Falls and Hypoglycemia in a 79-Year-Old on Thirteen Medications
Mr. T is 79, lives in assisted living, and has HFpEF, permanent AF, CKD stage 3b (eGFR 36), type 2 diabetes (A1c 6.1%), and knee osteoarthritis. His medication list: apixaban 5 mg BID, aspirin 81 mg daily, naproxen 375 mg BID, glyburide 5 mg BID, lisinopril 20 mg, metoprolol succinate 100 mg, furosemide 40 mg, atorvastatin 40 mg, omeprazole 20 mg, oxybutynin 10 mg, zolpidem 5 mg at night, diphenhydramine 25 mg at night PRN, and calcium with vitamin D. He has fallen twice in six weeks, both after getting up at night; the second caused a forehead laceration needing a staple. Glucose logs show three readings under 70 mg/dL in two weeks, one of 52. He says his knee 'still hurts,' sleeps about four hours, and describes his bowels as 'sluggish.' He wants to 'stay in my own apartment.'
1. How do you rank the medications for deprescribing, and what is your reasoning for the top targets?
Read the worked answer
Rank by probability of harm x reversibility x fit with this patient's goals, not by drug class.
- Naproxen (plus aspirin, plus apixaban). Triple threat: NSAID + antiplatelet + anticoagulant in a faller with CKD. NSAIDs also cause fluid retention and worsen HFpEF and renal function. Stop naproxen; re-examine whether aspirin has any indication (it usually does not when apixaban is used for AF) and stop it if not.
- Glyburide. Long-acting sulfonylurea with active metabolites, hazardous in CKD, and here it is documented to be causing hypoglycemia (52 mg/dL). An A1c of 6.1% in a 79-year-old with falls is over-treatment - the target itself is the problem.
- Oxybutynin. Strongly anticholinergic; explains the 'sluggish' bowels and contributes to confusion and falls.
- Zolpidem plus PRN diphenhydramine. Sedative-hypnotic and anticholinergic at bedtime, temporally linked to both nocturnal falls. Together they are the most modifiable cause of the mechanism of his injuries.
- Omeprazole without a documented indication - lower yield, but part of the total burden.
Also verify the apixaban dose: 5 mg BID unless 2 of 3 criteria (age >=80, weight <=60 kg, creatinine >=1.5 mg/dL) are met, in which case 2.5 mg BID. He is 79, so check weight and creatinine before leaving the dose as written.
2. How would you sequence the changes and what safety netting and monitoring would you put in place?
Read the worked answer
Change one or two things at a time so a new symptom can be attributed to a specific change.
Sequence:
- First, naproxen. Highest acute risk; substitute scheduled acetaminophen (max 3 g/day) plus a topical NSAID (much lower systemic exposure), and review apixaban/aspirin with the prescriber.
- Second, glyburide. Stop or markedly reduce it and set a more realistic individualized A1c target (roughly 7.5–8%) agreed with the patient. Note that A1c can be falsely low in CKD, so do not chase the number.
- Third, sleepers. Taper zolpidem (e.g., 5 mg to 2.5 mg to alternate nights) rather than stopping abruptly, and remove diphenhydramine. Before doing this, identify why he is awake: nocturia from furosemide timing, pain, or the napping that follows poor sleep. Move the diuretic earlier in the day and address pain.
- Fourth, oxybutynin - deprescribe or switch, and treat constipation with fluids, fiber, and a bowel regimen.
Safety netting:
- Two weeks of glucose monitoring with teach-back on recognizing and treating lows.
- Ask him to report increased knee pain, new insomnia, or urinary urgency - untreated symptoms lead to less mobility and more falls, which is the opposite of the goal.
- Involve the assisted living staff and pharmacist; one reconciled list, one written taper schedule, and a named person responsible for each change. Follow-up call in 1–2 weeks.
3. How do you reconcile this plan with his stated goal of staying in his apartment and his report that his knee 'still hurts'?
Read the worked answer
'Staying in my own apartment' is a functional goal, and every medication change should be explained as serving it: fewer falls, clearer thinking, fewer night trips to the bathroom. Say that explicitly rather than presenting the changes as a list of restrictions.
Practical steps:
- Elicit his priorities first. Ask what matters more: walking with less pain, sleeping better, or not feeling 'foggy.' His answer determines the order and pace of the taper.
- Negotiate the trade-off out loud. 'If we stop the naproxen, your knee may ache more for a week or two. Here is what we will do instead, and here is when to call.' Unspoken trade-offs are what cause patients to restart the drug or refuse the plan.
- Treat the pain seriously. Acetaminophen, topical agent, PT, and weight/activity modification are not consolation prizes; uncontrolled pain is a direct cause of falls and of institutionalization.
- Document his own words and his preferences, not just the new medication list. Shared decision-making that is not written down tends to be reversed at the next prescriber visit.