Case Study: Aubre R. presents as a new patient to your practice having recently relocated from
rural Tennessee. She is 68 years old and complains of irritable bowel syndrome (IBS) with
abdominal cramping and frequent diarrhea with occasional constipation. She has a history of
domestic violence with resultant anxiety requiring inpatient hospitalization 8 years ago. She is
also complaining of urinary retention, insomnia, and hip pain since a hip fracture 4 years ago.
Her drugs include zolpidem 10 mg hs, bethanechol 25 mg tid, metoclopramide 10 mg tid,
amitriptyline 100 mg hs, alprazolam 0.25 mg tid, hydrocodone/APAP 5/500 tid, and
dicyclomine 20 mg four times daily.
● What are your concerns about this drug regimen?
○ My immediate concerns are related to polypharmacy. This patient is prescribed
several medications that can cause significant drowsiness and sedation, especially
in an older adult. These medications include zolpidem, amitriptyline, alprazolam,
and hydrocodone. Also related to polypharmacy, this patient is prescribed some
medications that are contradictory to each other such as bethanechol and
amitriptyline (Padda, 2024). Amitriptyline is known to have many adverse effects
in which the prevalence increases with the dose (Thour, 2023). Amitriptyline was
most likely prescribed for her diagnosis of IBS with diarrhea, but she is now
experiencing urinary retention due to its anticholinergic effects (Thour, 2023).
Bethanechol was prescribed to help increase urination and empty the bladder by
stimulating the muscarinic receptors (Padda, 2024). It is also important to note
that the patient may take her dicyclomine up to 4 times a day, this medication is
also an anticholinergic that may contribute to her issues with urination
(Dicyclomine, 2025).
● What recommendations do you have for this patient?
○ First we will begin to slowly taper down the amitriptyline. This medication is
most likely causing her issues with urinary retention, especially at a dose of
100mg in an older adult (Thour, 2023). The American Geriatric Society
recommends for older adults to avoid this medication due to its
anticholinergic effects, however, if it is used they recommend a low dose of
10mg/day (Thour, 2023). This patient is also still reporting symptoms of her
IBS such as diarrhea
, and abdominal cramping, even with the amitriptyline, so this is not an appropriate
treatment for her.
○ Second, we will discontinue the bethanechol. This medication should be used
cautiously in older adults due to its limited effectiveness, the patient is still
complaining of urinary retention issues (Padda, 2024). This drug is also not
recommended for older adults because of adverse effects such as abdominal
cramps, nausea, vomiting, diarrhea, etc, possibly contributing to her worsening
IBS symptoms (Padda, 2024). Decreasing the amitriptyline over time and
discontinuing this medication should help begin to decrease urinary retention and
additional abdominal cramps or diarrhea related to the medication.
○ The dicyclomine should also be discontinued because it is an anticholinergic,
contributing to her urinary retention (Dicyclomine, 2025).
○ In addition, the patient will be educated on ways to treat IBS-D through lifestyle
such as increasing exercise, avoiding foods identified as a trigger, eating more
high fiber foods or supplements, and increasing fluid intake (Irritable Bowel,
2024). If her IBS symptoms have not improved with lifestyle changes and
discontinuing the Amitriptyline, Alosetron may be a good alternative. Alosetron
is a 5-HT3 receptor antagonist that will slow colonic transit time, increase water
absorption, and promote stool formation (Butt, 2024). This medication has been
approved by the FDA to reduce pain and abdominal discomfort, diarrhea, and
urgency (Butt, 2024). This medication is also approved to be used in older adults
but started at the minimal dose of 0.5mg twice daily due to the possible adverse
effect of constipation (Butt, 2024). If a patient is experiencing severe constipation,
this medication may have to be discontinued (Butt, 2024).
○ The alprazolam may be continued at 0.25mg three times daily as needed. This
patient has a significant history of anxiety and domestic violence resulting in
hospitalization. This medication has been deemed safe for older patients at a low
dose of 0.25mg up to 2 to 3 times daily (George, 2023). However, there is still a
concern for polypharmacy with some of her other medications. With the
continuation of Xanax, it is recommended to avoid other CNS depressants such as
her hydrocodone because it may contribute to severe sedation, respiratory
depression, coma, and/or death (George, 2023). The patient is still experiencing
rural Tennessee. She is 68 years old and complains of irritable bowel syndrome (IBS) with
abdominal cramping and frequent diarrhea with occasional constipation. She has a history of
domestic violence with resultant anxiety requiring inpatient hospitalization 8 years ago. She is
also complaining of urinary retention, insomnia, and hip pain since a hip fracture 4 years ago.
