A 70-year-old woman comes to the physician for a new patient visit. She reports intermittent headaches and poor sleep. During review of systems, she also describes a sensation of incomplete emptying of the bladder and constipation. The patient has a history of migraines and chronic insomnia. Her other medical problems include hypercholesterolemia and osteoarthritis. Her medications include amitriptyline prescribed for migraines, simvastatin, diclofenac, and over-the-counter diphenhydramine for insomnia. Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old woman comes to the physician for a new patient visit.  She reports intermittent headaches and poor sleep.  During review of systems, she also describes a sensation of incomplete emptying of the bladder and constipation.  The patient has a history of migraines and chronic insomnia.  Her other medical problems include hypercholesterolemia and osteoarthritis.  Her medications include amitriptyline prescribed for migraines, simvastatin, diclofenac, and over-the-counter diphenhydramine for insomnia.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

New patient visits should always include a thorough review of current medications (including over-the-counter medications) to determine if any are inappropriate and/or causing adverse effects or problematic drug-drug interactions. The risk of adverse drug events increases with the number of medications, and minimizing the use of non-essential medications can reduce the risk of an adverse event. This patient is likely experiencing anticholinergic side effects (ie, urinary retention, constipation) due to the combined anticholinergic effects of amitriptyline and diphenhydramine. Anticholinergic side effects are particularly common in older adults and can also include impaired memory, confusion, hallucinations, dry mouth, blurry vision, impaired sweating, tachycardia, and increased risk for falls. Physicians should prioritize discontinuing unnecessary medications prior to pursuing further workup or adding additional medications for chronic problems. In this case, diphenhydramine should be discontinued as it is highly anticholinergic and has not helped with the patient's chronic insomnia. (Choice A) Although topiramate can be considered for migraine prevention, discontinuing unnecessary medication that is causing adverse effects takes priority. (Choice B) Zolpidem is a pharmacological treatment option for insomnia but should not be added to the patient's regimen as it has adverse effects in older adults, including increased risk of falls and confusion. Non-pharmacological strategies (eg, cognitive behavioral therapy) are preferred for initial management of primary insomnia in older adults. (Choices C and E) Cystography is not indicated as this patient's urinary retention is more likely due to anticholinergic side effects. A head CT scan would be extremely low yield in this patient with chronic headaches. (Choice F) Increasing the dose of amitriptyline would likely exacerbate the patient's anticholinergic side effects. Educational objective: Review of medications to determine if any are unnecessary or causing adverse effects is essential in providing high-quality patient care. The cumulative anticholinergic burden of multiple medications is especially problematic in the elderly. __________ References: Minimizing inappropriate medications in older populations: a 10-step conceptual framework. (http://www.ncbi.nlm.nih.gov/pubmed/22385783) Anticholinergic activity of 107 medications commonly used by older adults. (http://www.ncbi.nlm.nih.gov/pubmed/18510583) American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/22376048)

A 70-Year-Old Woman Comes to the Physician for a New