| Course | NU677 PMHNP Diagnosis and Management Across the Lifespan III |
|---|---|
| Unit | Unit 6 |
| Paper type | Deprescribing review |
| Length | About 1,080 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU677 Unit 6
Down at 3 A.M. on a Tuesday: A Deprescribing Review Testing Nine Medicines Against One Fall in an 84-Year-Old With Kidney Disease
[Student Name]
Purdue University Global
NU677: PMHNP Diagnosis and Management Across the Lifespan III
Unit 6 Deprescribing Review
[Instructor Name]
[Date]
The patient is composite; doses, values and times are bracketed.
The Fall and the Patient
Mrs. [H.] is [84], lives alone in a farmhouse and kept bees until three years ago. She has shingles pain on her left chest from an outbreak two years ago, depression treated by her primary care clinician, urge incontinence, hypertension, hypothyroidism and chronic kidney disease, stage 3b, with an eGFR of [38]. Heading for the bathroom at [3 a.m.], she felt "woozy and heavy," and fell in the hallway. She had no fracture, but she could not get up for four hours. Her daughter found her cold and frightened. She has fallen once before, in [spring].
In the emergency department her blood pressure was [134/72] lying and [128/70] standing, without symptoms, and her sodium and glucose were normal. She had taken her usual evening medications and, she mentioned later, an over-the-counter sleep aid.
Her Nine Medications
1. Gabapentin [300] mg three times daily, started [two] years ago for post-herpetic pain.
2. Mirtazapine [30] mg at bedtime, for depression and sleep.
3. Diphenhydramine [50] mg at bedtime, over the counter, most nights for the past [six] months.
4. Oxybutynin extended release [10] mg daily, for urge incontinence.
5. Amlodipine [10] mg daily.
6. Hydrochlorothiazide [25] mg each morning.
7. Levothyroxine [75] mcg daily.
8. Atorvastatin [20] mg daily.
9. Omeprazole [20] mg daily, started during a hospital stay [four] years ago.
Testing Each Medicine Against the Fall
Two tools guided the review. STOPPFall, developed by European experts through a Delphi process, lists fall-risk-increasing drugs and criteria for when to consider stopping them in older adults with high fall risk (Seppala et al., 2021). The 2023 Beers update from the American Geriatrics Society sorts risky prescribing for older adults into drugs to avoid, drugs to use with caution and doses to reduce in kidney impairment (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
1. Gabapentin. A likely major contributor. Gabapentin is cleared by the kidneys, and at an eGFR of [38] the usual total daily dose should be substantially reduced; she is taking [900] mg a day, a dose set two years ago when her kidney function was better. Accumulation causes dizziness, sedation and unsteadiness; Zand and colleagues, reviewing gabapentin toxicity in people with reduced kidney function, called it a preventable cause of harm, usually from doses never adjusted for clearance (Zand et al., 2010). Nobody changed her gabapentin when her kidneys changed, and the fall happened at the hour when its sedation, added to everything else, was greatest.
2. Diphenhydramine. A likely contributor. A strongly anticholinergic, sedating antihistamine, listed among drugs older adults should avoid. She takes it on top of mirtazapine.
3. Mirtazapine. A possible contributor through sedation, especially combined with the other two. Her depression is in remission, and it may help her sleep.
4. Oxybutynin. A possible contributor: anticholinergic, with sedation and confusion as possible effects in older adults, and on the list of drugs to avoid. It is also treating the urge that sends her to the bathroom at night.
5. Amlodipine and hydrochlorothiazide. Unlikely contributors on this night; no orthostatic drop was found, and the diuretic is taken in the morning.
6. Levothyroxine, atorvastatin, omeprazole. Not fall-related. Omeprazole has no current indication and can be reviewed separately.
The Deprescribing Plan, in Order
1. Stop diphenhydramine now. It is over the counter, adds anticholinergic and sedative burden, and has a safer alternative for sleep in her existing mirtazapine.
2. Reduce gabapentin to a dose adjusted for her kidney function, in steps over [two] weeks to avoid withdrawal, and review her shingles pain at each step. If pain worsens, topical lidocaine will be tried.
3. Replace oxybutynin with a non-anticholinergic option for urge incontinence after discussion with her primary care clinician, and add bladder training and a bedside commode.
4. Keep mirtazapine for now, reassessing sedation after the first three changes.
5. Review omeprazole at the next visit.
What She Wanted
Mrs. [H.] was clear about her priorities. She wanted to stay in her own house, to sleep through the night, and above all not to spend another four hours on a cold floor. She was willing to give up the sleep aid once she learned it was "an allergy pill," but she was worried about her shingles pain returning if the gabapentin was cut, since the pain had once kept her awake for weeks. She agreed to a slow reduction on the condition that she could call if the pain came back. Nobody, she said, had ever explained that her kidneys affected how her medicines worked, and she asked for a list of which ones depended on them. That list was written out for her and her daughter to keep.
Why Not Stop Everything at Once
Four of her nine medicines could plausibly have contributed to the fall, and stopping all four at once might seem the fastest way to lower her risk. It would also make it impossible to tell which change helped or harmed, could bring back shingles pain, depression and urgency together, and could leave her sleeping worse, which might send her back to the over-the-counter aid. The order chosen removes the drug with no clear benefit first, then corrects the dose that is plainly too high for her kidneys, then replaces the anticholinergic with an alternative, and only then reconsiders the antidepressant. Each step is small enough that her daughter can report what changed.