Her drugs include zolpidem 10 mg hs, bethanechol 25 mg tid, metoclopramide 10 mg tid,
amitriptyline 100 mg hs, alprazolam 0.25 mg tid, hydrocodone/APAP 5/500 tid, and
dicyclomine 20 mg four times daily.
● What are your concerns about this drug regimen?
○ My immediate concerns are related to polypharmacy. This patient is prescribed
several medications that can cause significant drowsiness and sedation, especially
in an older adult. These medications include zolpidem, amitriptyline, alprazolam,
and hydrocodone. Also related to polypharmacy, this patient is prescribed some
medications that are contradictory to each other such as bethanechol and
amitriptyline (Padda, 2024). Amitriptyline is known to have many adverse effects
in which the prevalence increases with the dose (Thour, 2023). Amitriptyline was
most likely prescribed for her diagnosis of IBS with diarrhea, but she is now
experiencing urinary retention due to its anticholinergic effects (Thour, 2023).
Bethanechol was prescribed to help increase urination and empty the bladder by
stimulating the muscarinic receptors (Padda, 2024). It is also important to note
that the patient may take her dicyclomine up to 4 times a day, this medication is
also an anticholinergic that may contribute to her issues with urination
(Dicyclomine, 2025).
● What recommendations do you have for this patient?
○ First we will begin to slowly taper down the amitriptyline. This medication is
most likely causing her issues with urinary retention, especially at a dose of
100mg in an older adult (Thour, 2023). The American Geriatric Society
recommends for older adults to avoid this medication due to its
anticholinergic effects, however, if it is used they recommend a low dose of
10mg/day (Thour, 2023). This patient is also still reporting symptoms of her
IBS such as diarrhea
, and abdominal cramping, even with the amitriptyline, so this is not an appropriate
treatment for her.
○ Second, we will discontinue the bethanechol. This medication should be used
cautiously in older adults due to its limited effectiveness, the patient is still
complaining of urinary retention issues (Padda, 2024). This drug is also not
recommended for older adults because of adverse effects such as abdominal
cramps, nausea, vomiting, diarrhea, etc, possibly contributing to her worsening
IBS symptoms (Padda, 2024). Decreasing the amitriptyline over time and
discontinuing this medication should help begin to decrease urinary retention and
additional abdominal cramps or diarrhea related to the medication.
○ The dicyclomine should also be discontinued because it is an anticholinergic,
contributing to her urinary retention (Dicyclomine, 2025).
○ In addition, the patient will be educated on ways to treat IBS-D through lifestyle
such as increasing exercise, avoiding foods identified as a trigger, eating more
high fiber foods or supplements, and increasing fluid intake (Irritable Bowel,
2024). If her IBS symptoms have not improved with lifestyle changes and
discontinuing the Amitriptyline, Alosetron may be a good alternative. Alosetron
is a 5-HT3 receptor antagonist that will slow colonic transit time, increase water
absorption, and promote stool formation (Butt, 2024). This medication has been
approved by the FDA to reduce pain and abdominal discomfort, diarrhea, and
urgency (Butt, 2024). This medication is also approved to be used in older adults
but started at the minimal dose of 0.5mg twice daily due to the possible adverse
effect of constipation (Butt, 2024). If a patient is experiencing severe constipation,
this medication may have to be discontinued (Butt, 2024).
○ The alprazolam may be continued at 0.25mg three times daily as needed. This
patient has a significant history of anxiety and domestic violence resulting in
hospitalization. This medication has been deemed safe for older patients at a low
dose of 0.25mg up to 2 to 3 times daily (George, 2023). However, there is still a
concern for polypharmacy with some of her other medications. With the
continuation of Xanax, it is recommended to avoid other CNS depressants such as
her hydrocodone because it may contribute to severe sedation, respiratory
depression, coma, and/or death (George, 2023). The patient is still experiencing
