Use of deprescribing to reduce polypharmacy and potentially inappropriate medications in geriatric patients in a tertiary care hospital

Abstract

OBJECTIVES:

The objective of the study was to assess the burden of polypharmacy and potentially inappropriate medications (PIMs) among geriatric patients and evaluate the impact of a structured deprescribing approach in these patients.

SUBJECTS AND METHODS:

Elderly outpatients (≥60 years) with polypharmacy were included. Data on prescribed, over-the-counter (OTC), and traditional medicines were collected through a structured questionnaire and detailed patient interviews. Deprescribing was carried out using Sivagnanam G’s “S and S” approach (Seek, Screen, Save, Sever, Sensitize, and Supervise) adapted from Scott et al.

RESULTS:

Among 385 participants, polypharmacy was prevalent in 182 participants (47.27%) with a mean of 6.5 drugs/prescription. Among participants with polypharmacy, PIMs were noted in 131 (72%) with an average of 1.64 PIMs identified per each inappropriate prescription. PIMs increased with an increase in the number of comorbidities and medication count. A total of 215 PIMs were identified and recommended for deprescribing. These were mainly drugs to be avoided in the elderly (34.88%), OTC PIMs (17.21%), traditional medicines (13.02%), and drug–drug interactions (9.77%). Deprescribing reduced the mean drug count per prescription to 4.86 with a potential to decrease adverse drug reactions by 16.4%, and also lowered daily prescription costs from INR 51.91 to INR 32.70, saving INR 576.42 per patient per month.

CONCLUSION:

Polypharmacy and PIMs are widely prevalent among elderly patients, significantly increasing the risk of ADEs. Structured deprescribing effectively reduced medication burden, improved safety, and decreased healthcare costs. These findings highlight the need for routine deprescribing interventions to optimize geriatric medication management.

Introduction

The most frequent outcome of a doctor–patient interaction is the prescription of drug therapy. While medications can be beneficial, they are also associated with potential risks, especially as the number of prescribed drugs increases.[1] This elevated risk is primarily due to drug–drug and drug–disease interactions, and the cumulative harm can at times outweigh the therapeutic benefits.[1]

Polypharmacy, typically defined as the regular use of five or more medications, is especially concerning in elderly patients who often have multiple chronic conditions requiring treatment from various healthcare providers.[2] The elderly population in India has risen dramatically from 20 million in 1951 to approximately 149 million in 2022 and is projected to reach 324 million by 2050, accounting for 21.2% of the country’s total population.[3]

The current healthcare system is predominantly oriented toward initiating treatment, with limited structured guidance on when and how to reduce or discontinue medications. This often results in patients continuing unnecessary medications, driven by the perception that every complaint should be addressed with a drug. Studies show that 44% of patients at discharge are prescribed at least one unnecessary medication, and one in three patients on five or more drugs experiences at least one adverse drug reaction (ADR) annually, over 25% of which are preventable.[4] Moreover, medication nonadherence increases with the number of prescribed drugs and the burden of ADRs, especially from potentially inappropriate medications (PIMs), is significant in the elderly.[5] PIMs refer to medications for which the risk of harm may outweigh the expected clinical benefit, particularly in older adults, due to age-related physiological changes, comorbidities, and altered pharmacokinetics and pharmacodynamics.[5]

PIMs contribute to a range of problems, including drug interactions, ADRs, reduced compliance, financial strain, and overall diminished quality of life.[6] Therefore, addressing polypharmacy and minimizing the use of PIMs in geriatric patients is essential to enhancing healthcare outcomes.[7]

Deprescribing has emerged as a vital strategy in this regard. Defined as the planned and supervised process of dose reduction or discontinuation of medications that are potentially harmful or no longer beneficial, deprescribing aims to improve health outcomes and reduce medication-related risks.[8] It has even been conceptualized as “prescription metabolism,” likened to drug metabolism, representing the systematic elimination of unnecessary pharmacologic agents, especially relevant for elderly patients.[9] Deprescribing decisions are typically based on concerns about medication-related harm, lack of ongoing benefit, or mismatched treatment goals.[10] The growing body of evidence suggests that, when done carefully, deprescribing is more likely to benefit than harm elderly patients.[11]

Recognizing the critical importance of this approach, the present study was undertaken to explore deprescribing as a strategy to tackle polypharmacy and reduce the use of PIMs in geriatric patients attending the outpatient department (OPD) of a tertiary care hospital.

