An 82-year-old man is brought to the clinic by his daughter after 3 falls in the past 4 months and 2 months of increasing confusion and daytime drowsiness. He has benign prostatic hyperplasia with nocturia and urgency, chronic low back pain and long-standing insomnia. His medications are diphenhydramine 50 mg at bedtime (over the counter), oxybutynin 5 mg TID, diazepam 5 mg at bedtime for 12 years, amitriptyline 25 mg at bedtime, tamsulosin 0.4 mg daily and acetaminophen as needed. On examination he is drowsy but attentive when prompted, has a dry mouth, scores 21/30 on the MoCA, and takes 17 seconds to complete the Timed Up and Go test; blood pressure falls by 10/6 mm Hg on standing without symptoms and post-void residual is 150 mL. Sodium is 139 mmol/L (135-145), TSH 2.1 mIU/L (0.4-4.0), vitamin B12 and glucose are normal, and eGFR is 64 mL/min (60 or higher).
| Heart rate | 70/min |
| Respiratory rate | 16/min |
| Temperature | 36.8 °C |
| O2 saturation | 97%, room air |
| Blood pressure | 136/78 mm Hg supine |
Question 1 of 45
Which one of the following is the most appropriate medication strategy for this patient?
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