Coordination
Three prescribers had contributed to her list: her primary care clinician, a urologist and, for the sleep aid, no one. The review was sent to her primary care clinician with the proposed order of changes, and the clinic pharmacist added a note to her record to flag any future gabapentin prescription against her current kidney function.
Beyond the Medicines
The fall was also made worse by four hours on the floor. A medical alert pendant, a night light in the hallway and a commode by the bed address the circumstances as well as the causes. Her daughter will check in each morning by phone for the next month.
Monitoring
Sleep, pain, nighttime urgency and any near falls recorded by her daughter; review in [two] weeks and again after each change.
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
Seppala, L. J., Petrovic, M., Ryg, J., Bahat, G., Topinkova, E., Szczerbińska, K., van der Cammen, T. J. M., Hartikainen, S., Ilhan, B., Landi, F., Morrissey, Y., Mair, A., Gutiérrez-Valencia, M., Emmelot-Vonk, M. H., Mora, M. Á. C., Denkinger, M., Crome, P., Jackson, S. H. D., Correa-Pérez, A., . . . van der Velde, N. (2021). STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): A Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age and Ageing, 50(4), 1189-1199. https://doi.org/10.1093/ageing/afaa249
Zand, L., McKian, K. P., & Qian, Q. (2010). Gabapentin toxicity in patients with chronic kidney disease: A preventable cause of morbidity. The American Journal of Medicine, 123(4), 367-373. https://doi.org/10.1016/j.amjmed.2009.09.030
What the NU677 Unit 6 assignment asks for
For Unit 6 you review an older adult's medications after an adverse event and plan which to stop or change. Expect to list every medication, including over-the-counter products, test each against recognized criteria for older adults, rank their likely contribution, and set an order and pace for changes with monitoring. Reviews usually run four to six pages. Graders reward reviews that tie each verdict to criteria and to the patient's own physiology, such as kidney function, that change one thing at a time, and that account for the benefit each drug provides. Including the patient's priorities and the circumstances around the event, such as how long she lay on the floor, makes the plan complete.
How the NU 677 Unit 6 example is put together
The review opens with the fall, her conditions and the emergency department findings, then lists all nine medicines with doses and reasons. Two tools, STOPPFall and the Beers Criteria, are introduced. Each medicine is then judged as a likely, possible or unlikely contributor, with the Zand case series on gabapentin toxicity in kidney disease and a highlighted sentence on the unadjusted dose. The plan orders four changes, starting with the sleep aid. Sections record what she wanted, why the changes are not made all at once and how her three prescribers were coordinated, then address the circumstances of the fall and a monitoring schedule.
NU677 Unit 6 rubric: what earns full points
Graders of deprescribing reviews usually weigh how complete the medication list is, use of criteria, physiological reasoning, the order and pace of changes, and patient-centered planning. Completeness earns full points when over-the-counter products are included. Criteria points go to verdicts tied to named tools rather than general concern. Physiological reasoning rewards attention to kidney function, anticholinergic burden and sedation combined. The order row looks for one change at a time with a reason for the sequence and a plan to replace any lost benefit. Patient-centered planning is judged on her priorities, coordination among prescribers and steps that reduce harm if she falls again.
Common NU677 Unit 6 mistakes, and how to avoid them
The most common error is missing over-the-counter products, which were a major contributor here. Another is keeping a dose set years earlier without rechecking kidney function. Students often stop several drugs at once, making it impossible to tell which change helped or caused a problem. Some reviews ignore the benefit a drug provides, such as pain relief, and leave the patient with untreated symptoms. Others address the causes of the fall but not the four hours on the floor. And a review sent to no one changes nothing; the prescribers who wrote the orders must see the plan and agree to it. Remember that over-the-counter sleep aids rarely appear on the chart, so asking the patient and family to bring every bottle to the visit is often the step that finds the culprit.
Get an NU677 Unit 6 example written to your instructions
List every medication your NU677 Unit 6 case names, over-the-counter products included, with any history of falls, confusion or sleep complaints, and attach the rubric. Your first custom review is free within 24-48h, testing each agent against current criteria and the patient's own harms, sequencing reductions and defending what stays. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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NU677 Unit 6 questions, answered
Which criteria should a deprescribing review cite?
The AGS Beers Criteria, updated in 2023, and STOPP/START, whose version 3 appeared the same year, are the most widely cited. Some courses prefer one; many accept either or both. Name the edition, apply the criteria to each agent and remember that a flag starts a conversation rather than ending one, since the patient's circumstances decide the verdict.
Should over-the-counter products be included?
Yes. Sleep aids, antihistamines, pain relievers and supplements can add sedation, anticholinergic effects or interactions, and they often never appear on the chart. A review should record how they were identified, such as a bag of every bottle brought to the visit, and include them in the same analysis as the prescribed drugs.
How fast should medications be reduced in an older adult?
Usually one change at a time, with enough interval to see its effect, and gradual tapers for agents that cause withdrawal, such as sleep medications. The sample keeps intervals and amounts bracketed. Say why each reduction comes where it does, what would halt the next step and who watches for symptoms returning.
Where can I find a free NU677 Unit 6 sample paper?
The whole NU677 Unit 6 deprescribing review is on this page, testing nine medicines against the fall, with an ordered plan, her priorities, prescriber coordination and fall safety measures, plus three references. A review of your own patient's list can be requested.
Why is gabapentin a problem in NU677 Unit 6?
It is cleared by the kidneys, and at her eGFR of 38 the dose should have been reduced well below the 900 mg a day set two years earlier. Accumulation causes dizziness and sedation, and reports describe unadjusted gabapentin as a preventable cause of harm in kidney disease.