Falls, polypharmacy and frailty — structured clinical viva

This is a polypharmacy–falls–frailty formulation viva, not a request to rubber-stamp three new CNS drugs. Frame frailty (Fried phenotype and/or CFS/deficit thinking) and reduced reserve (Clegg) so the examiner hears systems thinking.[1][2]

FRID audit first. Temazepam and amitriptyline are high-yield Beers/STOPP problems (sedation, anticholinergic load, orthostasis, falls). Meta-analyses link psychotropics — including benzodiazepines, antidepressants and antipsychotics — to falls; Glass shows poor risk–benefit for sedative-hypnotics in older insomnia. Do not start quetiapine 50 mg for vague evening restlessness before DICE-style assessment (pain, delirium, environment, depression, benzo effects).[3][4][5][10] If cognitive impairment progresses toward dementia and severe risk behaviours later needed an antipsychotic, black-box mortality framing, lowest dose, short course and review date apply — not open-ended use.[8]

Multifactorial falls plan. History, orthostatic BP, gait, vision, environment, bone health, exercise/physio, and medication review as core AGS/BGS components — not physio alone while FRIDs continue.[6]

Treat depression safely. If syndromal MDD is confirmed, prefer a safer start than high-dose citalopram: e.g. sertraline 25 mg orally then 50 mg, with sodium monitoring and falls counselling; avoid TCA first-line in frailty. Start low, go slow, but go to a therapeutic trial (Mangoni PK/PD justifies lower starts, not under-treatment).[7][9] Plan supervised deprescribing of temazepam/TCA with non-drug sleep and pain review.[7]

How many Fried criteria define frail? Three or more of five.[1]

Name psychotropic FRID classes. Benzodiazepines/Z-drugs, antipsychotics, antidepressants, anticholinergics; stacks multiply risk.[4]

What is deprescribing? Planned supervised taper/stop of medicines that harm or no longer help — not chaotic cessation.[7]

Why not escalate antipsychotics for wandering? Wrong target; modest efficacy; increased death risk vs placebo in dementia trials meta-analysis.[8]