Decision Making
Fajardo et al.53 recently conducted a review of patient
education materials for deprescribing. Through a sys-
tematic review and environmental scan, 48 resources
© 2020 The Society of Hospital Pharmacists of Australia
Deprescribing tools
were identified. The materials were in a variety of for-
mats, although most were fact sheets. Only four were
decision aids/option grids which are recommended for-
mats for assisting and engaging patients in decision
making. There were patient educational materials on
deprescribing in general as well as for specific medica-
tions. However, a limited number of medications were
addressed, with most materials addressing benzodi-
azepines, opioids or antipsychotics. No drug-specific
materials were found for preventative medications.
There are some concerns about existing patient educa-
tional materials for deprescribing.53 Only half of the
materials referred to peer reviewed evidence and
approximately two-thirds presented unbalanced infor-
mation on the potential benefits and harms of depre-
scribing (with most focusing on benefits). The average
reading level of the materials was higher than the liter-
acy level of the average patient. Because of these limita-
tions the clinical utility of most of these materials in
practice is unclear.53
Research from Canada shows the potentially power-
ful impact of patient education materials. Use of the
EMPOWER (Eliminating Medications Through Patient
Ownership of End Results) brochure for benzodi-
azepines and Z-drugs led to deprescribing in 27% of the
intervention group participants, compared to only 5% in
the control group.54 A before-after study of a patient
decision aid for PPIs led to improved patient knowl-
edge, realistic expectations and decisional confidence.55
Tools to aid with ascertaining patients’ (and their car-
ers’) attitudes to deprescribing, and willingness to stop
taking one or more medications, have also been devel-
oped (Table 1).
Other Supportive Tools
In Canada, a communication tool called a ‘pharmaceuti-
cal opinion’ was developed to aid in communicating
deprescribing recommendations from pharmacists to
physicians.56,57 In the D-PRESCRIBE randomised con-
trolled trial, these pharmaceutical opinions, used in con-
junction with an EMPOWER patient education brochure
led to a 43% reduction in use of four different classes of
medications (compared to 12% in the control group).58
SPECIAL POPULATIONS
People with Frailty and Limited Life Expectancy
Thompson et al.59 recently conducted a systematic
review of tools available to support deprescribing in
people living with frailty and those with limited life
expectancy. Several of the included tools were those
© 2020 The Society of Hospital Pharmacists of Australia
103
already discussed which also contain recommendations
in relation to frailty or limited life expectancy (e.g. the
antihyperglycemic deprescribing guideline22 and the
GP-GP algorithm50). A model for appropriate prescrib-
ing for people with limited life expectancy highlights
the consideration of remaining life expectancy, time
until benefit, goals of care and appropriate treatment
targets.60 Two explicit lists of potentially inappropriate
medications have been developed specifically for use in
frail older adults, the STOPPFrail criteria61 and the List
of Evidence-Based Deprescribing for Chronic Patients
(LESS-CHRON).62 Both tools also provide some moni-
toring or follow-up advice when deprescribing.61,62
Additionally, Thompson’s review reported guidelines
developed by the Palliative and Therapeutic Harmo-
nization (PATH) Program Clinic for frail older adults.
They currently have four disease guidelines: Type 2
diabetes,63 hypertension,64 statin use65 and depression66
which were developed via evidence review and expert
consensus. While these are not solely focused on
deprescribing, they do contain recommendations
related to when treatment may be stopped. Overall,
the tools identified in Thompson’s review were varied
in their content and complexity. Methodology of devel-
opment of the tools were generally poorly reported.
Only four out of the 15 tools had been tested in clini-
cal practice, and all were considered very low quality
studies.59
People with Dementia
Several tools exist to aid deprescribing in people with
dementia, such as drug-specific deprescribing guidelines
for antipsychotics26 and cholinesterase inhibitors and
memantine.25 Holmes et al.67 reviewed medications
taken by people with advanced dementia and used a
modified Delphi consensus method to create lists of
medications that were never, rarely, sometimes or
always appropriate. There were several commonly used
medications for which consensus could not be achieved
(e.g. vitamins, aspirin, iron supplements). This high-
lights the complexity of developing such lists for real-
world populations. Page and colleagues similarly devel-
oped a study protocol where, using a Delphi method,
they aimed to develop a list of appropriate and inappro-
priate medications in people with dementia.68 However,
led by the responses from experts in their initial survey,
they instead developed a list of consensus statements to
guide appropriate prescribing in people with dementia.
