Medication Management
Psychiatric Medication for Older Adults: Safer Choices and Deprescribing
By Dr. Stacey Forbes, DNP, APRN, PMHNP-BC · Updated October 12, 2026
Key Takeaways
- With age, the body clears many medications more slowly and the brain becomes more sensitive to sedating ones, so the same prescription can act differently at 75 than it did at 45.
- The American Geriatrics Society’s 2023 Beers Criteria advise avoiding benzodiazepines, “Z-drug” sleep medications and strongly anticholinergic antidepressants in most older adults, and using antipsychotics only for approved indications.
- SSRIs, SNRIs, mirtazapine and several other psychiatric medications can lower sodium in older adults, and many raise fall risk, so checking labs and balance is part of good prescribing.
- Deprescribing is a planned, gradual process done with a prescriber, one change at a time, never a sudden stop.
Older adults can and often should take psychiatric medication: depression and anxiety in later life respond to treatment. But the rules change with age. Medications stay in the body longer, the brain reacts more strongly to sedation, and each added prescription multiplies the chance of a fall, a confused week or an interaction. This guide explains what changes, which medications geriatric experts flag, and how a careful prescriber trims a medication list without destabilizing mood.
Why the same pill acts differently after 65
A 2004 review of age-related pharmacology by Mangoni and Jackson describes several shifts that matter for psychiatric medication. With age, total body water and lean muscle decline while the share of body fat rises. Fat-soluble drugs, which include many sedatives and antidepressants, spread into that larger fat compartment and take longer to leave. The review gives diazepam as an example of a drug whose half-life lengthens in older people.
The liver and kidneys also clear many drugs more slowly. Reduced liver size and blood flow lower the clearance of a long list of medications, and declining kidney function matters most for drugs with a narrow safety margin. Lithium is the classic psychiatric example: when the kidneys slow down, levels can climb even though nothing about the prescription has changed.
Then there is sensitivity. The same review notes that older brains respond more strongly to the central nervous system effects of benzodiazepines, producing sedation at lower blood levels. Put those together and you get the core principle of geriatric prescribing: start low, go slow, and re-check whether a dose that was right years ago is still right now.
What the 2023 AGS Beers Criteria say about psychiatric drugs
The American Geriatrics Society’s Beers Criteria are the most widely used list of “potentially inappropriate” medications for adults 65 and older. The 2023 update, published in the Journal of the American Geriatrics Society, includes several categories that touch psychiatry directly.
| Category | What the 2023 criteria advise | Main concern |
|---|---|---|
| Benzodiazepines | Avoid | Cognitive impairment, delirium, falls, fractures; misuse and dependence |
| “Z-drug” sleep aids (eszopiclone, zaleplon, zolpidem) | Avoid | Similar harms to benzodiazepines, with minimal improvement in sleep |
| Strongly anticholinergic antidepressants (for example amitriptyline, imipramine, nortriptyline, paroxetine) | Avoid | Confusion, sedation, constipation, drops in blood pressure on standing |
| Antipsychotics | Avoid except for FDA-approved uses such as schizophrenia, bipolar disorder or Parkinson disease psychosis | In people with dementia: higher risk of stroke, faster cognitive decline and higher mortality |
| SSRIs, SNRIs, tricyclics, mirtazapine, antipsychotics, carbamazepine, oxcarbazepine | Use with caution | Can cause low sodium (hyponatremia/SIADH); check sodium when starting or changing doses |
| Three or more CNS-active medications together | Avoid the combination | Compounded fall and fracture risk |
Two caveats keep this list in perspective. The AGS itself says the criteria are a tool, not a rulebook: a listed drug can still be the best choice for a particular person, and clinicians should not be penalized for prescribing one when it is. And the criteria are not meant for hospice or end-of-life care, where comfort changes the calculation.