Subjects and Methods

Selection and description of participants

This cross-sectional study was conducted in the OPD of a tertiary care hospital over 2 months. Elderly patients aged 60 years and above who were taking more than five medications were included. The study was conducted across multiple OPD departments, including General Medicine, General Surgery, Community and Family Medicine, Dermatology, Endocrinology, ENT, Orthopedics, Oncology, and Psychiatry. The sample size was determined based on a pooled prevalence of polypharmacy at 49%, with a 95% confidence interval and a Type 1 α-error of 5%, leading to a final sample size of 385. Ethics approval was obtained from the Institutional Ethics Committee, and informed consent was secured from all participants.

Data collection and analysis

Following ethical approval, elderly participants attending OPD were randomly selected, and those meeting the inclusion criteria were included after informed consent. Data collection was done using a pre-designed questionnaire, recording details on prescription drugs, over-the-counter (OTC) medications, and traditional medicines, including their duration, purpose, current usage status, and cost. To guide deprescribing, Sivagnanam G ‘s S and S approach was used which was adapted from Scott et al.[8,9]

Seek and screen

The patients’ current prescriptions were collected, and each medication was screened thoroughly. Based on the clinical condition and a careful assessment of the benefit-harm ratio, the medications were categorized as essential or nonessential. This evaluation was guided primarily by the 2023 AGS Beers Criteria, which are widely accepted guidelines for identifying PIMs in older adults.[12] These criteria classify drugs into five key categories: medications that are potentially inappropriate regardless of diagnosis; those that may worsen specific diseases or syndromes; drugs that require caution in older adults; drugs involved in high-risk drug-drug interactions; and medications needing dose adjustment or avoidance depending on kidney function. Alongside prescribed drugs, OTC and traditional medicines were also reviewed for their clinical relevance, interactions with ongoing prescriptions, and their benefit-harm profile. Consideration was also given to the patient’s personal preferences and the cost of the medications.

Save and severe

Medications identified as essential were continued. Those that were unnecessary, potentially harmful, duplicative, or self-prescribed, whether OTC or traditional, were flagged for deprescribing. For each drug identified for deprescription, it was ensured that there was a solid clinical rationale supported by the BEERS Criteria, including the strength of recommendation and quality of supporting evidence. This process was further validated using standard pharmacological references and expert consultation with specialists when required. Only after confirmation from these multiple reliable sources were medications marked and recommended for deprescribing.

Sensitize and supervise

Patients were then counseled about the importance and benefits of deprescribing, such as reducing the risk of ADRs and minimizing financial burden. The value of nonpharmacological and lifestyle-based alternatives was also emphasized wherever applicable. Follow-up appointments were conducted to monitor adherence, assess outcomes, and make any necessary further adjustments to the treatment plan. This ensured that deprescribing was not a one-time event, but a continuous, supervised process tailored to each patient’s needs.

Data were entered into MS Excel and analyzed using SPSS (IBM Corp. IBM SPSS Statistics. Version 29. [Computer software]. Armonk, NY: IBM Corp., 2023). Descriptive statistics were applied to assess polypharmacy prevalence, classification of inappropriate medications, and the impact of deprescribing interventions. The analysis focused on medication patterns, identification of PIMs, and the outcomes of deprescribing efforts in the study population.

A flowchart showing the methodology of the study is shown in Figure 1.

Figure 1.

