How to manage a 91-year-old female patient who is bedbound, recently started on Tramadol (tramadol hydrochloride) for chronic pain, and experienced a fall, presenting with dizziness, lethargy, and hypotension?

Immediate Management of Fall in 91-Year-Old on Tramadol

Discontinue tramadol immediately and conduct a comprehensive fall evaluation including orthostatic blood pressure assessment, neurological examination, and medication review, as tramadol is a known fall risk medication that causes dizziness, sedation, and orthostatic hypotension—particularly dangerous in this frail, bedbound patient. 1, 2

Immediate Actions

Discontinue Tramadol

• Stop tramadol now—this medication causes dizziness/vertigo (26-33%), somnolence (16-25%), and orthostatic hypotension, all of which directly increase fall risk 2, 3
• The FDA label explicitly documents dizziness/vertigo as the most common adverse effect occurring in up to 33% of patients, with sedation in 25% 2
• Tramadol was started just 2 days before the fall (11/15/2025), making it the most likely precipitant 2
• Consider morphine or another opioid not dependent on CYP2D6 metabolism if pain control remains necessary 4

Comprehensive Fall Assessment

• Perform orthostatic blood pressure measurements immediately—her BP readings show borderline low diastolic pressures (50-72 mmHg range), and she's on midodrine for hypotension, suggesting baseline orthostatic instability 1, 3
• Document fall circumstances: loss of consciousness, time on floor, presence of confusion or altered mental status 1
• Complete head-to-toe examination for occult injuries, particularly hip fracture given her age and frailty 1
• Assess the head injury and spine pain she reported—these require imaging if any neurological deficits present 1

Medication Review and Optimization

High-Risk Medications to Address

• Midodrine 10mg TID: Her BP readings show she's achieving adequate pressures (106-132 systolic), suggesting midodrine may be causing excessive vasoconstriction contributing to dizziness 1
• Apixaban 2.5mg BID: Increases bleeding risk from falls; however, continue for atrial fibrillation unless bleeding complications develop 1
• Memantine and Donepezil: Continue for dementia but recognize these patients have inherently higher fall risk 1
• Ropinirole for restless leg syndrome: Can cause orthostatic hypotension and dizziness; consider if truly necessary 3

Polypharmacy Concerns

• This patient is on 15 medications—polypharmacy itself is an independent fall risk factor 3
• Vestibular suppressants and psychotropic medications significantly increase fall risk, particularly in the elderly 3
• The combination of tramadol (CNS depressant), midodrine (BP effects), and multiple other medications creates dangerous interactions 2, 3

Specific Interventions

Immediate Safety Measures

• Implement bed alarm system and increase supervision—she is bedbound and dependent in all ADLs, making unsupervised falls catastrophic 1
• Lower bed to lowest position and ensure call bell within reach 1
• Assess home safety if in residential facility, including lighting, floor surfaces, and assistive device availability 1, 3

Physical Therapy Consultation

• Refer for gait and balance assessment using the "Get Up and Go Test" once medically stable 1, 3
• Implement individualized exercise program focusing on balance training, gait training, and strength training if patient can participate 3
• Provide training on appropriate use of assistive devices 1

Multifactorial Risk Assessment

• The American Geriatrics Society recommends comprehensive multifactorial assessment for patients who present with an acute fall 3, 1
• Evaluate: balance and mobility, vision, orthostatic hypotension, medication use, cognitive function, and environmental hazards 3, 1
• Address each identified risk factor with targeted interventions 3

Monitoring and Follow-Up

Short-Term Monitoring

• Reassess within 1 month to document resolution or persistence of symptoms after tramadol discontinuation 3
• Monitor orthostatic vital signs daily while adjusting medications 1
• Track any recurrent falls or near-falls 1
• Evaluate pain control with alternative regimen—scheduled acetaminophen 650mg BID is already prescribed and should be optimized before adding other opioids 2

Long-Term Prevention

• This patient remains at extremely high risk for recurrent falls given age, frailty, bedbound status, dementia, and polypharmacy 3, 1
• Continue multifactorial interventions including ongoing medication review, environmental modification, and supervised mobility 3
• Counsel family/caregivers about fall risk and need for constant supervision 3

Critical Pitfalls to Avoid

• Do not restart tramadol—the temporal relationship between tramadol initiation and fall is too strong to ignore, and safer alternatives exist 2, 4
• Do not assume the fall was mechanical—in a bedbound patient, falling out of bed suggests altered mental status, orthostatic hypotension, or medication effect 1
• Do not overlook occult injuries—elderly patients may not manifest typical signs of serious injury like hip fracture or intracranial hemorrhage 1
• Do not continue midodrine without reassessing need—her BP readings suggest adequate control, and midodrine itself can cause dizziness 1
• Do not use vestibular suppressants (antihistamines, benzodiazepines) as they increase fall risk without addressing the underlying cause 3