Geriatric PharmacyIntermediate 8 min

Clinical Case: Polypharmacy and Falls Risk in an Older Adult

An elderly patient on multiple medications reports dizziness. An educational case on polypharmacy review, falls risk, and deprescribing considerations.

PharmaSim · Updated October 7, 2026

Educational material; no clinical peer review is claimed. Methodology and limitations

Fictional teaching case, not a real patient record or a simulator answer key.

Patient presentation

A 78-year-old woman collects her regular medications and mentions she has felt dizzy when standing up quickly in the mornings. She takes seven different medications and sometimes forgets doses.

History

Hypertension, type 2 diabetes, atrial fibrillation, osteoarthritis, and mild anxiety. Medications include an antihypertensive, an anticoagulant, metformin, a sulfonylurea, an NSAID she buys herself for joint pain, a sleeping tablet she has used for years, and an antihistamine. She lives alone and had a minor fall last month.

Medication information

Multiple: antihypertensive, anticoagulant, metformin, sulfonylurea, OTC NSAID, long-term sedative, first-generation antihistamine.

Clinical problem

The dizziness on standing suggests postural hypotension, a common consequence of polypharmacy in older adults, especially with antihypertensives. The combination also includes several bleeding-risk, hypoglycemia-risk, and sedation-risk drugs, plus a first-generation antihistamine that increases fall and confusion risk in the elderly. The picture is one of accumulated medication burden rather than a single faulty drug.

Important considerations

Postural hypotension is a common cause of falls in older adults on antihypertensives.
First-generation antihistamines increase fall and confusion risk in the elderly and are best avoided.
The NSAID adds bleeding risk on top of the anticoagulant.
A medication review with the prescriber is the correct path; the pharmacist does not deprescribe independently.

Questions for the learner

Which medications are most likely contributing to the dizziness and fall risk?
Which drug is inappropriate for an elderly patient and why?
What is the pharmacist's role in a polypharmacy review, and what is the prescriber's?
How do you counsel the patient on standing slowly and avoiding falls while the review is arranged?

Clinical reasoning

The pharmacist recognises the pattern of accumulated risk: the antihypertensive may cause postural hypotension, the first-generation antihistamine adds confusion and fall risk in the elderly, and the OTC NSAID on top of the anticoagulant increases bleeding risk. The pharmacist does not independently change any prescription. Instead, they counsel the patient on standing up slowly to reduce dizziness, flag the concern to the prescriber for a formal medication review (which may include deprescribing the first-generation antihistamine, reassessing the antihypertensive dose, and reviewing the NSAID), and document the advice. The patient is given clear interim safety advice while the structured review is arranged.

Possible approaches

Attribute dizziness to ageing and recommend standing slowly. This misses treatable or urgent causes.
Assess the fall and symptoms, reconcile the actual drugs and coordinate a prioritised review.
Stop several drugs at once without agreement. Withdrawal and loss of treatment benefit can cause harm.

Safer approach

Assess whether a recent fall involved head injury, especially with anticoagulation, and whether dizziness reflects low glucose, bleeding or postural hypotension. Reconcile named drugs and doses; classes alone are not enough to make changes. Coordinate review of NSAID exposure, sedating and anticholinergic burden and treatment goals. Do not abruptly withdraw a long-standing sedative.

Counseling points

Use a single list and involve a carer with consent if memory, sight or dexterity affects use.
Give interim falls advice and a definite review date, not reassurance that slow standing resolves the cause.

Red flags and urgency

Head injury while anticoagulated, collapse, new confusion, focal weakness, black stools or severe hypoglycaemia needs urgent assessment.

Key learning points

Polypharmacy risk is cumulative — the problem is often the combination, not any single drug.
First-generation antihistamines increase fall and confusion risk in older adults and are best avoided.
Postural hypotension from antihypertensives is a common, preventable cause of falls.
Deprescribing is a prescriber decision; the pharmacist's role is to flag, counsel, and document.

Sources and references

Sources reflect their own jurisdictions. For real practice, check the current product label and local guidance.

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