Flowchart showing the methodology of the study - from ethics approval and participant selection to data collection, analysis, and the deprescribing process using the Seek and Screen, Save and Severe, and Sensitize and Supervise approach

Results

A total of 385 patients were included in the study, and out of these, 182 (47.27%) met the criteria for polypharmacy, while 203 (52.72%) did not. Among the 182 patients who met the criteria of polypharmacy, 82 (45.05%) were taking 5–6 drugs, 54 (29.67%) had 7–8 drugs, 32 (17.58%) had 9–10 drugs, and 14 (7.69%) were taking 11 or more medications [Figure 2]. The mean age of the study population was 69.32 years.

Figure 2.

Distribution of the number of drugs per prescription among patients with polypharmacy (n = 182). Most prescriptions contained 5–6 drugs (45%), followed by 7–8 drugs (30%), 9–10 drugs (17%), and ≥11 drugs (8%)

Among the 182 patients with polypharmacy, the most common presenting complaints were musculoskeletal and genitourinary disorders, each reported by 20 patients (10.99%). These were followed by cardiovascular conditions (18 patients, 9.89%), ENT and endocrine disorders (17 each, 9.34%), pulmonary issues (13, 7.14%), eye problems (12, 6.59%), and gastrointestinal complaints (11, 6.04%). Skin and hair conditions, psychiatric disorders, and cerebrovascular complaints were each observed in 10 patients (5.49%). In addition, postoperative follow-ups accounted for 9 cases (4.94%), cancer-related issues for 8 (4.39%), and tropical infections for 7 (3.84%).

Multimorbidity was observed in 126 out of 182 polypharmacy patients (69.23%). Among them, 59 patients (32.42%) had one comorbidity, 67 (36.81%) had two, 31 (17.03%) had three comorbidities, while 25 patients (13.74%) presented with four or more comorbidities. Diabetes mellitus (n = 42), hypertension (n = 35), and osteoarthritis (n = 28) were the most common comorbidities observed.

A total of 1179 medications were prescribed to the 182 polypharmacy patients, resulting in a mean of 6.47 drugs per prescription. Of these prescriptions, 131 (72%) included PIMs, amounting to 215 individual PIMs. This corresponds to an average of 1.64 PIMs per inappropriate prescription.

The prevalence of PIMs increased with the increasing number of drugs in the prescription [Figure 3].

Figure 3.

Correlation between the number of drugs per prescription and potentially inappropriate medications (PIMs). Among 182 prescriptions, 131 contained at least one PIM. The proportion of prescriptions with PIMs increased with the number of drugs: 67% for 5–6 drugs, 74% for 7–8 drugs, 75% for 9–10 drugs, and 86% for >10 drugs

Furthermore, as comorbidities increased, the number of PIMs also increased [Figure 4].

Figure 4.

Correlation between the number of comorbidities and potentially inappropriate medications (PIMs). Among 182 prescriptions, 131 contained at least one PIM. The proportion of prescriptions with PIMs increased with comorbidity burden: 66% with one, 70% with two, 77% with three, and 84% with four comorbidities

The distribution of PIMs under different categories of the BEERS criteria is shown in Figure 5.

Figure 5.

Distribution of potentially inappropriate medications (PIMs) under different categories (n = 215). The most common category was drugs inappropriate in the elderly regardless of disease/diagnosis (35%), followed by inappropriate OTCs (17%), inappropriate traditional medicines (13%), drugs used with caution in older adults (13%), drug–disease interactions (7%), drug–drug interactions (10%), and drug duplications (5%)

Seventy-five patients received PIMs as per the BEERS Criteria-1, i.e., ”Drugs that are potentially inappropriate regardless of diagnosis or disease in geriatric patients.”

Common drug classes included first-generation antihistamines (e.g., diphenhydramine), cardiovascular agents (e.g., doxazosin), CNS medications (e.g., amitriptyline, quetiapine), NSAIDs (e.g., ibuprofen, ketorolac), and endocrine drugs (e.g., glimepiride, glyburide). Distribution of PIMs under the above mentioned criteria is shown in Table 1.

Table 1.

