Polypharmacy in older adults is one of the most underappreciated drivers of adverse health outcomes, hospitalizations, and functional decline — yet the systematic removal of unnecessary medications remains far more loosely defined in practice than its counterpart, prescribing. A comprehensive scoping review now quantifies just how wide that operational gap truly is, with implications for clinicians, care teams, and patients navigating complex medication regimens.
Drawing on 92 studies sourced from PubMed, Embase, and Web of Science, researchers evaluated deprescribing protocols against Reeve's five-step patient-centered framework — a widely referenced structure covering medication review, identification of cessation candidates, prioritization, planning withdrawal, and monitoring outcomes. While 98.9% of studies described at least some portion of the process, only a single study fulfilled all five steps with sufficient operational detail. The most documented phase was the mechanics of tapering or stopping a drug (present in 68.97% of studies), while the critical upstream decision — determining which medications are appropriate candidates for discontinuation — was adequately described in fewer than 8% of studies. Patient participation in shaping the deprescribing plan was inconsistently reported in nearly half of cases.
These findings expose a structural blind spot in geriatric pharmacology. Deprescribing has attracted growing institutional support as a patient safety intervention, particularly as polypharmacy — often defined as five or more concurrent medications — affects an estimated 40–50% of older adults in high-income countries and correlates with falls, cognitive impairment, and drug-drug interactions. Yet the evidence base appears to have advanced faster in principle than in practice. The near-total absence of standardized criteria for identifying which drugs to stop first is clinically significant: without reproducible decision logic, implementation depends heavily on individual clinician judgment, which varies substantially. This scoping review is primarily descriptive and does not assess patient outcomes, so the direct health impact of these gaps remains to be established. Still, as health systems build deprescribing into routine geriatric care, this review provides a useful diagnostic: the field needs less advocacy and more operational precision.