Psych CASC / OSCE · Old age psychiatry — falls polypharmacy frailty
Explain falls risk and deprescribing to family — CASC communication station
MRCPsych/FRANZCP-style communication station: explain frailty, psychotropic fall risk, multifactorial prevention, and supervised deprescribing with a restart threshold.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar meeting the resident's son after a falls and medication review.[1]
Candidate instructions. Explain frailty and why sedative and antipsychotic medicines increase fall risk in plain language; outline a supervised deprescribing plan that is not abandonment; describe non-drug sleep and behaviour supports and multifactorial falls prevention; agree safety-netting and teach-back. Examiner plays the son.[2][5][6]
Candidate scenario
Mrs K, 85, is frail with moderate Alzheimer disease and two falls in five weeks. She takes temazepam 15 mg most nights and risperidone 0.5 mg at night for 8 months without a documented target or review. Personal care triggers calling-out; pain has not been systematically assessed. You plan gradual reduction of both agents, pain and constipation review, staff ABC strategies, exercise/physio as able, environment checks, and a written plan to restart a low-dose antipsychotic only if severe aggression with risk of harm returns. The son fears both "more falls if she is restless" and "turning Mum into a zombie with tablets."[2][3][4]
Marking domains
- Empathy, structure, and dual-agenda setting (falls harm vs behaviour/sleep fears)
- Accurate plain-language explanation of frailty and psychotropic fall/mortality risks
- Clear deprescribing plan with monitoring and restart threshold (not abandonment)
- Multifactorial non-drug falls and behaviour plan
- Safety-netting, written facility plan, teach-back [4][5][6]
Reveal assessor key
Open. Thank him for coming; name both worries (falls if medicines reduced vs harm if oversedated). Shared goal: comfort, dignity, fewer falls, and least harmful medicines.[1]
Explain frailty and FRIDs without jargon. Mum's body has less reserve, so sleeping tablets and antipsychotics that cause drowsiness, unsteadiness or low blood pressure on standing make falls more likely. Studies link these drug groups to falls; sleeping tablets in older people often give more risk than benefit for insomnia. Antipsychotics can help severe aggression or distressing psychosis a little for some people, but also raise the risk of death and stroke-like events in dementia if used open-ended for mild behaviours.[2][3][4]
Explain the plan. We are not abandoning care. Calling-out often means pain, constipation, fear during washing, or a noisy environment — we will assess and treat those and train staff approaches. Because she has been relatively stable, we will reduce temazepam and risperidone slowly while watching carefully. If dangerous aggression returns, we can restart the lowest effective antipsychotic dose for the shortest time with a clear review date. Falls care also means checking blood pressure standing, vision, footwear, room hazards and gentle exercise/physio — not tablets alone.[5][6]
Close. Written plan for the facility, your contact for early review if behaviour escalates or another fall occurs, and teach-back of the key message: fewer sedatives plus better non-drug care is the safer path.[5]
References
- [1]Clegg A, Young J, Iliffe S, et al. Frailty in elderly people Lancet, 2013.PMID 23395245
- [2]Seppala LJ, Wermelink AMAT, de Vries M, et al. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: II. Psychotropics J Am Med Dir Assoc, 2018.PMID 29402652
- [3]Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
- [4]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [5]Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing JAMA Intern Med, 2015.PMID 25798731
- [6]Panel on Prevention of Falls in Older Persons, AGS/BGS Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons J Am Geriatr Soc, 2011.PMID 21226685