BCGP Geriatric Pharmacy: The Art of Deprescribing, How to Pass the BPS Geriatric Board Exam in 2026

BCGP Geriatric Pharmacy: The Art of Deprescribing, How to Pass the BPS Geriatric Board Exam in 2026

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Geriatric pharmacy is more than knowing dose adjustments and long drug lists. It is the craft of helping older adults live better with fewer, safer medicines. That is why deprescribing sits at the center of Board Certified Geriatric Pharmacist (BCGP) practice. If you plan to sit for the BPS Geriatric exam in 2026, mastering deprescribing is both a clinical duty and a test-day advantage. This guide shows you what to study, how to think, and how to practice—so you pass the exam and improve care.

What the BCGP Exam Actually Tests

The exam checks whether you can solve real geriatric problems. It leans on application, not rote memory. You will see cases with competing risks, limited life expectancy, multimorbidity, and polypharmacy.

Expect questions to probe your judgment in these areas:

  • Patient-centered care: Medication review, risk–benefit analysis, prioritizing goals (function, symptoms, survival), and deprescribing decisions.
  • Evidence-based therapeutics: Using guidelines and trials, but adapting them to older adults with frailty or organ dysfunction.
  • Safety: Adverse drug events (ADEs), anticholinergic burden, falls, delirium, orthostasis, QTc, bleeding, and drug–drug interactions.
  • Systems and collaboration: Transitions of care, interprofessional work, documentation, and patient/caregiver communication.
  • Public health and policy: Vaccination, opioid stewardship, and ethical decision-making.

Blueprint details and item counts can change. For 2026, review the most current content outline and candidate guide before you commit your plan. Use the outline to shape your study calendar and weighting.

The Art of Deprescribing: A Stepwise Approach

Deprescribing is the planned, supervised process of stopping or reducing medicines that no longer help or that cause harm. It improves function, lowers ADEs, and respects patient goals. The key is to proceed in a structured way and explain the rationale to patients and caregivers.

Use this framework:

  • 1) Clarify goals of care. Ask what matters most: living longer, staying independent, avoiding pain, or thinking clearly. Goals guide trade-offs. For example, aggressive blood pressure treatment may prevent stroke in 5 years, but may worsen dizziness and falls today.
  • 2) Inventory all medications. Include OTCs, herbals, PRNs, and supplements. Look for duplications, drug cascades (a new drug to treat a side effect), and therapy started in the hospital that never stopped.
  • 3) Screen for high-risk drugs and low-value therapy. Red flags include strong anticholinergics, benzodiazepines, sedative-hypnotics, antipsychotics in dementia, long-term proton pump inhibitors without indication, NSAIDs in CKD or heart failure, and tight-control regimens in frail diabetes.
  • 4) Estimate time-to-benefit vs life expectancy. Primary prevention drugs (e.g., statins for first event) may take years to help. If life expectancy is limited, the patient may see only harms. Symptom relief medicines can be prioritized.
  • 5) Check renal/hepatic function and interactions. Improper dosing drives toxicity. Adjust before you deprescribe, or deprescribe because you cannot safely adjust.
  • 6) Plan the sequence. Stop the riskiest, least helpful drugs first. Taper agents with physiologic dependence to avoid withdrawal.
  • 7) Taper thoughtfully and monitor. Set follow-up checkpoints, teach what to watch for, and document each step.
  • 8) Share decisions. Explain the why. Fear fades when patients understand benefits, timelines, and what the plan looks like.

