Managing complex and long-term care for MRCGP AKT

An 82-year-old woman living alone takes 11 regular medicines. She has had two falls in three months. Her medications include amitriptyline 25 mg at night for neuropathic pain, oxybutynin for urinary urgency, and bisoprolol. Which single action is most likely to reduce her falls risk?

1. Refer for a bathroom grab-rail assessment Worth doing within a multifactorial assessment, but environmental modification alone has a smaller effect than removing drugs causing sedation and postural hypotension.
2. Start vitamin D and calcium supplementation Appropriate for bone health in a housebound older adult, but a smaller lever than deprescribing two high-burden anticholinergics.
3. Review and reduce the anticholinergic burden, starting with amitriptyline and oxybutynin correct Correct. Both carry high anticholinergic burden, independently associated with falls, cognitive impairment and mortality in older people. Deprescribing the highest-burden agents is the largest lever available here.
4. Stop bisoprolol Possibly relevant if she has postural hypotension, but it should not go before the anticholinergics and may be treating a genuine cardiac indication. Check lying and standing blood pressure first.
5. Add a bisphosphonate Reasonable for fracture risk if FRAX warrants it, but it reduces the consequence of falls rather than their frequency.

The point: Falls in polypharmacy: anticholinergic burden, postural hypotension and sedatives first. Structured medication review is a clinical intervention with an effect size, not an administrative task.

Source: NICE CG161 — Falls in older people NICE · tier 1, national regulator or guidance

A 46-year-old woman with a BMI of 31 attends for a review. She has been taking sertraline 100 mg for 8 months for a first episode of moderate depression and has been symptom-free for 5 months. She asks whether she can stop. What is the most appropriate advice?

1. Stop immediately, since she has been well for five months Wrong on both counts: it is short of the recommended continuation period, and abrupt cessation of an SSRI causes discontinuation symptoms.
2. Switch to a different antidepressant before stopping Wrong. There is no reason to switch a drug that has produced remission and is well tolerated.
3. Halve the dose now and stop in two weeks Too fast, and dose reduction while still within the continuation period risks relapse rather than discontinuation symptoms alone.
4. Continue for at least 6 months after full remission, then taper gradually correct Correct. Continuing antidepressant treatment for at least six months after remission roughly halves relapse risk. She has been well for five months, so she is close but not there, and when she does stop it should be by gradual taper rather than abruptly.
5. Continue lifelong, as a first episode predicts recurrence Wrong. Lifelong treatment is considered after multiple recurrences or where there are strong risk factors, not after a single episode.

The point: Antidepressant continuation: at least six months after remission for a first episode, longer for recurrent illness. Taper over at least four weeks and longer for paroxetine and venlafaxine. Discontinuation symptoms are not addiction, but explain them or the patient will assume they are.

Source: NICE NG222 — Depression in adults: treatment and management NICE · tier 1, national regulator or guidance