People with dementia face a higher risk of polypharmacy and potentially inappropriate medication use compared to those without cognitive impairment.¹ Deprescribing has been proposed as a promising strategy to prevent iatrogenic harm, provide goal-concordant care, and improve health and quality of life for this vulnerable population.² Yet, how best to implement deprescribing, particularly for individuals with dementia, is unknown. Deprescribing intervention trials have had underwhelming results. Pragmatic interventions that are effective under daily practice conditions are needed.

In this issue of JAMA Internal Medicine, Singh and colleagues³ describe DPRESCRIBE-AD, a large, pragmatic, randomized clinical trial of a mailed patient/caregiver and prescriber educational intervention to reduce the use of high-risk medications among individuals with dementia. The researchers randomized patients with dementia from 2 national health plans to 1 of 3 arms: (1) a mailing to both the patient and their prescribing physician of individualized educational materials; (2) a mailing to the physician only, including deprescribing algorithms and tapering guides; or (3) usual care. The primary outcome was the dispensing of high-risk medications, including antipsychotics, sedatives/hypnotics, and strong anticholinergics, during a 6-month observation period. During the 6-month observation period, the authors found no difference between groups in the likelihood of discontinuation or dose reduction of any of the targeted classes. Also, no differences were found between groups in the secondary outcomes, including dose reduction, prevalence of polypharmacy, health service utilization, or inpatient mortality.