Medications recommended for deprescribing as per criteria-1 of the BEERS criteria – Drugs inappropriate in the elderly regardless of diagnosis or disease

Therapeutic category/class	Drug	Number of patients (n)
Antihistamine (first generation)	Diphenhydramine (oral), Meclizine, Hydroxyzine	5
Anti-infective	Nitrofurantoin	4
Non-selective peripheral alpha-1 blockers for the treatment of hypertension	Doxazosin, prazosin	2
Central alpha-agonists for the treatmentof hypertension	Clonidine	1
Calcium channel blocker	Nifedipine, immediate release	2
Antidepressants with strong anticholinergic activity, alone or in combination	Amitriptyline, Clomipramine, Paroxetine	4
Antipsychotics, second generation	Quetiapine , Risperidone	2
Benzodiazepines	Diazepam, Lorazepam	3
Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (Z-drugs)	Zaleplon, Zolpidem, Eszopiclone	3
Estrogens	Ethinyl estradiol+Desogestrel	3
Insulin, sliding scale (containing only short or rapid-acting)	Insulin Aspart, Insulin Glulisine	5
Sulfonylureas (short, long-acting)	Gliclazide, Glimepiride, Glipizide, Glyburide (Glibenclamide)	13
Proton pump inhibitors	Omeprazole, Pantoprazole, Rabeprazole	5
GI Antispasmodics with strong anticholinergic activity	Dicyclomine, Hyoscyamine, Scopolamine	4
Genitourinary (for nocturia)	Desmopressin	2
Nonselective NSAIDs, oral	Aspirin>325 mg/day, Naproxen, Piroxicam, Ketorolac, Ibuprofen	14
Skeletal muscle relaxants	Chlorzoxazone, Methocarbamol, Orphenadrine	3
Total		75

The strength of recommendation for deprescribing these medications is strong. NSAIDs=Nonsteroidal anti-inflammatory drugs

Sixteen patients received medications as per the BEERS Criteria-2, i.e., ”PIMs due to drug-disease interactions that may exacerbate the disease or syndrome.” These included opioids and corticosteroids in patients with delirium, anticholinergics and Z-drugs in dementia, CNS depressants in patients with a fall history, NSAIDs in gastric ulcer patients, and thiazolidinediones in those with heart failure. Distribution of PIMs under the above mentioned criteria is shown in Table 2.

Table 2.

Medications recommended for deprescribing as per criteria 2 of the BEERS criteria - potentially inappropriate medications due to drug-disease interactions that may exacerbate the disease or syndrome

Disease or syndrome	Drug class	Drug	Number of patients (n)
Delirium	Corticosteroids (oral and parenteral)	Prednisone	1
	Opioids	Tramadol	2
Dementia or cognitive impairment	Anticholinergics	Promethazine	1
	Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (z-drugs)	Zaleplon	1
History of falls or fractures	Antidepressants-SSRIs	Paroxetine	1
	Antipsychotics	Quetiapine	1
	Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (z-drugs)	zolpidem	1
History of gastric or duodenal ulcers	Aspirin	Aspirin	1
	Nonselective NSAIDs	Ibuprofen	1
Urinary incontinence (all types) in women	Estrogen (oral and transdermal)	Ethinyl estradiol	2
Benign prostatic hyperplasia	Strongly anticholinergic drugs	Homatropine eye drops and promethazine	1
Heart failure	NSAIDs	Paracetamol	1
	Thiazolidinediones	Pioglitazone	2
Total			16

The strength of recommendation for deprescribing these medications is strong. NSAIDs=Nonsteroidal anti-inflammatory drugs, SRI= Selective serotonin reuptake inhibitors

Twenty-seven patients were prescribed drugs as per the BEERS Criteria-3, i.e., ”PIMs to be used with caution in geriatric patients.” Frequently used medications included Tramadol, SSRIs, TCAs, antipsychotics, and diuretics. Distribution of PIMs under the above mentioned criteria is shown in Table 3.

Table 3.

