# A 82-year-old presents to clinic with recent falls and worsening confusion. After reviewing the EHR (History, Vitals, Labs, Notes, Orders), which medication should the nurse advocate to discuss with the provider as the highest priority deprescribing target per Beers criteria?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=373873&lang=en  
> language: en  
> subject: Management of Care  
> category: MOC

## Question

A 82-year-old presents to clinic with recent falls and worsening confusion. After reviewing the EHR (History, Vitals, Labs, Notes, Orders), which medication should the nurse advocate to discuss with the provider as the highest priority deprescribing target per Beers criteria?

History

Vitals

Labs

Orders

Notes

82-year-old female. HTN, type 2 diabetes, hyperlipidemia, mild osteoarthritis. Lives independently. Two falls in past 3 months without serious injury. Daughter reports daytime drowsiness and increased forgetfulness over past 2 months.

BP 138/82, HR 72, RR 16, T 36.8 C, SpO2 97% on room air, MMSE 24/30 (down from 28 last year).

A1c 7.2%, eGFR 64 mL/min/1.73 m2, LDL 92 mg/dL, sodium 138, potassium 4.1, normal LFTs.

Lisinopril 10 mg daily. Metformin 500 mg BID. Atorvastatin 20 mg at bedtime. Diphenhydramine 50 mg at bedtime PRN for sleep (taking nightly per patient). Calcium carbonate / vitamin D supplement daily.

Daughter requests medication review due to falls and cognitive decline. Patient denies symptoms but acknowledges occasional dry mouth and drowsiness during the day.

1

Lisinopril 10 mg daily for hypertension.

✕

2

Metformin 500 mg twice daily for type 2 diabetes.

✕

3

Diphenhydramine 50 mg at bedtime for sleep.

✕

4

Atorvastatin 20 mg at bedtime for hyperlipidemia.

✕

## Explanation

Diphenhydramine is on the AGS Beers list of potentially inappropriate medications (PIMs) in older adults: strong anticholinergic burden causes confusion, sedation, urinary retention, dry mouth, and increases fall and dementia risk. It should be avoided as a sleep aid in adults ≥ 65. Lisinopril, metformin, and atorvastatin are appropriate for ongoing chronic disease management at usual doses (with monitoring) and not Beers-flagged in this scenario.

## In-depth explanation

Diphenhydramine, doxepin, and other anticholinergics are the most-tested Beers culprits because they appear under "PM/sleep aids" or OTC cold medicine and are easily missed. Other classic Beers PIMs: long-acting benzodiazepines, sliding-scale-only insulin, glyburide, NSAIDs in CKD or HF, muscle relaxants like cyclobenzaprine.

## Clinical scenario

**82-year-old at outpatient follow-up** with **recent falls and worsening confusion**. Living at home; daughter is concerned about cognitive decline. Multiple chronic medications. The nurse reviews the chart and prepares to flag medications for review with the provider.

## Key concepts

- **Beers criteria** — American Geriatrics Society list of potentially inappropriate medications in adults ≥ 65 due to risk-benefit imbalance.
- **Anticholinergic burden** — Cumulative anticholinergic load from medications causing confusion, falls, urinary retention, and accelerated cognitive decline.
- **Deprescribing** — Systematic process of identifying and stopping medications when potential harms outweigh benefits.

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