Reference no: EM133343439

Questions: Scenario Lois is a 77-year old woman who has been your patient for a number of years. Over the last two years, she has had a gradual decline in her cognitive function, primarily manifesting as difficulty with names and memory impairment. Two months ago, she started risperidone 0.5 mg twice daily because of increased agitation and nocturnal wandering. Lois is cared for by her daughter, Anne, who now lives with her. Anne works evenings three days per week and on those days, Lois is at home by herself. Anne brings Lois to see you today for review after she was seen in the local emergency department two days ago. Lois had a pre-syncopal episode at home and sustained a left Colles' fracture in the fall. This was treated conservatively and she was discharged from the department with analgesia (tramadol 50 mg four times daily, as needed). No underlying cardiac or neurological event was identified as the cause of the fall. Lois' other medical problems are insomnia, hypertension and depression. Her current medications are: aspirin 150 mg in the morning, risperidone (Risperdal) 0.5 mg twice daily, diltiazem CR (Cardizem CD) 180 mg at night, metoprolol (Betaloc) 50 mg twice daily, paroxetine (Aropax) 20 mg in the morning, temazepam 20 mg at night, tramadol (Tramal) 50 mg four times daily as needed. On examination, Lois is alert and interactive. She is afebrile. Her BP is 150/70 mmHg and her pulse rate is 65 (regular). Her MMSE score is 22/30 (unchanged from previous visit). Her gait is steady and her visual acuity is 6/6 in each eye. Her left wrist is in a backslab and there appears to be good distal perfusion of her left hand with no loss of sensation. The remainder of the physical examination is normal. Anne's three main concerns are:

• the cause of the fall and that it may happen again, saying that she 'can't be there all the time'

• the current complex medication regimen. When Anne is at work, she lays out Lois' tablets with written instructions. Anne is worried about possible misadventure associated with this

• Lois still has episodes of agitation. Anne feels that this has been reduced but not ameliorated by the addition of risperidone.

1. List three potential causes for Lois' fall (excluding cardiac or cerebrovascular event).

2. Identify at least two possible drug interactions (and potential effects) with Lois' current medication. Interacting drugs Possible effect/s

3. What specific advice would you offer Anne about non-drug measures to help with Lois' agitation?

4. List any changes you would consider making to Lois' medication regimen. (Please list in order of importance, starting with most important.)

5. List up to three reasons why the elderly are more prone to adverse effects of drugs and drug interactions.