Grades are shown as the source states them. Neither source grades its recommendations: both are expert consensus. NICE NG56 (2016) and the American Geriatrics Society guiding principles (2012) could not be read in full here and are listed as further reading.
Key recommendations
Put shared, realistic treatment goals at the centre of care. They come from three things: an assessment of how the person's conditions, treatments, constitution and circumstances interact; priorities that reflect the person's most and least desired outcomes; and management tailored to reach those goals. Follow goals up at planned visits, and restart the process when conditions or circumstances change.
Abstract; The Ariadne principlesInternational expert workshop (Ariadne principles) 2014
Check for drug–drug, drug–disease and disease–disease interactions. Complex regimens raise the risk of adverse effects, and also of poor adherence and under-treatment.
Interaction assessmentInternational expert workshop (Ariadne principles) 2014
Assess every medicine list for both over-treatment and under-treatment, in the light of the person's goals, current function, life expectancy, values and preferences.
IntroductionEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Review medicines regularly as health and prognosis change — ideally every 6 months for frail or cognitively impaired older adults — and also when new symptoms or adverse drug reactions appear, or with advanced disease, severe dementia, extreme frailty or a move into long-term care.
The process of deprescribing; Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Prioritising does not automatically mean doing less: a careful assessment may reveal under-treatment, and some people do not experience several medicines as a burden.
DiscussionInternational expert workshop (Ariadne principles) 2014
Diagnosis
Keep a list of every current condition with its severity and impact, review the medicines actually being taken, list the other clinicians and therapists involved, and assess the overall burden of treatment.
Box 1International expert workshop (Ariadne principles) 2014
Look actively for anxiety, distress, depression and cognitive problems, including addiction and non-specific signs such as poor sleep, poor appetite or dehydration.
Box 1International expert workshop (Ariadne principles) 2014
Ask about social circumstances, finances, living conditions and support, health literacy, independence in daily activities and how the person copes.
Box 1International expert workshop (Ariadne principles) 2014
A new problem may come from an existing disease or its treatment. In the authors' worked example, fluctuating blood pressure could reflect Parkinson's disease or antihypertensives, and a cough could reflect worsening Parkinson's disease or a beta-blocker in someone with asthma.
Management of the presenting problem(s)International expert workshop (Ariadne principles) 2014
Suspect that a new symptom is an adverse effect of a recently started medicine, to avoid a prescribing cascade — prescribing a new drug to treat another drug's side effect.
Undergraduate trainingEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Investigations
Not covered in this summary — see the original guideline.
Treatment
For each diagnostic, therapeutic or preventive step, weigh the expected benefit against likely harm for this person: people at higher risk stand to gain more. Consider time to benefit against expected survival and the person's preferences.
Individualized management and follow-up; Box 1International expert workshop (Ariadne principles) 2014
Some conditions shift the balance. Kidney and liver failure narrow the therapeutic window of many drugs; heart failure adds fluid-retention risk to an anti-inflammatory for arthritis; and some diseases reduce a treatment's benefit, such as statins in people on dialysis.
Figure 3International expert workshop (Ariadne principles) 2014
Be more conservative when adding treatments, while staying alert to under-treatment. Check for interactions before and after each change, use community pharmacists and decision-support tools (judging clinical relevance), and simplify regimens with modified-release preparations or dosette boxes.
Individualized management and follow-upInternational expert workshop (Ariadne principles) 2014
Use structured tools — deprescribing guidelines, clinical decision support and lists such as STOPP/START — to find potentially inappropriate and potentially omitted medicines. In trials, tools that take account of the patient (STOPP/START, FORTA) did better than drug-only lists.
The process of deprescribing; Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Ask about the person's willingness to stop medicines rather than assuming reluctance: most older people say they would stop a medicine if their clinician advised it. Present deprescribing as a trial, and explain that a medicine can be restarted if needed.
Deprescribing settings; Undergraduate trainingEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Deprescribing can also cause harm — trials that stopped antihypertensives in older people showed more serious adverse events (not statistically significant) — so weigh each decision and monitor afterwards.
IntroductionEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Coordinate care across professionals with one clinician, usually the family physician, responsible for the whole picture, and keep appointments minimally disruptive. Agree follow-up to check goals and reassess interactions, and give safety-netting advice about side effects.
Individualized management and follow-up; Box 1International expert workshop (Ariadne principles) 2014
Record each medicine's indication, planned duration, rationale, treatment goal and adherence, and use standard documents to communicate changes — including tapering and monitoring plans — especially at hospital discharge.
Deprescribing settings; Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Important geriatric considerations
Two-thirds of adults over 65 take several medicines. In Europe adverse drug reactions cause about 8.6 million unplanned admissions a year, 70% of them in older people with polypharmacy, and medication-related harm is now regarded as a geriatric syndrome.
IntroductionEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Over time, goals often shift from disease-specific targets (such as blood glucose) to general ones such as function and quality of life, and preferences can change or reverse, so revisit them regularly.
Prioritization and patient's preferences; Reflections on the case of Mr. PInternational expert workshop (Ariadne principles) 2014
Consider the preferences and burden of informal carers and family, and involve them in agreeing goals where appropriate.
Box 1International expert workshop (Ariadne principles) 2014
Be aware of your own preferences, which may differ from the person's and may be shaped by outside pressures such as fear of legal or financial consequences.
Prioritization and patient's preferencesInternational expert workshop (Ariadne principles) 2014
Frail older people are under-represented in trials and functional outcomes are often not measured, so evidence for both prescribing and deprescribing in multimorbidity is often uncertain; discuss that uncertainty openly.
Clinical trials; Undergraduate trainingEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Family physicians should review medicines regularly with pharmacists. In complex cases, geriatricians, clinical pharmacologists or pharmacists can support the review or take responsibility for it, depending on the health system.
Organizing healthcare systems; Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
A structured, person-centred medication review, including deprescribing, should be a standard part of every comprehensive geriatric assessment.
Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Red flags
An admission related to medicines, new symptoms after a recent prescription, or a sudden change in health or circumstances: each should trigger a fresh review of conditions, medicines and goals.
The process of deprescribing; Deprescribing settingsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023
Recent updates
The 2023 EuGMS position paper calls for deprescribing guidance in disease-specific guidelines, national lists of potentially inappropriate medicines, and routine assessment of patients' willingness to deprescribe.
Organizational factors, implementation, and policy; Table 2European Geriatric Medicine Society (EuGMS) Special Interest Group on Pharmacology 2023