The research, led by pharmacist-researcher Aili Langford of the University of Sydney and Monash University’s Centre for Medicine Use and Safety, together with colleagues including deprescribing specialists Barbara Farrell of the Bruyère Research Institute in Ottawa, Wade Thompson of the University of British Columbia, and Emily Reeve of Monash University, involved in-depth interviews with 24 Australian healthcare professionals. The sample comprised ten medical practitioners—specialists spanning cardiology, clinical pharmacology, emergency medicine, general practice, geriatrics, nephrology, and psychiatry—alongside nine pharmacists and five nursing professionals, recruited across five Australian states and territories through professional organizations, social media, and the Australian Deprescribing Network. Between March and October 2024, participants completed semi-structured interviews lasting 33 to 56 minutes, in which they dissected real deprescribing recommendations drawn from published guidelines, ranked deliberately varied versions of the same recommendation, and explained what would make them follow such advice at the bedside. The team then analyzed the transcripts with thematic framework analysis, deductively mapping the data onto the Guideline Language and Format Instrument, or GLAFI—a validated tool that specifies how the wording, structure, and layout of guideline recommendations determine whether clinicians adopt them or abandon them—while remaining alert to themes the instrument could not capture.

The stakes are anything but academic. Deprescribing—the clinician-supervised process of tapering or stopping medications that are inappropriate or no longer necessary—remains uncommon, while the global prevalence of potentially inappropriate medication use continues to climb. Single-disease guidelines, which dominate clinical practice, routinely fail to account for older adults living with multiple conditions, generating stacks of disease-specific recommendations that can cumulatively promote polypharmacy, drug interactions, and medication-related harm. Class-specific deprescribing guidelines do exist for benzodiazepines, proton pump inhibitors, antipsychotics, and antihyperglycemic agents, among others, but their advice has never been routinely woven into mainstream treatment guidelines. A recent scoping review by the same research group found that only two percent of evidence-based deprescribing recommendations were supported by high-certainty evidence—a stark measure of the evidentiary hole that guideline developers are being asked to write their way out of.

The first and most striking finding was a double standard. Participants consistently described deprescribing as a distinct, more complex, and higher-risk clinical activity than initiating a drug, and consequently demanded far more from any recommendation telling them to do it. They wanted the full decision logic spelled out—who is suitable for deprescribing, who is responsible, which medications, when, and why—but above all, how: explicit tapering regimens, monitoring parameters, co-interventions, and strategies for engaging patients in the conversation. “With deprescribing, it’s much more common than in prescribing to have to work out complex regimens…a little bit of handholding would definitely make someone more comfortable,” one physician told the researchers. GLAFI’s content checklist asks developers to state the action to be performed, by whom, for whom, and under what conditions, yet stays silent on these operational mechanics—the precise gap participants kept flagging. The authors argue the instrument itself will need extending for de-implementation, the deliberate withdrawal of established practices, which poses challenges that implementation frameworks built for rolling out new interventions were never designed to handle.

Stopping a medication also collides with deeply ingrained clinical psychology. Participants summarized the prevailing mentality bluntly: “adding things is doing good, taking things away is doing bad.” Because deprescribing is rarely incentivized in practice settings while prescribing is reinforced by clear guidance, workflow defaults, and entrenched habit, clinicians default to continuation—a pattern the researchers frame as clinical inertia. To counter it, participants favored direct, active-voice language of the form “we recommend A for B” over hedged phrasing like “consider this,” paired with explicit statements of the relative advantage of stopping, whether the benefit of deprescribing or the harm of continued use. Perceived legal exposure sharpened the reluctance: “It takes balls to deprescribe something that someone’s been on for a long time,” one physician admitted. And because deprescribing typically aims to avert future harm rather than deliver immediate benefit, the persuasive framing that props up prescribing recommendations is intrinsically harder to construct for the reverse maneuver.

Evidence, or the perceived absence of it, compounded the hesitancy. Many participants assumed deprescribing recommendations rest on expert consensus rather than robust trials—”it would be some well-intentioned group of clinicians coming up with what seems reasonable,” in one physician’s words—and several said weak, low-certainty recommendations were so off-putting that they would rather the evidence ratings be omitted entirely, even though that would violate current best practices in guideline development. The researchers argue this reflects a misunderstanding of what evidence ratings mean rather than a genuine design flaw, and calls instead for plain-language interpretation of GRADE-style ratings and targeted clinician education. Participants also exposed a striking double standard: prescribing recommendations built on trials conducted in younger, healthier populations are applied to older, more complex patients without question, while deprescribing advice lacking direct evidence is met with suspicion. Some argued that the absence of evidence for a drug’s ongoing benefit should itself justify stopping it, and that guidelines should distinguish “evidence of no benefit” from “no current evidence of benefit” so clinicians can judge for themselves—while still anchoring decisions in patient goals and preferences rather than rigid evidence thresholds.

