Recurrent falls and a prescribing cascade in an 84-year-old with mild cognitive impairment
Fatima is 84, widowed, and lives with her son's family in Farwaniya. She attends with her daughter-in-law, who says Fatima has fallen twice in three months, once in the bathroom at night and once in the kitchen; neither fall caused a fracture. Her MoCA was 21/30 six months ago. She takes amitriptyline 25 mg at night for 'nerve pain', oxybutynin 5 mg twice daily for urgency, zopiclone 7.5 mg at night, lisinopril 20 mg, amlodipine 10 mg, furosemide 40 mg, metformin 500 mg twice daily, atorvastatin 40 mg, and ibuprofen 400 mg most days for knee pain. Supine blood pressure is 148/82 and standing at one minute 118/70; she says she feels dizzy on standing. Sodium is 131 mmol/L, eGFR 58, HbA1c 7.4%. The daughter-in-law says the amitriptyline 'is the only thing that helps her sleep'.
1. Which medicines are contributing to her falls and hyponatraemia, and in what order would you deprescribe?
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There is a prescribing cascade running through this list, and naming it helps the family accept change.
Amlodipine causes ankle oedema, which is often treated with furosemide; furosemide plus lisinopril produces volume depletion and hyponatraemia (131 mmol/L); amitriptyline and oxybutynin are both strongly anticholinergic and worsen cognition, urinary retention, dry mouth and postural instability; zopiclone adds sedation and night-time falls risk; ibuprofen, used daily at 84 with an eGFR of 58 and on an ACE inhibitor and a diuretic, risks acute kidney injury and blunts blood pressure control.
Order of withdrawal, one change at a time with review in one to two weeks:
- Stop ibuprofen immediately and substitute paracetamol plus a topical NSAID, with knee strengthening.
- Stop the furosemide if there is no evidence of fluid overload. Check for oedema; if the only reason was amlodipine-related ankle swelling, treating the swelling with a diuretic was the error. Recheck sodium and renal function in one to two weeks.
- Taper and stop zopiclone; substitute sleep hygiene and CBT for insomnia.
- Taper amitriptyline over two to four weeks, depending on what the 'nerve pain' actually is; if neuropathic pain is genuine, consider duloxetine or gabapentin with caution, accepting that both have their own risks.
- Replace oxybutynin with bladder training and, if needed, mirabegron, monitoring blood pressure. Do not change everything at once, or you will not know what caused improvement or harm.
2. How do you negotiate these changes with her and her daughter-in-law, given her mild cognitive impairment?
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Assume she can participate. Mild cognitive impairment is not incapacity; she should be spoken to first, not discussed over her head, and the daughter-in-law's role is supporter, not decision-maker, unless a formal guardianship exists.
Start with her priorities, which are probably sleep and the fear of falling, not the sodium level. Ask what she is most afraid of. Then link each proposed change to that fear: the tablets that make her dizzy in the night are the ones most likely to be causing the falls.
The daughter-in-law's resistance is about the amitriptyline and sleep, so do not lead with it. Lead with the ibuprofen, which is easy to explain and gives a quick win, then the water tablet once the swelling is examined. When you reach the amitriptyline, acknowledge that it does help her sleep and that stopping it may mean two or three difficult nights; offer a concrete alternative and a review date rather than a vague promise.
Use teach-back, write the plan down in Arabic, and give a single-page medicine list with what to stop and when. Warn about withdrawal effects (rebound insomnia, cholinergic rebound) and tell them what to do if these occur. Book a follow-up appointment before they leave, and check what she is actually taking, including any herbal remedies or medicines shared with relatives.
3. Beyond medicines, what assessment does she need after two falls?
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Two falls in three months is a falls syndrome, not frailty-by-default, and it needs a multifactorial assessment.
Check postural blood pressure properly (supine, then at one and three minutes), pulse for irregularity, and consider an ECG for atrial fibrillation or conduction disease. Examine gait and balance (Timed Up and Go), feet and footwear, vision, and cognition. Ask about urinary urgency and nocturia, which drive night-time falls, and about alcohol and sedative use. Assess fear of falling, because it predicts further falls.
Bone health: at 84 with falls, she needs a fracture risk assessment (FRAX or equivalent) and a DEXA scan; start calcium and vitamin D and consider an antiresorptive, since her falls are recurrent and a hip fracture is the outcome you are trying to prevent. Check for previous fractures and height loss.
Home assessment: night lighting on the route to the toilet, a commode or bedside urinal, grab rails in the bathroom, removal of loose rugs, and a review of the kitchen layout.
Also screen for depression and ask about pain at night. Arrange a follow-up in two weeks with the daughter-in-law present, and give a falls leaflet. Refer to community physiotherapy for strength and balance training if available.