DeprescribingHub.com - Interactive Deprescribing Audit & Resource Hub

Why Deprescribing is Crucial

Polypharmacy, defined as the concurrent use of five or more medications, presents a significant and growing challenge in older adults within Australian healthcare. This widespread issue leads to an elevated incidence of adverse drug events (ADEs), increased rates of hospitalisations, falls, confusion, delirium, frailty, and cognitive impairment. Beyond the sheer number of drugs, factors like "legacy prescribing" (medications continued indefinitely despite original intent) and the "prescribing cascade" (where an adverse effect is treated with another drug) actively contribute to the complexity and persistence of polypharmacy. Understanding these mechanisms is key to effective medication management.

9 in 10

Residents in Aged Care Facilities take at least 5 medicines daily.

40%

of older Australians (75+) are prescribed more than 5 medications.

250,000

Annual hospital admissions in Australia are due to medication-related problems.

Polypharmacy: Australia vs. OECD Average

Common PIM Categories (Illustrative)

Medication Class Distribution (Illustrative)

A Systematic Approach to Deprescribing

Effective deprescribing is a planned, patient-centered process. This 6-step framework, adapted from leading guidelines, provides a clear path for clinicians to follow.

Consider the Patient

Review goals of care, life expectancy, and overall health status in a shared decision-making context.

Review Medications

Conduct a Best Possible Medication History (BPMH) including all prescribed, OTC, and complementary medicines.

Identify Targets

Use tools like STOPP/START or Beers criteria to identify Potentially Inappropriate Medications (PIMs).

Prioritise for Cessation

Rank medications for deprescribing based on risk vs. benefit, starting with one drug at a time.

Implement & Monitor

Develop and execute a tapering plan. Monitor closely for withdrawal symptoms or return of conditions.

Document & Communicate

Update all records and clearly communicate changes to the patient, carers, and other healthcare providers (e.g., GP).

Interactive Audit Tool

Use this form to conduct a comprehensive deprescribing audit. Fill in the details for each patient to track interventions and outcomes. The data you enter will populate the dashboard below.

Deprescribing at a Glance: Your 6-Step Guide

A quick overview of the systematic approach to deprescribing. For more details, refer to "The Process" section above.

1 Consider the Patient's Goals

2 Review All Medications

3 Identify PIMs (Targets)

4 Prioritise for Cessation

5 Implement & Monitor

6 Document & Communicate

Learn More About The Process

Quick Guide: Common Medications for Deprescribing

Brief guidance on some frequently deprescribed medication classes. Always refer to full guidelines and patient context.

Antidepressants

**Why Deprescribe:** Risk of falls, sedation, hyponatremia, and withdrawal symptoms upon abrupt cessation.
**Key Considerations:** Gradual tapering is crucial to avoid severe withdrawal. Consider liquid formulations for precise dose reduction.
**Resources:** Refer to the University of Tasmania's work on liquid formulations and the Deprescribing.org guidelines.

Antipsychotics

**Why Deprescribe:** High risk of falls, sedation, cognitive decline, stroke, and extrapyramidal symptoms in older adults. Often used inappropriately for BPSD.
**Key Considerations:** Gradual tapering is essential. Prioritise non-pharmacological strategies for BPSD.
**Resources:** Consult Deprescribing.org guidelines.

Benzodiazepines

**Why Deprescribe:** Significant risk of falls, cognitive impairment, dependence, and withdrawal seizures.
**Key Considerations:** Very slow, gradual tapering is mandatory. Consider converting to a longer-acting benzodiazepine (e.g., diazepam) before tapering.
**Resources:** Refer to Deprescribing.org for guidelines.

Proton Pump Inhibitors (PPIs)

**Why Deprescribe:** Often continued as "legacy prescribing" without clear ongoing indication. Long-term risks include C. difficile infection, bone fractures, and kidney disease.
**Key Considerations:** Gradual tapering to avoid acid rebound symptoms. Re-evaluate ongoing need regularly.
**Resources:** Find guidelines on Deprescribing.org.

Opioids

**Why Deprescribe:** Risks include sedation, constipation, falls, dependence, and respiratory depression. Often ineffective for chronic non-cancer pain long-term.
**Key Considerations:** Gradual tapering is essential, often with pain management support. Focus on functional goals.
**Resources:** Consult the Australian Deprescribing Network's opioid guidelines.

Corticosteroids (Systemic)

**Why Deprescribe:** Long-term risks include adrenal insufficiency (with abrupt stop), osteoporosis, hyperglycemia, increased infection risk, and muscle weakness.
**Key Considerations:** Gradual tapering is crucial if used for more than a few weeks to allow adrenal recovery. Monitor for withdrawal symptoms.
**Resources:** Refer to general medical guidelines (e.g., Australian Prescriber) for tapering schedules.

