What is the best management plan for an elderly female patient with multiple comorbidities and a recent unwitnessed fall, considering her complex medical history and current lab results?

Management of Elderly Female with Multiple Comorbidities and Recent Unwitnessed Fall

The current management plan is comprehensive and appropriate, with priority focus on fall prevention through medication review, environmental modifications, and multidisciplinary assessment, while maintaining anticoagulation with enhanced bleeding surveillance given the high-risk profile.

Critical Immediate Actions

Fall Risk Mitigation

• Continue hourly safety rounds and maintain all environmental precautions (low bed, floor mats, assist x2 for transfers) as these interventions are strongly supported for high-risk patients 1
• The unwitnessed fall on anticoagulation mandates daily clinical assessment with in-person examination during the acute phase 2
• Document that rubber/nonskid floor surfaces, handrails, adequate lighting, and bedside commodes are in place per evidence-based fall prevention protocols 1

Medication Review Priority

• Immediate comprehensive medication review is essential given polypharmacy (>10 medications) and fall risk 1
• Gabapentin requires particular scrutiny as it acts on the central nervous system and increases fall risk; consider tapering if sedation effects are contributing to falls 1
• The prescribing cascade must be avoided—ensure the gabapentin for polyneuropathy is not masking or causing new symptoms that could lead to additional prescriptions 1

Anticoagulation Management Post-Fall

Apixaban Continuation Decision

• Continue apixaban with enhanced monitoring as the benefits of VTE prevention outweigh bleeding risk in this patient with personal history of venous thrombosis 3, 4
• The current standard dose (presumably 5mg BID) is appropriate unless she meets dose-reduction criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 3
• At 130.8 lb (59.4 kg) and CKD3A, she approaches but may not definitively meet reduction criteria—verify exact creatinine value 3
• Shift-by-shift bleeding surveillance is appropriate and should continue 1

Polypharmacy Optimization Strategy

Systematic Medication Assessment

Apply the following structured review to each medication 1, 5:

1. Glipizide (diabetes): A1C 6.6% meets ADA goal—consider whether this sulfonylurea is necessary or if it increases hypoglycemia/fall risk. Monitor BID accuchecks closely 1

2. Gabapentin (polyneuropathy): Assess benefit versus sedation/fall risk. If minimal benefit, taper slowly as it acts on CNS 1

3. Lansoprazole (GERD): Appropriate to continue through esophagitis treatment, but plan discontinuation timeline to avoid indefinite PPI use 1

4. Trelegy Ellipta (COPD): Continue—respiratory benefit outweighs risks 1

5. Levothyroxine (hypothyroid): TSH 1.05 indicates appropriate dosing; continue 1

6. Apixaban (VTE history): Continue with monitoring as discussed above 3, 4

Deprescribing Approach

• Stop medications one at a time with detailed plans for safe discontinuation 1
• Medications acting on cardiovascular or CNS require cautious tapering 1
• Partner with pharmacist for optimization and to identify drug-drug interactions 1, 5

Nutritional and Wound Healing Support

Protein-Calorie Malnutrition Management

• Continue Pro-Stat BID and monitor weekly weights x3 weeks as ordered 1
• Albumin 2.8 and prealbumin 15 indicate significant malnutrition affecting wound healing and fall risk 1
• Registered dietitian involvement is appropriate and should continue 1

Vitamin D Deficiency

• Level of 17.2 ng/mL requires continued ergocalciferol weekly 1
• Vitamin D supplementation has moderate evidence for fall prevention in deficient patients 1

Blood Pressure Management Considerations

Current Status Assessment

• BP 125/75 is stable and within acceptable range for this 130.8 lb elderly patient 1
• Do not intensify BP treatment despite guidelines suggesting <130/80 targets, as this patient has frequent falls, multiple comorbidities, and frailty 1
• The 2017 ACC/AHA guidelines specifically caution that "patients with prevalent and frequent falls, advanced cognitive impairment, and multiple comorbidities should be managed cautiously" 1
• Monitor for orthostatic hypotension during each assessment given fall history 1

Multifactorial Fall Intervention Components

Evidence-Based Assessment Elements

Comprehensive evaluation must address 1:

• Gait and balance assessment by PT/OT (already ordered—appropriate)
• Vision evaluation (not mentioned—should be added)
• Cardiovascular assessment including orthostatic vitals (should be documented at each visit)
• Footwear evaluation (not mentioned—should be added)
• Cognitive factors beyond baseline (MMSE or similar if not recently done)

Therapy and Rehabilitation

• Long-term exercise and balance training is strongly recommended for patients with recurrent falls 1
• PT/OT should incorporate fall prevention strategies into therapy pathway as documented 1
• Weight-bearing as tolerated on LLE is appropriate for fracture healing 1

Anemia Management

Microcytic Anemia Approach

• Weekly CBC x3 is appropriate monitoring 1
• Hgb 10.5 with MCV 79.1 suggests iron deficiency component beyond chronic disease 1
• Consider iron studies if not recently done to guide supplementation 1
• Monitor for symptomatic decline, though patient currently asymptomatic 1

Care Coordination and Prognosis

Life Expectancy Considerations

• Treatment decisions should be prioritized based on short-term outcomes (within 1 year) given multiple comorbidities, frailty, and fall history 1
• Focus on interventions most likely to provide meaningful benefit: fall prevention, wound healing, symptom control 1
• Long-term preventive measures (e.g., aggressive lipid control) have lower priority 1

Interdisciplinary Team Approach

• Continue coordination between medicine, PT/OT, pharmacy, dietary, and wound care 1
• Document clear communication of treatment complexity and burden with patient and family 1
• Ensure discharge planning includes home safety assessment if/when discharged 1

Key Pitfalls to Avoid

1. Do not add medications without careful consideration of treatment burden and drug-drug interactions 1
2. Do not discontinue apixaban due to fall—bleeding risk does not outweigh VTE recurrence risk in this patient 3, 4
3. Do not pursue aggressive BP lowering given fall history and frailty 1
4. Do not overlook medication-induced contributions to falls, particularly CNS-active drugs 1
5. Do not assume all interventions beneficial in younger patients apply to this frail elderly patient with limited life expectancy 1