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础产辞耻迟听聽of people who are 75 years and older take five medicines or more. This is known as 鈥溾��. Many of these people are on more than ten medicines a day (hyperpolypharmacy).

It can be appropriate to prescribe multiple medicines for someone with complex or multiple illnesses if there is evidence of the benefits, and harms are minimised. But we know taking multiple medicines strongly increases the risk of unwanted side effects such as drowsiness, dizziness, confusion, falls and injuries and聽.

Older people may be taking medicines that are not working or no longer needed; medicines may have been prescribed to treat the side effects of other medicines (); other treatment options may be more suitable; or they may have difficulty taking the medicines.聽Reducing these聽inappropriate and unnecessary medicines聽in older people is one of the most important challenges of modern medicine.

For example, let鈥檚 consider Robert, a 60-year-old man who starts taking blood-pressure-lowering medicine to reduce his chance of having a heart attack or stroke. He tolerates this well for many years and continues taking the medicine, as his doctor told him he needs to take it for the rest of his life.

By the age of 80 he is on ten medicines for various conditions (including arthritis, reflux and sleeping problems) and starts to get dizzy spells. On occasions the dizziness has led to a fall, and his concerns about falling have made him less independent.

What can be done in Robert鈥檚 case?聽where medicines are selectively and carefully stopped (also called 鈥溾��) show reducing specific types of medicines, such as blood-pressure-lowering medicine,听聽without causing harmful withdrawal effects. In the case of medicines such as antidepressants or sleeping tablets, reduction聽聽of reducing the risk of falls and improving cognition.

However, discussions between doctor and patient about coming off medicines are聽not easy聽and there is little guidance on how to do it. We are used to talking about why medicines need to be started, but less familiar with stopping or reducing the doses of medicines.

The evidence for the benefit of many medicines is less clear for older patients as randomised controlled trials聽generally study聽with no other illnesses. This means, especially for older people, that聽聽versus harms聽depends on what is important to the individual patient.

Robert鈥檚 priority might be living independently by avoiding dizziness and reducing his risk of having a fall. He therefore may prefer to reduce his blood-pressure medicine. His friend James may be more concerned about avoiding death or disability from a heart attack or stroke. He therefore may prefer to continue his medication and accept he may experience dizzy spells as a result.

Biases in the way we think often influence decisions on medicine. Patients may not realise change is an option, doctors may incorrectly assume patients always want to聽, and older people may experience聽聽that make it more challenging for them to be involved in an informed decision. But all of these issues can be overcome with good communication.

Using Robert鈥檚 situation as an example, here are four steps to ensure an informed and聽.

1. You have options

Continuing, reducing the dose, or discontinuing blood-pressure medicine should all be identified as options to manage the problem of dizziness.

2. Discuss the harms and benefits

The likelihood of preventing a heart attack or stroke by continuing blood-pressure medicine versus preventing dizziness or falls by reducing or stopping the medicine should be discussed. This should take into account other medicines taken and the strength of the evidence for the relevant age group.

3. What does the patient want?

Robert鈥檚 concerns about reduced independence after a fall now, versus death or disability from a heart attack or stroke in the future, should be discussed. This includes talking about possible trade-offs between quality of life in the short term and life expectancy in the long term.

4. Make a decision

A decision about maintaining, reducing or stopping blood-pressure medicine should be made by Robert together with his doctor, carer and/or family, depending on who Robert wants to be involved. The decision made now can be changed later on.

If patients have any concerns about their medicines, experience troublesome symptoms or think a medicine may no longer be needed, they should talk to their GP or pharmacist about reviewing their medicines and discussing the potential for reducing or stopping. More information about medicines and older people is available on the聽.

Deprescribing, or carefully ceasing medicines, is not taking away care; it is a positive strategy that reduces avoidable harmful effects and can improve quality of life.

The article was originally published in聽聽by University of Sydney scholars聽,听,听听补苍诲听.