Older Patients are more likely to have multiple diseases and more complicated prescription regimens, necessitating the need to stop taking medications, a practice known as deprescribing . Polypharmacy increases the pill burden, which increases the risk of side effects [18, 19]. To reduce these major health problems and to optimize older patients' medication regimens, patients and healthcare providers should find mutual agreement, to use only a few medications if patients are willing to do so .
In our study, the median number of patients’ daily medications was three (range:1–6) which is similar to reports of Tegegn et al  and Liew et al  studies, but it was very low compared with other studies, such as  and  with a mean of 5.12 and 8.00 respectively. This difference might be due to access to medication, intake of prophylaxis, life expectance and the multi-morbidity difference between the low-income country, like Ethiopia and industrialized countries. Moreover, a narrative review indicated that polypharmacy is more prevalent, at 30–60% in people aged ≥ 65 years in high-income countries  unlike 34(17.4%) in our finding.
Our study revealed that although a larger number of patients were satisfied with their current medicines (49%), a significant number of them (85%) were willing to deprescribe their current medications if their doctors said. This might be also comparable to the previous studies conducted in Gonder, Ethiopia (81.6%), in Netherlands (88.0%), Quebec, Canada (84.5%) , in Singapore (83%) and in Malaysia (82.7%). However, it was higher than the study conducted in Nepal (54.7%) , and in Switzerland (74.3%)  and (77.0%) . But it was less than studies conducted in Netherland (92.0%) , in the UK (97.3%) and in Canada (93.0%) .
Our data also showed that older persons' willingness to discontinue taking medications extends to their caregivers as well (77.2%) which is higher than the study conducted in Malaysia (65.4%) and in Quebec, Canada (70.5%) but comparable to the study in the UK (80.5%) . But lower than the study in Singapore (87.1%). Moreover, the majority of our study participants (i.e. around 70% in both groups) also did not feel that ‘the physicians were being given up on them if physician recommended stopping medications’. This indicates that the patients are open to deprescribing, particularly if proposed by the physician.
When we look at the overall aggregate score, 81.3% of our current study participants are willing to stop one or more of their medications if the physicians said so. Conversely, a current systematic review  revealed that willingness to stop medication was significantly lower in low-middle-income countries (< 70% in Nepal and Malaysia) compared to high-income countries (> 85% in USA, Australia, European countries). Moreover, the same study reported no significant differences were observed when results were compared by global region or by healthcare setting but a high willingness (> 95%) was seen in the two studies conducted in an inpatient population . In current study, being satisfied with current medicine they receiving (i.e. 51% of the overall study participant) was not hinder them from the thought of stopping medication/s based on their physician recommendations. Being willing to stop one or more of their medications despite satisfaction with their medication was also confirmed by other authors too [14, 23] and . Therefore, the physicians should not rely solely on satisfaction with the medications they had been receiving which might not be sufficient to identify relevant deprescribing opportunities as we are also evident in our current finding.
In burden factors of rPATD, our study found that around half of older patients and caregivers felt that they spent a lot of money to buy their medicines. However, the majority of older patients (71.0%) were feeling that taking their medicines every day is convenient despite a higher willingness to stop taking medications. In older patients, economic considerations should always be factored into therapeutic decision-making and drug selection, as these patients are more likely to require prolonged care, polypharmacy, and lower output to cover their therapeutic costs . And deprescribe plays a significant role in cost-saving.
Our study found that a significant number of both groups, 71% of older patients and 67% of caregivers, perceived that they are taking the right medication. Thus why only 27% of older patients would like to try to stop one of their medications to see how they feel without it. Nevertheless, a comparatively higher number of participants, 65% of older patients and 52.2% of caregivers, would like dose reduction. This also reflects that older adults are open to discussion on deprescribing and even they seek opportunities to commence communication about deprescribing with healthcare professionals in routine care, clinicians in particular . Therefore, clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice [23, 29, 32] which also need to be tailored to individual patients as attitudes affected by characteristics of individual patients.
The response to concerns of the older patients and caregivers about stopping medications, our study found that most of the older patients (57%) and caregivers (64.2%) would not be reluctant to stop medications that they had been taking for a long period. However, the majority (69%) of the older patients would be worried about missing their medication’s future benefit if it stopped.
Hence, patients should also be counseled that some medications could be discontinued if they develop side effects, have no benefit, or are less important. Moreover, studies suggest that deprescribing could be safe, feasible, well-tolerated, and can lead to important benefits like reducing the risk of all-mortality in specific types of patients [34, 35] and fall .