Medications recommended for deprescribing as per criteria - 3 of the BEERS criteria-Potentially inappropriate medications to be used with caution in geriatric patients

Therapeutic category/class	Drug	Number of patients (n)
Antidepressants	SSRIs (paroxetine), TCAs (amitriptyline), TCAs (clomipramine)	4
Antiepileptics	Carbamazepine	1
Antipsychotics	Quetiapine, Risperidone	2
Synthetic opioids	Tramadol	8
Antibiotics	Trimethoprim-sulfamethoxazole	3
Sodium-glucose co-transporter 2 inhibitor	Dapagliflozin, Empagliflozin	4
Diuretics	Loop diuretics, Thiazides	5
Total		27

The strength of recommendation for deprescribing these medications is strong. SSRI= Selective serotonin reuptake inhibitors, TCAs= Tricyclic antidepressants

Twenty-one patients were prescribed drugs as per the BEERS Criteria-4, i.e., ”Potentially inappropriate drug-drug interactions that should be avoided in the elderly.” Examples included concurrent RAS inhibitors, opioids with gabapentinoids, poly-CNS-active drug combinations, and combinations involving lithium, phenytoin, or warfarin with known interactants. Distribution of PIMs under the above mentioned criteria is shown in Table 4.

Table 4.

Medications recommended for deprescribing as per criteria 4 of the BEERS criteria, potentially inappropriate drug-drug interactions that should be avoided in the elderly

Object drug or class	Interacting drug or class	Remarks	Number of patients
RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) or potassium-sparing diuretics (amiloride, triamterene)	Another RAS inhibitor or a potassium-sparing diuretic	Increased risk of hyperkaliemia	3
Opioids	Gabapentin, Pregabalin	Increased risk of severe sedation-related adverse events, including respiratory depression	1
Anticholinergic	Anticholinergic	Increases the risk of cognitive decline, delirium, falls, and fractures	1
Antiepileptics (including gabapentinoids), Antidepressants (TCAs, SSRIs, and SNRIs) Antipsychotics Benzodiazepines Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (i.e., “Z-drugs”) opioids Skeletal muscle relaxants	Any combination of ≥3 of these CNS-active drugs	Increased risk of falls and fractures with the concurrent use of ≥3 CNS-active agents	4
Lithium	ACEIs, ARBs, ARNIs	Increased risk of lithium toxicity	4
Phenytoin	Trimethoprim-sulfamethoxazole	Increased risk of phenytoin toxicity	2
Theophylline	Ciprofloxacin	Increased risk of theophylline toxicity	1
Warfarin	Amiodarone, ciprofloxacin, macrolides (excluding azithromycin) Trimethoprim sulfamethoxazole SSRIs	Increased risk of bleeding	4
Opioids	Benzodiazepines	Increased risk of falls and fractures	1
Total			21

The strength of recommendation for deprescribing these medications is strong. ACEIs=Angiotensin-Converting Enzyme inhibitors, ARBs=Angiotensin receptor blockers, ARNIs=Angiotensin receptor-neprilysin inhibitors, RAS=Renin-angiotensin system

Drug duplication was found in 11 patients. The most common duplications involved multivitamin combinations, RAS inhibitors, pain medications, anticholinergics, and corticosteroids. Distribution of PIMs under the above mentioned category is shown in Table 5.

Table 5.

Drug duplication, inappropriate over-the-counter medication categories and Inappropriate traditional medicines in polypharmacy prescriptions recommended for deprescribing

