Tapering Psychotropic Medications in a 75-Year-Old Patient
In this 75-year-old patient taking multiple psychotropic medications, taper one medication at a time over extended periods (typically >1 month per medication), starting with the highest-risk agent (risperidone), followed by escitalopram, then mirtazapine, and finally divalproex, with careful monitoring for withdrawal symptoms and clinical deterioration at each step. 1
General Principles for Deprescribing in Older Adults
Stop medications one at a time to clearly identify any withdrawal effects or clinical deterioration attributable to each specific medication 1. This approach is critical in older adults with polypharmacy to avoid confusion about which medication change caused any adverse effects.
Gradual tapering is essential for medications acting on the cardiovascular or central nervous system 1. Abrupt discontinuation risks serious withdrawal syndromes, particularly with antipsychotics, antidepressants, and mood stabilizers 1.
Medication-Specific Tapering Approach
1. Risperidone (0.5 mg daily) - Taper First
Antipsychotics require the most cautious approach with gradual withdrawal extending over a period greater than 1 month 1. The current dose of 0.5 mg is already at the lower end for older patients 1.
- Reduce dose by 25% every 2-4 weeks (e.g., 0.5 mg → 0.375 mg → 0.25 mg → 0.125 mg → discontinue) 1
- Monitor for withdrawal symptoms: dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome 1
- Watch for return of behavioral symptoms that may have prompted initial prescription 1
- If withdrawal symptoms cause distress, re-escalate dosing temporarily 1
Common pitfall: Abrupt discontinuation can cause serious movement disorders and psychiatric decompensation 1.
2. Escitalopram (10 mg daily) - Taper Second
SSRIs require dose tapering to reduce risk of discontinuation syndrome 1. Discontinuation syndrome manifests primarily as adrenergic hyperactivity, dizziness, and mood changes 1.
- Reduce by 25-50% every 1-2 weeks (e.g., 10 mg → 5 mg → 2.5 mg → discontinue) 1
- Use small increments with adequate observation periods (at least one week at each dose level) 1
- Monitor for discontinuation syndrome: anxiety, agitation, insomnia, dizziness, paresthesias 1
Important consideration: The evidence for analgesic efficacy of SSRIs like escitalopram is weak compared to SNRIs, making this a reasonable candidate for discontinuation if prescribed for pain 1.
3. Mirtazapine (7.5 mg daily) - Taper Third
Mirtazapine lacks strong evidence for analgesic efficacy compared to SNRIs and TCAs, though it may have been prescribed for depression or sleep 1. The current dose of 7.5 mg is very low (typical antidepressant doses are 30-60 mg) 2, 3.
- Taper over 2-4 weeks given the low dose 1
- Reduce by 50% for 1-2 weeks, then discontinue (e.g., 7.5 mg → 3.75 mg → discontinue)
- Monitor for withdrawal symptoms: though less common than with SSRIs, discontinuation effects can occur 1
4. Divalproex (250 mg daily) - Taper Last
Antiseizure medications require tapering to avoid withdrawal seizures and rebound symptoms 1. The current dose of 250 mg daily (two 125 mg capsules) is relatively low for mood stabilization.
- Reduce by 125 mg every 1-2 weeks (e.g., 250 mg → 125 mg → discontinue) 1
- Taper more gradually if used for seizure disorder (not indicated in your question but important to verify)
- Monitor for withdrawal symptoms: anxiety, agitation, mood instability 1
Critical consideration: If divalproex was added to augment antipsychotic therapy, it may be reasonable to discontinue after the antipsychotic is tapered, as combination therapy was the strategy 4.
Monitoring During Tapering Process
At each dose reduction, monitor for:
- Withdrawal symptoms specific to each medication class 1
- Return of psychiatric symptoms that prompted initial prescription 1
- Falls risk, which may paradoxically improve as sedating medications are reduced 1
- Cognitive function changes 1
Total timeline: Expect the complete deprescribing process to take 4-6 months minimum given the need to taper one medication at a time with adequate observation periods 1.
High-Risk Considerations in This 75-Year-Old Patient
This medication combination poses significant risks in older adults:
- Risperidone increases risk of falls, stroke, and death in elderly patients 1
- Multiple CNS-active medications increase fall risk and cognitive impairment 1
- Polypharmacy burden with four psychotropic medications increases medication-related emergencies 1
If uncertain about discontinuation, consider a time-limited withdrawal trial to clarify whether each medication remains necessary 1.