More importantly, the majority of the study participants (≥ 56.5%) wouldn’t get stressed if changes are made to their medicines regimen, and they wouldn’t consider that doctors are giving up on them if they were to recommend stopping their medications. These reflect that patients were willing to have medications deprescribing and that older patients/caregivers trust their medical provider for deprescribing. As a result, the health care provider should proactive and build trust and relationships with their patients or caregivers for shared informed decision to initiate a process of a deprescribing [29, 32] by utilizing different standard guidelines such as beer’s criteria and STOPP/START criteria.
This study also found that only 30% of older patients know exactly what medicines they were taking which is similar to a study conducted by , and a majority of older patients and their caregivers (≥ 90%) would like to know as much as possible about their and their care recipients’ medicines. Additionally, the majority of the respondents (55% of the older patients and 69.5% of the caregivers) would like to ask their doctors, pharmacists, or other healthcare professionals if there is any misunderstanding about their medications. This implies that the older patients and caregivers wish to know about their medications, ask their healthcare provider, and want to involve in the clinical decision-making process . This is very important to patient-provider relationships, centered on the themes of trust and reliance on experts and shared decision making, which is imperative to better patient outcomes [14, 29]. Our study also confirmed that the concept of the patient-provider relationship plays a pivotal role as the majority of our study participants (≥ 68%) would like to be actively involved in medication decision-making with their health care providers. And a study also found that having a good relationship with physicians would facilitate the process of deprescribing . Thus, attempts to increase the level of involvement of caregivers and older adults in medication use could be an important facilitator of deprescribing [38, 39].
On aggregate factors score, the study participants are ambivalent regarding the perceived burden of the medications and the concerns regarding stopping one or more of their medications even though they believed that they had received appropriate medications. Besides, they are eager to be actively involved in medicine decision-making with their healthcare provider. Therefore health professionals should use a patient-centered approach to weigh the risks and benefits of every medicine against the particular goals of the elderly patient, to reduce the overall number of drugs administered . At the same time, the physicians need to aware about the risk of the patients being feeling well on their current medicines and being convinced that they need all their medicines, that might create barriers to deprescribing .
A study in Canada indicated that older adults and caregivers are disposed to undertake deprescribing, regardless of sociodemographic characteristics . However, in our study, except the perceived inappropriateness of medications the patient socio-demographics and clinical characteristics influence most of the attitudes towards deprescribing; age, sex, and a number of medications were highly associated with the perceived burden of medications. But only occupation (being a farmer) was associated with patients’ general concerns about stopping medications. Level of education (higher level) and having no comorbidity were associated with involvement factors. A study in Singapore also indicated that having higher educational background increases their seeking for involvement in medical decision-making that might relate to the health literacy status of the patients .
For the two general questions of rPATD in our study, having higher perceived concerns for stopping the medication and the perceived level of medication inappropriateness affect the patients' and/or caregivers' willingness to discontinue the medication and overall satisfaction with the medication respectively. Shrestha et al  and other author also reported as the perceived level of concerns regarding stopping medication affects willingness to deprescribe. Conversely, a study conducted by  showed that age and sex have no association with patients' attitudes towards deprescribing in opposite to Shrestha et al  where age was identified as one risk for willingness to deprescribe. Besides, Rozsnyai et al  identified no association of willingness to deprescribe with sex, age, or the number of medicines. On contrary, our study found that being younger age, female sex, and receiving a higher number of medicines were associated only with higher perceived burden scores. As a result, the health care provider may be able to decrease the patients’ concern about stopping medication by building trust with their patients and communicating evidence about the risks of medication use and discontinu[25, 26].
Strength and limitation
The study is the first in its kind in assessing attitudes of both older patients and caregivers towards deprescribing among older patients with chronic disease in Ethiopia. And we believe that, we generated knowledge that may be used as a base to educate future deprescribing actions and contribute to the implementation of shared decision-making in medication optimization activities. However, the results might need careful interpretation for generalizability as this study was conducted in a selected single hospital. So, further exploration might be needed to clarify whether the attitudes among older patients and caregivers in other parts of Ethiopia remain the same. Moreover, the attitudes and preference discordance between the older adults and caregivers could not determine as both were not paired. Besides, this study did not include the perspectives of the doctors, pharmacists and other concerned health professionals towards deprescribing that could have been helped us to gather more information about the topic.