Recurrent falls in an older adult with polypharmacy and cognitive change
An 82-year-old woman is brought by her daughter after two falls in 3 weeks, neither with loss of consciousness. She lives alone, has hypertension, atrial fibrillation, osteoarthritis, and mild cognitive impairment. Medications: warfarin (INR 2.4), amlodipine 10 mg, oxybutynin 5 mg three times daily, zolpidem 10 mg at night, naproxen 500 mg twice daily as needed, and loperamide for chronic diarrhea. She reports dizziness on standing and has had one episode of confusion. Exam: BP 138/70 sitting, 104/62 standing at 2 minutes, HR 76 irregular. She has bruising on the left hip but no fracture on X-ray. Labs: sodium 128 mmol/L, potassium 3.4 mmol/L, creatinine 1.3 mg/dL, hemoglobin 10.8 g/dL, TSH normal.
1. Identify the medication-related contributors to her falls and orthostatic hypotension, and explain the mechanism for each.
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Medication contributors
- Amlodipine 10 mg - vasodilator causing orthostatic hypotension; the drop from 138/70 to 104/62 at 2 minutes is diagnostic of orthostatic hypotension (≥20 mmHg systolic or ≥10 mmHg diastolic fall).
- Oxybutynin - anticholinergic; causes cognitive impairment, confusion, dry mouth, constipation, and urinary retention. It is on the Beers list of potentially inappropriate medications in older adults. Contributes to delirium and falls.
- Zolpidem - sedative-hypnotic; causes next-morning sedation, impaired balance, and falls; also associated with confusion and complex sleep behaviors. Beers-listed.
- Naproxen - NSAID; causes GI bleeding (Hb 10.8), worsening hypertension, and AKI. Also increases warfarin bleeding risk. Beers-listed in older adults, especially with anticoagulation.
- Warfarin - anticoagulant; increases bleeding risk from falls and from naproxen interaction. INR 2.4 is in range but the combination with NSAID is dangerous.
- Loperamide - used for chronic diarrhea; can cause constipation, ileus, and confusion at high doses; also masks the cause of diarrhea (which could be contributing to electrolyte loss: Na 128, K 3.4).
- Hyponatremia (Na 128) - likely multifactorial: thiazide? (not listed), SIADH from medications, or GI losses from diarrhea. Contributes to confusion and falls.
- Hypokalemia (K 3.4) - from diarrhea and possibly medications; contributes to weakness.
Key message: This is a classic prescribing cascade and polypharmacy presentation. The diarrhea may itself be caused by loperamide misuse or by another drug; the falls are multifactorial.
2. Outline a stepwise deprescribing and management plan for the next 2 weeks, prioritizing safety and explaining the order of changes.
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Stepwise plan (prioritized by immediate risk)
1. Stop naproxen immediately
- Highest priority: NSAID + warfarin + anemia + falls = high bleeding risk. Replace with topical NSAID or paracetamol for osteoarthritis.
- Check for GI bleeding (stool occult blood, repeat Hb).
2. Address orthostatic hypotension
- Reduce amlodipine to 5 mg and reassess BP lying/standing.
- Encourage slow position changes, hydration, and compression stockings.
- Recheck standing BP in 1 week; aim for systolic ≥110 standing without symptoms.
3. Stop zolpidem
- Taper or stop; substitute sleep hygiene and cognitive behavioral therapy for insomnia (CBT-I).
- Warn about rebound insomnia.
4. Stop oxybutynin
- If urinary symptoms persist, consider behavioral therapy first; if drug needed, use a beta-3 agonist (mirabegron) with BP monitoring, or a lower-anticholinergic burden agent.
- Reassess cognition after stopping.
5. Review loperamide and diarrhea
- Stop loperamide; investigate cause of chronic diarrhea (stool studies, medication review, celiac serology).
- Correct electrolytes: sodium 128 and potassium 3.4 - oral replacement, review fluid intake; avoid rapid correction of chronic hyponatremia (limit to <8-10 mmol/L/day).
6. Warfarin
- Continue but monitor INR closely after stopping naproxen (INR may change).
- Consider DOAC if appropriate, but assess renal function and falls risk; falls alone are not a contraindication to anticoagulation.
7. Non-pharmacologic
- Falls assessment: gait and balance, vision, home safety, physiotherapy, vitamin D.
- Cognitive assessment (MoCA) and delirium screen.
- Bone health: DEXA, calcium/vitamin D, consider osteoporosis treatment.
8. Follow-up
- Phone or visit in 1 week; repeat electrolytes, Hb, and standing BP.
- Involve daughter in medication administration and safety planning.
3. The daughter asks whether her mother's falls mean she should stop warfarin to avoid bleeding. How do you counsel her using evidence on falls risk and anticoagulation?
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Counseling: do not stop anticoagulation solely because of falls.
Evidence and rationale
- The risk of intracranial hemorrhage from a fall is often overestimated. Modeling studies suggest a patient would need to fall many times per year (often cited as ~295 falls/year) before the bleeding risk of anticoagulation outweighed the stroke-prevention benefit.
- Untreated atrial fibrillation carries a high stroke risk - strokes are often more disabling and fatal than fall-related bleeding.
- Falls are usually multifactorial and modifiable - addressing orthostatic hypotension, sedatives, and anticholinergics reduces fall risk more effectively than stopping anticoagulation.
- Choice of agent: DOACs have lower intracranial hemorrhage risk than warfarin in many trials; switching may be reasonable if renal function and cost allow.
Practical risk mitigation
- Remove naproxen (major bleeding risk multiplier).
- Optimize BP to reduce both falls and bleeding risk.
- Home safety assessment and physiotherapy.
- INR monitoring if warfarin continued.
- Educate on signs of bleeding (headache, confusion, black stools, unusual bruising).
Shared decision-making
- Document the discussion: the stroke risk without anticoagulation, the bleeding risk with it, and the patient's values.
- Reassess periodically, especially after any fall with head strike (urgent CT head if head injury on anticoagulation).
Bottom line: Falls are a reason to review and optimize medications and environment, not a reason to abandon stroke prevention.