High-Yield Deprescribing Targets (and Why)

  • Anticholinergics (e.g., diphenhydramine, oxybutynin IR, amitriptyline): Increase confusion, constipation, urinary retention, dry mouth, and falls. They worsen cognition in dementia and increase delirium risk in the hospital. Prefer non-drug strategies or low-anticholinergic options.
  • Benzodiazepines and Z-drugs: Cause falls, fractures, memory impairment, and motor vehicle accidents. They lose effectiveness for insomnia. Taper slowly: reduce 10–25% every 2–4 weeks, slower if long-term use or severe anxiety. Switch to non-drug sleep hygiene and CBT-I where possible.
  • Antipsychotics for dementia behaviors: Modest benefit, higher stroke and mortality risk. Reserve for severe distress or danger. Use the lowest dose, try non-drug strategies, and attempt gradual dose reduction every 3–6 months. Taper 25–50% every 2–4 weeks with monitoring.
  • Proton pump inhibitors: Long-term risks include fractures, C. difficile, hypomagnesemia, and B12 deficiency. If started for stress ulcer or GERD without erosive disease, step down or stop after 4–8 weeks. Taper or switch to H2 blocker PRN to avoid rebound acid hypersecretion.
  • NSAIDs: Increase GI bleeding, kidney injury, and blood pressure. Avoid chronic use in CKD, heart failure, or high bleed risk. Consider topical NSAIDs, acetaminophen, duloxetine, or physical therapy.
  • Tight diabetes regimens: Hypoglycemia harms cognition and causes falls. In frailty, liberalize A1c targets (often 7.5–8.5% depending on comorbidity and life expectancy). Deprescribe sulfonylureas first, especially glyburide. Reassess insulin complexity.
  • Primary prevention aspirin: Bleeding risk rises with age and polypharmacy. If no ASCVD and high bleed risk, stopping aspirin is often safer than continuing.
  • Statins in limited life expectancy: Benefit is delayed; pill burden and myopathy risk are immediate. Discuss stopping when life expectancy is short and goals shift to comfort and function.
  • Alpha-blockers for BPH (e.g., terazosin) and vasodilators: Can worsen orthostasis and falls. Switch to alternatives or reduce dose if symptomatic hypotension.

Renal Dosing and Calculations You Will Use

Many exam stems hinge on proper dosing in CKD. The “why” is straightforward: accumulation increases toxicity, and older adults often have low muscle mass, which can hide renal impairment.

  • Estimate renal function with Cockcroft–Gault for drug dosing. It aligns with most dosing guidance. In frail elders with low muscle mass, serum creatinine may look “normal” while true GFR is low. Do not arbitrarily “round up” SCr; instead, use clinical judgment and trends.
  • Weight selection in Cockcroft–Gault: Use actual body weight if underweight; use adjusted body weight if obese; consider ideal body weight if near normal BMI. The goal is to avoid overestimating clearance.
  • Drugs likely to require renal adjustment: DOACs, digoxin, gabapentin/pregabalin, metformin, SGLT2 inhibitors, antibiotics (e.g., fluoroquinolones, TMP/SMX), and allopurinol.
  • Digoxin: Narrow therapeutic index; reduce dose in CKD, older age, and low body weight. Watch for nausea, confusion, and arrhythmias. Hypokalemia and interacting drugs (amiodarone, verapamil) raise toxicity risk.
  • Phenytoin with low albumin: Correct total level for hypoalbuminemia or measure a free level. Older adults often have low albumin; uncorrected totals can mislead you.

Cardiovascular Pearls That Repeat on Exams

  • Orthostatic hypotension: Look for recent dose increases in antihypertensives, alpha-blockers, TCAs, or dopaminergic agents. Treat by deprescribing contributors first, then add non-drug measures (slow position changes, compression, fluids) before fludrocortisone or midodrine.
  • Anticoagulation: Match DOAC dose to renal function, age, and weight. Avoid underdosing without criteria. Consider fall risk, but do not deny anticoagulation reflexively if stroke risk is high; reduce other fall risks instead.
  • Heart failure in CKD: Monitor potassium and creatinine when starting ACEi/ARB/ARNI/MRA. Accept small creatinine rises; they often reflect hemodynamic changes, not injury. Deprescribe NSAIDs that worsen HF.
  • Amiodarone: Many interactions and organ toxicities. Use when needed, but review necessity at every visit and stop if risk > benefit.

