Question 1#

A 75-year-old woman is accompanied by her daughter to your clinic. The daughter reports that her mother fell in her yard last week while watering flowers. Her mother suffered scratches and bruises but no serious injury. The daughter is concerned that her mother might fall again with serious injury. The patient has hypertension and osteoarthritis of the knees. She takes HCTZ, lisinopril, naproxen, and occasional diphenhydramine for sleep. The daughter reports some mild forgetfulness over the past 2 years. The patient gets up frequently at night to urinate.

Blood pressure is 142/78 lying and 136/74 standing. Pulse is 64 lying and standing. Except for some patellofemoral crepitance of the knees, her physical examination is normal. A Folstein Mini-Mental Status test is normal except that she only remembers two of three objects after 3 minutes (29/30). She takes 14 seconds to rise from sitting in a hard backed chair, walk 10 ft, turn, return to the chair, and sit down (timed up-and-go test, normal less than 10 seconds). CBC, chemistry profile, and thyroid tests are normal.

What is the next best step?

a. CT scan of the brain
b. Holter monitor
c. Discontinue hydrochlorothiazide and prescribe donepezil
d. Discontinue diphenhydramine, assess her home for fall risks, and prescribe physical therapy
e. EEG

Correct Answer is D


Falls in the elderly are common. Nearly one-third of community dwelling adults over 65 years of age fall at least once yearly. Minor imbalances are common in everyday life. Falling in the elderly is usually associated with decreased ability of the elderly to compensate for these imbalances. Agerelated declines in vestibular function, autonomic function, hearing and eyesight, and muscular strength all contribute to the inability of the elderly to correct for minor imbalances. Medical illnesses and medications may also contribute to this difficulty. The evaluation of falling in the elderly includes a careful history to exclude syncope, a careful medication history, and a review of medical conditions, which may aggravate falling. Persons who have fallen more than once in the last 6 months are at high risk of falling again. The timed up-and-go (TUG) test also predicts who is likely to fall again in the next year.

In an elderly person who presents with falling, evidence-based literature supports three measures to prevent future falls: elimination of medications with sedating and anticholinergic properties, elimination of environmental and structural hazards in the home, and physical therapy. Diphenhydramine has both sedating and anticholinergic effects.

In the absence of syncope and focal neurologic findings, CNS imaging, EEG, and Holter monitoring are unnecessary. Since the patient does not have orthostatic hypotension, discontinuing HCTZ is not indicated. Donepezil is indicated for dementia but not just forgetfulness.