Health

Deprescribing in Older People: Practical Tools for Non-Medical Prescribers

Kurt

Polypharmacy remains one of the biggest challenges in the care of older adults. In UK primary care, it is common to see patients over 70 managing ten or more medications, prescribed by multiple specialists. While each prescription may once have been justified, together they can increase the risk of drug–drug interactions, adverse events, and hospital admissions.

For non-medical prescribers (NMPs) — nurse prescribers, pharmacists, and allied health professionals — deprescribing has become a core competence. This process involves critically reviewing medicines, stopping those that are no longer appropriate, and optimising treatment in line with patients’ goals. Several evidence-based tools are now available to support safe deprescribing, with major updates in the last two years.

STOPP/START v3 Criteria (2023)

The Screening Tool of Older People’s Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) criteria are widely used in Europe and the UK.

  • STOPP identifies potentially inappropriate medications, such as benzodiazepines in patients at risk of falls, duplicate drug classes, or NSAIDs without gastroprotection.
  • START highlights potential prescribing omissions, such as missing anticoagulation in atrial fibrillation or calcium/vitamin D in osteoporosis.

The 2023 update (version 3) significantly expanded the criteria, reflecting changes in prescribing trends and emerging safety evidence. For NMPs, STOPP/START v3 provides a structured checklist for medication review, helping ensure both over- and under-prescribing are addressed systematically.

AGS Beers Criteria (2023 Update)

The American Geriatrics Society Beers Criteria remains one of the most comprehensive lists of potentially inappropriate medications in older adults. The 2023 update includes:

  • Newly added drug–disease interactions.
  • Expanded cautions for certain antidepressants and anticholinergics.
  • Revised recommendations on glucose-lowering agents and cardiovascular drugs.

While developed in the US, Beers Criteria is increasingly relevant in the UK, particularly where legacy prescribing patterns persist. For NMPs, the Beers list is a practical reference for spotting high-risk drug classes during reviews, especially where UK guidance is less explicit.

NICE Multimorbidity Guidance

Polypharmacy is usually a consequence of multimorbidity. NICE NG56 emphasises moving away from a single-disease model, instead focusing on:

  • Aligning treatment with what matters most to the patient.
  • Actively stopping drugs with limited current benefit or disproportionate harm.
  • Integrating structured medication review into routine care, especially for those with frailty or functional decline.

For NMPs, this framework supports patient-centred deprescribing and underlines the importance of shared decision-making.

Practical Steps for NMPs

  1. Start with patient priorities: Explore what the patient values most — independence, reduced pill burden, or symptom control.
  2. Apply structured tools: Use STOPP/START v3 or Beers 2023 systematically, rather than relying on memory or intuition.
  3. Balance risks and benefits: Factor in frailty, prognosis, and time-to-benefit for preventive drugs.
  4. Taper where needed: Benzodiazepines, opioids, and PPIs may require gradual withdrawal. Always safety-net and review.
  5. Work across the MDT: Communicate with GPs, community pharmacists, and geriatric teams to embed deprescribing into care pathways.

Why It Matters in Primary Care

  • Reduced harm: Adverse drug reactions account for up to 10% of hospital admissions in older people.
  • Simplified regimens: Fewer medicines improve adherence and reduce administration errors.
  • Improved quality of life: Stopping unnecessary drugs may reduce falls, dizziness, or cognitive impairment.
  • System benefit: Effective deprescribing reduces costs and workload downstream in secondary care.

Training and Development

Deprescribing requires confidence, skill, and a structured approach. Non-medical prescribers who want to build competence in this area can benefit from practical, case-based training.

Explore the Confident Deprescribing: Practical Skills for Safer Prescribing in Older People course from Practitioner Development UK: Confident Deprescribing Course

This hands-on programme equips prescribers with strategies to apply STOPP/START v3, Beers 2023, and NICE guidance in real-world practice.

Conclusion

Deprescribing is central to safe, person-centred care in older adults. Tools such as STOPP/START v3, the 2023 AGS Beers Criteria, and NICE multimorbidity guidance give NMPs an evidence-based framework for making safe, consistent decisions. By integrating these into routine medication reviews, non-medical prescribers can reduce harm, simplify care, and improve outcomes for some of the most vulnerable patients in primary care.

References

  • O’Mahony, D. et al. (2023) ‘STOPP/START criteria for potentially inappropriate prescribing in older people: version 3’, European Geriatric Medicine, 14(1), pp. 1–22. doi:10.1007/s41999-023-00777-y.
  • American Geriatrics Society (2023) American Geriatrics Society 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 71(4), pp. 774–805. doi:10.1111/jgs.18372.