Drug duplications
Category/class	Drug	Number of patients (n)
Pain killers	Acetaminophen + Aceclofenac	2
Antihypertensives	RAS inhibitors (Enalapril, Telmisartan)	2
Anticholinergic	Promethazine, Homatropine	1
Steroids	Betamethasone, Dexamethasone	1
Multivitamins	Supradyn, Neurobion forte	5
Total		11
Inappropriate over-the-counter medication categories
Category of medication	Number of patients (n)
Pain relievers	9
Multivitamins	8
Laxatives	4
Antidiarrheal	3
Topical steroids	2
Nasal decongestants	1
Cough suppressants	7
Antacids	3
Total	37
Inappropriate traditional medicines
Primary complaint	Medicine	Number of patients (n)
Arthritis	Turmeric (C. longa), Boswellia (B. serrata)	7
Skin problems	Neem (A. indica), Aloe Vera (A. barbadensis)	3
Hair problems	Brahmi (B. monnieri), Amla (E. officinalis)	5
Constipation	Triphala, Castor oil (R. communis)	2
Diabetes/hyperglycemia	Amalaki (E. officinalis), Bitter melon (M. charantia)	4
Obesity/weight loss	Guggul (C. wightii), Green tea (C. sinensis)	1
Spondylitis	Ashwagandha (W. somnifera), Triphala Guggulu	2
Cold and cough	Trikatu, Ginger (Z. officinale)	3
Paralysis/stroke	Ashwagandha (W. somnifera), Gotu kola (C. asiatica)	1
Total		28

The strength of recommendation for deprescribing these medications is strong. E. officinalis=Emblica officinalis, C. longa=Curcuma longa, B. serrate=Boswellia serrate, A. indica=Azadirachta indica, A. barbadensis=Aloe barbadensis, B. monnieri=Bacopa monnieri, R. communis=Ricinus communis, M. charantia=Momordica charantia, C. wightii=Commiphora wightii, C. sinensis=Camellia sinensis, W. somnifera=Withania somnifera, Z officinale=Zingiber officinale, C. asiatica=Centella asiatica

Thirty-seven patients used inappropriate OTC medications. These included pain relievers (n = 9), cough suppressants (n = 7), multivitamins (n = 8), laxatives (n = 4), and other OTC products such as antidiarrheals and topical steroids. Twenty-eight patients used inappropriate traditional medications. Distribution of PIMs under the above mentioned category.

Across 131 polypharmacy prescriptions containing 215 PIMs, an average of 1.64 drugs were recommended for deprescribing. Considering a 10% increase in ADR risk per drug, the deprescribing initiative potentially led to an average ADR risk reduction of 16.4%.[13]

The average daily cost of a polypharmacy prescription was INR 51.92 (INR 1557.30/month). Deprescribing potentially reduced the monthly medication costs by INR 19.21 per prescription per day or INR 576.42 per prescription per month which is 37% of the original cost.

Discussion

This study offers a nuanced understanding of polypharmacy among the elderly, revealing that 47.27% of geriatric OPD patients met the criteria for polypharmacy. While this prevalence is lower than figures from rural regions and other South Indian hospitals, it remains significantly high, reflecting the persistent challenge of polypharmacy in geriatric care.[14,15] Instead, comorbidities – chiefly diabetes mellitus, hypertension, and osteoarthritis – emerged as the primary drivers of polypharmacy, corroborating findings from prior studies across India and globally.[14]

The WHO recommends that older adults should take an average of 1.3–2.2 medications. Applying this to multimorbid patients is clinically impractical; therefore, we focused mainly on the inappropriate polypharmacy, i.e., removing the “harmful excess” (PIMs) rather than adhering to an arbitrary number. Reducing the nonessential pill burden improves adherence to critical medications, thereby enhancing overall management. In our study, the average was 6.5 medications per prescription, which is consistent with findings from similar studies in elderly populations.[14] Notably, 71% of polypharmacy prescriptions contained at least one PIM, with the frequency of PIMs strongly correlating with both the number of comorbidities and the total number of drugs prescribed. Although the presence of multiple chronic conditions often justifies higher drug counts in older adults, the observed prescribing patterns suggest a tendency towards overprescribing, particularly with PIMs.[16]

