The 78-Year-Old with Falls, Polypharmacy and a Normal ECG
A 78-year-old woman is brought by her daughter after two falls in 6 weeks, neither with loss of consciousness. She has hypertension, type 2 diabetes (HbA1c 7.9%), osteoarthritis and insomnia. Her medications: amlodipine 10 mg, hydrochlorothiazide 25 mg, metformin 1 g twice daily, ibuprofen 400 mg three times daily, zopiclone 7.5 mg at night, and oxybutynin 5 mg twice daily started 3 months ago for urinary urgency. Blood pressure sitting 128/74 mmHg, standing after 1 minute 96/58 mmHg with mild dizziness. Pulse 68 regular. eGFR 52 mL/min/1.73 m². She lives alone, uses a stick, and her daughter works away during the week. She says the falls are 'just old age' and wants 'a tablet to stop them'.
1. List the medication-related contributors to her falls and orthostatic hypotension, and state the specific action you would take for each, with the reasoning.
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Contributors and actions
- Hydrochlorothiazide 25 mg - volume depletion, hyponatraemia/hypokalaemia risk, worsens orthostasis, and limited benefit at this eGFR. Action: stop; recheck BP and electrolytes in 1–2 weeks.
- Amlodipine 10 mg - with the diuretic removed, her standing BP of 96/58 is already borderline; a high-dose dihydropyridine contributes to postural drop. Action: reduce to 5 mg and reassess; do not stop both at once without a plan to recheck.
- Ibuprofen - NSAID in a patient with eGFR 52 and on a diuretic/ACE-pathway risk: precipitates AKI, raises BP, GI bleed risk, and contributes to fluid retention. Action: stop; offer paracetamol and topical NSAID for knee OA, plus exercise-based OA management.
- Zopiclone - sedative-hypnotic, causes next-morning psychomotor impairment, falls and fractures in older adults. Action: taper and stop with sleep hygiene/CBT-I; warn about rebound insomnia.
- Oxybutynin - anticholinergic: confusion, blurred vision, dry mouth, urinary retention, and strongly associated with falls and cognitive decline in older adults. Action: stop; if urgency persists, consider a non-anticholinergic pathway (bladder training, pelvic floor, review caffeine) before any beta-3 agonist, weighing cost.
Reasoning to articulate: apply a structured review (e.g. STOPPFall/Beers principles), one change at a time where possible, with a monitoring plan. The temporal clue - oxybutynin started 3 months ago, falls for 6 weeks - makes it a prime suspect. Her request for 'a tablet' should be reframed: deprescribing is the intervention.
2. She asks whether she needs a brain scan and whether she should move into her daughter's home. How do you answer both, using the history to justify your advice?
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Imaging: The falls were not associated with loss of consciousness, she has no head injury, no focal neurology, no new confusion and no anticoagulation. There is no red flag for urgent neuroimaging. The yield of CT/MRI for unexplained falls without focal signs is low, and her presentation is explained by orthostatic hypotension plus sedative/anticholinergic burden. I would explain this, document a normal neurological exam, and set a review trigger: any head strike (especially if she starts anticoagulation), focal deficit, new cognitive change or a further fall despite deprescribing prompts reassessment.
Living arrangement: This is her decision, and the evidence does not support relocation as a fall-prevention measure per se - loss of familiar environment and independence can worsen function. What the history does justify is a multifactorial falls assessment: strength and balance exercise (e.g. Otago), home hazard review (loose rugs, lighting, bathroom rails), vision and footwear check, vitamin D if deficient, and a personal alarm or phone accessible at floor level. Her daughter being away on weekdays is a real safety gap - address it with a daily check-in call, a neighbour/community contact, and a written escalation plan, rather than framing it as 'you must move'. Offer a joint visit with the daughter to agree the plan and respect the patient's autonomy while being explicit about residual risk.
3. Her daughter asks: 'Can't you just give her a higher blood pressure tablet so she doesn't faint?' Explain the physiological problem with this request and how you would monitor the change you are making.
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The physiological problem: her sitting BP is 128/74 - reasonable for an older adult - but it drops to 96/58 on standing. The issue is not an absolute low BP; it is impaired postural compensation (baroreflex, volume status, drug effects). Raising sitting BP with more antihypertensive would worsen the postural drop and increase stroke/renal risk, while pushing BP up would not fix the sedative and anticholinergic contributors. The correct move is to remove the causes of the drop, not to treat the number.
Monitoring plan:
- Teach lying-to-standing BP measurement (lie 5 min, stand at 1 and 3 min); record a diary for 1–2 weeks.
- Stop hydrochlorothiazide and reduce amlodipine; recheck standing BP, U&E and creatinine at 1–2 weeks (expect a small creatinine rise with diuretic withdrawal - interpret in context).
- Stop ibuprofen; recheck eGFR at 2 weeks.
- Taper zopiclone over 2–4 weeks; stop oxybutynin and review urinary symptoms at 4 weeks.
- Review falls at 4–6 weeks: any further falls, dizziness or BP <110 systolic sitting triggers a medication review rather than adding a drug.
- Safety-net: written advice on rising slowly, hydration, and when to call.