A 72-year-old woman is brought to the emergency department after a fall. The patient landed on her side and has extensive bruising over the right hip area. She was able to reach her phone and call an ambulance to bring her to the hospital. She says, "I lost my balance on the way to the bathroom. I usually have to get up to go to the bathroom once or twice a night." The patient has no history of lightheadedness, dizziness, or syncope. She leads an active lifestyle and walks 2 miles every day. Her medical problems include type 2 diabetes mellitus, urge incontinence, chronic insomnia, transient ischemic attacks, and osteoarthritis. Her daily medications include aspirin, glyburide, lorazepam, and naproxen. The patient lives alone. She does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination and subsequent x-rays reveal a right-sided femoral neck fracture. Neurological examination is normal. Item 1 of 2
Which of the following is the most appropriate intervention to reduce this patient's risk of falls?

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Quizplus · Accepted Answer

Explanation: Medication use is one of the most common modifiable risk factors for falls and subsequent hip and femur fractures. In older adults, most falls result in injury, with 10%-15% resulting in fractures. Benzodiazepine use is strongly associated with a risk of falls and increased mortality in older patients. Intermediate- and long-acting agents and higher doses increase this risk further by contributing to impaired balance and decreased mental alertness. Discontinuing lorazepam in this patient would be the most appropriate intervention to reduce her risk of falls and fractures. Other risk factors associated with increased falls include advanced age, female sex, history of a fall, use of other psychotropic medications (eg, antipsychotics, antidepressants), cognitive impairment, lower-extremity weakness, balance problems, and arthritis. (Choice A) Although this patient's urge incontinence likely contributes to her need to use the bathroom at night, adding a strongly anticholinergic agent such as oxybutynin would create a high risk of delirium and increased falls. The first step is to assess the role her current medications play in her symptoms. (Choice C) A structured program of muscle strengthening and balance training is highly useful in preventing falls in susceptible persons. However, this patient's osteoarthritis is not associated with significant limitations or balance problems, and avoiding benzodiazepines would take precedence. (Choice D) This patient's normal neurological examination makes it unlikely that she has diabetic neuropathy, which could contribute to imbalance and falls. Strict control of diabetes in older individuals is associated with a higher incidence of hypoglycemia, which could lead to more frequent falls. (Choice E) Providing a walker is not indicated as the patient leads an active life and walks without difficulty. Educational objective: The use of benzodiazepines in older adults is associated with a higher incidence of falls and resulting fractures, with overall increases in mortality. The need for such drugs should be reevaluated periodically, and they should be avoided if possible. References: Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/21267523) Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. (http://www.ncbi.nlm.nih.gov/pubmed/25313240)

A 72-Year-Old Woman Is Brought to the Emergency Department After