Received: 7 November 2023 Revised: 3 December 2023 Accepted: 16 December 2023

DOI: 10.1111/jgs.18756
Journal of the
COMMENTARY American Geriatrics Society

Polypharmacy, deprescribing, and trust in the

clinician–patient relationship

Columba Thomas MD 1 | Andrew B. Cohen MD, DPhil 2,3 |

2,3
Marcia C. Mecca MD
1
Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
2
VA Connecticut Healthcare System, West Haven, Connecticut, USA
3
Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA

Correspondence
Marcia C. Mecca, VA Connecticut Healthcare System, West Haven, Yale Geriatrics, 333 Cedar Street, P.O. Box 208025, New Haven, CT 06504, USA.
Email: marcia.mecca@yale.edu

Funding information
Health Resources and Services Administration Geriatric Workforce Enhancement Program, Grant/Award Number: U1QHP28745; National Institute
on Aging, Grant/Award Numbers: K76AG059987, P30AG021342, R24AG064025; Health Services Research and Development, Grant/Award Number:
IIR20-079; McDonald Agape Foundation

“Based on our experiences
with deprescribing in an
educational primary care
setting, we propose an
approach that focuses on
maintaining and enhancing
patients' trust in their
clinicians.”
Polypharmacy, the use of multiple medications, is asso-
ciated with an increased risk of adverse drug effects,
hospitalizations, and mortality in older adults—even
after adjusting for comorbid illness.1 Although no con-
sensus exists as to the number of medications at which
polypharmacy begins (≥5 is typical),1,2 efforts to develop
effective approaches to deprescribing are growing.3–7
Broadly defined, deprescribing is “the systematic pro-
cess of identifying and discontinuing medications in
instances in which existing or potential harms outweigh
existing or potential benefits.”6
In academic work, little attention has been devoted to
the pivotal role of trust between the patient and the cli-
nician in making this process successful. Based on our
experiences with deprescribing in an educational pri-
mary care setting,3 we propose an approach that
focuses on maintaining and enhancing patients' trust
in their clinicians.
Trust is of fundamental significance to the clinician–
patient relationship.8–11 When patients undergo depre-
scribing at the recommendation of their clinician, they
become vulnerable to future consequences and may find it
challenging to set aside their concerns about the changes
involved.12,13 In situations like this, patients' trust in their
deprescribing clinician may provide the assurance needed
to continue to engage in the plan of care.
Whereas a variety of definitions for trust exist,8–10,14,15
we propose a concise definition tailored to the clinician–
patient relationship: trust is the confidence that the clini-
cian has the relevant expertise and will be devoted to the
patient's well-being. Maintaining and enhancing patients'
trust through deprescribing require several elements:
(1) clinicians must establish with their patients mutual
motives for deprescribing; (2) they must consider and dis-
cuss potential deprescribing measures with sensitivity
toward their patients' individual circumstances and goals,
as well as the roles of other prescribers; and (3) they must

