Prescribing psychotropics in older adults — safety and deprescribing (MEQ)

(i) Medication review (Beers / STOPP/START). Risperidone without current documented target or review date after 8 months is a classic inappropriate continuation risk: antipsychotics in dementia are high-harm agents needing time-limited use. Temazepam is a Beers-listed benzodiazepine/hypnotic concern (falls, cognition, dependence). Oxybutynin adds anticholinergic burden (delirium, constipation, retention). Thiazide is a SIADH co-factor if an SSRI is added. STOPP thinking stops long-term sedative and poorly indicated antipsychotic load; START thinking asks whether untreated pain, depression, sensory deficits, or constipation are missing treatments — calling out is not automatically an indication for "something stronger."^[2][3][4]

(ii) PK/PD. Ageing reduces hepatic blood flow/metabolism and GFR, alters body composition (longer half-life of lipophilic drugs), and increases CNS sensitivity to sedatives and anticholinergics with reduced orthostatic reserve — so the same milligram produces more sedation, confusion and falls risk than in midlife.^[1]

(iii) Antipsychotics in dementia. Schneider meta-analysis: increased death risk with atypical antipsychotics versus placebo. Cerebrovascular event signals (e.g. risperidone dementia trials) and observational mortality data reinforce class caution. CATIE-AD: limited effectiveness and high discontinuation for intolerance/inefficacy. Do not escalate blindly. Deprescribe: if no current severe risk behaviours, supervised taper (DART-AD supports withdrawal attempts for many; monitor for relapse as in Devanand-style teaching), reinforce non-drug care, document restart threshold. If severe risk returns, lowest effective dose, short course, new review date.^{[4][5][6][10]}

(iv) Possible depression / SSRI. Assess for syndromal major depression versus apathy, delirium, sedation, and understimulation — do not reflexively add an antidepressant for "flat" affect alone. If clear late-life MDD warrants treatment, example start sertraline 25 mg orally daily then 50 mg with plan to titrate if needed (start low, go slow, but go). With age + thiazide, baseline and early sodium monitoring for SIADH; counsel on falls and early side-effects.^[7]

(v) QTc and falls. Review cumulative QT and sedative load before adding agents; baseline ECG if cardiac risk or QT-prolonging polypharmacy; correct K/Mg; avoid stacking. Falls: prior falls + temazepam + antipsychotic + anticholinergic = high risk — deprescribe sedatives, treat pain/vision/environment, involve physiotherapy. Woolcott meta-analysis links sedatives/hypnotics, antidepressants and benzodiazepines to falls.^[8][9]