While many of the statements are general, it does
include several specific deprescribing recommendations
such as ceasing lipid lowering therapy and medications
for osteoporosis in late stage dementia.69
Journal of Pharmacy Practice and Research (2020) 50, 98–107
104 E. Reeve

the implementation process, rather than a limitation of

People with Cancer and Limited Life Expectancy
The OncPal Deprescribing Guideline is a list of medica-
tions which have limited benefit in palliative cancer
patients and therefore are targets for deprescribing. In a
cohort of patients with a prognosis of less than
six months, there was a high level of concordance
between medications identified using OncPal and those
identified by a panel of medical experts.70
DISCUSSION
There are many tools available to assist clinicians with
deprescribing. They vary significantly in form and func-
tion. There are both general and drug-specific tools,
although the drug-specific tools generally focus on a lim-
ited range of drug classes. There is significant variation
in the methods of development of the tools (and whether
the method of development is reported), and few have
undergone evaluation in clinical practice. Therefore, it is
unclear which of these tools are likely to have the great-
est impact in increasing deprescribing and improving
clinical outcomes. Impact, or effectiveness, of a tool is
likely to depend both on the validity of the tool and how
the tool is implemented in practice. For example, the
Bruy
ere deprescribing guidelines were developed to the
highest standard of guideline development,28 but in an
implementation study there was limited change in depre-
scribing of the target medication.32 This may be due to
the guideline itself. This distinction is likely to be particu-
larly relevant when researching the impact of electronic
CDSSs; while the systems may incorporate validated and
robust tools, simply making the tools available or causing
alerts or other triggers based on these tools may not lead
to increased deprescribing in practice.
Currently available tools may help address some of
the barriers to deprescribing, such as lack of awareness
of inappropriate medications, patient resistance or lack
of guidance on how to deprescribe. But in each individ-
ual patient scenario, barriers to deprescribing are often
multifactorial and may not be able to be overcome when
considered individually. For example, where time limita-
tions are significant (such as in primary care71), tools
which highlight inappropriate medications may not be
effective at increasing deprescribing as time is needed to
assess the appropriateness in the individual, discuss it
with the patient and/or carers and plan the deprescrib-
ing process.
As deprescribing is not an event that can be com-
pletely isolated from other care activities, useful web-
sites (Table 2) often contain resources for a wide range
of activities related to optimising medication use (such
as NPS MedicineWise). Indeed, deprescribing should be
a part of comprehensive medication management
reviews with a holistic view of the patient and their
medications, including consideration of adherence, abil-
ity to manage medications, appropriate dosing and
undertreatment. Despite the limitations of currently

Table 2 Useful websites for deprescribing resources

Organisation Description Website

NPS MedicineWise (Australia)
Bruy
ere Research Institute (Ottawa) and
Universite de Montreal (Canada)
Canadian Deprescribing Network (CaDeN)
American Geriatrics Society
RxISK (owned and operated by Data Based
Medicine Americas Ltd), Canada
PrescQIPP (an independent, not for profit
social enterprise with the aim of supporting
quality prescribing in the NHS), UK
Contains many resources for consumers and https://www.nps.org.au/
healthcare professionals on topics related to
optimising medication use.
Hosts and links to a number of resources including https://deprescribing.org/
the Bruy
ere Deprescribing Guidelines, patient
information pamphlets as well as current research.
Includes information for the public and health care https://www.deprescribingne
professionals. Hosts and links to a number of twork.ca/
resources including the Bruy
ere Deprescribing
Guideline algorithms and the EMPOWER brochures.
Includes a toolkit which provides guidance for https://geriatricscareonline.org/
discontinuing unnecessary and potentially harmful ProductAbstract/ags-depresc
medications (free registration required to access). ribing-toolkit/TK013
Contains searchable information on medications and https://rxisk.org
their side effects as well as links to other resources.
A webkit of resources for polypharmacy and https://www.prescqipp.info/our-
deprescribing (some sections publicly available; resources/webkits/polypha
others only available to UK National Health Service rmacy-and-deprescribing/
employees).

