Geriatric Syndrome Management Plan Beers Criteria
Geriatric Falls Polypharmacy Cognitive Change Case Study for Advanced Primary Care of Family I-HBN-HY01
Successful management of recurrent falls in a 78-year-old male with hypertension, osteoarthritis, insomnia, and BPH requires integration of aging physiology, Beers Criteria medication review, and patient-centered deprescribing to reduce orthostatic risk and preserve cognition in primary care practice.
Mr. A.S. is a 78-year-old male presenting after two falls in the past month. Age-related reductions in baroreceptor sensitivity and renal clearance increase vulnerability to volume depletion and sedative effects, amplifying fall risk when multiple agents are combined. History includes PMH of HTN, osteoarthritis, insomnia, and BPH. Medications currently include hydrochlorothiazide, diphenhydramine nightly, tamsulosin, and ibuprofen PRN. The patient reports dizziness and forgetfulness. Positive orthostatic blood pressure and borderline MMSE scores further signal the interplay of medication effects and physiologic aging. Recent evidence confirms that fall-risk-increasing drugs remain highly prevalent among community-dwelling older adults who have already fallen, underscoring the need for structured reconciliation at every visit.
Student Assignment Requirements
1. Pathophysiology (25%)
- Aging physiology and medication sensitivity
- Mechanisms of orthostasis and cognitive impairment
- Fall-related morbidity
Declines in hepatic metabolism and increased blood-brain barrier permeability heighten central nervous system effects of anticholinergic agents such as diphenhydramine. Orthostatic hypotension arises when arterial stiffness and reduced compensatory vasoconstriction combine with diuretic-induced volume loss and alpha-blockade from tamsulosin. Fall-related morbidity includes fracture, fear of falling, and accelerated functional decline that often leads to loss of independence.
2. Geriatric Assessment (35%)
- Medication reconciliation and Beers Criteria application
- Cognitive and fall-risk evaluation
- Functional and safety assessment
A complete medication list must be verified against the 2023 AGS Beers Criteria, which continue to flag first-generation antihistamines and certain antihypertensives as potentially inappropriate in older adults with a history of falls. Cognitive screening with the MMSE, timed-up-and-go testing, and a home safety checklist form the core of a practical geriatric evaluation. Functional assessment should also document activities of daily living and instrumental activities of daily living to identify early loss of independence that may be reversed with targeted intervention.
3. Pharmacology & Deprescribing Plan (30%)
- Identification of high-risk medications
- Deprescribing strategy with rationale
- Non-pharmacologic interventions
Diphenhydramine carries strong anticholinergic burden and is linked to both cognitive decline and falls; gradual taper with substitution of sleep hygiene measures is warranted. Hydrochlorothiazide and tamsulosin together promote orthostasis and may be reduced or switched after blood-pressure goals are reassessed. Non-pharmacologic steps include progressive balance exercise, adequate hydration, raised toilet seats, and night-lights to lower environmental hazard risk.
4. APA & Professional Writing (10%)
RUBRIC – CASE STUDY 3 – Geriatric Falls, Polypharmacy & Cognitive Change (100 Points)
1. 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. |
2. 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. |
3. 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. |
4. APA & Professional Writing (10 points)
(Same descriptors as Case 1)
Submission
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Details & Information
Sample Clinical Response Excerpt
Age-related stiffening of baroreceptors and reduced renal clearance leave Mr. A.S. highly susceptible to the orthostatic effects of hydrochlorothiazide and tamsulosin. Diphenhydramine’s potent anticholinergic activity further impairs attention and balance, consistent with the borderline MMSE findings. Application of the 2023 AGS Beers Criteria identifies these agents as potentially inappropriate in the presence of recurrent falls. A staged deprescribing plan begins with slow taper of the nighttime antihistamine while introducing cognitive-behavioral strategies for insomnia; blood-pressure targets can then be liberalized and the diuretic dose reduced. Non-pharmacologic measures such as supervised balance training and home hazard modification complete the safety plan. Evidence from the American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults supports this sequence as both safe and effective for reducing fall recurrence.