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2 COMMENTARY
align their recommendations with these circumstances,
goals, and respective roles (Figure 1). Lack of attention to
these elements risks undermining patients' trust in their
clinicians and introducing a barrier to ongoing care.
To explore the dynamics of trust when clinicians
engage with their patients in deprescribing, it is helpful
to consider a case. Mr. P is a 76-year-old man, recently
widowed, who presents to primary care for a 3-month
follow-up evaluation. He has a history of falls, mild
cognitive impairment, hypertension, heart failure,
atrial fibrillation, chronic kidney disease, insomnia,
and depression. Mr. P underwent recent evaluations by
his cardiologist and nephrologist, whose clinic notes
indicate conflicting recommendations on his blood
pressure regimen. Also, he reports that some of his
medications are too expensive for him.
Review of systems is notable for drowsiness in the
mornings. Mr. P reports “feeling down” lately over the loss
of his wife, but he has been sleeping well. A medication rec-
onciliation confirms that he is taking amlodipine, lisinopril,
metoprolol succinate, apixaban, clonazepam, sertraline, and
hydroxyzine. Physical examination is notable for orthostatic
hypotension and trace edema up to his ankles bilaterally.
MOTIVES FOR DEPR E S CRI B I N G
Establishing mutual motives for deprescribing provides
helpful context for conversations about potential changes
to Mr. P's medication regimen. It is not yet clear what he
understands and believes about the effects of his current
medications on his health.4,16 Clinicians might begin this
conversation by asking, “Could you tell me what you
think about your current medications?”
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F I G U R E 1 Maintaining and
enhancing patients' trust
through deprescribing require
these key elements. Lack of
attention to these elements risks
undermining patients' trust in
their clinicians and introducing
a barrier to ongoing care.
Mr. P's response to this initial question may give a
sense of his baseline level of trust in his clinicians' pre-
scribing and provide a window into how receptive he
will be to deprescribing. Mr. P's views on his medica-
tions may be informed by several considerations.
Regarding his recent drowsiness, he may suspect that
his medications are contributing to this. His specialists'
conflicting recommendations may be confusing to him
or lead him to wonder how necessary his medications
are, especially considering his difficulty affording some
of them. For these reasons, Mr. P may have concerns
about his medications, and even harbor some distrust
of his clinicians—although he did not state this.17
Despite Mr. P's difficulties, he may still believe in
the importance of his medications and trust that his
clinicians are indispensable for his present health.4 If
he fears adverse effects from “rocking the boat” by
adjusting his medications, he may be resistant to
deprescribing. If clinicians push too hard in such cases,
they may risk violating their patients' trust. In addi-
tion, if Mr. P perceives that taking away medications is
for cost-savings or a reduction in his care, he may resist
deprescribing.
A conversation about motives for deprescribing gives
the clinician an opportunity to provide education and
demonstrate concern for Mr. P's well-being—which, in
turn, may enhance his trust. It may be helpful to share
that when patients take approximately five or more medi-
cations, the risk starts to increase for different adverse
outcomes.2 This added risk seems to be due to the effects
of individual medications as well as the way medications
affect each other.1 Sometimes problems occur without a
prescribing error; hence, deprescribing is not meant to
call into question other clinicians' judgment.