Journal of Pharmacy Practice and Research (2020) 50, 98–107 © 2020 The Society of Hospital Pharmacists of Australia
Deprescribing tools 105

available deprescribing tools, they are an essential part 11 Scott IA, Hilmer SN, Reeve E, Potter K, Couteur DL, Rigby D,
of the modern clinician’s armamentarium. Different tools et al. Reducing inappropriate polypharmacy: the process of
deprescribing. JAMA Intern Med 2015; 175: 827–34.
may be beneficial to the clinician in different scenarios,
12 Medicines optimisation: the safe and effective use of medicines to
for different patients.
enable the best possible outcomes: NICE: National Institute for
Health and Care Excellence, 2015. Available from <https://www.
nice.org.uk/guidance/ng5/chapter/1-Recommendations#clinical-dec
FUNDING
ision-support>.
13 Farrell B, Thompson W. Polypharmacy and Deprescribing Module.
ER is supported by an NHMRC-ARC Dementia Ottawa, ON, Canada: Bruy
ere Continuing Care; 2017. Available
Research Development Fellowship (APP1105777). from <https://www.bruyere.org/en/polypharmacy-deprescribing>.
14 Scott I, Anderson K, Freeman C. Review of structured guides for
deprescribing. Eur J Hospital Pharm 2017; 24: 51–7.
Conflicts of interest statement 15 Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of
deprescribing processes and development of an evidence-based,
The author declares that she has no conflicts of interest.
patient-centred deprescribing process. Br J Clin Pharmacol 2014; 78:
However, reports that she has been involved in the
738–47.
development of several of the listed tools and research 16 Todd A, Jansen J, Colvin J, McLachlan AJ. The deprescribing
studies examining their validity and implementation (as rainbow: a conceptual framework highlighting the importance of
shown by author lists in the references). patient context when stopping medication in older people. BMC
Geriatr 2018; 18: 295.
17 Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green
AR, et al. Decision making for older adults with multiple chronic
REFERENCES
conditions: executive summary for the American Geriatrics Society
guiding principles on the care of older adults with
1 Reeve E, Thompson W, FarrellB. Deprescribing: narrative
multimorbidity. J Am Geriatr Soc 2019; 67: 665–73.
review of the evidence and practical recommendations for
18 Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green
recognizing opportunities and taking action. Eur J Intern Med
AR, et al. Framework for Decision-making for Older Adults with
2017; 38.
Multiple Chronic Conditions: Action Steps for the AGS Guiding
2 Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the
Principles on the Care of Older Adults with Multimorbidity:
emerging definition of ‘deprescribing’with network analysis:
American Geriatrics Society; 2019. Available from <https://geria
implications for future research and clinical practice. Br J Clin
tricscareonline.org/ProductAbstract/Framework-for-Decision-ma
Pharmacol 2015; 80: 1254–1268.
king-for-Older-Adults/CL026>.
3 Anderson K, Freeman C, Stowasser D, Scott I. Prescriber barriers
19 Reeve E, Andrews JM, Wiese MD, Hendrix I, Roberts MS, Shakib
and enablers to minimising potentially inappropriate medications
S. Feasibility of a patient-centered deprescribing process to reduce
in adults: A systematic review and thematic synthesis. BMJ Open
inappropriate use of proton pump inhibitors. Ann Pharmacother
2014; 4: e006544.
2015; 49: 29–38.
4 Reeve E, Bell S, Hilmer SN. Barriers to optimising prescribing and
20 McKean M, Pillans PI, Scott IA. A medication review and
deprescribing in older adults with dementia: a narrative review.
deprescribing method for hospitalised older patients receiving
Curr Clin Pharmacol 2014; 10: 168–77.
multiple medications. Intern Med J 2015; 46: 35–42.
5 A practical guide to stopping medicines in older people. Best
21 Deprescribing.org. Ottawa, ON, Canada; 2019. Available from
Practice Journal 2010; 27: 10–23.
<https://deprescribing.org/>.
6 Duerden M, Avery T, Payne R. Polypharmacy and medicines
22 Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C,
optimisation: Making it safe and sound. London: The Kings Fund, 2013.
Lochnan H, et al. Deprescribing antihyperglycemic agents in older
7 Howard C. Polypharmacy: Getting our medicines right UK: Royal
persons: evidence-based clinical practice guideline. Can Fam
Pharmaceutical Society 2019. Available from <https://www.rpha
Physician 2017; 63: 832–43.
rms.com/recognition/setting-professional-standards/polypharmacy-
23 Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L,
getting-our-medicines-right>.
Rashid FJ, et al. Deprescribing proton pump inhibitors evidence-
8 Scottish Government Effective Prescribing and Therapeutics
based clinical practice guideline. Can Fam Physician 2017; 63:
Division and the Digital Health and Care Division. Polypharmacy
354–64.
