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 grad

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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 the
previous visit- mild dementia). Her gait is steady and her visual
acuity is 6/6 in each eye. Her left wrist is in a splint 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. Answer these
questions: 1.List three potential causes for Lois’ fall (excluding
cardiac or cerebrovascular event) Identify at least two possible
drug interactions (and potential effects) with Lois’ current
medication. 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.