The second theme captured a tension every guideline writer will recognize: clinicians want recommendations that are simultaneously succinct and complete. Ambiguous verbs were a particular worry. Terms such as “de-escalate,” “taper,” and “withdraw” leave it unclear whether dose reduction, abrupt cessation, or both are intended—a gap that can translate directly into harm when a drug requiring gradual weaning is stopped cold. “Taper slowly means nothing to anybody. Slowly for one person is a day and another person is a month…I think it’s quite easy for something like this to be misinterpreted or misapplied,” one pharmacist explained. Participants called for standardized, precise terminology—for example, “discontinue”—supported by glossary definitions, and they generally praised bullet points, color coding to signal evidence strength, and clinical algorithms that strip cognitive load from dense text and speed up decisions in time-poor environments.

Yet the same participants, when shown fully detailed step-by-step recommendations, judged them long, cumbersome, and overwhelming—text that nobody would actually read in a busy clinic. Recommendations offering multiple tapering regimens and co-intervention options triggered decision fatigue, delaying or deferring choices altogether. Intriguingly, some participants defended a degree of deliberate ambiguity, arguing that overly directive instructions risk a one-size-fits-all approach that tramples individual patient goals, while others complained that open-ended guidance left them feeling unsafe making the call. “The guidelines are meant to be guidelines, right? They’re meant to be giving you a direction. When it’s kind of open, I don’t feel good about making that call,” one physician said, while another bristled at the prospect of a “cookbook of medicine.” The authors suggest the resolution lies in flexibility of format rather than ambiguity of language: layered resources combining comprehensive technical documents, concise clinical tools, and plain-language summaries, plus multiple tailored options where the optimal strategy is genuinely uncertain.

Placement proved equally consequential. Some clinicians wanted deprescribing advice co-located with prescribing recommendations, so that the question of eventual withdrawal surfaces at the very moment of initiation, shifting deprescribing from a reactive response to adverse events—a fall, a hospitalization—toward proactive planning. “You might be prescribing it with no thought or intention of deprescribing it. But if you see that at the bottom of the article…you’re like, oh, hang on…I need to plan to wean this,” one physician reflected. Others preferred a standalone deprescribing section, reasoning that clinicians rarely open a hypercholesterolemia guideline to ponder statin withdrawal and that a dedicated section can hold broader principles and patient-conversation strategies beyond medication-specific advice. There was consensus, however, that paper alone is not enough: deprescribing advice must be embedded in national medicine handbooks, formularies, and prescribing and dispensing software, delivered as context-sensitive, patient-data-driven prompts engineered to avoid the alert fatigue that buries clinicians under notifications. Participants even envisioned artificial intelligence systems cross-referencing prescribing behavior against guidelines in real time, reducing reliance on external documents altogether.

Synthesizing the themes, the team distilled seven implementability design principles for deprescribing recommendations: specify the full decision logic—who, what, when, why, and how; use active, directive language with harmonized verbs; counteract clinical inertia with positive framing that states the relative advantage of stopping; standardize terminology and define it in a glossary; communicate the strength and certainty of evidence clearly, with plain-language interpretation; visualize information through bullet points, flowcharts, and algorithms; and place recommendations where clinicians will actually act on them, whether alongside prescribing guidance, in a dedicated section, or within digital workflows. The findings have already informed an international clinician survey designed to test preferred content, format, and terminology across a broader sample. The authors acknowledge the study’s limits—a qualitative design, an Australian volunteer sample, and analysis led by researchers with pharmacy backgrounds—while arguing the principles target universal features of clinical cognition, from cognitive load to the appetite for clear, directive guidance. If they hold up, guideline developers finally have a concrete recipe for writing the half of prescribing that has gone unwritten—a step that could shrink the burden of medications patients no longer need, before another 92-year-old like the nurse participant’s “Dot,” who fell while taking “a truckload of anti-hypertensives,” pays the price for medicine’s silence.

Deprescribing, defined as the process of tapering or stopping medications that may no longer be beneficial or may be causing harm, is crucial for the elderly population, particularly those in nursing homes. With age comes an increased likelihood of multiple health conditions, which often results in patients being prescribed numerous medications. However, this extensive medication regimen can lead to complications. Therefore, understanding the factors that support or hinder deprescribing practices is essential for promoting better health outcomes for these vulnerable patients.

The study conducted by Makan and colleagues engaged elderly care specialists in focus group discussions to explore their perceptions and experiences related to deprescribing in nursing homes. Participants included a diverse range of healthcare professionals, comprising nurses, physicians, pharmacists, and geriatricians. This multifaceted approach allowed for a richer understanding of the various viewpoints and experiences surrounding the topic. One key finding highlighted that while many specialists recognize the importance of deprescribing, there are systemic barriers that often impede their efforts.