Interpretation of PIM patterns revealed that a significant proportion (35%) of PIMs belonged to a category of the BEERS Criteria – Criteria 1: “Drugs that are potentially inappropriate regardless of diagnosis or disease in geriatric patients.” Nonselective NSAIDs emerged as a particularly concerning group in our study, given their well-established links to gastrointestinal bleeding, kidney damage, and cardiovascular complications in elderly patients.[17] Although many prescriptions included a co-prescribed proton pump inhibitor, this measure alone does not eliminate the risk, and in fact, often leads to a “prescription cascade,” further worsening Polypharmacy creating a vicious cycle.[17] Similarly, sulfonylureas like glimepiride continued to be widely used despite being flagged in the updated Beers Criteria due to their high risk of prolonged hypoglycemia in older adults.[12] In practice, however, glimepiride remains a staple in many diabetes prescriptions, suggesting a gap between guideline awareness and clinical implementation.[18]

Other commonly encountered PIMs, including anticholinergic antihistamines, nitrofurantoin, sliding-scale insulin, and estrogen therapies, further stress the complexity of geriatric pharmacotherapy. The consistent presence of such medications, despite established guidelines cautioning against their use, may reflect a gap in practitioner awareness or systemic inertia in adapting to evolving prescribing norms. This underscores the importance of continuous medical education and robust geriatric-specific clinical decision support tools.

Drug–disease interactions were another area of concern. While they comprised a smaller proportion (7.44%) of total PIMs, their potential for harm was significant. NSAIDs and thiazolidinediones in heart failure, corticosteroids and opioids in delirium, and anticholinergics in cognitive impairment pose grave risks.[12] Furthermore, medications such as SSRIs, Z-drugs, and antipsychotics were often prescribed in patients with fall histories, exacerbating their vulnerability.[12]

Medications used with caution, such as tramadol and thiazides, were frequently present in prescriptions. While not inherently inappropriate, these drugs require careful monitoring due to altered pharmacokinetics and dynamics in the elderly.[12] The associated risks of hyponatremia, hypokalemia, and CNS depression necessitate individualized risk–benefit analysis and regular follow-up.[12]

Drug–drug interactions (9.77%) and duplications (5.12%) of total PIMs further added to the complexity. A notable pattern involved concurrent use of RAS inhibitors with potassium-sparing diuretics or lithium, increasing the risks of hyperkalemia and lithium toxicity.[12] Moreover, drug duplications often resulted from consultations across multiple departments/specialties and the use of multiple branded formulations, highlighting the need for a centralized medication review process.

Equally significant was the extensive use of OTC and traditional medications, comprising 17.21% and 13.02% of total PIMs, respectively. OTC medications such as NSAIDs, multivitamins, and laxatives were commonly consumed without adequate understanding of their risks. Although no patient attributed adverse effects, several complaints could be indirectly linked to unsupervised OTC usage.[19] This silent burden emphasizes the role of community education and pharmacist involvement in geriatric medication safety.[20]

Traditional medicines, despite perceived benefits by the majority of users, posed unrecognized risks. Herbal preparations frequently interacted with allopathic prescriptions, leading to adverse symptoms requiring additional medications, thereby exacerbating polypharmacy.[21] The lack of regulatory oversight, standardization, and reporting on these remedies remains a major pitfall in elderly care.[21] This area warrants urgent attention through both patient education and physician inquiry into nonallopathic medication use.

A key component of our deprescribing process was patient engagement through clear, respectful communication. By explaining the reasons for stopping certain medications, addressing fears of symptom recurrence, and offering nondrug alternatives where appropriate, we helped patients feel heard and involved. Clinicians played an active role by participating in focused discussions and meetings to review each patient’s medication list, share their expertise, and collaboratively decide on safe and effective deprescribing steps. This led to noticeably better acceptance of deprescribing decisions. Evidence from previous studies shows that up to 92% of older adults are willing to stop one or more of their medications if advised by their doctor, provided the rationale is explained clearly.[22] Improved medication adherence was observed when deprescribing was presented as a collaborative decision rather than a top-down directive.[22] In our experience, patients appreciated the reduced pill burden, fewer side effects, and financial relief. For clinicians, this approach offered valuable insight into patient preferences, lifestyle, and medication behaviours; factors often overlooked in routine care. These findings support the growing understanding that deprescribing is most successful when done “with the patient” and “not just for the patient.”

