Three Drugs, One Receptor and a Memory Complaint: Deprescribing Anticholinergic Medicines in an 80-Year-Old Woman Using a Five-Step Process
[Student Name]
University of Phoenix
NRP/556: Adult and Geriatric Management II
Week 7 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mrs. S., an 80-year-old widow living alone, comes with her son, who has noticed that she forgets conversations and misplaced her keys in the refrigerator. She also reports dry mouth, constipation and unsteadiness. Her medications include oxybutynin 5 mg twice daily for urinary urgency, started four years ago; amitriptyline 25 mg nightly, started years ago for "nerve pain" in her feet; diphenhydramine 50 mg nightly for sleep, bought over the counter; plus lisinopril and atorvastatin. Her Montreal Cognitive Assessment score is 23 of 30. This paper describes how I approached her medications.
Recognizing the Pattern
Oxybutynin, amitriptyline and diphenhydramine all block muscarinic acetylcholine receptors. Separately prescribed for bladder, pain and sleep, together they create a heavy anticholinergic burden. Her dry mouth, constipation, unsteadiness and memory problems are all consistent with anticholinergic effects.
The Evidence on Cognitive Harm
Gray et al. (2015) followed 3,434 adults aged 65 and older without dementia for a mean of 7.3 years and found that the more strong anticholinergic medicine people had taken over ten years, the higher their risk of developing dementia; the most common drugs were tricyclic antidepressants, first-generation antihistamines and bladder antimuscarinics, exactly the three classes Mrs. S. takes. The authors called for greater awareness to minimize anticholinergic use over time. The geriatric society's list of potentially inappropriate medicines advises against strongly anticholinergic drugs for people her age, including first-generation antihistamines, tertiary tricyclic antidepressants such as amitriptyline and oxybutynin (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
Each prescription made sense when it was written; together they may be making her forget.
A Structured Process
Scott et al. (2015) describe five steps for deprescribing: ascertain all drugs the patient is taking and the reasons for each; consider the overall risk of drug-induced harm to determine the required intensity of intervention; assess each drug for its current or future benefit compared with its harm; prioritize drugs for discontinuation that have the lowest benefit-harm ratio and the lowest likelihood of withdrawal reactions; and implement a discontinuation regimen with close monitoring.
Step 1: Ascertain
I ask Mrs. S. and her son to bring every bottle, including over-the-counter and herbal products. Besides the five drugs above, she takes an acid reducer occasionally and a calcium supplement. I confirm the indication for each.
Step 2: Consider Overall Risk
She is 80, has cognitive complaints, lives alone and is unsteady: her risk of harm is high, and a vigorous deprescribing intervention is justified.
Step 3: Assess Each Drug
Diphenhydramine for sleep: little benefit, high harm. Amitriptyline for neuropathic pain: some benefit, but her pain is mild now, and it causes sedation, anticholinergic effects and fall risk. Oxybutynin for urgency: modest benefit, high harm; bladder training and nonanticholinergic alternatives exist. Lisinopril and atorvastatin: benefits outweigh harms; continue.
Step 4: Prioritize
Diphenhydramine first, since it has the lowest benefit and is easiest to stop. Oxybutynin second. Amitriptyline third, because it needs a slower taper to avoid withdrawal and possible pain flare.
Step 5: Implement and Monitor
Diphenhydramine: stop, replacing it with sleep hygiene measures and a consistent bedtime routine; if needed, cognitive behavioral therapy for insomnia. Oxybutynin: stop after two weeks, starting timed voiding and pelvic floor exercises; if urgency is bothersome, mirabegron, a beta-3 agonist without anticholinergic effects, is an option. Amitriptyline: reduce to 10 mg for two weeks, then stop; if foot pain returns, topical lidocaine or duloxetine at low dose may be considered, depending on her mood and kidney function. Throughout, I monitor sleep, urinary symptoms, pain and withdrawal effects such as nausea or vivid dreams from amitriptyline.
Why Taper Amitriptyline
Stopping amitriptyline suddenly can cause cholinergic rebound, with nausea, sweating, vivid dreams and sleep disturbance, and it may bring back neuropathic pain. A slow reduction over several weeks lowers these risks. Scott et al. (2015) emphasize prioritizing drugs with a low likelihood of withdrawal reactions first, which is why diphenhydramine and oxybutynin come before amitriptyline in the plan.
