Case Reports

The following series of clinical vignettes demonstrate successful medication reduction in Bruyère Continuing Care Geriatric Day Hospital patients. These case reports illustrate that there is no one right place to start when thinking about deprescribing and that each approach is individualized. We’ve included group discussion questions and worksheets so that you can use these vignettes for interprofessional education. Please let us know how you are using the care reports in practice or education here.

If you want to give us other feedback about the case reports, please email [email protected]

Turning over the rocks: Role of anticholinergics and benzodiazepines in cognitive decline and falls
Barbara Farrell,  Pamela Eisener-Parsche,  Dan Dalton

This case illustrates how the quality of life and functioning of an elderly person with multiple medical problems
was affected by medication review, tapering and deprescribing of medications, and contributions of an interprofessional team during admission to the Bruyère Continuing Care Geriatric Day Hospital (GDH) in Ottawa, Ont. A 69-year-old woman was referred to the GDH for concerns about polypharmacy, mobility, cognition, and recurrent falls. Her medical history was relevant for 3 cerebral vascular accidents (CVAs), hypertension, asthma, gastroparesis, recurrent esophageal strictures requiring monthly dilation, controlled severe depression, hypothyroidism, chronic functional bowel problems, and meningioma. The CVAs resulted in a substantial decline in her overall functional abilities, including left hemiplegia and deterioration in balance […] read full report


Reducing fall risk while managing hypotension, pain, and poor sleep in an 83-year-old woman
Barbara Farrell,  Salima Shamji, Nafisa Ingar

This case illustrates how various cardiovascular therapies (eg, β-blockers, calcium channel blockers, loop diuretics) can contribute to dizziness, orthostatic hypotension, and subsequent falls in elderly patients. We describe how some of these medications were successfully tapered and discontinued with beneficial patient outcomes. An 83-year-old woman was referred to the GDH for uncontrolled chronic pain and recurrent falls. Her pain was most pronounced in her low back, right hip, neck, and shoulder, hindering her sleep and affecting her ability to perform instrumental activities of daily living (IADLs), such as doing laundry. She had a history of falling about once per month, likely as a result of dizziness, loss of balance, and tripping over objects […] read full report


Identifying and managing drug-related causes of common geriatric symptoms
Barbara Farrell,  Anne Monahan,  Nafisa Ingar

This case illustrates how medications might contribute to common, distressing geriatric symptoms. Despite patient sensitivity to medication changes, we were successfully able to stop several medications without worsening of symptoms for which the medications were being used. An 84-year-old woman was referred to the GDH for assessment of mobility and falls, mood, and cognitive changes. She was diagnosed with Parkinson disease earlier that year, and in the past couple of years had had a number of falls and near falls, during which she “felt her legs give way.” Her walking tolerance was diminished even with a 4-wheeled walker, and cognition had declined with slower processing speed. Her past medical history was relevant for a probable dementia secondary to Parkinson disease, benign positional vertigo, hemorrhagic stroke, diverticulosis, osteoporosis, osteoarthritis, degenerative disk disease, type 2 diabetes (diet controlled), glaucoma, and allergic rhinitis […] read full report


Revisiting medication use in a frail 93-year-old man experiencing possible adverse effects
Barbara Farrell, Anne Monahan, Wade Thompson

This case underscores the importance of assessing drug-related causes of symptoms in older patients and whether the causative agent is still required. Few drug trials include participants in their 80s or 90s, and given pharmacokinetic and pharmacodynamic changes in older people, little is known about the safety and effectiveness of medications in this patient group. A 93-year-old man was referred to a geriatric day hospital for assessment of falls, mobility, mood and function. A month earlier, he had presented to a local hospital following a fall that resulted in lacerations to his right arm. At that time, he reported worsening balance and frequent falls over several months, as well as low mood. Comorbidities included coronary artery disease with previous myocardial infarction and angioplasty 15 years earlier, carotid endarterectomy, hypertension, vertebral fractures, bullous pemphigoid and osteoporosis […] read full report 


Managing polypharmacy in a 77-year-old woman with multiple prescribers
Barbara Farrell, Véronique French Merkley, Wade Thompson

In the case of our patient, several drugs caused or contributed to additive CNS depression, falls, cognitive difficulties and excessive sedation. An assessment of her medications for indication, effectiveness, safety and compliance identified drug-related contributors and allowed us to reduce her pill burden while optimizing her function and quality of life. A 77-year-old woman was referred to a geriatric day hospital with concerns about mobility and falls, pain, constipation, cognition and polypharmacy. Comorbidities included cerebrovascular disease, coronary artery disease, hypertension, dementia, fibromyalgia, myositis, bipolar disorder, arthritis, remote duodenal ulcer and hypothyroidism. A stroke 3 years earlier resulted in increasing difficulties with transfers and ambulation, leading to 3–4 falls weekly […] read full report

Managing chronic diseases in the frail elderly: More than just adhering to clinical guidelines

Barbara Farrell, Salima Shamji, Dan Dalton

This case illustrates how addressing hypoglycemia by reducing medication use and addressing low blood pressure by reducing heart failure medications were effective in reducing fall risk. A 79-year-old man was referred to the GDH for assessment of cognition, pain, falls, difficulty with mobility and transfers, mood, dizziness and insomnia. His medical history was significant for prostate cancer, low back pain secondary to severe spinal stenosis, long-standing depression, osteoarthritis of the hips and knees, myocardial infarction 7 years previously with coronary artery bypass grafting (CABG), left-sided heart failure secondary to ischemic cardiomyopathy (NYHA class II), bilateral total knee replacements, type 2 diabetes, moderate sensory neural hearing loss, 3 previous upper gastrointestinal bleeds and bilateral cataract surgery […]  read full report

Reducing fall risk while managing pain and insomnia: Addressing polypharmacy in an 81-year-old woman

Barbara Farrell, Salima Shamji, Nafisa Ingar

This case illustrates how medications, including a tricyclic antidepressant, beta blocker, calcium channel blocker and diuretic, can potentially contribute to orthostatic hypotension, dizziness and falls. n 81-year-old woman was referred to the GDH by her new family physician for assessment of a long history of falls, difficulty with mobility and transfers, medication review, cognitive assessment, mood and future planning. She had been having difficulty with balance and falling backwards, often hurting the back of her head. Her gait was such that she described herself as “walking like a drunken sailor.” She had been having trouble sleeping recently, particularly with falling asleep again after waking and was often having daytime naps. Although she was independent in terms of her instrumental activities of daily living, her growing concern over these may have been contributing to her low mood […] read full report


Reducing pill burden and helping with medication awareness to improve adherence
Barbara Farrell, Veronique French Merkley, Nafisa Ingar

This case illustrates an approach to reducing the pill burden of polypharmacy that includes eliminating medications that are not working or are potentially harmful, reducing dosing frequency and using fixed combination products. A 78-year-old woman was referred to the GDH for assessment of cognition and review of her multiple medical problems. Her past medical history included hypertension, diabetes, dyslipidemia, a recent stroke, hypothyroidism, osteoporosis, gout, restless leg syndrome, and psoriatic arthritis. She had recently scored 14 of 30 on the Montreal Cognitive Assessment (MOCA) (normal being ≥26) ( At the initial assessment, her daughter raised concerns about progressive memory loss and reported a family history of Alzheimer disease. Low mood/unresolved grief, decreased mobility and endurance, and ongoing pain (particularly in her right heel) were also identified as active issues. […] read full report