Family Medicine · Year 3 · from Family Medicine

Case 3: Deprescribing in an Elderly Patient

Patient Demographics

• Age: 82 years old
• Sex: Female
• Living Situation: Lives alone, daughter checks daily

Chief Complaint

"My daughter brought me in. She's worried I've been confused and falling."

History of Present Illness

Mrs. Helen O'Brien is an 82-year-old woman brought by her daughter who reports her mother has been increasingly confused over the past 3 months and has fallen twice in the past month (no injuries). She has been less active and complains of "dizziness when I stand up." Her daughter also notes she seems more sleepy than usual.

Review of the medication list reveals she is on 14 medications prescribed by multiple providers.

Current Medications

1. Metoprolol 50 mg twice daily (hypertension)
2. Lisinopril 10 mg daily (hypertension)
3. Furosemide 40 mg daily (leg swelling)
4. Potassium chloride 20 mEq daily
5. Atorvastatin 40 mg daily (cholesterol)
6. Aspirin 81 mg daily (primary prevention)
7. Omeprazole 20 mg daily (acid reflux - taking for 5+ years)
8. Oxybutynin 5 mg twice daily (overactive bladder)
9. Diphenhydramine 25 mg at bedtime (sleep)
10. Diazepam 5 mg at bedtime (anxiety/sleep)
11. Gabapentin 300 mg three times daily (neuropathic pain)
12. Tramadol 50 mg twice daily (back pain)
13. Acetaminophen 650 mg four times daily
14. Vitamin D 1000 units daily

Physical Examination

• Vital Signs:
• Supine: BP 118/68, HR 58
• Standing (1 min): BP 96/60, HR 62 (orthostatic hypotension)
• General: Appears drowsy, slow to respond
• Mental Status: Alert but processing slowly, MMSE 22/30 (mild impairment)
• Cardiovascular: Bradycardic, regular rhythm
• Neurologic: Unsteady gait, decreased lower extremity strength

Assessment

1. Polypharmacy with 14 medications
2. Medication-related adverse effects likely:

• Confusion: diphenhydramine, oxybutynin, diazepam, tramadol
• Falls/orthostatic hypotension: diazepam, metoprolol, furosemide, tramadol, gabapentin
• Sedation: diphenhydramine, diazepam, tramadol, gabapentin
• Bradycardia: metoprolol

1. Orthostatic hypotension - symptomatic
2. Cognitive impairment - likely multifactorial (medications vs. early dementia)

Beers Criteria Medications Identified

Deprescribing Plan

Immediate Changes (High Priority):

1. STOP diphenhydramine - Replace with sleep hygiene counseling, consider melatonin 3mg at bedtime if needed
2. STOP oxybutynin - Behavioral measures for overactive bladder (timed voiding, fluid management)

Gradual Tapers (To Prevent Withdrawal):

1. TAPER diazepam - Reduce by 25% per week over 4 weeks to discontinue
2. TAPER tramadol - Reduce by 25% every 5-7 days; switch to scheduled acetaminophen

Reassess and Consider Discontinuing:

1. Aspirin - Primary prevention in 82-year-old with fall risk: risks > benefits

• Discussed with patient and daughter; agreed to stop

1. Omeprazole - On > 5 years, original indication unclear

• Plan: Taper to every other day x 2 weeks, then stop. Use PRN antacid if needed.

1. Atorvastatin - Consider benefit at age 82 with limited life expectancy

• Patient prefers to continue - respect this preference

Adjust for Orthostatic Hypotension:

1. Reduce furosemide 40 mg to 20 mg (reassess need for diuretic)
2. Reduce metoprolol 50 mg BID to 25 mg BID (address bradycardia)

Continue:

• Lisinopril 10 mg (monitor BP)
• Potassium (adjusted with furosemide change)
• Gabapentin (continue for now, reassess after other changes)
• Acetaminophen (scheduled for pain)
• Vitamin D

Communication with Patient and Family

• Explained concerns about medication burden and side effects
• Used the word "deprescribing" - "We're going to carefully remove some medications that may be causing more harm than good at your age"
• Provided written schedule showing medications to stop, taper, and continue
• Ensured daughter understands the plan

Safety Monitoring

• Recheck orthostatic BP in 1 week
• Monitor for diazepam withdrawal (anxiety, insomnia)
• Monitor cognitive function after medication changes
• Fall prevention: home safety evaluation, PT referral

Follow-Up

• Phone call: 3 days (check for problems)
• Office visit: 2 weeks
• Reassess cognition: 6 weeks (after medication changes complete)

Outcome (6-Week Follow-Up)

• Medications reduced from 14 to 9
• No longer orthostatic
• MMSE improved to 26/30
• No falls in past 6 weeks
• Patient feels "more like myself"
• Daughter: "She's so much more alert"

Teaching Points

1. Polypharmacy is not just a number: The harm comes from specific high-risk medications and drug-drug interactions, not simply the medication count.

1. Beers Criteria: A practical tool for identifying potentially inappropriate medications in older adults. Not absolute prohibitions, but prompts for critical review.

1. Deprescribing is a process: Some medications can be stopped immediately; others require gradual tapers. Communication and monitoring are essential.

1. Reversible causes of cognitive impairment: Always consider medications before attributing cognitive changes to dementia. Anticholinergic burden is a major contributor.

1. Goals of care: In an 82-year-old, quality of life and symptom management may take priority over aggressive disease prevention.

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