COMMENTARY
POTENTIAL DEPRESCRIBING
MEASURES
Since Mr. P's cardiologist and nephrologist have offered
conflicting recommendations, it makes sense to address
this first and consider appropriate deprescribing mea-
sures. The dynamics of trust are complex here, especially
given the involvement of his specialists. Conversations
between Mr. P and his primary care clinician may have
downstream effects on his trust in his specialists. How-
ever, the primary care clinician is likely to have the most
comprehensive grasp of Mr. P's care plan—and thus is
uniquely positioned to take the lead in care decisions.18
Clinicians should approach this role sensitively, acknowl-
edging that better coordination may have avoided the
conflicting recommendations, but refraining from specu-
lation about other prescribers' decisions.
Review of the specialists' notes reveals that the cardi-
ologist recommended increasing amlodipine and lisinopril
for tighter blood pressure control, whereas the nephrologist
recommended decreasing amlodipine and keeping lisinopril
the same due to the risk of inducing kidney failure from
aggressive blood pressure lowering. Mr. P is unsure which
recommendations he followed, but his current medication
list suggests only that he increased lisinopril.
Given Mr. P's orthostatic hypotension, a reasonable
next step is to recommend that Mr. P resume his previous
doses of amlodipine and lisinopril. Here, “deprescrib-
ing” involves a decrease in the dosage of a medication
rather than discontinuation. To avoid undermining
Mr. P's trust in his specialists, the primary care clini-
cian might explain that it can be difficult to predict
how individuals will tolerate medication changes. The
concern about overtreating his high blood pressure is
that it may lead to kidney injury and additional falls.
The clinician should also update Mr. P's specialists
about this change in the care plan.
It may be risky to consider other deprescribing mea-
sures during this visit, given Mr. P's cognitive impairment
and recent confusion about medication changes. The cli-
nician should make a judgment call based on Mr. P's level
of motivation and understanding. An aggressive approach
that induces stress and confusion for Mr. P could function
against his trust. For instance, the clinician may defer to a
future visit a discussion about adjusting his sleep
medications—clonazepam and hydroxyzine—both of
which can cause morning drowsiness. Additionally, Mr. P's
recent bereavement may be affecting his mood, although he
denied changes in sleep patterns.
Finally, it is worth addressing with Mr. P the cost of
his medications. This effort may enhance Mr. P's trust by
demonstrating that his clinicians care about his financial
security. Of his current medications, likely the costliest is
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3
his blood thinner, apixaban. Mr. P may wish to discuss this
with his cardiologist, who could consider cheaper alterna-
tives to apixaban—weighing their effectiveness and safety
profile—or could even discontinue anticoagulation given
his history of falls and the risk of complications from
bleeding.
ALIGNING RECOMMENDATIONS
WITH PATIENTS' CIRCUMSTANCES
A N D GO A L S
As Mr. P's case shows, there are differences between what
deprescribing measures might function well in theory
and practice. In cases like this, it is helpful to approach
deprescribing with a focus on maintaining and enhanc-
ing patients' trust in their clinicians, rather than simply
devising a “reasonable” care plan. During Mr. P's clinic
visit, several issues arose—including conflicting special-
ists' recommendations, recent symptoms that increase his
fall risk, and his concerns about medication costs. Mr. P
appeared confused about his recent medication changes;
he may not be prepared to manage several additional
changes in one visit, especially given his cognitive
impairment and the lack of a family member to help him
carry out the care plan. Thus, it seems safest in Mr. P's
case to focus on the urgent matters, including the recent
change in his blood pressure treatment and his ortho-
static hypotension, and to defer further medication
changes to future visits.
Looking ahead, the clinician could ask Mr. P to iden-
tify a nearby family member who will help him with his
medications and future clinic visits. Involvement of a rel-
ative could enhance communication and ensure that
Mr. P can continue to grow in the trust he has for his cli-
nicians. Notably, family members and caregivers partici-
pating in his care also must trust that the clinician has
the relevant expertise and will be devoted to the patient's
well-being.
AUTHOR CONTRIBUTIONS
Study concept and design: all authors; acquisition of sub-
jects and/or data: all authors; analysis and interpretation
of data: all authors; and preparation of manuscript: all
authors.
C O N F L I C T O F I N T E R E S T S T A TE M E N T
The authors have no conflicts.
SP ONS O R 'S RO LE
The funding sources had no role in the design, methods,
subject recruitment, data collections, analysis, or prepara-
tion of the paper.

4 COMMENTARY
F I N A N CI A L D I S C L O S U R E
Dr. Thomas is supported by a grant from the McDonald
Agape Foundation. Dr. Cohen is supported by grants
from the National Institute on Aging (P30AG021342 and
K76AG059987). Dr. Mecca is supported by grants from
the National Institute on Aging (R24AG064025), VA
Health Services Research and Development Investigator
Initiated Research Program (IIR20-079), and Health
Resources and Services Administration Geriatric Work-
force Enhancement Program (U1QHP28745).
ORCID
Columba Thomas https://orcid.org/0000-0001-9395-
5380
Andrew B. Cohen https://orcid.org/0000-0001-9161-
8436
Marcia C. Mecca https://orcid.org/0000-0003-4392-
9963
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How to cite this article: Thomas C, Cohen AB,
Mecca MC. Polypharmacy, deprescribing, and trust
in the clinician–patient relationship. J Am Geriatr
Soc. 2024;1‐4. doi:10.1111/jgs.18756.