Guidance – Medicines Review: NHS Scotland, 2019. Available
24 Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin P,
from <http://www.polypharmacy.scot.nhs.uk/polypharmacy-guida
et al. Evidence-based Clinical Practice Guideline for Deprescribing
nce-medicines-review/for-healthcare-professionals/>.
Cholinesterase Inhibitors and Memantine Sydney: The University
9 Starkey V, Omorinoye E, Railton D, Aslam S, Jones N, Goodwin
of Sydney; 2018. Available from <https://cdpc.sydney.edu.au/resea
T, et al. Deprescribing: A Practical Guide: NHS North Derbyshire
rch/medication-management/deprescribing-guidelines/>.
CCG, NHS Erewash CCG, NHS Hardwick CCG, NHS South
25 Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin
Derbyshire CCG, 2017. Available from <http://www.derbyshire
PJ, et al. Deprescribing cholinesterase inhibitors and memantine in
medicinesmanagement.nhs.uk/assets/Clinical_Guidelines/clinical_
dementia: guideline summary. Med J Aust 2019; 210: 174–9.
guidelines_front_page/Deprescribing.pdf>.
26 Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L,
10 Therapeutics Initiative. Reducing polypharmacy: A logical
et al. Deprescribing antipsychotics for behavioural and
approach. Therapeutics Letter 2014.

© 2020 The Society of Hospital Pharmacists of Australia Journal of Pharmacy Practice and Research (2020) 50, 98–107
106
psychological symptoms of dementia and insomnia: Evidence-
based clinical practice guideline. Can Fam Phys 2018; 64: 17–27.
27 Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch
V, et al. Deprescribing benzodiazepine receptor agonists. Evidence-
based Clin Pract Guideline 2018; 64: 339–51.
28 Farrell B, Pottie K, Rojas-Fernandez CH, Bjerre LM, Thompson W,
Welch V. Methodology for developing deprescribing guidelines:
Using evidence and GRADE to guide recommendations for
deprescribing. PLoS ONE 2016; 11: e0161248.
29 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck- Y, Alonso-coello
P, et al. Rating quality of evidence and strength of
recommendations: GRADE: an emerging consensus on rating
quality of evidence and strength of recommendations. Br Med J
2008; 336: 924–6.
30 Sch€unemann HJ, Wiercioch W, Etxeandia I, Falavigna M, Santesso
N, Mustafa R, et al. Guidelines 2.0: systematic development of a
comprehensive checklist for a successful guideline enterprise. Can
Med Assoc J 2014; 186: E123–42.
31 Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F,
Feder G, et al. AGREE II: advancing guideline development,
reporting and evaluation in health care. Can Med Assoc J 2010;
182: E839–42.
32 Thompson W, Hogel M, Li Y, Thavorn K, O'Donnell D, McCarthy
L, et al. Effect of a proton pump inhibitor deprescribing guideline
on drug usage and costs in long-term care. J Am Med Dir Assoc
2016; 17: 673e1–e4.
33 Farrell B, Richardson L, Raman-Wilms L, de Launay D,
Alsabbagh MW, Conklin J. Self-efficacy for deprescribing: A
survey for health care professionals using evidence-based
deprescribing guidelines. Res Social Adm Pharm 2018; 14: 18–25.
34 Deprescribing resources Tasmania, Australia: Primary Health
Tasmania; 2019. Available from <https://www.primaryhealthtas.c
om.au/resources/deprescribing-resources/>.
35 Deprescribing tools Sydney. NSW, Australia: NSW Therapeutic
Advisory Group Inc; 2018. Available from <http://www.nswtag.
org.au/deprescribing-tools/>.
36 Scott IA, Pillans PI, Barras M, Morris C. Using EMR-enabled
computerized decision support systems to reduce prescribing of
potentially inappropriate medications: a narrative review.
Therapeutic Adv Drug Safety 2018; 9: 559–73.
37 Cassels A. ‘Can I stop even one of these pills?’ The development of
a tool to make deprescribing easier. Eur J Hospital Pharm 2017; 24: 3.
38 Medstopper. Available from <https://medstopper.com/>.
39 Sawan M, O'Donnell L, Reeve E, Gnjidic D, Chen T, Kelly P, et al.
Implementation of the goal-directed medication review electronic
decision support system (G-MEDSS). Res Soc Admin Pharm 2018; 14.