Falls, fractures and low sodium
For someone with a history of falls or a fracture, the Beers panel recommends avoiding antidepressants (SSRIs, SNRIs and tricyclics), antipsychotics, benzodiazepines, Z-drugs, antiepileptics and opioids unless safer alternatives are not available. That is a striking list, because it includes the medications most often used for late-life depression. It does not mean those medications are off limits. It means the risk has to be named, weighed against the risk of untreated depression (which also raises fall risk through poor sleep, poor appetite and inactivity), and actively managed.
Hyponatremia deserves its own mention. Low sodium can arrive quietly in the first weeks of an SSRI or SNRI and show up as fatigue, unsteadiness, headache or new confusion, symptoms that are easy to blame on age or on the depression itself. A baseline sodium level and a repeat check after starting or changing a dose is a simple safeguard; our sibling guide on lab monitoring for psychiatric medications covers which tests go with which drugs.
Call the prescriber the same day if…
- new confusion, unusual sleepiness or unsteadiness appears after a medication change
- there has been a fall, even without injury, since a new medication started
- nausea, headache and muddled thinking appear together in the first weeks of an antidepressant (possible low sodium)
- someone taking lithium develops vomiting, diarrhea, a new tremor or confusion
For a medical emergency call 911.
Antipsychotics and dementia: the boxed warning
Every antipsychotic label carries a boxed warning that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. The Beers criteria add stroke risk and faster cognitive decline. That is why families are right to ask hard questions if an antipsychotic is suggested for agitation, sleep or “sundowning” in someone with dementia.
The picture is not entirely black and white. One antipsychotic, brexpiprazole, is FDA-approved for agitation associated with dementia due to Alzheimer’s disease, and its label still carries the same boxed warning. When an antipsychotic is used in dementia, the reasonable standard is a clear target symptom, the lowest effective dose, a defined review date and a plan to try tapering once the crisis passes. For antipsychotics used as add-ons in depression, see our guide to antipsychotic augmentation and its metabolic risks.
Is it depression, dementia, or the medication?
Memory complaints in an older adult who is also depressed create one of the hardest diagnostic puzzles in medicine. Depression slows thinking, attention and recall, and older textbooks called the result “pseudodementia.” The label can mislead in both directions. According to the National Institute on Aging, dementia can produce some of the same symptoms as depression, and depression can be an early warning sign of possible dementia. Improvement in mood therefore does not rule out a later cognitive problem, and memory trouble does not rule out a treatable depression.
Medication is the third suspect, and the most fixable. Anticholinergic drugs (including some bladder, allergy and sleep products bought over the counter), benzodiazepines and sleep aids can all blunt memory. A careful evaluation lines up the timeline: when the memory change started, what was added or increased around then, and what labs show about thyroid, B12, sodium and kidney function. Brief cognitive screening is useful as a baseline, and repeating it after treatment or after a medication is removed often tells more than a single score.
How deprescribing works in practice
Deprescribing means deliberately reducing or stopping medications whose risks now outweigh their benefits. It is not the same as stopping everything, and it is never done abruptly with psychiatric medication, where sudden stops can cause withdrawal, rebound insomnia or relapse.
- Gather the whole list. Prescriptions from every clinician, over-the-counter products and supplements. The NIA suggests using one pharmacy where possible so interactions are caught.
- Ask why each one is there. Some medications outlive the problem they were started for; a sleep aid from a hospital stay years ago is a common example.
- Rank by risk. Benzodiazepines, Z-drugs and strongly anticholinergic drugs usually come first, especially after a fall.
- Change one thing at a time. Slow, stepwise reductions make it clear what caused any change in sleep, mood or anxiety.
- Replace, not just remove. Sleep habits, daytime light and activity, therapy, treating pain and correcting low vitamin D or B12 can do part of the job a medication was doing.
Long-term benzodiazepine users often need the most patience; our guide to a supported benzodiazepine taper explains why the last steps are usually the slowest. When several prescribers are involved, a structured psychiatric medication review is a good place to start.
For caregivers and adult children
Caregivers often see what the patient cannot: the afternoon naps that started with a new prescription, the stumble in the hallway, the pill organizer that is half full on Friday. That information is clinically valuable. With the patient’s permission, it helps to come to appointments, bring the actual bottles rather than a remembered list, and write down specific changes with dates.
