Low blood pressure and orthostatic hypotension (and frequent falls)
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Immediate: 1 wk later: decrease acebutolol to 100 mg twice daily; consider further decrease in future Future: if needed, consider reducing quinapril, because current daily dose is at maximum Future: consider reducing diltiazem ER to 240 mg/d if possible
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Resolution of orthostatic hypotension Angina/use of nitroglycerin as needed Blood pressure target: 120/65 mm Hg to 140/90 mm Hg Decrease in falls Improvement in renal function: repeat serum creatinine once quinapril dose reduced
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Orthostatic hypotension, poor balance, excessive sedation and frequent falls
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Decrease amitriptyline to 50 mg at bedtime for 1 wk, then to 25 mg for 2 wk, then stop if possible Decrease cyclobenzaprine to twice daily (morning and bedtime); reduce frequency further if possible or reduce dose to 2.5 mg; eventually stop if possible (note: patient finds this medication most effective for pain control, so may be hardest to taper) Re-evaluate usefulness of morphine and taper or stop if possible Consider tapering carbamazepine to 100 mg twice daily and eventually stopping Once effect of above changes assessed, begin tapering oxazepam
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Sleep initiation Pain control Resolution of orthostatic hypotension Decrease in excessive sedation Improvement in balance, decrease in falls Seizure control Thyroid-stimulating hormone levels (decrease in carbamazepine may alter levothyroxine requirements)
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Reduced cognition
May be contributed to by anticholinergic load and CNS depressants (diltiazem, furosemide, amitriptyline, cyclobenzaprine, carbamazepine, morphine, oxazepam) May not require treatment with galantamine once medication contributors tapered
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See above for recommendations to reduce anticholinergic load, and for tapering morphine and diltiazem Consider reassessing need for galantamine once above medication changes are made
| Forgetfulness, difficulty finding words, apraxia |
Constipation (stools infrequent, straining)
May be contributed to by anticholinergic load (plus other mechanisms for diltiazem and morphine) Requires alternate treatment, because patient is not using current regimen successfully
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See above for recommendations to reduce anticholinergic load, and for tapering morphine and diltiazem Stop lactulose, fibre supplement, bisacodyl and suppository Start polyethylene glycol 3350, 15 mL in water daily
| Reduced straining |
Risk of hypermagnesemia and associated toxicity (e.g., hypotension and cramps)
| Stop magnesium | Consider checking magnesium level |
Risk of bradycardia, atrioventricular block
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Consider further tapering of acebutolol and possible discontinuation (as above) Consider reducing diltiazem ER dose (as above) also or instead of step 1
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Omeprazole: ongoing need unclear (duodenal ulcer several years ago but no heartburn) |
Stop omeprazole and start rabeprazole 10 mg/d (least expensive proton pump inhibitor on provincial drug formulary) for 2 wk, then stop Use calcium carbonate or alginate or low-dose ranitidine as needed for rebound heartburn
| Rebound heartburn for 2–4 wk |
Rosuvastatin: not needed twice daily given potency and half-life |
Reduce rosuvastatin to 20 mg once daily Consider requesting cholesterol levels from nursing home to confirm whether patient is at LDL target
| LDL target < 2.0 mmol/L |
Salbutamol: not needed if no shortness of breath and not being used | Stop salbutamol | Shortness of breath |
Levofloxacin: taken daily, but prescribed only for 10 days more than a month ago | Stop levofloxacin | |
Concomitant amitriptyline and levofloxacin use: can cause prolonged QT interval |
Taper and stop amitriptyline as suggested Stop levofloxacin
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Glucosamine: benefit unlikely given questionable efficacy in osteoarthritis pain control and low dose (doses of 1.5 g/d in clinical trials) (3) | Stop glucosamine | |
Patient at increased risk of falls but is not receiving prophylaxis for osteoporosis |
Start vitamin D 1000 IU/d Once constipation has resolved, start elemental calcium 500 mg twice daily (review options with patient) Consider bone density scan and bisphosphonate if indicated and if renal function improves
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