40 Sawan M, Kouladjian O’Donnell L, Hilmer SN. Perspectives of
residential aged care facilities' staff on the identification and recording
of residents' medication-related goals of care. Austr J Ageing 2019.
41 TaperMD: Pause and Monitor: Data Based Medicine Americas
Ltd; 2019. Available from <https://tapermd.com/about/>.
42 McDonald EG, Wu PE, Rashidi B, Forster AJ, Huang A, Pilote L,
et al. The MedSafer Study: a controlled trial of an electronic
decision support tool for deprescribing in acute care. J Am Geriatr
Soc 2019; 67: 1843–1850.
43 American Geriatrics Society 2015 updated beers criteria for
potentially inappropriate medication use in older adults. J Am
Geriatr Soc 2015; 2015: 2227–46.
44 O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C,
Gallagher P. STOPP/START criteria for potentially inappropriate
Journal of Pharmacy Practice and Research (2020) 50, 98–107
E. Reeve
prescribing in older people: version 2. Age Ageing 2015; 44:
213–18.
45 Wright A, Aaron S, Seger DL, Samal L, Schiff GD, Bates DW.
Reduced effectiveness of interruptive drug-drug interaction alerts
after conversion to a commercial electronic health record. J Gen
Intern Med 2018; 33: 1868–76.
46 Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. Tools for
assessment of the appropriateness of prescribing and association
with patient-related outcomes: a systematic review. Drugs Aging
2018; 35: 43–60.
47 Hill-Taylor B, Walsh K, Stewart S, Hayden J, Byrne S, Sketris I.
Effectiveness of the STOPP/START (Screening Tool of Older
Persons' potentially inappropriate Prescriptions/Screening Tool to
Alert doctors to the Right Treatment) criteria: systematic review
and meta-analysis of randomized controlled studies. J Clin Pharm
Ther 2016; 41: 158–69.
48 Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC,
Ryan C, et al. Interventions to improve the appropriate use of
polypharmacy for older people. Cochrane Database Syst Rev 2014;
10: CD008165.
49 Elliott RA, Stehlik P. Identifying inappropriate prescribing for
older people. J Pharm Pract Res 2013; 43: 312–319.
50 Garfinkel D, Mangin D. Feasibility study of a systematic approach
for discontinuation of multiple medications in older adults:
addressing polypharmacy. Arch Intern Med 2010; 170: 1648–
54.
51 Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in frail
older people: a randomised controlled trial. PLoS ONE 2016; 11:
e0149984.
52 Page A, Etherton-Beer CD, Clifford RM, Burrows S, Eames M,
Potter K. Deprescribing in frail older people–do doctors and
pharmacists agree? Res Soc Admin Pharm 2016; 12: 438–449.
53 Fajardo MA, Weir KR, Bonner C, Gnjidic D, Jansen J.
Availability and readability of patient education materials for
deprescribing: An environmental scan. Br J Clin Pharmacol 2019;
bcp.13912.
54 Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S.
Reduction of inappropriate benzodiazepine prescriptions
among older adults through direct patient education: The
empower cluster randomized trial. JAMA Intern Med 2014; 174:
890–8.
55 Thompson W, Farrell B, Welch V, Tugwell P, Way C, Richardson
L, et al. Continuation or deprescribing of proton pump
inhibitors: A consult patient decision aid. Can Pharm J 2019; 152:
18–22.
56 Martin P, Tannenbaum C. A prototype for evidence-based
pharmaceutical opinions to promote physician-pharmacist
communication around deprescribing. Can Pharm J (Ott) 2018;
151: 133–41.
57 Canadian Deprescribing Network Montreal, QC, Canada; 2019.
Available from <https://www.deprescribingnetwork.ca/>.
58 Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C.
Effect of a pharmacist-led educational intervention on
inappropriate medication prescriptions in older adults: The D-
prescribe randomized clinical trial effect of a pharmacist-led
intervention on inappropriate prescriptions in older adults effect
of a pharmacist-led intervention on inappropriate prescriptions in
older adults. JAMA 2018; 320: 1889–98.
59 Thompson W, Lundby C, Graabæk T, Nielsen DS, Ryg J,
Søndergaard J, et al. Tools for deprescribing in frail older persons
© 2020 The Society of Hospital Pharmacists of Australia
Deprescribing tools
and those with limited life expectancy: a systematic review. J Am
Geriatr Soc 2019; 67: 172–80.
60 Holmes HM, Hayley DC, Alexander GC, Sachs GA.
Reconsidering medication appropriateness for patients late in life.
