Loss of Balance Case Study

JK is a 77-year-old male who reports a 1-week history of intermittent dizziness and episodes of loss of balance, particularly when walking around. He denies any recent falls, headaches, visual changes, or chest pain. He describes the sensation as “lightheaded” and “like the room spins a little.”

Past Medical History:

Atrial fibrillation (on warfarin)
Hypertension (on lisinopril)
Chronic lower back pain with recent exacerbation
Osteoarthritis
Hyperlipidemia

Current Medications:

Warfarin 5 mg daily
Lisinopril 20 mg daily
Cyclobenzaprine 10 mg TID PRN
Atorvastatin 40 mg nightly
Ibuprofen 400 mg TID PRN

What should be reviewed?

My first step in this situation would be to get more information about blood pressure. This sounds like orthostatic hypotension and lisinopril could certainly be a cause if this is the issue. Obtaining orthostatic readings of laying, sitting, and standing could be helpful in identifying if a drop in blood pressure is happening with position changes.

Cyclobenzaprine use is concerning and I would be inquiring about how much this medication is being used on an as needed basis. Cyclobenzaprine can cause sedation, dizziness, and impaired balance, especially in older adults. It is anticholinergic and may lead to increased fall risk.

My final concern with the loss of balance would be surrounding warfarin. First, if this patient falls, they are at significant risk of a bleeding event. The other concern that should be assessed is anemia. Low hemoglobin could contribute to balance concerns and increase the risk of falls. I’d like to know a CBC and if low hemoglobin is a concern that may be causing these issues. In addition, blood loss (particularly GI) is of even higher concern because of the possible use of ibuprofen. I would like to discontinue this medication and find an alternative to this medication given the interaction risk with warfarin.

What other concerns might you have with this “Loss of Balance” case?

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