Why the Bladder Symptoms May Not Worsen
Mrs. S. worries that stopping oxybutynin will bring back urgency. Anticholinergic bladder drugs often provide modest benefit, and scheduled bathroom trips, cutting back on caffeine and on drinks after dinner and strengthening the pelvic floor can keep urgency manageable for many women her age. If needed, mirabegron offers bladder relaxation without anticholinergic effects on the brain.
Why the Sleep Aid Is Easy to Stop
Diphenhydramine loses much of its sleep-promoting effect with nightly use as tolerance develops, but its anticholinergic effects persist. Many older adults sleep about as well without it once a routine is established. Her son will remove it from the house to prevent restarting.
Other Contributors to Her Memory
Deprescribing is only part of the evaluation. I also check vitamin B12, thyroid function and a metabolic panel, screen for depression and review her hearing and vision, since each can affect memory. If her cognition does not improve after the anticholinergic drugs are gone, further evaluation for dementia will follow.
Explaining the Plan
I explained to Mrs. S. that her medicines were not wrong when started but that together they may be affecting her memory and balance. Framing deprescribing as removing a burden rather than taking away help made her more willing. She said she had never been told that her sleeping pill and bladder pill worked on the same system.
Communicating With Other Prescribers
Amitriptyline was started by a neurologist years ago. I send a note explaining the plan, so that the change is understood and not reversed at her next specialist visit.
Measuring the Result
I will repeat the Montreal Cognitive Assessment in three months. If memory improves, the drugs likely contributed; if not, I will evaluate further for a neurodegenerative cause. Dry mouth, constipation and unsteadiness should also improve.
Pharmacist Support
The clinic pharmacist will review her medication list after each change and call her son at two and six weeks, catching problems early and reinforcing the plan.
Falls While Tapering
While medications change, her fall risk remains. I refer her for a physical therapy balance assessment and suggest night lights on the path to the bathroom, since nighttime urgency and grogginess together increase falls.
Tracking Symptoms
A simple diary kept by her son will record sleep hours, nighttime bathroom trips, foot pain and any confusion each day, giving an objective picture of how each step affects her.
Involving Her Son
Her son will help with the plan: removing the diphenhydramine from the house, noting sleep and bladder symptoms and attending the next visit.
Conclusion
Mrs. S.'s memory complaints, dry mouth, constipation and unsteadiness may reflect the combined anticholinergic burden of three drugs prescribed for different reasons. Cohort evidence links cumulative anticholinergic use to dementia, and the Beers Criteria advise avoiding all three. A five-step deprescribing process identified, prioritized and tapered each drug, replaced them with safer approaches and set measures to see whether her memory and symptoms improve.
References
American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Gray, S. L., Anderson, M. L., Dublin, S., Hanlon, J. T., Hubbard, R., Walker, R., Yu, O., Crane, P. K., & Larson, E. B. (2015). Cumulative use of strong anticholinergics and incident dementia: A prospective cohort study. JAMA Internal Medicine, 175(3), 401-407. https://doi.org/10.1001/jamainternmed.2014.7663
Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D., Gnjidic, D., Del Mar, C. B., Roughead, E. E., Page, A., Jansen, J., & Martin, J. H. (2015). Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Internal Medicine, 175(5), 827-834. https://doi.org/10.1001/jamainternmed.2015.0324
How this NRP 556 Week 7 example is structured
The NRP/556 Week 7 work usually addresses multimorbidity, polypharmacy and deprescribing. This paper follows a structured deprescribing process step by step, showing how each drug is judged, prioritized, tapered and replaced, with monitoring for benefit and for withdrawal effects. Students search this week as NRP 556 Week 7, NRP556 Wk 7 or NRP/556 Wk 7; all three are the same assignment.
NRP/556 Week 7 questions, answered
What does NRP/556 Week 7 usually ask for?
Many sections ask students to address polypharmacy in an older adult with multiple conditions, including medication review, deprescribing and monitoring.
What is anticholinergic burden?
The cumulative effect of taking several medicines with anticholinergic properties, which can cause confusion, memory problems, constipation, urinary retention, dry mouth and falls in older adults.
What are the steps of deprescribing?
Ascertain all drugs and reasons, consider overall risk, assess each drug's benefit and harm, prioritize drugs for discontinuation and implement and monitor a discontinuation plan.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.