In a 71-year-old African American man who is confused (oriented to person and place only), has had multiple falls, decreased appetite, and no known drug allergies, what medication(s) should be prescribed?

Immediate Workup Required Before Prescribing

This patient requires urgent evaluation for delirium and reversible causes of confusion before initiating any dementia medications. The acute presentation of confusion with multiple falls and decreased appetite in a 71-year-old suggests delirium until proven otherwise, which represents a medical emergency 1.

Critical First Steps

Rule Out Delirium

• Assess for acute onset and fluctuating course of confusion over hours to days
• Interview family/caregivers to establish baseline cognitive function and timeline of changes
• Use a validated tool like the Confusion Assessment Method (CAM) 1
• Look for underlying causes: infection (UTI, pneumonia), electrolyte disturbances (especially hyponatremia), dehydration, hypoxia, medication toxicity 1, 2

Key Point: Delirium superimposed on undiagnosed dementia accelerates cognitive decline and increases mortality risk. It must be identified and treated first 1.

Essential Laboratory and Clinical Evaluation

• Complete metabolic panel (hyponatremia from diuretics is a common cause of confusion) 2
• CBC, urinalysis, chest X-ray to identify infection
• Thyroid function, B12 level (reversible causes of cognitive impairment)
• Medication review - even without known allergies, polypharmacy is a major fall risk 3, 4
• Formal cognitive assessment using MMSE or MoCA once delirium is excluded 5

If Dementia is Confirmed After Delirium Exclusion

Pharmacologic Treatment

For mild to moderate Alzheimer's disease, initiate donepezil 5 mg once daily at bedtime 6, 7, 5. This is the preferred first-line cholinesterase inhibitor based on:

• Once-daily dosing improves adherence
• Not hepatotoxic (no monitoring required)
• Mild side effects (nausea, vomiting, diarrhea) reduced when taken with food
• Can increase to 10 mg after 4 weeks if tolerated 6

Alternative cholinesterase inhibitors if donepezil not tolerated:

• Rivastigmine: Start 1.5 mg twice daily with meals, titrate slowly every 4 weeks to 6-12 mg/day 6
• Galantamine: Start 4 mg twice daily with meals, increase to 8 mg twice daily after 4 weeks 6

Critical Medication Considerations for This Patient

DO NOT prescribe these fall-risk medications 3, 4, 2:

• Benzodiazepines - increase confusion and fall risk 13.6% of drug-induced confusion cases 2
• Anticholinergics - worsen cognition and increase falls 3
• Antipsychotics - increase stroke and death risk; only use as last resort for severe behavioral symptoms 8, 6
• Tricyclic antidepressants - cause 13.6% of drug-induced confusion 2

Review and potentially discontinue:

• Diuretics (cause 15.1% of drug-induced confusion via hyponatremia) 2
• Any sedating medications
• Medications causing orthostatic hypotension 3, 4

Expected Outcomes and Monitoring

Set realistic expectations 6, 7:

• Cholinesterase inhibitors provide modest benefit (20-35% of patients show 7-point improvement on neuropsychological tests)
• This represents slowing decline by approximately 1 year, not cure
• Benefits are temporary stabilization or reduced rate of decline
• Assess response at 6-12 months using caregiver report and cognitive testing 6

Multimodal Fall Prevention Strategy

Beyond medication management, implement 3, 6:

Environmental Safety

• Remove throw rugs, secure electrical cords, improve lighting
• Install grab bars in bathroom
• Use safety locks on doors if wandering risk 6

Physical Interventions

• Structured exercise program (balance, strength, aerobic training) 3
• Gait assessment and assistive device evaluation 3
• Vision and hearing screening - sensory impairments worsen falls and cognition 3

Nutritional Support

• Address decreased appetite with small frequent meals
• Consider nutritional supplementation if weight loss present
• Evaluate for depression affecting appetite 3

Common Pitfalls to Avoid

1. Assuming confusion equals dementia - Nearly half of patients with drug-induced confusion have undiagnosed dementia, but the acute presentation suggests delirium 2

2. Polypharmacy blindness - Systematically review ALL medications; combinations of drugs with hypotensive effects significantly increase dizziness and falls 9

3. Starting cholinesterase inhibitors during acute illness - Stabilize medical conditions first; these drugs can initially increase agitation 6

4. Using antipsychotics for behavioral symptoms - Exhaust non-pharmacologic interventions first (predictable routine, simplified tasks, distraction techniques) 6

5. Ignoring the 48% of demented patients with undiagnosed dementia - This may be the first presentation requiring formal diagnosis 2

Immediate Action Plan

1. Hospitalize or urgent evaluation for delirium workup
2. Hold all non-essential medications until confusion etiology clarified
3. Once delirium excluded and dementia confirmed: Start donepezil 5 mg daily
4. Implement fall precautions and environmental modifications immediately
5. Schedule follow-up in 4 weeks to assess medication tolerance and titrate dose
6. Arrange comprehensive geriatric assessment including physical therapy, occupational therapy, and social work 6, 3