Family Medicine · Year 3 · from Family Medicine

Case 1: Polypharmacy and Deprescribing

Patient Demographics

• Age: 82 years old
• Sex: Female
• Living Situation: Lives alone in apartment, daughter visits weekly

Chief Complaint

"I've been feeling dizzy and had two falls in the past month."

History of Present Illness

Mrs. Eleanor Fitzgerald is an 82-year-old woman presenting with dizziness and recurrent falls. She fell twice in the past month - once when getting up from a chair and once while walking to the bathroom at night. She did not lose consciousness and did not sustain any fractures, but she is now afraid of falling again. The dizziness is described as lightheadedness, worse when standing quickly, not spinning. She also reports feeling more fatigued than usual and having some memory difficulties, though her daughter hasn't noticed significant cognitive decline.

Past Medical History

• Hypertension
• Osteoarthritis
• Chronic insomnia
• Gastroesophageal reflux disease
• Atrial fibrillation (on anticoagulation)
• Osteoporosis
• Depression (treated 10 years ago, currently stable)
• Urinary urgency

Current Medications (12 medications)

1. Lisinopril 20 mg daily
2. Amlodipine 10 mg daily
3. Hydrochlorothiazide 25 mg daily
4. Metoprolol succinate 100 mg daily
5. Apixaban 5 mg twice daily
6. Omeprazole 40 mg daily (for 8 years)
7. Acetaminophen 650 mg three times daily
8. Diphenhydramine 50 mg nightly (for sleep)
9. Oxybutynin 5 mg twice daily (for urinary urgency)
10. Calcium 1200 mg with vitamin D 800 IU daily
11. Alendronate 70 mg weekly
12. Sertraline 50 mg daily

Functional Status

• ADLs: Independent in bathing, dressing, toileting, transfers, eating
• IADLs: Manages medications with pill organizer, shops with daughter's help, cooks simple meals, manages finances with difficulty

Physical Examination

• Vital Signs:
• Supine: BP 138/72 mmHg, HR 62
• Standing (1 min): BP 108/60 mmHg, HR 68
• Standing (3 min): BP 104/58 mmHg, HR 70
• Orthostatic hypotension confirmed (drop of 30 mmHg systolic)
• General: Thin, frail-appearing elderly woman
• HEENT: Dry mucous membranes
• Cardiovascular: Irregular rhythm (atrial fibrillation), no murmurs
• Neurological: Alert, oriented to person, place, year; mild difficulty with serial 7s; mild proximal weakness
• Gait: Slow, cautious, no assistive device used currently
• Timed Up and Go: 18 seconds (elevated - high fall risk)

Clinical Image

Image: Infographic showing common potentially inappropriate medications in older adults according to the American Geriatrics Society Beers Criteria, highlighting anticholinergic medications, sedative-hypnotics, and other high-risk drug classes.

Image Source: Wikimedia Commons Attribution: Based on AGS Beers Criteria, Educational Use URL: https://commons.wikimedia.org/wiki/File:Medication_safety.jpg

Cognitive Screening

• Mini-Cog: 3/5 (recalled 1/3 words, clock drawing normal)
• Borderline - warrants monitoring but not diagnostic of dementia

Assessment and Diagnosis

1. Falls (recurrent) - multifactorial etiology
2. Orthostatic hypotension - likely medication-related (multiple antihypertensives)
3. Polypharmacy - 12 medications with multiple high-risk drugs per Beers Criteria
4. Potential anticholinergic burden - diphenhydramine + oxybutynin contributing to cognitive complaints
5. Increased fall risk - Timed Up and Go 18 seconds

Beers Criteria Analysis

Potentially Inappropriate Medications Identified:

Management Plan - Deprescribing

Immediate Changes:

1. STOP Diphenhydramine

• Strongly anticholinergic - contributing to confusion and fall risk
• Substitute: Sleep hygiene education; if medication needed, consider low-dose trazodone 25 mg or melatonin

1. STOP Hydrochlorothiazide

• Blood pressure overtreated (orthostatic hypotension)
• Continue lisinopril and amlodipine; reassess BP in 1-2 weeks

1. REDUCE/STOP Oxybutynin

• High anticholinergic burden
• Trial discontinuation with behavioral strategies for urgency (timed voiding, pelvic floor exercises)
• If needed, consider mirabegron (beta-3 agonist) with fewer anticholinergic effects

Short-term Changes (2-4 weeks):

1. Taper Omeprazole

• After 8 years of use, attempt step-down
• Reduce to 20 mg daily for 2 weeks, then every other day, then discontinue
• Monitor for rebound reflux; consider H2 blocker PRN

Fall Prevention:

1. Physical therapy referral for balance training and strengthening
2. Home safety evaluation - occupational therapy referral
3. Assistive device - recommend rollator walker for stability
4. Vitamin D - continue for bone and muscle health

Medication List After Deprescribing (reduced to 9)

1. Lisinopril 20 mg daily
2. Amlodipine 10 mg daily (may reduce further if BP remains low)
3. Metoprolol succinate 100 mg daily (may reduce if HR allows)
4. Apixaban 5 mg twice daily
5. ~~Omeprazole~~ - tapering
6. Acetaminophen 650 mg three times daily PRN
7. Calcium 600 mg with vitamin D 800 IU daily (reduced calcium dose)
8. Alendronate 70 mg weekly
9. Sertraline 50 mg daily

Follow-Up

• Phone check in 1 week for symptoms
• Return visit in 2-3 weeks to reassess orthostatic BP, cognitive symptoms, and urinary symptoms
• Serial Timed Up and Go testing
• Monitor for any symptom recurrence after deprescribing

Teaching Points

1. Polypharmacy (5+ medications) exponentially increases adverse event risk - medication review should be performed at every visit

1. Beers Criteria identifies potentially inappropriate medications - diphenhydramine and oxybutynin are among the most commonly implicated anticholinergics

1. Anticholinergic burden is cumulative - effects of multiple anticholinergic medications add up

1. Falls in older adults are multifactorial - always evaluate medications, orthostatic BP, vision, home environment, and gait/balance

1. Deprescribing is prescribing - systematically reducing inappropriate medications is an active therapeutic intervention

1. Timed Up and Go >14 seconds indicates high fall risk - triggers comprehensive fall evaluation

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