Falls, polypharmacy and frailty in old-age psychiatry (MEQ)

(i) Frailty and the integrated problem. Frailty is increased vulnerability to poor recovery after stressors (Clegg). Fried phenotype uses five criteria (weight loss, exhaustion, low activity, slow gait, weak grip; ≥3 frail). Rockwood frames cumulative deficits / Clinical Frailty Scale. In this resident, dementia, multimorbidity, polypharmacy and recurrent falls mark high vulnerability: the same psychotropic load that might be tolerated mid-life drives sedation, orthostasis and injury. Falls, polypharmacy and frailty are one system — not separate checklists.[1][2]

(ii) Beers / STOPP / FRID review. Temazepam is a classic Beers PIM and FRID (sedative-hypnotic fall risk). Long-term risperidone without review for non-specific "behaviour" fails dementia antipsychotic principles and adds FRID + mortality/stroke concerns. Oxybutynin adds anticholinergic burden (cognition, falls). Sertraline may be appropriate if depression is real, but thiazide + age raise hyponatraemia risk that can present as falls/confusion — check sodium. STOPP thinking stops unnecessary CNS sedatives; START thinking still asks whether pain, constipation, depression or sensory needs are under-treated.[3][4][5][6][10]

(iii) Multifactorial falls plan. Structured falls history (timing vs doses, prodrome, injury), orthostatic BP, gait/balance, vision, footwear, environment, cognition/delirium screen, bone health. Interventions: exercise/physio where feasible, environmental modification, treat orthostasis, medication review as core (not physio-only), staff ABC strategies for personal-care distress. Gillespie supports exercise and home safety in community; AGS/BGS supports multifactorial assessment — adapt intensity to RACF context.[7][8]

(iv) Deprescribe vs treat. Deprescribing is planned supervised taper/stop of harmful or non-beneficial drugs (Scott), not chaos and not permanent ban on all psychotropics. Plan gradual temazepam reduction with sleep supports; supervised risperidone taper with restart threshold only if severe aggression/risk returns, documenting target and time-limit — Schneider mortality meta-analysis underpins black-box literacy. For depression, continue or adjust sertraline carefully (e.g. ensure therapeutic trial, early Na check with thiazide) rather than under-treating severe mood illness solely for falls fear. One change at a time when frail when possible.[9][10][4]

(v) Family and disposition. Empathic dual-agenda talk: reduce drug harm and falls without abandoning comfort/safety. Plain language on antipsychotic risks in dementia; written facility plan; pharmacy and GP shared care; early review if behaviour escalates; teach-back. Disposition may include old-age CMHT input, falls/physio pathways, RACF medication advisory processes.[9][10]