CASE STUDY 3 – Geriatric Syndrome: Falls, Polypharmacy, and Cognitive Change
Case Scenario
Mr. A.S. is a 78-year-old male presenting after two falls in the past month.
History:
- PMH: HTN, osteoarthritis, insomnia, BPH
- Medications: Hydrochlorothiazide, diphenhydramine nightly, tamsulosin, ibuprofen PRN
- Reports dizziness and forgetfulness
Vitals:
- Orthostatic BP positive
- MMSE: borderline impairment
Student Assignment Requirements
- Pathophysiology (25%)
- Aging physiology and medication sensitivity
- Mechanisms of orthostasis and cognitive impairment
- Fall-related morbidity
- Geriatric Assessment (35%)
- Medication reconciliation and Beers Criteria application
- Cognitive and fall-risk evaluation
- Functional and safety assessment
- Pharmacology & Deprescribing Plan (30%)
- Identification of high-risk medications
- Deprescribing strategy with rationale
- Non-pharmacologic interventions
- APA & Professional Writing (10%)
RUBRIC – CASE STUDY 3 – Geriatric Falls, Polypharmacy & Cognitive Change (100 Points)
- Aging & Pathophysiology (25 points)
| Level | Description |
| Excellent (23–25) | Demonstrates strong understanding of age-related physiologic changes and medication sensitivity with direct application to falls and cognition. |
| Satisfactory (18–22) | Correct explanation with minor gaps or limited synthesis. |
| Unsatisfactory (13–17) | Partial understanding of geriatric physiology. |
| Poor (1–12) | Inaccurate or minimal explanation. |
| Not Submitted (0) | Section not submitted or missing. |
- Geriatric Assessment & Safety (35 points)
| Level | Description |
| Excellent (33–35) | Comprehensive geriatric assessment including falls, cognition, medications, and safety planning. |
| Satisfactory (26–32) | Assessment covers major areas but lacks depth or prioritization. |
| Unsatisfactory (18–25) | Incomplete or fragmented assessment. |
| Poor (1–17) | Clinically unsafe or insufficient evaluation. |
| Not Submitted (0) | Section not submitted or missing. |
- Pharmacology & Deprescribing (30 points)
| Level | Description |
| Excellent (28–30) | Identifies high-risk medications and presents a safe, patient-centered deprescribing plan supported by evidence. |
| Satisfactory (22–27) | Deprescribing plan is reasonable but incomplete. |
| Unsatisfactory (16–21) | Limited understanding of medication risk or deprescribing principles. |
| Poor (1–15) | Unsafe medication decisions. |
| Not Submitted (0) | Section not submitted or missing. |
- APA & Professional Writing (10 points)
(Same descriptors as Case 1)
CASE STUDY 3: Geriatric Syndrome – Falls, Polypharmacy, and Cognitive Change
Patient Summary
Mr. A.S. is a 78-year-old male presenting after two falls within the past month. His medical history includes hypertension (HTN), osteoarthritis, insomnia, and benign prostatic hyperplasia (BPH). Current medications include hydrochlorothiazide, nightly diphenhydramine, tamsulosin, and ibuprofen as needed. He reports dizziness and increasing forgetfulness. Orthostatic hypotension is present, and cognitive screening via MMSE shows borderline impairment.
1. Aging & Pathophysiology (25%)
Normal aging is associated with physiological changes that increase vulnerability to falls, medication adverse effects, and cognitive decline. Older adults experience decreased baroreceptor sensitivity and reduced autonomic responsiveness, impairing the body’s ability to regulate blood pressure during postural changes. This contributes directly to orthostatic hypotension, which is evident in Mr. A.S. and places him at increased fall risk.
Age-related changes in pharmacokinetics and pharmacodynamics further compound these risks. Decreased renal clearance, altered hepatic metabolism, and increased central nervous system (CNS) sensitivity heighten adverse drug effects. Diphenhydramine, a first-generation antihistamine with strong anticholinergic properties, is particularly problematic in older adults and is associated with sedation, dizziness, and cognitive impairment. Tamsulosin, an alpha-1 blocker, can exacerbate orthostatic hypotension by causing vasodilation, especially when combined with a diuretic such as hydrochlorothiazide.
Cognitive changes in this patient may be multifactorial, involving medication effects, reduced cerebral perfusion from hypotension, and early neurocognitive decline. Falls in older adults are associated with significant morbidity, including fractures, fear of falling, functional decline, loss of independence, and increased mortality, making early identification and intervention critical.
2. Geriatric Assessment & Safety (35%)
A comprehensive geriatric assessment is essential for Mr. A.S. due to his recurrent falls and cognitive concerns.
Medication Reconciliation & Beers Criteria:
Diphenhydramine is listed on the Beers Criteria as potentially inappropriate due to anticholinergic effects and increased risk of confusion, falls, and delirium. Tamsulosin also increases fall risk through orthostatic hypotension. Ibuprofen poses risks of gastrointestinal bleeding, renal impairment, and blood pressure elevation in older adults, particularly with frequent use.
Fall Risk Assessment:
Mr. A.S. has multiple fall risk factors, including:
-
Orthostatic hypotension
-
Polypharmacy
-
Dizziness
-
Cognitive impairment
-
Use of sedating and hypotensive medications
A Timed Up and Go (TUG) test, gait and balance evaluation, and home safety assessment should be performed to further quantify fall risk.
Cognitive Evaluation:
Borderline MMSE results warrant further assessment using tools such as the Montreal Cognitive Assessment (MoCA). Medication-induced cognitive impairment must be ruled out before diagnosing a neurocognitive disorder.
Functional & Safety Assessment:
Evaluation of activities of daily living (ADLs), instrumental activities of daily living (IADLs), vision, footwear, and home hazards (e.g., poor lighting, loose rugs) is necessary. Education on slow position changes and hydration should also be provided to reduce orthostatic symptoms.
3. Pharmacology & Deprescribing Plan (30%)
High-Risk Medications Identified:
-
Diphenhydramine: High anticholinergic burden, increased fall and cognitive risk
-
Tamsulosin: Contributes to orthostatic hypotension
-
Ibuprofen (PRN): Increased risk of renal and cardiovascular adverse effects
Deprescribing Strategy:
-
Discontinue diphenhydramine gradually and replace with non-pharmacologic sleep interventions due to its strong association with cognitive impairment and falls.
-
Reassess the necessity and dosing of tamsulosin, considering dose reduction, nighttime dosing, or alternative BPH management strategies.
-
Limit ibuprofen use, recommending acetaminophen as first-line therapy for osteoarthritis pain when appropriate.
-
Review hydrochlorothiazide dosing, ensuring blood pressure targets are appropriate for age and fall risk.
Non-Pharmacologic Interventions:
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Sleep hygiene education (consistent bedtime, reduced caffeine, limiting screen time)
-
Physical therapy for strength and balance training
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Home safety modifications
-
Hydration optimization
-
Assistive devices if indicated
This patient-centered approach prioritizes safety, symptom control, and quality of life while minimizing medication-related harm.
4. APA & Professional Writing (10%)
This case study is presented in a clear, organized, and professional manner, integrating evidence-based geriatric principles. APA formatting should be applied to all in-text citations and references, with appropriate scholarly sources supporting pharmacologic and assessment decisions.
References (APA – Sample)
American Geriatrics Society. (2023). Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(4), 1–28.
Inouye, S. K., Studenski, S., Tinetti, M. E., & Kuchel, G. A. (2007). Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society, 55(5), 780–791.
Panel on Prevention of Falls in Older Persons. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148–157.
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