What is the safest approach to taper her current medications and initiate new therapy in an elderly female patient with polypharmacy, renal/hepatic impairment, fall risk, delirium, and cardiovascular disease?

Medication Tapering and Initiation Strategy in Elderly Patient with Polypharmacy

In this high-risk elderly patient with delirium, fall risk, renal/hepatic impairment, and cardiovascular disease, you must taper medications one at a time using a slow, percentage-based reduction protocol while avoiding any new medication starts until the deprescribing process stabilizes her clinical status. 1

Critical Safety Framework

Stop all medications one at a time to clearly identify withdrawal effects or clinical deterioration attributable to each specific medication. 1 Never taper multiple medications simultaneously in this complex patient, as it becomes impossible to determine which drug is causing adverse effects. 1

Gradual tapering is essential for all medications acting on the cardiovascular or central nervous system, as abrupt discontinuation risks serious withdrawal syndromes, particularly with antipsychotics, antidepressants, and mood stabilizers. 1

Prioritization of Medications to Taper First

Highest Priority: Medications Causing Immediate Harm

Deprescribe anticholinergic medications first (if present: diphenhydramine, hydroxyzine, cyclobenzaprine, oxybutynin) as these cause delirium, slowed comprehension, impaired vision, sedation, and falls in older adults. 2

Benzodiazepines and benzodiazepine-like agents (if present: diazepam, lorazepam, clonazepam, zolpidem, zaleplon) should be prioritized for tapering due to sedation, cognitive impairment, unsafe mobility with injurious falls, and motor skill impairment. 2 However, benzodiazepine tapering must be done extremely slowly as abrupt discontinuation can cause seizures and death. 3

Antipsychotics (if present: chlorpromazine, haloperidol, quetiapine, risperidone, olanzapine) used for behavioral control in dementia should be tapered, as they worsen cognitive function and carry an FDA black box warning for increased risk of death. 2

Second Priority: Medications with Unfavorable Risk-Benefit in This Context

NSAIDs (if present: indomethacin, naproxen, ibuprofen) worsen renal clearance in kidney disease, hypertension, heart failure, and cause GI ulceration/bleeding. 2

Sulfonylureas and peak insulins (if present: glyburide, glipizide) accumulate in chronic kidney disease with higher risk of hypoglycemia. 2

Cholinesterase inhibitors (if present: donepezil, galantamine) can be safely tapered to off, especially when there is perceived lack of benefit, particularly in advanced dementia. 2

Multiple vitamin/mineral supplements and herbal supplements contribute to medication burden without substantiated benefit and should be discontinued. 2

Specific Tapering Protocols by Drug Class

Antipsychotics (e.g., Risperidone)

Reduce the dose by 25% every 2-4 weeks, with careful monitoring for withdrawal symptoms such as dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. 1

For chlorpromazine 100 mg at bedtime: reduce by 25% every 2-4 weeks (100 mg → 75 mg → 50 mg → 25 mg → discontinue), extending the overall taper to a minimum of 8-12 weeks. 4

Antidepressants (e.g., Escitalopram, Mirtazapine)

Reduce escitalopram by 25-50% every 1-2 weeks, with monitoring for discontinuation syndrome including anxiety, agitation, insomnia, dizziness, and paresthesias. 1

Taper mirtazapine over 2-4 weeks, with monitoring for withdrawal symptoms, though these are less common than with SSRIs. 1

Agents with shorter half-lives such as venlafaxine, fluvoxamine, and paroxetine should be tapered gradually to minimize discontinuation symptoms. 5

Mood Stabilizers (e.g., Divalproex)

Reduce divalproex by 125 mg every 1-2 weeks, with monitoring for withdrawal symptoms such as anxiety, agitation, and mood instability. 1

Benzodiazepines

A gradual tapering schedule with reductions of 25% of the initial dose every 1-2 weeks is recommended for benzodiazepine tapering. 3 However, for patients with long-term use or high doses, a more extended taper over months may be necessary. 3

Benzodiazepine withdrawal carries greater risks than opioid withdrawal and should always be conducted gradually. 3 Abrupt discontinuation can lead to seizures and, rarely, death. 3

Reduce benzodiazepines by a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions. 3

Cardiovascular Medications

ACEIs/ARBs: Start at low doses when initiating; high starting doses can precipitate hypotension or renal insufficiency. Monitor renal function closely. 2

Antihypertensive drugs: Any/all classes can result in blood pressure drops with falls and injury when causing hypotension or orthostatic blood pressure changes. 2 Blood pressure lowering increases instability and falls in older people. 2

Monitoring During Tapering Process

Monitor at each dose reduction for:

• Withdrawal symptoms specific to each medication class 1
• Return of psychiatric symptoms 1
• Falls risk 1
• Cognitive function changes 1

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

Follow up at least monthly during the taper, and more frequent contact may be needed during difficult phases. 3

When NOT to Start New Medications

Do not initiate new medications during the tapering process unless there is an acute, life-threatening indication. 2 The attempt to reach recommended targets may lead to adverse drug reactions in this population. 2

Before adding a new drug, prescribers should keep in mind that any new symptom in older people should be considered a possible adverse drug reaction until proven otherwise. 2 This prevents prescribing cascades where adverse drug reactions are misinterpreted as new medical conditions. 2

Decision-Making Framework

Base therapeutic decisions on a comprehensive individual geriatric risk assessment, taking into consideration health habits, cardiovascular risk factors, multimorbidity, physical/cognitive status, life expectancy, time to benefit or harm, and goals of care—not on chronological age alone. 2

Consider the time to benefit versus time to harm of cardiovascular drugs with respect to symptoms, quality of life, morbidity, and mortality. 2 In older patients with short life expectancy or advanced diseases, treatment with secondary prevention medications that take several years to provide benefits may no longer be beneficial, particularly when they can produce adverse drug reactions early in treatment (e.g., statins causing myalgia, glucose-lowering drugs causing hypoglycemia). 2

Prioritize medications most likely to produce benefit and least likely to harm the patient, using clinical judgment rather than rigid adherence to disease-specific guidelines. 2

Adjunctive Strategies to Improve Success

Integrate cognitive-behavioral therapy (CBT) during the taper; evidence shows it significantly increases success rates for medication discontinuation. 3, 4

Provide patient education about medication risks and benefits of tapering to improve outcomes and engagement. 3, 4

For sleep issues, prioritize sleep-hygiene counseling rather than substituting another medication to avoid new dependencies. 3

Common Pitfalls to Avoid

Never taper too quickly—the taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 3 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 3

Never abandon the patient even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy. 3

Do not substitute one high-risk medication for another (e.g., replacing one benzodiazepine with another, or replacing a benzodiazepine with a Z-drug like zolpidem). 3

Abrupt discontinuation of benzodiazepines or antihypertensives is never appropriate and is equivalent to suddenly stopping antihyperglycemics—it can lead to severe withdrawal symptoms including seizures and death. 3

Realistic Timeline

The minimum taper duration is 4-6 months for a patient on multiple psychotropic and cardiovascular medications. 1 For benzodiazepines alone, the taper will likely take 6-12 months minimum, and possibly longer. 3

For patients on benzodiazepines for more than 1 year, consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks. 3