Many families, including the large community of retirees in Florida where Willow & Stone offers telehealth, help a parent manage medication from a distance. Our guide to depression and anxiety in later life for older Floridians covers recognizing late-life depression and local support; this page is about the medication side. Caregivers also carry their own risk of depression, and their own care matters too.
How we approach it at Willow & Stone
Older adults are a good fit for the way the practice already works: a 90-minute integrative psychiatric evaluation, time to go through the full medication list, and a minimal-effective-dose philosophy. Lab work looks at the contributors that commonly mimic or worsen depression in later life, such as thyroid function, B12 and vitamin D, and pharmacogenomic testing can help when someone has had side effects at ordinary doses. The goal is the fewest medications that keep a person well, chosen with them and, when they wish, their family. Our integrative medication management page explains the overall approach.
Common Questions
What are the safest antidepressants for older adults?
There is no single safest antidepressant, because the right choice depends on other conditions, other medications and past response. Geriatric guidance mainly steers away from strongly anticholinergic options such as tricyclics and paroxetine. Whatever is chosen, older adults usually start at a lower dose, increase more slowly and have sodium and fall risk checked, since SSRIs and SNRIs can lower sodium.
Should my elderly parent stop taking a benzodiazepine?
The 2023 Beers Criteria recommend avoiding benzodiazepines in most older adults because of falls, fractures and memory effects. But stopping suddenly after long-term use can cause withdrawal and, rarely, seizures. The safer path is a gradual taper planned with the prescriber, often over months, with support for sleep and anxiety along the way.
Can antidepressants cause confusion in older people?
They can. Strongly anticholinergic antidepressants are a known cause, and SSRIs and SNRIs can lower sodium, which may show up as confusion, unsteadiness or headache, often in the first weeks. New confusion after a medication change deserves a same-day call to the prescriber and usually a blood test.
Are antipsychotics safe for people with dementia?
All antipsychotics carry a boxed warning about increased risk of death in older people with dementia-related psychosis, and geriatric guidance advises avoiding them outside approved uses. They are sometimes used when distress or danger is severe, ideally with a specific target, the lowest dose, a set review date and a plan to taper.
What is deprescribing?
Deprescribing is the planned reduction or discontinuation of medications whose risks now outweigh their benefits. It is done gradually, one change at a time, with monitoring for withdrawal or relapse. It is a clinical process led by a prescriber, not a reason to stop medications on your own.
Part of our medication management guide
Sources & Further Reading
- American Geriatrics Society — 2023 Updated AGS Beers Criteria (J Am Geriatr Soc, PMC full text)
- HealthinAging.org (AGS) — Medications Older Adults Should Avoid or Use with Caution
- National Institute on Aging — Taking Medicines Safely as You Age
- National Institute on Aging — Depression and Older Adults
- Mangoni & Jackson — Age-related changes in pharmacokinetics and pharmacodynamics (Br J Clin Pharmacol, 2004)
- DailyMed — Rexulti (brexpiprazole) prescribing information
This article is general education, not advice for your situation. Do not start, stop, or change a medication or supplement without talking to the clinician who prescribes it.
If you need help right now
Willow & Stone is an outpatient practice and is not an emergency service. If you or someone you care about is in immediate danger, call 911.
For urgent mental health support at any hour, call or text 988 to reach the Suicide & Crisis Lifeline, or text HOME to 741741 for the Crisis Text Line. Both are free, confidential, and available 24/7 nationwide.
Dr. Stacey Forbes, DNP, APRN, PMHNP-BC
Board-certified Psychiatric-Mental Health Nurse Practitioner and founder of Willow & Stone Integrative Mental Health. Nearly two decades of clinical experience; integrative, root-cause psychiatry in person in Arlington and by telehealth. Licensed in Texas, New Mexico, Florida, Alaska, Arizona & Colorado.
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