Neuropsychiatric and Pain Management Nuances

  • Delirium: Identify and remove offenders: anticholinergics, benzodiazepines, opioids, and polypharmacy. Treat underlying causes (infection, dehydration, pain, constipation). Antipsychotics are last resort and short term.
  • Dementia behaviors: First-line is non-drug care: routines, sleep hygiene, sensory aids, caregiver training. If antipsychotic used for danger or severe distress, document rationale and plan to taper.
  • Chronic pain: Prefer multimodal therapy: acetaminophen scheduled (if liver safe), topical NSAIDs, duloxetine for OA or neuropathic pain, gabapentinoids with renal adjustment and fall precautions. Opioids only when benefits outweigh risks; start low, go slow, and reassess often. Deprescribe by 5–10% dose reductions weekly or slower if long-term use.

Three Deprescribing Case Walkthroughs

Case 1: The night-time faller. 83-year-old with mild dementia, urinary urgency, and insomnia. Meds: oxybutynin IR 5 mg TID, diphenhydramine nightly, zolpidem 10 mg, and amlodipine 10 mg. Falls twice in a month.

  • Why: High anticholinergic load and sedatives impair gait and cognition. Amlodipine may worsen edema and nocturia.
  • Plan: Stop diphenhydramine now. Taper zolpidem by 25% weekly; add sleep hygiene and CBT-I strategies. Switch oxybutynin IR to ER or to mirabegron if BP allows, or trial bladder training and pelvic floor therapy. Consider reducing amlodipine if edema or low BP contributes to nocturia.
  • Monitor: Sleep quality, daytime alertness, falls, BP, and urinary symptoms.

Case 2: Frail diabetes. 79-year-old with weight loss and CKD (CrCl 32 mL/min). A1c 6.6% on glargine 30 units plus glyburide.

  • Why: Tight control raises hypoglycemia risk and hospitalizations; benefit is minimal in frailty.
  • Plan: Stop glyburide immediately. Reduce basal insulin by 20–30% and set a higher fasting target. Consider simplifying to basal-only or even stopping if fasting stable.
  • Monitor: Hypoglycemia symptoms, fasting glucose, nutrition, and renal function.

Case 3: Primary prevention overload. 86-year-old with multimorbidity and limited mobility, on aspirin, statin, PPI, and multiple vitamins. No ASCVD history.

  • Why: Aspirin and statin benefits for primary prevention are delayed; bleeding and myalgias are immediate risks. PPI may be unnecessary.
  • Plan: Stop aspirin after shared decision. Discuss stopping statin if goals focus on comfort and function. Reassess PPI indication; step down if no erosive disease.
  • Monitor: Any new GI symptoms, muscle issues, and patient-reported outcomes like energy and mobility.

Study Strategy for 2026: How to Learn What the Exam Rewards

Memorizing lists is not enough. Practice making decisions with incomplete information. Build a system that forces spaced retrieval and reflection.

  • Use the current BPS content outline to set weekly targets. Weight your time toward patient care, deprescribing, and safety.
  • Do case-based questions daily. After each session, write a 3–5 line “lesson” on why you missed items. Focus on mechanism (why the wrong drug fails and why the right one fits).
  • Create one-page algorithms for high-yield topics: benzodiazepine taper, PPI step-down, antipsychotic reduction, anticoagulant dosing by renal function, and orthostasis workup.
  • Drill calculations and dosing with flash cards: Cockcroft–Gault setup, weight selection, DOAC criteria, digoxin intervals.
  • Review core tools: Beers Criteria, STOPP/START themes, anticholinergic burden scales, and fall-risk medication lists. Learn the rationale, not just the lists.
  • Simulate test conditions twice before the real exam. Practice time management and a steady pace.