Statins

**Why Deprescribe:** Benefits for primary prevention may diminish with limited life expectancy or declining functional status. Potential for muscle pain, weakness, and cognitive side effects.
**Key Considerations:** Discuss patient's goals of care. Consider stopping if life expectancy is less than 1-2 years or if experiencing significant side effects impacting quality of life.
**Resources:** Consult Deprescribing.org guidelines for statins.

Antihypertensives

**Why Deprescribe:** Risk of orthostatic hypotension, falls, and syncope, especially in frail older adults. Blood pressure targets may need to be less stringent with age or frailty.
**Key Considerations:** Gradual reduction of one agent at a time. Monitor blood pressure closely, especially orthostatic readings.
**Resources:** Refer to the NPS MedicineWise for general medication management principles.

Oral Hypoglycemics (e.g., Sulfonylureas)

**Why Deprescribe:** High risk of hypoglycemia, particularly with sulfonylureas, leading to falls, cognitive impairment, and hospitalisation. Glycemic targets may need to be relaxed in frail older adults.
**Key Considerations:** Prioritise patient safety over strict glycemic control. Gradual dose reduction or switch to safer alternatives (e.g., DPP-4 inhibitors, SGLT2 inhibitors if appropriate).
**Resources:** Consult Deprescribing.org guidelines for antihyperglycemics.

Digoxin

**Why Deprescribe:** Narrow therapeutic index, increased risk of toxicity (nausea, visual disturbances, arrhythmias) in older adults due to impaired renal function and drug interactions.
**Key Considerations:** Review current indication and patient's heart rhythm/failure status. Monitor digoxin levels and renal function closely.
**Resources:** Refer to the Australian Prescriber for updated guidance.

Anticoagulants/Antiplatelets

**Why Deprescribe:** Increased risk of major bleeding (intracranial, GI) in older adults, especially those with high fall risk, renal impairment, or concomitant use of other antiplatelets/NSAIDs.
**Key Considerations:** Balance bleeding risk against thrombotic risk. Engage in shared decision-making regarding patient's values and preferences for stroke/VTE prevention versus bleeding risk.
**Resources:** Consult the ACSQHC for medication safety resources.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

**Why Deprescribe:** High risk of gastrointestinal bleeding, renal dysfunction, hypertension, and cardiovascular events in older adults. Often used for chronic pain where non-pharmacological alternatives may be safer.
**Key Considerations:** Explore non-pharmacological pain management. Consider lowest effective dose for shortest duration, or switch to safer analgesics if appropriate.
**Resources:** Refer to NPS MedicineWise for pain management guidelines.

Urinary Incontinence Medications (Anticholinergics)

**Why Deprescribe:** Significant anticholinergic burden contributing to cognitive impairment, dry mouth, constipation, blurred vision, and increased fall risk. Many older adults have limited benefit.
**Key Considerations:** Consider non-pharmacological interventions (e.g., bladder training, pelvic floor exercises). Gradual tapering to avoid rebound symptoms.
**Resources:** Consult the NSW Therapeutic Advisory Group (TAG) for anticholinergic burden resources.

Muscle Relaxants

**Why Deprescribe:** High risk of sedation, dizziness, and falls in older adults due to central nervous system effects. Limited evidence of long-term efficacy for musculoskeletal pain.
**Key Considerations:** Often used for acute, short-term pain. Re-evaluate chronic use. Taper gradually to avoid withdrawal symptoms.
**Resources:** Refer to general prescribing guidelines like the Australian Prescriber.

Dementia Medications (Cholinesterase Inhibitors & Memantine)

**Why Deprescribe:** Limited or no benefit in advanced stages of dementia. Potential for side effects like nausea, vomiting, diarrhea, bradycardia (ChEIs), or dizziness (Memantine).
**Key Considerations:** Assess current cognitive and functional status. Engage patient/carer in discussion about goals of care. Gradual tapering is recommended.
**Resources:** Consult the Cognitive Decline Partnership Centre's deprescribing guidelines.

Bisphosphonates

**Why Deprescribe:** Long duration of action means benefits can persist after discontinuation. Risks include osteonecrosis of the jaw and atypical femoral fractures, though rare.
**Key Considerations:** Consider a "drug holiday" after 3-5 years for low-risk patients. Re-evaluate bone mineral density and fracture risk.
**Resources:** Refer to osteoporosis management guidelines from Australian professional bodies like RACGP.

Anticholinergics (General)

**Why Deprescribe:** Contribute to cognitive impairment, delirium, dry mouth, constipation, and increased fall risk. Many medications have anticholinergic properties (e.g., some antihistamines, TCAs, bladder medications).
**Key Considerations:** Review total anticholinergic burden. Identify and prioritise agents with high anticholinergic activity. Explore non-pharmacological alternatives.
**Resources:** Consult the NSW Therapeutic Advisory Group (TAG) for anticholinergic burden resources.

