Elderly patient with recurrent falls and a medication list
Mrs. Eileen Park, 82, lives alone in a two-storey house. Her daughter brings her in after three falls in six weeks, none with loss of consciousness or injury beyond bruising. She reports feeling "a bit unsteady" and has stopped going to the shops. She denies dizziness, palpitations, or chest pain. Her medications: perindopril 5 mg daily, metoprolol 50 mg twice daily, frusemide 40 mg daily, amlodipine 10 mg daily, oxybutynin 5 mg three times daily, temazepam 20 mg nightly, and paracetamol as needed. Observations: BP 118/64 sitting, 102/58 on standing at one minute, HR 58 regular. She weighs 48 kg. She has not had blood tests in 18 months. Her daughter asks whether she should move to a care home.
1. Take a focused history that would identify the likely contributors to her falls. What specific questions and domains do you prioritise?
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Falls history (each fall): Where and when did it happen, what was she doing, was there a trip or was it a true loss of balance, any warning symptoms (light-headedness, palpitations, chest pain, focal weakness, speech disturbance, visual change), did she lose consciousness, how long was she on the floor, could she get up, any injury, and what she remembers. Ask about falls indoors versus outdoors, on stairs, and at night.
Syncope versus falls: Ask specifically about presyncope on standing, after meals, after hot baths, and after starting or increasing medications. Ask about palpitations and any family history of sudden death.
Medication review as history: Establish exactly what she takes, who administers it, whether she uses a dosette, any recent changes, and whether she has had postural symptoms since starting or increasing any drug. The combination of a beta-blocker, two antihypertensives, a diuretic, an anticholinergic, and a benzodiazepine is a major red flag.
Cognitive and functional history: Memory changes, orientation, ability to manage medications and finances, continence, and any decline in activities of daily living. Ask the daughter separately for corroboration.
Other domains: Alcohol intake, vision (last eye test), hearing, footwear, home hazards (rugs, lighting, stairs, bathroom), fear of falling, nutrition and weight loss, and symptoms of urinary urgency that might cause rushing to the toilet.
Reasoning: The history must separate syncope from mechanical falls, identify iatrogenic contributors, and screen for cognitive impairment - each leads to a different management path. Collateral history is essential because patients often under-report falls.
2. Interpret the findings and outline your management, including how you address the daughter's question about residential care.
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Interpretation: She has symptomatic orthostatic hypotension (a fall of 20 mmHg systolic on standing, with symptoms) plus a resting bradycardia of 58. Multiple contributors are plausible and likely additive:
- Antihypertensive burden (perindopril, amlodipine, metoprolol) plus frusemide causing volume depletion.
- Oxybutynin - anticholinergic, sedating, and associated with confusion and falls in older adults.
- Temazepam - sedative-hypnotic, increases fall and fracture risk, and is not recommended long term in older people.
- Possible electrolyte disturbance (hyponatraemia, hypokalaemia) from frusemide, unmonitored for 18 months.
- Possible cognitive impairment, vision problems, and home hazards.
Management:
- Blood tests: electrolytes, renal function, full blood count, glucose, calcium, thyroid function, and vitamin D.
- Medication review with deprescribing: stop oxybutynin or substitute a better-tolerated option; plan a gradual taper of temazepam; review frusemide dose and need; consider reducing or stopping metoprolol given bradycardia; rationalise antihypertensives with a target that avoids orthostasis.
- Non-pharmacological: hydration advice, slow position changes, avoid hot baths, review of home hazards, occupational therapy home assessment, physiotherapy for balance and strength, vision check, podiatry and footwear, and a personal alarm or phone access.
- Consider ECG, and a lying/standing BP check at each review.
- Assess cognition formally and screen for depression.
The daughter's question: Reframe it away from a binary decision. Explain that falls in older people are often multifactorial and modifiable, and that the priority is to identify and reverse contributors before considering a change of residence. Discuss her goals and fears, what support she currently has, and what a stepped approach might look like (home modifications, carers, day services, then residential care if needed). Emphasise that the decision belongs to Mrs. Park if she has capacity, with family support.
Reasoning: The exam rewards recognising iatrogenic harm, acting on it systematically, and handling a family request without either dismissing it or prematurely institutionalising the patient.