Arch Intern Med 2006; 166: 605–9.
61 Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail
(Screening Tool of Older Persons Prescriptions in Frail adults with
limited life expectancy): consensus validation. Age Ageing 2017; 46:
600–7.
62 Rodrıguez-Perez A, Alfaro-Lara ER, Albi~nana-Perez S, Nieto-
Martın MD, Dıez-Manglano J, Perez-Guerrero C, et al. Novel tool
for deprescribing in chronic patients with multimorbidity: List of
Evidence-Based Deprescribing for Chronic Patients criteria. Geriatr
Gerontol Int 2017; 17: 2200–7.
63 Mallery LH, Ransom T, Steeves B, Cook B, Dunbar P, Moorhouse,
et al. Evidence-informed guidelines for treating frail older adults
with type 2 diabetes: from the Diabetes Care Program of Nova
Scotia (DCPNS) and the Palliative and Therapeutic. Harmonization
(PATH) Program 2013; 14: 801–8.
64 Mallery LH, Allen M, Fleming I, Kelly K, Bowles S, Duncan J, et al.
Promoting higher blood pressure targets for frail older adults: a
consensus guideline from Canada. Cleve Clin J Med 2014; 81: 427–37.
65 Mallery LH, Moorhouse P, McLean Veysey P, Allen M, Fleming I.
Severely frail elderly patients do not need lipid-lowering drugs.
Cleve Clin J Med 2017; 84: 131–42.
66 Systematic review and meta-analysis of antidepressants for
depression in frail, older adults with and without dementia and
the neuropsychiatric symptoms of dementia, 2016. Available from
<https://cdn.dal.ca/content/dam/dalhousie/pdf/faculty/medicine/
departments/core-units/cpd/Research/ADreview2016.pdf>.
67 Holmes HM, Sachs GA, Shega JW, Hougham GW, Cox Hayley D,
Dale W. Integrating palliative medicine into the care of persons
with advanced dementia: identifying appropriate medication use.
J Am Geriatr Soc 2008; 56: 1306–11.
68 Page A, Potter K, Clifford R, McLachlan A, Etherton-Beer C.
Prescribing for Australians living with dementia: study protocol
using the Delphi technique. BMJ Open 2015; 8: e008048.
69 Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C.
Medication appropriateness tool for co-morbid health conditions
in dementia: consensus recommendations from a multidisciplinary
expert panel. Intern Med J 2016; 46: 1189–97.
© 2020 The Society of Hospital Pharmacists of Australia
107
70 Lindsay J, Dooley M, Martin J, Fay M, Kearney A, Khatun M,
et al. The development and evaluation of an oncological palliative
care deprescribing guideline: the ‘OncPal deprescribing guideline.
Supportive Care Cancer 2015; 23: 71–78.
71 Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for
older adults in the primary care context: A mixed studies review.
Health Sci Report 2018; 1: e45.
72 Scott IA, Le Couteur DG. Physicians need to take the lead in
deprescribing. Int Med J 2015; 45: 352–356.
73 Hanlon JT, Schmader KE. The Medication Appropriateness Index
at 20: where it started, where it has been, and where it may be
going. Drugs Aging 2013; 30: 893–900.
74 Reeve E, Low L-F, Shakib S, Hilmer SN. Development and
validation of the revised Patients’ Attitudes Towards
Deprescribing (rPATD) questionnaire: versions for older adults
and caregivers. Drugs Aging 2016; 33: 913–928.
75 Reeve E, Anthony A, O’Donnell LK, Low L-F, Ogle S, Glendenning
J, et al. Development and pilot testing of the revised Patients’
Attitudes Towards Deprescribing questionnaire for people with
cognitive impairment. Australas J Ageing 2018; 37: E150–E154.
76 Linsky A, Simon SR, Stolzmann K, Meterko M. Patient
perceptions of deprescribing: survey development and
psychometric assessment. Med Care 2017; 55: 306–313.
Received: 28 August 2019
Revised version received: 13 October 2019
Accepted: 06 November 2019
This activity has been
accredited for 1 hour of
Group 1 CPD activity
(or 1 CPD credit) suita-
ble for inclusion in an
individual pharmacist’s
CPD plan, which can
be converted to 1 hour
of Group 2 CPD (or 2
CPD credits) upon suc-
cessful completion of
the relevant assessment
activity. No: S2020/09.
Journal of Pharmacy Practice and Research (2020) 50, 98–107