Falls and polypharmacy in an older patient with a recent fracture
An 84-year-old woman is admitted after a mechanical fall at home, sustaining a distal radius fracture. She lives alone, has mild cognitive impairment (MMSE 24/30), hypertension, atrial fibrillation, osteoporosis, and osteoarthritis. Medications: warfarin (INR 2.6), amlodipine 10 mg, bisoprolol 5 mg, oxybutynin 5 mg three times daily, amitriptyline 25 mg at night, omeprazole 20 mg, calcium/vitamin D, and alendronate weekly. She had two falls in the last 6 months. BP 138/76, HR 72/min and irregular, weight 48 kg. She is keen to go home alone.
1. Which medications contribute to her fall risk, and what would you change before discharge?
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This is a classic falls-plus-polypharmacy problem. Contributors:
- Oxybutynin - anticholinergic, causes sedation, confusion, dry mouth, and urinary retention; in an 84-year-old with cognitive impairment it worsens cognition and falls. Stop and consider a non-anticholinergic alternative or non-drug management of urinary symptoms.
- Amitriptyline - tricyclic with anticholinergic and sedative effects, orthostatic hypotension, and QT risk; particularly risky in older adults. Stop or switch to a safer agent if a clear indication exists (it is not listed for a specific diagnosis - clarify).
- Amlodipine 10 mg + bisoprolol - antihypertensives can cause orthostatic hypotension; check lying and standing BP. BP 138/76 is reasonable, but I would review whether both are needed and check postural drop.
- Warfarin - not a direct fall risk, but the risk of intracranial haemorrhage after a fall is the key concern. INR 2.6 is in range; I would continue anticoagulation (the stroke risk from AF usually outweighs fall risk) but document a falls risk assessment and consider whether she is on the right agent. Do not stop anticoagulation simply because she falls.
- Alendronate - appropriate for osteoporosis, but ensure she can take it correctly (upright, 30 minutes before food) and that she is not at risk of oesophageal issues; continue.
- Omeprazole - review indication; long-term PPI has been associated with fractures and B12 deficiency, but do not stop abruptly if there is a GI indication.
Actions: stop oxybutynin and amitriptyline (or replace), check postural BP, review antihypertensives, and perform a falls assessment (vision, footwear, home hazards, gait and balance, vitamin D).
2. She wants to go home alone. How do you assess whether this is safe, and what would you put in place?
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I would not discharge her home alone without a structured assessment. Key elements:
- Functional assessment - can she mobilise safely, manage stairs, prepare meals, and manage her medications? Involve occupational therapy and physiotherapy for a home safety assessment and mobility aids.
- Cognitive assessment - MMSE 24/30 suggests mild impairment; assess medication management capacity (can she take warfarin safely and attend INR checks?). Consider a formal capacity assessment if there are concerns.
- Fracture and bone health - she has osteoporosis and a fragility fracture; ensure she is on appropriate treatment (alendronate, calcium/vitamin D) and consider a DEXA if not recent. This is a secondary prevention opportunity.
- Falls prevention - home hazard modification, grab rails, lighting, footwear, and a falls alarm/personal alarm. Review vision and hearing.
- Anticoagulation safety - ensure INR monitoring is arranged, she understands bleeding precautions, and there is a plan for head injury (she should seek urgent review after any head strike).
- Social support - who checks on her? Arrange a care package, district nurse, and follow-up. Consider a geriatrician-led falls clinic.
- Medication simplification - a compliance aid and a clear medication list after stopping the anticholinergics.
If, after assessment, she cannot manage safely, I would discuss a package of care or a short period of intermediate care/reablement rather than discharge home unsupported. Her wish to go home should be respected where safe, but safety comes first.