Beyond reducing the pill burden and PIMs, Deprescribing also brought clear economic advantages. Reducing unnecessary and inappropriate medicines lowered the monthly medication bill by more than one-third (37%), which is a considerable relief for older adults managing on limited resources. In countries like ours, where healthcare costs are largely paid out-of-pocket, this financial saving can ease a major burden and improve access to essential medicines.[23] Similar cost-related benefits have been reported in other studies, where deprescribing interventions significantly reduced medication expenditure and avoided wasteful spending on ineffective therapies.[23,24] Simplifying prescriptions also reduced the hidden costs of polypharmacy, such as missed doses, extra consultations, and complications linked to inappropriate medication use.[24]

Following deprescribing, we expect the risk of ADRs to reduce by 16.4% - a strong indication of safer prescribing practices.[13] These results are in line with previous evidence showing that structured deprescribing reduces ADR-related hospitalizations and prevents medication-related harm.[24,25] For patients, this means fewer side effects and hospital visits, translating into better comfort and quality of life. For clinicians, it reaffirms that deprescribing is not merely about cutting down the pill count but a proactive, safety-enhancing intervention.

A major strength of this study lies in its comprehensive scope. The inclusion of patients from various departments and with a wide range of chief complaints added depth and diversity to the sample, allowing the findings to reflect a broad spectrum of clinical scenarios. This variety not only enriched the dataset but also strengthened the generalizability of the results to similar healthcare settings. Added to this, it not only evaluates prescription medications but also includes OTC and traditional therapies, providing a holistic picture of medication burden in the elderly. A key part of this approach was the effort to engage patients in the process of deprescribing; educating them about why certain medicines need to be discontinued, how it could benefit them, and what to expect next. This created a sense of trust and involvement, making them more open to deprescribing and improving adherence. From a clinician’s perspective, this offered valuable insights into the patient’s lifestyle, challenges, and preferences, which helped in personalizing care.

However, the study is not without limitations. The setting in a tertiary care hospital may not reflect practices in primary care or rural contexts. Moreover, the absence of long-term follow-up data limits conclusions about the sustained impact of deprescribing interventions. During the follow-up visits of the patients, we did not use any structured tool to measure changes in their attitudes or satisfaction levels with regards to deprescribing. This might have limited our ability to quantify the emotional or psychological impact of deprescribing. Further longitudinal studies are needed to assess the durability of deprescribing effects on patient outcomes, medication adherence, and quality of life.

Conclusion

This study highlights the high burden of polypharmacy and inappropriate medication use among the elderly, driven largely by multimorbidity, self-medication, and fragmented healthcare access. The results support the implementation of structured deprescribing protocols and regular medication reviews to enhance geriatric care. One of the most important findings was that deprescribing is most effective when patients are involved in the conversation. Simple explanations, reassurance, and offering lifestyle-based alternatives went a long way in improving acceptance and outcomes. Beyond strengthening trust, deprescribing also helped ease the financial strain of treatment and made therapy safer by reducing the likelihood of medication-related harm. Given these combined advantages, deprescribing should be integrated into routine clinical practice, particularly in geriatric and primary care settings. Future interventions must also consider OTC and traditional medicine use, which significantly contribute to hidden polypharmacy. Ultimately, optimizing geriatric pharmacotherapy requires a multipronged approach involving physicians, pharmacists, caregivers, and patients themselves.

An outline of this study has been depicted in Figure 6.

Figure 6.

Outline of the research study. Among 385 participants screened, 182 fulfilled the criteria for polypharmacy. These participants were taking a total of 1179 drugs, averaging 6.5 drugs per prescription. A total of 215 potentially inappropriate medications (PIMs) were identified across categories, and deprescribing reduced the average drug count to 4.86, with a 16.4% reduction in adverse drug events and a monthly cost saving of INR 576.42 per participant

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.