Prescribing psychotropics in older adults — structured clinical viva

This is a polypharmacy safety and formulation viva, not a request to rubber-stamp three new CNS drugs. Reconcile indications: temazepam and amitriptyline are high-yield Beers/STOPP problems (falls, anticholinergic load, sedation) in someone with falls and cognitive impairment. "Evening agitation" needs DICE-style assessment (pain, delirium, environment, undertreated depression, benzo effects) before any antipsychotic.^[2][8][7]

Do not start quetiapine 50 mg as first response for vague agitation — especially with emerging cognitive impairment and fall risk; if dementia-related severe aggression later needed an antipsychotic, black-box mortality/stroke framing, lowest dose, short course and review date apply.^[3] Prefer deprescribing temazepam/TCA pathway with non-drug sleep strategies and pain review.^[2]

If syndromal depression is confirmed, choose a safer antidepressant than high-dose citalopram: e.g. sertraline 25 mg orally then 50 mg, with sodium monitoring and bleeding vigilance on anticoagulation; avoid citalopram 40 mg in older adults given QT labelling concerns. ECG and electrolyte awareness for any QT-risk plan.^[4][5][6] PK/PD ageing (Mangoni) justifies lower starts and slower titration but not under-treatment of major depression.^[1][6]