A review published in June worked through the clinical trials of deprescribing in adults over 65 with polypharmacy, covering studies from 2017 through this year. Its central finding is easy to misread in either direction. Deprescribing had a neutral effect on mortality and hospitalisation, which the authors read as evidence that it is safe. It improved quality of life and functional status, particularly when what came off the list were drugs acting on the central nervous system or carrying anticholinergic properties. On falls, the results were inconclusive.

The sentence that deserves to travel is the authors' own conclusion: rational medication selection, rather than the total number of medications, is what matters.

From the Lab to the Ledger

Two things change with age that make a stable medication list slowly stop being stable. Kidney function declines, usually without any symptom, so drugs cleared by the kidney accumulate at doses that were correct a decade earlier. And the brain becomes more sensitive to anything that dampens acetylcholine signalling, which is the pathway underlying attention and memory.

That second point is the one most people have never heard framed clearly. Anticholinergic effect is not a property of one drug class. It is a shared side effect spread across drugs for overactive bladder, older antidepressants, some antipsychotics, muscle relaxants, certain heart rhythm drugs, and the diphenhydramine in most over-the-counter sleep aids and night-time cold remedies. Each contributes a small amount. Researchers add them up as an anticholinergic burden score, and the total, not any single prescription, tracks with confusion, falls and dry mouth in older adults.

This is why the review's finding that CNS-acting and anticholinergic reductions produced the clearest gains is more useful than a general recommendation to take fewer pills. It identifies which pills.

The methodological problem that runs through this literature is worth naming, because it explains the inconclusive results. A trial of stopping a medication has to enrol people who are on it, which means people for whom it was once prescribed for a reason. Follow-up is usually months, while the harms being avoided accumulate over years. And the outcome that matters most, a fall that does not happen, is rare enough that these trial sizes cannot detect a moderate change in it. A neutral result on mortality in that setting means the intervention did not hurt anyone, which is genuinely reassuring and is not the same as proof that it helped.

Bio-Pipeline Ledger

Structured deprescribing reviews in adults over 65 with polypharmacy: supported by trial evidence for quality of life and function, neutral on mortality and hospitalisation, and inconclusive on falls.

Reducing anticholinergic and CNS-acting drug burden specifically: the subgroup where the benefits in these trials were clearest, and the most actionable version of the advice.

Explicit criteria lists that flag potentially inappropriate medications in older adults: established tools used by clinicians and pharmacists, useful for generating the conversation and not a substitute for judgement about an individual.

Pharmacist-led medication reviews: the delivery model behind much of the positive trial evidence, available through many health systems and often unrequested.

Over-the-counter antihistamines used as sleep aids: heavily anticholinergic, invisible on most medication lists because patients do not count them, and frequently the single easiest thing to remove.

Stopping a medication without supervision: not deprescribing. Several common drugs, including beta blockers, steroids, benzodiazepines and some antidepressants, cause real harm when stopped abruptly rather than tapered.

Proton pump inhibitors, long-term: the classic example of a drug started for a defined reason and continued indefinitely by inertia. Worth reviewing, and worth tapering rather than stopping.

The Clinical Reality Check

What is established is that a careful, supervised review of an older adult's medications is safe and improves how people feel and function, and that the gains concentrate in the drugs affecting the brain. That is a modest claim, and it is backed by nine years of trials rather than by intuition.

What is overstated is the idea that a long list is itself the problem. Several of the drugs on a typical list in later life are preventing exactly the events people fear, and dropping them to hit a lower number would be a straightforward harm. The review makes this point directly, and it is the part that gets lost when deprescribing is presented as decluttering.

The practical version is a request rather than a decision. Bring every prescription, every supplement and every over-the-counter item, including the sleep aid and the cold medicine, to one appointment, and ask which of these are still doing the job they were started for and whether any of them add to anticholinergic burden. A pharmacist can run that review where a physician's appointment is too short. Whatever comes off should come off one at a time, with a plan, and nothing should come off on the strength of an article.