Alpha-blockers (for BPH)

**Why Deprescribe:** Risk of orthostatic hypotension, dizziness, and falls, especially in older men. Evaluate ongoing symptomatic benefit.
**Key Considerations:** Assess for symptomatic relief of BPH. Consider alternative management strategies if symptoms are mild or if side effects outweigh benefits. Taper gradually.
**Resources:** Refer to general prescribing guidelines like the Australian Prescriber.

H2 Receptor Antagonists (H2RAs)

**Why Deprescribe:** Similar to PPIs, often continued without clear long-term indication. Potential for B12 deficiency and drug interactions.
**Key Considerations:** Re-evaluate ongoing need for acid suppression. Consider step-down therapy or discontinuation if symptoms are controlled and no high-risk indication.
**Resources:** Consult Deprescribing.org for related guidelines.

Non-Benzodiazepine Hypnotics (Z-drugs: Zolpidem, Zopiclone)

**Why Deprescribe:** High risk of falls, fractures, cognitive impairment, and dependence in older adults. Short-term benefits often outweighed by long-term risks.
**Key Considerations:** Very gradual tapering is essential to avoid rebound insomnia and withdrawal symptoms. Prioritise non-pharmacological sleep hygiene strategies.
**Resources:** Refer to Deprescribing.org for hypnotic guidelines.

Tricyclic Antidepressants (TCAs)

**Why Deprescribe:** High anticholinergic burden, significant sedative effects, orthostatic hypotension, and cardiac conduction abnormalities in older adults.
**Key Considerations:** Gradual tapering is critical to avoid withdrawal symptoms. Consider safer antidepressant alternatives if ongoing treatment is needed.
**Resources:** Consult Deprescribing.org for antidepressant guidelines.

Antiarrhythmics (e.g., Amiodarone, Flecainide)

**Why Deprescribe:** Significant side effect profiles (e.g., thyroid, pulmonary, hepatic toxicity with amiodarone; proarrhythmia with flecainide) and potential for drug interactions. Benefits may not outweigh risks in older, frail patients.
**Key Considerations:** Re-evaluate the ongoing need for rhythm control versus rate control. Discuss patient's goals of care and quality of life. Requires specialist consultation.
**Resources:** Refer to the Australian Prescriber for guidance on complex cardiac medications.

Iron Supplements

**Why Deprescribe:** Often continued long-term without documented iron deficiency or anaemia. Can cause gastrointestinal side effects (constipation, nausea) and drug interactions.
**Key Considerations:** Review recent iron studies and full blood count. Discontinue if iron stores are repleted and anaemia is resolved/stable.
**Resources:** Refer to general practice guidelines (e.g., RACGP) for anaemia management.

Vitamins and Mineral Supplements

**Why Deprescribe:** Often taken without a diagnosed deficiency or clear benefit, contributing to pill burden and cost. High doses of some vitamins can be harmful.
**Key Considerations:** Review patient's diet and specific deficiencies. Discontinue if no clinical or laboratory evidence of deficiency. Educate on balanced nutrition.
**Resources:** Consult NPS MedicineWise for information on supplement use.

Antispasmodics (e.g., Hyoscine butylbromide)

**Why Deprescribe:** Many have anticholinergic properties, contributing to cognitive impairment, dry mouth, and constipation. Often used for non-specific abdominal discomfort.
**Key Considerations:** Re-evaluate the indication and efficacy. Explore non-pharmacological approaches for abdominal symptoms. Consider total anticholinergic burden.
**Resources:** Refer to the NSW Therapeutic Advisory Group (TAG) for anticholinergic burden resources.

Dopamine Agonists (for Parkinson's Disease)

**Why Deprescribe:** Can cause significant side effects in older adults, including orthostatic hypotension, hallucinations, impulse control disorders, and sedation.
**Key Considerations:** Requires careful assessment in consultation with a neurologist or movement disorder specialist. Gradual tapering is essential to avoid withdrawal symptoms and worsening Parkinsonian symptoms.
**Resources:** Refer to specialist guidelines for Parkinson's disease management.

1. Audit Details

Auditor Name

Audit Date

2. Patient & Admission Data

Patient ID

Age

Admission Date

Discharge Date

Reason for Admission

Primary Diagnosis

Frailty Score

Cognitive Score

3. Medications on Admission

✨ AI-Powered Insights

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4. Deprescribing Plan & Actions

5. Discharge Outcomes

Outcome Notes (e.g., QoL, Function, ADEs)

Follow-up Plan (GP/Community Pharmacy)

Patient/Carer Agreement

Patient/Carer Education Provided

Audit Dashboard

This dashboard visualizes the data from all submitted audits. It provides a real-time overview of deprescribing activities and outcomes.

Deprescribing Actions

Top 5 Targeted PIMs

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Key Resources & Tools

Explore these external resources for evidence-based guidelines, tools, and further information on deprescribing.