Why This Approach Matters in Practice
Primary-care clinicians who routinely apply structured medication review and deprescribing reduce subsequent falls and preserve independence for older adults living with multiple chronic conditions. Longitudinal data show that continued exposure to fall-risk-increasing drugs after an index fall remains common and is associated with higher rates of injury and institutionalization. Integrating Beers Criteria screening into every geriatric visit therefore constitutes a high-yield, low-cost intervention that aligns with current World Guidelines for Falls Prevention and Management.
- Document orthostatic vital signs at each encounter and adjust antihypertensives accordingly.
- Replace first-generation antihistamines with sleep-hygiene education and, if needed, short-term melatonin.
- Schedule follow-up within four weeks to reassess cognition, gait, and medication tolerance.
Authority and Citation Optimization
Falls, polypharmacy, and mild cognitive change form a classic geriatric syndrome that responds best to simultaneous attention to pathophysiology, structured assessment, and evidence-based deprescribing. Students who master these three domains produce safer care plans and higher-scoring submissions.
FAQ
Which medications in this case most clearly violate the 2023 Beers Criteria?
Diphenhydramine is listed as a strong anticholinergic to avoid in older adults with a history of falls or cognitive impairment; hydrochlorothiazide and tamsulosin require caution because of orthostatic risk.
How should orthostatic hypotension be confirmed before deprescribing?
Measure blood pressure and heart rate after five minutes supine and again at one and three minutes of standing; a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirms orthostasis.
What non-pharmacologic steps reduce fall risk while medications are tapered?
Home safety modification, progressive strength and balance exercise (for example the Otago program), adequate fluid intake, and footwear assessment form the foundation of secondary prevention.
Does deprescribing antihypertensives increase cardiovascular events in frail older adults?
Recent meta-analyses of randomized trials report no significant rise in mortality or major adverse cardiovascular events when blood-pressure targets are modestly liberalized in the presence of orthostasis or recurrent falls.
How soon should cognition be rechecked after anticholinergic withdrawal?
Repeat MMSE or Montreal Cognitive Assessment at four to six weeks; many patients show measurable improvement once the anticholinergic load is removed.
Learning Materials
- American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372
- Seppala, L. J., et al. (2023). European position paper on polypharmacy and fall-risk-increasing drugs recommendations in the World Guidelines for Falls Prevention and Management: Implications and implementation. European Geriatric Medicine, 14(4), 649–658. https://doi.org/10.1007/s41999-023-00824-8
- Moncada, L. V. V., & Mire, L. G. (2024). Falls in older adults: Approach and prevention. American Family Physician, 109(5), 447–456. https://www.aafp.org/pubs/afp/issues/2024/0500/falls-older-adults.html
- Linsky, A. M., et al. (2025). Deprescribing in community-dwelling older adults: A systematic review and meta-analysis. JAMA Network Open, 8(5), e259375. https://doi.org/10.1001/jamanetworkopen.2025.9375
- Hung, A., Kim, Y. H., & Pavon, J. M. (2024). Deprescribing in older adults with polypharmacy. BMJ, 385, e074892. https://doi.org/10.1136/bmj-2023-074892
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- Submit a 3–4-page clinical analysis applying 2023 Beers Criteria and multifactorial fall-prevention strategies to Mr. A.S. Sample case study answer geriatric falls polypharmacy cognitive change Advanced Primary Care Family
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Next Assignment Preview – Week 8 / Module 4 Discussion
Advanced Primary Care of Family I-HBN-HY01
Post a 400–500-word response that compares two validated fall-risk screening tools (for example STEADI versus Timed Up and Go) and proposes an interprofessional care plan for an older adult living alone after a hip fracture. Include at least two peer-reviewed sources published within the last five years and address both pharmacologic and environmental risk reduction. Reply substantively to two classmates by the end of the week.
