An 84-year-old woman comes to the office to follow up on multiple chronic medical conditions. She has intermittent dizziness and has recently fallen twice, although she was not injured. During the most recent episode, the patient was standing in the living room when she felt lightheaded and slipped backward onto a chair. She did not lose consciousness or experience involuntary movements. Medical history is notable for hypertension, type 2 diabetes mellitus, severe osteoporosis, coronary artery disease, and chronic renal disease. Current medications include hydrochlorothiazide, low-dose metformin, vitamin D, and metoprolol, and she has taken alendronate for the past 4 years.
Supine blood pressure is 129/75 mm Hg, pulse is 66/min, and respirations are 16/min. Physical examination shows a grade 2/6 midsystolic murmur at the right second intercostal area, moderately severe thoracic kyphosis, and decreased pulses bilaterally in the feet. The remainder of the examination is normal.
Laboratory results are as follows:
Complete blood count is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Question

An 84-year-old woman comes to the office to follow up on multiple chronic medical conditions.  She has intermittent dizziness and has recently fallen twice, although she was not injured.  During the most recent episode, the patient was standing in the living room when she felt lightheaded and slipped backward onto a chair.  She did not lose consciousness or experience involuntary movements.  Medical history is notable for hypertension, type 2 diabetes mellitus, severe osteoporosis, coronary artery disease, and chronic renal disease.  Current medications include hydrochlorothiazide, low-dose metformin, vitamin D, and metoprolol, and she has taken alendronate for the past 4 years.
Supine blood pressure is 129/75 mm Hg, pulse is 66/min, and respirations are 16/min.  Physical examination shows a grade 2/6 midsystolic murmur at the right second intercostal area, moderately severe thoracic kyphosis, and decreased pulses bilaterally in the feet.  The remainder of the examination is normal.
Laboratory results are as follows:
 Complete blood count is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_974d_368d_853d_0f4c71a677f0_MD0002_00 Thiazide diuretics are one of the preferred classes of medication for initial treatment of hypertension and significantly reduce the risk of stroke, especially in elderly patients. However, they can cause volume depletion and multiple adverse metabolic effects (eg, hyponatremia, hypokalemia, azotemia), leading to orthostasis and increased risk for falls (other antihypertensives also have increased risk). This patient has had recurrent falls associated with mild hyponatremia and elevated creatinine. Considering this, thiazide should be discontinued with close follow-up of blood pressure. If her blood pressure rises significantly, alternate options would include a long-acting calcium channel blocker (Choice A), ACE inhibitor, or angiotensin II receptor blocker. In addition, the patient would likely benefit from a home safety assessment to evaluate the need for additional lighting, handrails/grab bars, and slip-resistant surfaces. Exercise programs focusing on balance training and strength are also effective in preventing falls. (Choices B and E) Elderly patients, especially those with significant comorbidity, are at increased risk for hypoglycemia, and most guidelines advise less aggressive glycemic targets (eg, hemoglobin A1c <8% rather than <7%) in this population. Sulfonylureas (eg, glipizide) carry a significant risk of hypoglycemia and should be used with caution. Sitagliptin also should be used with caution, although it may be considered at a limited dose. Metformin is relatively contraindicated in patients with impaired renal function, but it may be continued in patients with glomerular filtration rate (GFR) >30 mL/min/1.73 m², such as this patient. ² (Choice C) Bisphosphonate use for >5 years has been associated with increased risk for atypical femoral fractures. Discontinuation should be considered after 5 years, but at 4 years of therapy, this patient can continue. Educational objective: Thiazide diuretics can cause volume depletion and other metabolic effects, leading to orthostasis and increased risk for falls. Thiazides should be discontinued in elderly patients with orthostatic hypotension and recurrent falls. Home safety assessment and directed exercise programs also reduce the risk of falls. __________ References: Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/29710140)

An 84-Year-Old Woman Comes to the Office to Follow Up