Mrs. H is an 82-year-old resident in a long-term care facility with a history of generalized anxiety disorder, COPD, osteoarthritis, hypertension, insomnia, GERD, and mild cognitive impairment. She is taking duplicate PRN anxiety medications. Her full medication list includes:

• Lisinopril 10 mg daily
• Metoprolol tartrate 25 mg twice daily
• Omeprazole 20 mg daily
• Acetaminophen 650 mg three times daily
• Sertraline 50 mg daily
• Albuterol inhaler as needed for shortness of breath
• Budesonide/formoterol inhaler twice daily
• Calcium carbonate 500 mg daily
• Vitamin D3 1000 units daily
• Lorazepam 0.5 mg every 6 hours as needed for anxiety
• Hydroxyzine (Atarax) 25 mg every 6 hours as needed for anxiety
• Melatonin 3 mg nightly as needed for insomnia

Over the past two weeks, staff notes show both lorazepam and hydroxyzine have been administered multiple times for “resident appears anxious.”

When a resident has duplicate PRN anxiety medications ordered for the same symptom, it can create several problems for staff:

1. Lack of Clarity – Nursing staff may not know which medication should be tried first, especially if there’s no specific protocol. This can lead to inconsistent care between shifts.
2. Documentation Confusion – PRN documentation should include the medication used, the reason, and the effect. If both medications are given close together, it can be unclear which one actually helped, making future decision-making harder.
3. Increased Risk of Side Effects – Lorazepam carries sedation, fall, and dependence risks; hydroxyzine also has sedating and anticholinergic effects. If both are given within a short period, sedation can be compounded, raising fall risk and impairing cognition. It may also be unclear which one is contributing more to adverse effects.
4. Regulatory Concerns – Surveyors may question why two PRNs are ordered for the same indication without clear guidance, especially in facilities under scrutiny for psychotropic use. If you’d like to learn more about long term care consulting, our Insider’s Guide to LTC Consulting is a great place to start.
5. Potential Overmedication – Anxiety may be triggered by an underlying cause (pain, urinary urgency, constipation, environmental stressors). Jumping to medication—especially two different ones—without addressing root causes can mask symptoms rather than resolve them.

In a case like this, facilities often benefit from:

• Documentation of non-drug interventions that have been tried and failed
• Establishing a “first-line PRN” and only using the second if the first is ineffective
• Clear documentation requirements for which medication was used and why
• Review which PRN medication has been more effective for the condition, and consider discontinuation of the other one
• Consideration of starting (or increaseing) SSRIs or a medication like buspirone

Bottom line: Duplicate PRN anxiety medications for the same indication can lead to double-dosing, unclear effectiveness, adverse effects, and regulatory headaches. A clear and simple plan can save time, reduce risk, and improve resident safety.