Falls and Polypharmacy in an 82-Year-Old
An 82-year-old woman presents after a fall at home. She tripped on a rug and landed on her hip, but X-ray is negative for fracture. She lives alone and has a history of hypertension, type 2 diabetes, osteoarthritis, and depression. Her medications include lisinopril, metformin, glipizide, acetaminophen, sertraline, and zolpidem. She reports two other falls in the past year. She has lost 5 kg unintentionally in 6 months. Her blood pressure is 150/80, and her HbA1c is 6.8%. She admits to feeling dizzy when standing. She scores 24/30 on the Mini-Mental State Examination. The clinic has a pharmacist and a physical therapist available.
1. What are the contributing factors to her falls, and which medications should be reviewed?
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Contributing factors: polypharmacy (zolpidem increases fall risk; glipizide can cause hypoglycemia; sertraline may cause orthostasis; lisinopril can cause dizziness), orthostatic hypotension (dizziness on standing), cognitive impairment (MMSE 24), unintentional weight loss (frailty, possible depression or malnutrition), and environmental hazard (rug). Medications to review: zolpidem should be discontinued or tapered (Beers criteria), glipizide may be unnecessary given HbA1c 6.8% (risk of hypoglycemia), sertraline dose may need adjustment, and lisinopril may contribute to orthostasis. Deprescribing should be done gradually with monitoring.
2. What is your approach to reducing her fall risk, including referrals and follow-up?
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Approach: medication review with pharmacist to deprescribe zolpidem and possibly glipizide; orthostatic vital signs and adjust antihypertensives if needed. Physical therapy for gait and balance training, and home safety evaluation (remove rugs, improve lighting). Vitamin D supplementation and calcium intake. Vision and hearing screening. Depression screening (PHQ-9) and management. Nutritional assessment for weight loss. Follow-up in 2-4 weeks to reassess falls, orthostasis, and medication changes. Consider referral to a falls clinic if available. Discuss advanced care planning and community resources.