American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the June ACP Observer, copyright 2003 by the American College of Physicians.

Clinical scenario

An 80-year-old, thin, white woman is hospitalized with a hip fracture that resulted from a fall. Her medical history is remarkable for isolated systolic hypertension, insomnia, osteoarthritis of the knee and a hysterectomy 20 years ago. Her medications are hydrochlorothiazide, 25 mg daily; zolpidem, 0.5 mg as needed at bedtime; conjugated estrogens, 0.625 mg daily; and a multivitamin daily. She has at least eight ounces of yogurt and two glasses of milk daily, in addition to a cheese sandwich. Her bone mineral density T-score is -2.8.

Which one of the following management options will most likely reduce her risk of a future fracture?

A. Stopping hydrochlorothiazide
B. Stopping conjugated estrogens and beginning nasal calcitonin
C. Stopping zolpidem
D. Starting calcium, 1,000 mg daily

Answer: C

Educational Objective: Recognize drugs that may predispose a frail elderly patient to falls.

Zolpidem, a hypnotic, has recently been shown to be associated with falls in frail older adults, similar to antidepressants, benzodiazepines and antipsychotics. The patient's daily calcium intake is about 1,100 mg a day just from her diet, close to the 1,500 mg a day recommended for a postmenopausal woman. Thiazide diuretics decrease calcuria, and have been associated with a 20% decrease in hip fractures. Although recent studies have clearly shown that conjugated estrogens do not prevent coronary artery disease, the same study by the Working Group for the Women's Health Initiative found that it reduced the risk of fractures. There is no evidence that nasal calcitonin is more effective at preventing fractures than conjugated estrogens.


1. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Zolpidem use and hip fractures in older people. Journal of the American Geriatrics Society. 2001;49:1685-90.

2. Jones G, Nguyen T, Sambrook PN, Eisman JA. Thiazide diuretics and fractures: Can meta-analysis help? Journal of Bone and Mineral Research. 1995;10:106-11.

3. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. Journal of the American Medical Association. 2002;288:321-33.

The above feature contains questions and answers excerpted from MKSAP 12 Update, an enhancement to the College's popular self-assessment program. For more information about MKSAP 12 Update, contact ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.


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