One of the most significant barriers identified in the study was the lack of adequate evaluation protocols tailored for deprescribing. The absence of standardized guidelines leaves healthcare professionals uncertain about when to consider reducing or discontinuing medications. This gap often leads to a reliance on established prescribing habits, rather than evidence-based decision-making. Moreover, the concerns about potential negative outcomes associated with deprescribing—such as the risk of withdrawal symptoms or the return of previously managed conditions—serve as a deterrent. Such apprehensions reinforce the necessity for developing rigorous clinical guidelines that provide clear pathways for safe deprescribing practices.

Another critical enabler emerged from the study: the role of interprofessional collaboration. Specialists who worked closely with colleagues across various disciplines reported a more supportive environment for discussing medication management. Regular team meetings to review patient medications created an atmosphere where concerns regarding polypharmacy could be openly addressed, fostering a culture of learning and improvement. Such collaboration can significantly enhance the quality of care, as it ensures that all team members are on the same page regarding patient needs and treatment plans.

Patients and their families also play an integral role in the deprescribing process. The focus group revealed that having open lines of communication with patients and their caregivers can facilitate better understanding and acceptance of medication changes. Health care specialists noted that when they involved patients in discussions about their medications—explaining the potential risks and benefits—they were more likely to gain cooperation and trust. This collaborative approach not only honors patient autonomy but also aligns treatment with the patients’ values and preferences.

Despite recognizing the benefits of involving patients and families, many specialists indicated that time constraints significantly hindered their ability to engage in such meaningful conversations. The fast-paced nature of nursing home environments often leaves little room for in-depth discussions about medication management. This highlights the need for systematic changes in time allocation and workflow to better incorporate patient-centered care into daily practices. Healthcare facilities must prioritize training and support for staff to ensure they can dedicate sufficient time to these crucial interactions.

Additionally, the research pointed to the role of education in empowering care specialists. Continuous professional development and training sessions focused on deprescribing principles could equip healthcare professionals with the necessary skills and confidence to undertake this task effectively. Familiarizing staff with successful deprescribing strategies and real-life examples can foster a stronger commitment to optimizing medication regimens for elderly patients. This educational aspect is paramount, especially as more specialists enter the field and grapple with the complexities of geriatric pharmacotherapy.

Importantly, the study underscores that deprescribing should not be viewed as a one-time event but as an ongoing process. Patients’ health statuses, goals of care, and medication efficacy should be periodically reassessed to ensure treatment remains appropriate and beneficial. Healthcare providers must adopt a proactive approach to medication management that emphasizes regular reviews, rather than waiting for an adverse event to trigger a re-evaluation of the treatment plan.

The implications of this research extend beyond the nursing home walls. As the global population ages, the challenges of medication management in elderly care will only become more pronounced. Policymakers and healthcare leaders must prioritize initiatives that promote safe prescribing and deprescribing practices as integral components of elder care. This includes advocating for research funding, establishing guidelines, and creating supportive regulatory frameworks that recognize the unique needs of this demographic.

Moreover, the findings serve as a reminder of the importance of a patient-centered approach in healthcare. By acknowledging the voices of both care specialists and patients, we move towards a more collaborative model that ultimately seeks to empower those who are often disenfranchised in their care journeys. Incorporating all stakeholders in discussions about medication management not only enhances transparency but also fosters stronger relationships that are key to successful healthcare interventions.

As we reflect on the findings of the focus group study, it’s clear that addressing the barriers to deprescribing is vital to enhancing the quality of care for elderly patients in nursing homes. The awareness of the importance of medication management is growing, but a collective effort is necessary to turn acknowledgment into action. By drawing on the insights provided by Makan and colleagues, we can work towards creating an environment that not only encourages deprescribing practices but also champions the health and autonomy of our aging population.

Ultimately, the quest for improved elderly care through effective deprescribing practices is a crucial step towards empowering both patients and healthcare providers. As the discussion continues, we must remain committed to fostering an adaptable, informed healthcare system that prioritizes the well-being of the elderly, ensuring they receive safe, effective, and personalized care tailored to their unique needs and circumstances.

Subject of Research: Barriers and enablers to deprescribing in elderly care.

Article Title: Barriers and enablers of elderly care specialists towards deprescribing practices in the nursing homes: a focus group study.

Article References:

Malek Makan, A., Lee, M.C., van Hein, H. et al. Barriers and enablers of elderly care specialists towards deprescribing practices in the nursing homes: a focus group study.
BMC Health Serv Res 25, 1466 (2025). https://doi.org/10.1186/s12913-025-13630-8

Image Credits: AI Generated

DOI: https://doi.org/10.1186/s12913-025-13630-8

Keywords: deprescribing, elderly care, nursing homes, medications, interprofessional collaboration, patient-centered care, healthcare challenges, polypharmacy.