Test-Day Tactics That Raise Your Score

  • Read the stem for goals and constraints. Look for life expectancy clues, fall history, renal function, and caregiver capacity. These often trump disease-specific targets.
  • Eliminate answers that “treat the number.” Older adult care adjusts targets to context. Absolute lower is not always best.
  • Prefer stop/simplify when harm outweighs benefit. Many best answers remove the problem drug.
  • Choose the option that prevents the next ADE. If two choices help, pick the one that reduces falls, bleeding, or delirium.
  • Beware absolutes like “never” or “always.” Nuance wins in geriatrics.
  • Do the math first if dosing is involved. Jot the Cockcroft–Gault quickly to anchor the dose choice.

30-Day Study Plan (You Can Expand to 60–90 Days)

  • Weeks 1–2: Patient-centered care and safety. Build deprescribing algorithms. Review Beers/STOPP themes. Daily cases (20–30). Calculate CrCl and adjust doses in 10 mixed cases per day.
  • Week 3: Systems questions: transitions, long-term care, documentation, interprofessional communication. Focus on anticoagulation, heart failure, CKD, and diabetes in frailty. Full-length practice exam at end of week; analyze misses.
  • Week 4: Fill gaps. Redo weak domains. Run two timed 75–100 question blocks. Practice taper and step-down scenarios. Two final days of light review and rest.

Communication and Ethics: The Heart of Deprescribing

Stopping a medication can feel risky to patients and clinicians. Trust and clarity make it safe.

  • Explain the “why.” “This pill now causes more dizziness than benefit. Reducing it lowers your fall risk and can make you steadier.”
  • Offer a clear plan. Show the taper schedule, expected milestones, and a safety net if symptoms return.
  • Document the conversation. Record goals, risks, and agreed steps. This supports continuity and protects patients during transitions of care.
  • Include caregivers. They notice early warning signs and help with adherence and monitoring.
  • Reassess regularly. Deprescribing is not one-and-done. It is a cycle that changes as health and goals change.

Common Tapers and Practical Notes

  • Benzodiazepines: Reduce 10–25% every 2–4 weeks; slower at low doses. Watch for rebound anxiety and insomnia; add non-drug strategies.
  • Antipsychotics: Reduce 25–50% every 2–4 weeks if behaviors are controlled; monitor closely for recurrence and distress.
  • PPIs: Step down dose for 1–2 weeks, then every-other-day, then stop; use antacids or H2 blockers PRN for rebound.
  • Beta-blockers and clonidine: Taper over 1–2 weeks (clonidine slower) to avoid rebound hypertension or tachycardia.
  • Opioids: Lower by ~5–10% of the original dose weekly; slower for long-term users. Treat withdrawal symptoms if needed.
  • Antidepressants with discontinuation risk (e.g., paroxetine, venlafaxine): Reduce 25% every 1–2 weeks; switch to longer-acting agents if needed for smoother taper.

Quick Checklists You Can Use Tomorrow

Pre-visit Deprescribing Checklist:

  • Update medication list (OTCs, herbals, PRNs).
  • Get vitals, orthostatics, recent labs (SCr, electrolytes, A1c if relevant).
  • Screen for goals, falls, confusion, constipation, pain, and sleep.
  • Calculate CrCl; flag doses needing adjustment.
  • Identify top 3 candidates to stop or reduce; draft tapers.

Exam Week Checklist:

  • Memorize Cockcroft–Gault and weight rules of thumb.
  • Review anticholinergic offenders and fall-risk meds.
  • Run through your deprescribing algorithms twice.
  • Do one timed block daily; review rationales, not just answers.
  • Sleep, hydrate, and plan your test-day timing.

Final Thoughts: Passing the Exam by Practicing Good Geriatrics

The BCGP exam rewards the same habits that help older adults thrive: reason through goals, cut harm, and simplify. When in doubt, choose the path that reduces falls, confusion, bleeding, and pill burden while honoring what matters to the patient. If you can explain why a medicine should continue, reduce, or stop—and back it with renal function, risks, and time-to-benefit—you will pass in 2026 and deliver better care the next morning.

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