A 78-year-old woman comes to the physician accompanied by her daughter to establish primary care. The patient has just relocated to the area and moved in with her daughter. The daughter feels that her mother is no longer able to live independently and is concerned about some forgetfulness and falls that her mother has experienced. After the last fall she was seen in the local emergency department, had a normal head CT scan, and was discharged home. The patient relates a history of insomnia, depression, osteoporosis, osteoarthritis, chronic dizziness, hypertension, atrial fibrillation, "early" Alzheimer's, and urinary incontinence. She performs all her own activities of daily living but requires help with bathing. Her current medications include amitriptyline, warfarin, diphenhydramine at bedtime, meclizine, oxybutynin, calcium, vitamin D, alendronate, and lisinopril.
On examination, she is a well-dressed, pleasant, frail-looking elderly woman in no distress. Her blood pressure is 140/90 mm Hg and pulse is 84/min and irregular. Her lungs are clear on auscultation. The abdomen is soft and non-tender. Her gait is slow but normal. There are no focal defects on neurological examination. Her score on a Mini-Mental State Exam is 25/30.
She brings with her a print-out of a recent INR (2.6) performed by her previous primary care provider.
Which of the following is the best next step in managing this patient?

Question

A 78-year-old woman comes to the physician accompanied by her daughter to establish primary care.  The patient has just relocated to the area and moved in with her daughter.  The daughter feels that her mother is no longer able to live independently and is concerned about some forgetfulness and falls that her mother has experienced.  After the last fall she was seen in the local emergency department, had a normal head CT scan, and was discharged home.  The patient relates a history of insomnia, depression, osteoporosis, osteoarthritis, chronic dizziness, hypertension, atrial fibrillation, "early" Alzheimer's, and urinary incontinence.  She performs all her own activities of daily living but requires help with bathing.  Her current medications include amitriptyline, warfarin, diphenhydramine at bedtime, meclizine, oxybutynin, calcium, vitamin D, alendronate, and lisinopril.
On examination, she is a well-dressed, pleasant, frail-looking elderly woman in no distress.  Her blood pressure is 140/90 mm Hg and pulse is 84/min and irregular.  Her lungs are clear on auscultation.  The abdomen is soft and non-tender.  Her gait is slow but normal.  There are no focal defects on neurological examination.  Her score on a Mini-Mental State Exam is 25/30.
She brings with her a print-out of a recent INR (2.6) performed by her previous primary care provider.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

This patient currently has polypharmacy, which is defined as > 5-10 prescriptions and over-the-counter supplements. Polypharmacy is common in older individuals and leads to adverse drug reactions, drug-drug interactions, prescribing cascades, and non-adherence. Prescribing cascades occur when an adverse drug event is misinterpreted as a new medical condition and leads to further drug therapy with additional potentially adverse effects. Drugs with anti-cholinergic side effects are among those most associated with adverse effects in the elderly. These include memory impairment, hallucinations, confusion, blurred vision, dry mouth, constipation, and urinary retention. This patient is taking four medications with significant anti-cholinergic effects (i.e., amitriptyline, diphenhydramine, meclizine, and oxybutynin), which could contribute to many of her problems. Reducing the use of anti-cholinergic medications should be a high priority for this patient. (Choices A, B, C, and E) Anticholinergic medications are particularly associated with cognitive decline, dizziness, and falls. These medications should be discontinued before an extensive dementia workup is performed. Further testing, including blood work (vitamin B₁₂, TSH, vitamin D), hearing and vision screening, and a detailed investigation of her home environment can be initiated if her symptoms do not improve. ₁₂ Educational objective: Polypharmacy often leads to adverse consequences in an aging patient. Drugs with anti-cholinergic effects (i.e., memory impairment, hallucinations, confusion, blurred vision, dry mouth, constipation, and urinary retention) can be especially troublesome in the geriatric population and should be avoided. __________ References: Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study. (http://www.ncbi.nlm.nih.gov/pubmed/19636034) Anticholinergic drugs and physical function among frail elderly population. (http://www.ncbi.nlm.nih.gov/pubmed/17192773) START (screening tool to alert doctors to the right treatment)-an evidence-based screening tool to detect prescribing omissions in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/17881418)

A 78-Year-Old Woman Comes to the Physician Accompanied by Her