What deprescribing recommendations based on the Beers criteria should a psychiatric mental health nurse practitioner follow for a 65‑year‑old patient taking five or more concurrent medications?

Beers Criteria Deprescribing Recommendations for PMHNPs Managing Polypharmacy in Older Adults

For psychiatric mental health nurse practitioners managing patients ≥65 years with polypharmacy (≥5 medications), prioritize immediate deprescribing of benzodiazepines, anticholinergics, and antipsychotics, while avoiding concurrent use of three or more CNS-active medications, as these pose the highest risk for falls, cognitive impairment, and mortality. 1

Priority 1: CNS-Active Medication Reduction

Avoid Concurrent Use of ≥3 CNS Agents

The 2019 AGS Beers Criteria explicitly warns against combining three or more CNS-active drugs (antidepressants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, antiepileptics, opioids) due to dramatically increased fall risk and cognitive impairment 1. Count all CNS medications currently prescribed and immediately develop a tapering plan if the total is ≥3.

Benzodiazepine Deprescribing (Highest Priority)

• Avoid all benzodiazepines and Z-drugs (zolpidem, zaleplon) in older adults due to cognitive impairment, falls, fractures, and addiction risk 1, 2
• Long-acting agents (diazepam) carry the highest risk; even moderate-acting agents (lorazepam, clonazepam) should be tapered 2
• Use the EMPOWER taper protocol: Provide patient education about risks, then implement gradual dose reduction over many weeks to prevent withdrawal 2
• Success rate: 27% complete discontinuation vs 5% in controls when using structured education and tapering 2
• Alternative approaches: Cognitive-behavioral therapy, problem-solving therapy, or consider short-term use of antidepressants during taper (though evidence is limited) 2

Antipsychotic Deprescribing

• Avoid antipsychotics for behavioral symptoms of dementia - this is off-label use without FDA approval and carries a black box warning for increased mortality 2
• Typical agents (haloperidol, chlorpromazine) and atypical agents (quetiapine, risperidone, olanzapine) all worsen cognitive function and increase stroke risk 2
• First-line alternatives: Redirection techniques, environmental modifications, addressing underlying causes (pain, infection, constipation) 2
• If antipsychotics must be used for severe agitation with risk of harm, use lowest dose for shortest duration with frequent reassessment

Anticholinergic Medication Elimination

• Immediately discontinue: Diphenhydramine, hydroxyzine, cyclobenzaprine, metaxalone, oxybutynin 2
• These cause delirium, cognitive slowing, urinary retention, constipation, falls, and vision impairment 2
• Common pitfall: Over-the-counter sleep aids often contain diphenhydramine - educate patients to avoid these 2

Priority 2: Critical Drug-Drug Interactions to Avoid

Never Combine:

• Opioids + benzodiazepines: Increased respiratory depression and death risk 1
• Opioids + gabapentinoids (gabapentin, pregabalin): Avoid unless actively transitioning from opioid to gabapentinoid 1
• Warfarin + TMP-SMX or macrolides (except azithromycin): Increased bleeding risk 1
• Warfarin + ciprofloxacin: Increased bleeding risk 1
• Phenytoin + TMP-SMX: Phenytoin toxicity 1

Potassium-Increasing Drug Combinations

Avoid combining ACEIs/ARBs with TMP-SMX, especially in patients with reduced kidney function - risk of life-threatening hyperkalemia 1

Priority 3: Disease-Specific Medication Avoidance

Heart Failure

• Avoid NSAIDs (ibuprofen, naproxen, indomethacin): Worsen heart failure, hypertension, kidney disease 1
• Avoid thiazolidinediones: Cause fluid retention and worsen heart failure 1
• Avoid nondihydropyridine CCBs (diltiazem, verapamil): Risk of bradycardia and worsening heart failure 1

Cognitive Impairment/Dementia

• Taper cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in advanced dementia - lack long-term benefit and cause nausea, vomiting, diarrhea, nightmares, bradyarrhythmias 2
• Safe to discontinue when perceived lack of benefit 2

Priority 4: Systematic Deprescribing Approach

Step 1: Medication Reconciliation

Obtain accurate list of what patient actually takes (not just what's prescribed) - check pill bottles, fill dates, pill boxes 2

Step 2: Assess Each Medication

For every medication, ask:

• Is there a clear indication?
• Does benefit still outweigh risk given patient's current functional status and goals?
• Is it a Beers Criteria high-risk medication?
• Are there drug-drug or drug-disease interactions?
• Is the dose appropriate for kidney function?

Step 3: Prioritize Deprescribing Targets

1. Medications causing current symptoms (sedation, falls, confusion)
2. Medications with no clear ongoing indication
3. Beers Criteria high-risk medications (benzodiazepines, anticholinergics, antipsychotics)
4. Duplicate therapies or medications with additive toxicity
5. Medications where goals of care have changed (e.g., tight glycemic control in advanced dementia)

Step 4: Implement Gradual Tapering

• Never abruptly stop: Benzodiazepines, antidepressants, antipsychotics, opioids, gabapentinoids
• Taper over weeks to months depending on duration of use
• Monitor for withdrawal symptoms and rebound effects

Priority 5: Additional PMHNP-Specific Considerations

Antidepressants

• SSRIs/SNRIs increase hyponatremia risk - monitor sodium levels 1
• Tramadol also increases hyponatremia risk 1
• TCAs have strong anticholinergic effects - avoid in older adults 1

Mood Stabilizers

• Lithium requires close monitoring of kidney function and levels - aging reduces clearance 2
• Valproate increases fall risk and cognitive impairment

Supplements

• Discontinue multivitamins and herbal supplements unless specifically indicated (exception: vitamin D) 2
• No evidence of benefit for mortality, cardiovascular disease, cancer, or cognitive function 2
• Contribute to medication burden, cost, and potential drug interactions 2

Critical Pitfalls to Avoid

1. Don't assume all medications are still needed - many are continued indefinitely without reassessment 2
2. Don't ignore over-the-counter medications - anticholinergic sleep aids are commonly used 2
3. Don't deprescribe in isolation - involve patient, caregivers, and other providers in shared decision-making 2
4. Don't forget to adjust for kidney function - many psychiatric medications accumulate with declining renal function 1
5. Don't continue medications "because the patient has been on them for years" - duration of use increases risk of dependence and withdrawal but doesn't justify continuation 2

Monitoring After Deprescribing

• Assess for withdrawal symptoms weekly during taper
• Monitor for return of original symptoms requiring treatment
• Reassess fall risk, cognitive function, and functional status at 1-3 months
• Document rationale for deprescribing and patient/caregiver agreement in medical record

The goal is not simply reducing medication numbers, but transitioning from harmful polypharmacy to optimized medication regimens that align with patient goals and minimize morbidity and mortality. 2