Falls and Orthostasis in an 86-Year-Old on Sedatives, Anticholinergics and a Diuretic
Mrs. K., 86, lives alone in a seniors' apartment and has fallen three times in four months; the most recent fall caused a wrist fracture. Her daughter brings her for a medication review. Current medications: amitriptyline 25 mg at bedtime (for sleep, started about 12 years ago), oxybutynin IR 5 mg BID (urinary urgency), zopiclone 7.5 mg at bedtime (insomnia), hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, metoprolol 50 mg BID, calcium with vitamin D, vitamin B12 and acetaminophen as needed. Today's blood pressure is 108/62 mmHg sitting and 96/58 mmHg after standing one minute; she reports dizziness on standing. Labs: eGFR 58 mL/min/1.73 m², sodium 134 mmol/L, potassium 3.9 mmol/L. She says, 'I don't want to change anything - the pills are fine,' while her daughter is clearly worried about another fall.
1. Which medications most contribute to her falls and orthostasis, and why?
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Highest-risk contributors, in order:
- Amitriptyline 25 mg HS - strongly anticholinergic and sedating, causes orthostatic hypotension through alpha-1 blockade, and is on the Beers list. It is a plausible cause of both the falls and the wrist fracture.
- Zopiclone 7.5 mg HS - sedative-hypnotic with next-morning impairment, psychomotor slowing and fall risk; Beers-listed.
- Oxybutynin IR 5 mg BID - anticholinergic; contributes to confusion, dry mouth, constipation, urinary retention and falls. Beers-listed.
- Hydrochlorothiazide 25 mg - volume depletion, orthostatic hypotension, hyponatremia (Na 134) and nocturia (night-time falls). The combination with lisinopril and metoprolol compounds the postural drop.
- Metoprolol and lisinopril - contribute to orthostasis but are more likely to be needed; address them after the sedatives.
Assessment: her sitting BP is 108/62 and standing 96/58 with symptoms - a clinically important postural drop even if it does not meet the strict 20/10 definition. Anticholinergic burden plus sedation plus volume depletion is the likely triad. The wrist fracture also flags untreated osteoporosis risk.
2. Propose a stepwise deprescribing plan and explain how you would engage the patient, who resists change.
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Stepwise plan - one change at a time, each with a reason, a taper and a review date.
- Hydrochlorothiazide: stop or reduce to 12.5 mg daily first, because it is the simplest contributor to orthostasis and hyponatremia. Recheck BP sitting and standing in 1–2 weeks and repeat sodium.
- Zopiclone: taper (e.g., 3.75 mg nightly for 2 weeks, then alternate nights, then stop) and replace with CBT-I and sleep hygiene. Warn about rebound insomnia for 1–2 weeks.
- Amitriptyline: taper (25 mg → 10 mg for 2–4 weeks → stop) to avoid cholinergic rebound; substitute non-drug sleep measures. If an antidepressant is genuinely needed for mood, choose one with a better fall profile (e.g., sertraline) after reassessment.
- Oxybutynin: trial of discontinuation or bladder training; if pharmacotherapy is essential, consider a less CNS-penetrant option and reassess renal function.
Engaging her: use shared decision-making - ask what matters most (staying independent, avoiding another fracture), explain the link between each drug and her falls, and agree on one change at a time. Involve the daughter as support, not as the decision-maker. Use a brown-bag review, the Beers/STOPP criteria, and document goals of care. Follow up by phone in 2 weeks and in person in 4 weeks.
3. What would you do about the hydrochlorothiazide and her blood pressure, and when would you refer?
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HCTZ and BP: Na 134 is mild but real, and 25 mg of HCTZ in an 86-year-old with orthostasis is more liability than benefit. Stop it and monitor home BP (sitting and standing) twice weekly. If systolic rises above about 150 mmHg or she becomes symptomatic from hypertension, add a low-dose calcium channel blocker (e.g., amlodipine 2.5–5 mg) rather than restarting a diuretic - but only after the orthostasis has resolved. Do not accept a standing systolic below 100 mmHg in a faller.
Refer to the family physician with the medication review and a proposed deprescribing plan, because changes to amitriptyline, zopiclone and oxybutynin need a prescriber. Also refer for:
- Falls assessment (gait, vision, home hazards, footwear, vitamin D).
- Bone health after the wrist fracture: DEXA, calcium/vitamin D, and consideration of osteoporosis therapy.
- Driving and home safety if sedation persists.
Red flags: syncope, chest pain, focal neurological symptoms, or a further fall - urgent assessment.