As a geriatric pharmacist working in long term care and assisted living facilities, I spend a lot of time trying to figure out which medications I should recommend to reduce. Polypharmacy is a big problem but deprescribing needs to be done the right way. There are certain times when it is not a good time to reduce psychotropic medications. I’ll outline some of those times when not to reduce psychotropic medications.

Infection

A new infection is a great example of a situation where the patient may have acute psychiatric changes. The patient is sick, not feeling well, and may be worried about the future. This is a poor time to attempt any type of psychotropic medication reduction.

Acute pain

When patients have acute pain issues going on, it can lead to an increase in stress, anxiety, and possibly depressive-type symptoms. When I see new orders for pain medications, it tells me that something is going on. This is typically not a good time to reduce psychotropic medications.

Abnormal Labs

Certain medical conditions can cause psychiatric changes. Blood work can be an indicator of possible medical concerns that need to be addressed. One of the more common situations is hypo or hyperthyroidism. Elevations in TSH can be indicative of hypothyroidism and if the dose of levothyroxine is being adjusted, it would likely not be an appropriate time to consider reducing an antidepressant or other psychotropic medication.

Life Events

Life-changing events are another reason to possibly hold off on deprescribing. The death of a spouse or another close family member is a reasonable justification to not rock the boat and allow some time for the grieving process prior to considering a reduction in medications.

Failed Reductions

For most, it is pretty obvious that if a patient has failed off of a medication in the past, we likely would not want to put the patient through that situation again. I say this with an exception. I have seen many cases where medications were inappropriately tapered/discontinued. Hopefully, you can review the taper/DC history with the patient and look at the medical records and how it was done previously.

Here’s an example. A patient has been taking sertraline 150 mg once daily for 10 years for depression. The primary provider wants to see if we can discontinue this medication and reduces it without tapering. This is an example of an inappropriate discontinuation and one that would likely lead to a failed reduction. If it had been tapered slowly, we likely would’ve had a better shot at getting to a lower dose and possibly even discontinuing.

If you are looking for more on geriatrics and long term care, check out my Insider’s Guide to LTC Consulting.

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