Falls assessment and prevention — KFP-style written assessment

KFP 1 (10 marks)

An 81-year-old woman presents after falling in her kitchen last night. She was not injured. Medications: temazepam 10 mg nocte (for 6 years), amlodipine 10 mg, metoprolol 50 mg bd, oxybutynin 5 mg bd (urgency), paracetamol PRN. She lives alone in a two-storey house with loose rugs. Timed Up and Go: 16 seconds. Lying BP 138/78, standing BP 112/64 after 1 minute with mild dizziness. ^[5]

1. List the modifiable contributors found in this assessment. (4) ^[2]
2. State the medication changes you would make and the monitoring each requires. (3) ^[2]
3. What does trial evidence say about the psychotropic withdrawal component of her plan? (3) ^[2]

Model answers

1. Modifiable contributors: sedative psychotropic (temazepam — falls risk class), antihypertensive burden with orthostatic hypotension (standing drop of 26 mmHg systolic with symptoms), anticholinergic (oxybutynin), home hazards (loose rugs, two-storey house), and raised Timed Up and Go (16 seconds exceeds the ~13.5 s risk threshold). Each maps to a specific intervention rather than generic advice. ^[2]
2. Temazepam: gradual taper and sleep-hygiene substitution — withdrawal cut fall hazard to 0.34 in a randomised trial, though permanent withdrawal is hard and needs support. Amlodipine/metoprolol: review doses against standing BP and current cardiovascular risk; reduce the agent contributing most to the orthostatic drop. Oxybutynin: switch to a bladder-training approach or a less anticholinergic alternative given its cognitive and falls burden. Recheck standing BP and TUG after each change. ^[2]
3. Campbell's randomised trial: psychotropic withdrawal over 44 weeks reduced the relative hazard of falling to 0.34 (95% CI 0.16–0.74) — a two-thirds reduction — but permanent withdrawal proved very difficult to achieve, so the plan needs tapering support, relapse planning, and non-drug sleep strategies to hold the gain. ^[2]