# A nurse is reviewing the medication list of a 78-year-old client with osteoarthritis, insomnia, and stress incontinence at a routine clinic visit. Current medications: ibuprofen 600 mg PO TID, diphenhydramine 50 mg PO HS, oxybutynin 5 mg PO BID, lisinopril 10 mg PO daily, and a multivitamin. Per Beers Criteria, which medications warrant discussion with the prescriber for safer alternatives? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368297&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A nurse is reviewing the medication list of a 78-year-old client with osteoarthritis, insomnia, and stress incontinence at a routine clinic visit. Current medications: ibuprofen 600 mg PO TID, diphenhydramine 50 mg PO HS, oxybutynin 5 mg PO BID, lisinopril 10 mg PO daily, and a multivitamin. Per Beers Criteria, which medications warrant discussion with the prescriber for safer alternatives? Select all that apply.

1

Acetaminophen — should be avoided in older adults due to high risk of hepatotoxicity per Beers criteria

2

Ibuprofen — chronic NSAID use is high-risk due to GI bleeding, AKI, and hypertension exacerbation; Beers recommends avoiding chronic use

3

Multivitamin — should be discontinued in older adults to prevent fat-soluble vitamin toxicity even at standard doses

4

Lisinopril — Beers Criteria recommends avoiding ACE inhibitors in clients over 75 due to renal risk

5

Oxybutynin — anticholinergic; risk of cognitive impairment, dry mouth, constipation, and urinary retention

6

Diphenhydramine — strong anticholinergic burden; increases falls, delirium, and urinary retention in older adults

## Explanation

Per Beers Criteria, the nurse should discuss safer alternatives for medications that pose significant risks in older adults. The correct selections are:
- Option 2 (Ibuprofen): Chronic NSAID use is associated with increased risk of GI bleeding, acute kidney injury, and worsening hypertension; Beers recommends avoiding chronic use unless other options are ineffective.
- Option 5 (Oxybutynin): Anticholinergic medication used for overactive bladder can cause cognitive impairment, dry mouth, constipation, and urinary retention; safer alternatives include mirabegron or pelvic floor therapy.
- Option 6 (Diphenhydramine): First-generation antihistamine with strong anticholinergic effects increases risk of falls, delirium, and urinary retention; safer alternatives include cognitive-behavioral therapy for insomnia or low-dose melatonin.
Incorrect options:
- Option 1 (Acetaminophen): This statement is false. Acetaminophen is not flagged by Beers criteria for hepatotoxicity at standard doses; it is generally a safer analgesic choice for older adults.
- Option 3 (Multivitamin): Standard multivitamin doses are not considered inappropriate; there is no Beers recommendation to discontinue all multivitamins to prevent toxicity.
- Option 4 (Lisinopril): ACE inhibitors are not broadly contraindicated by age; they are commonly used in older adults with hypertension and are not listed as PIMs.

## In-depth explanation

Beers Criteria — PIM in Older Adults
American Geriatrics Society biennial update of Potentially Inappropriate Medications in adults 65 and older.

High-Yield PIM Categories
1. Anticholinergics: first-generation antihistamines (diphenhydramine), bladder antimuscarinics (oxybutynin), TCAs, antipsychotics
2. Benzodiazepines and Z-drugs: falls, delirium
3. Chronic NSAIDs: GI bleed, AKI, HF
4. Long-acting sulfonylureas: hypoglycemia
5. PPIs greater than 8 weeks without indication: C-diff, fractures

Safer Alternatives
- Insomnia → CBT-I, melatonin
- OAB → mirabegron, pelvic floor PT
- OA pain → topical NSAID, acetaminophen, duloxetine

Wrong Answers
1: Acetaminophen is safe at standard doses; no Beers flag for hepatotoxicity in typical analgesic use.
3: Standard multivitamin is not a PIM; no recommendation for routine discontinuation.
4: Lisinopril and ACE inhibitors are safe for most older adults; not listed in Beers.

NCSBN Theme
PPT — Adverse effects and pharmacology in geriatrics.

## Clinical scenario

Scenario
78-year-old, routine clinic, polypharmacy review.

Conditions and Medications
- OA leads to ibuprofen 600 mg TID (chronic NSAID)
- Insomnia leads to diphenhydramine 50 mg HS (anticholinergic)
- Stress incontinence leads to oxybutynin 5 mg BID (anticholinergic)
- HTN leads to lisinopril 10 mg daily
- Multivitamin

Beers Flags
3 medications in this list (numbered 1, 2, 3 in choices)

Approach
Discuss safer alternatives with prescriber.

## Key concepts

- **Beers Criteria** — American Geriatrics Society biennial guideline (most recent 2023) of Potentially Inappropriate Medications (PIM) in adults 65 and older. Five lists: (1) PIMs to avoid; (2) PIMs to avoid in specific conditions; (3) drug-drug interactions; (4) drugs requiring renal dose adjustment; (5) drugs with strong anticholinergic effect. Used in inpatient and outpatient deprescribing.
- **Anticholinergic burden** — Cumulative effect of multiple drugs blocking muscarinic acetylcholine receptors. In older adults, this increases the risk of dry mouth, constipation, urinary retention, blurred vision, falls, delirium, and dementia (longitudinal evidence). Common offenders: diphenhydramine, oxybutynin, TCAs, antipsychotics, opioids and meperidine, paroxetine. Tools: ACB scale, Anticholinergic Risk Scale.
- **Deprescribing** — Planned, supervised reduction or discontinuation of medications no longer providing net benefit, considering goals of care, life expectancy, and patient preference. Indications: PIMs flagged by Beers, drug-drug interactions, prescribing cascade, end-of-life transition. Process: comprehensive medication review, taper schedule for high-risk classes (benzo, opioid, antidepressant), monitoring for withdrawal or recurrence.

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