Fragmented Care, Fragmented Safety: Care Coordination and Deprescribing Strategies to Reduce Polypharmacy-Related Harm in Assisted Living—A Public Health Perspective

Background: Assisted living houses an older, frailer and more heavily medicated population than ever, yet is often regulated as a social and not a clinical setting with no on-site nursing requirement. Polypharmacy accumulates where medication oversight is thinnest. Objective: To map the extent, nature and distribution of research on medication safety in assisted living in the narrow sense, and where the evidence clusters and thins. Methods: In this scoping review, PubMed and Web of Science were searched (26 May 2026; window 2010–2025) and records screened against a strict two-gate rule: assisted living in the narrow sense, explicitly labelled and central, plus a central medication-safety or coordination concept. Residential-care and long-term-care populations fell outside it. Titles, abstracts and full texts were screened and charted thematically. Results: Twenty-two sources met the strict definition, drawn from four countries: the United States (13), Finland (6), Canada (2) and the United Kingdom (1). Five themes emerged, covering burden (4), safety (4), interventions (4), antimicrobial stewardship (4) and coordination and regulation (6). A further 11 comparison-context reports were kept separately. Every randomised trial was Finnish and came from one research programme. Conclusions: Assisted living has become a high-acuity medication environment without matching oversight. The setting-specific literature is real but sparse, and rigorous deprescribing and coordination trials remain scarce. The binding constraint is structural rather than pharmacological, a missing point of clinical accountability that is patterned by regulation, so closing the gap is as much a public-health task as a clinical one.