Question:hard
An 86 year old lady presented with severe constipation. She was a known hypertensive on medications for 10 years. In clinic, her BP was 157/98 mm Hg with a heart rate of 58/min. On taking her BP in the supine position it was found to be 90/60 mm Hg. She had a recent history of depression. She is taking atenolol, thiazide, imipramine, haloperidol and docusate. What will be the next best step in the management?
An 86 year old lady presented with severe constipation. She was a known hypertensive on medications for 10 years. In clinic, her BP was 157/98 mm Hg with a heart rate of 58/min. On taking her BP in the supine position it was found to be 90/60 mm Hg. She had a recent history of depression. She is taking atenolol, thiazide, imipramine, haloperidol and docusate. What will be the next best step in the management?
Show Hint
Find the anticholinergic and alpha blocking culprits causing constipation and postural hypotension.
Updated On: Jun 24, 2026
- Change atenolol and thiazide to a calcium channel blocker and ACE inhibitor and add bisacodyl for constipation
- Change imipramine and haloperidol to fluoxetine and risperidone and add bisacodyl for constipation
- Only add bisacodyl for constipation and continue rest of the medications
- Discontinue all her medications and start her on steroids
Show Solution
The Correct Option is B
Solution and Explanation
Step 1: Read the case as a drug induced problem. An elderly patient shows both stubborn constipation and a wide swing in blood pressure with posture, and she is on a long medication list. The task is to find which agents cause this picture and replace them.
Step 2: Imipramine, a tricyclic, is the chief culprit. Its alpha blocking action produces orthostatic hypotension, and its potent anticholinergic effect slows the gut and aggravates constipation. Haloperidol layers on more anticholinergic effect. Together they explain the symptoms.
Step 3: The rational substitution is to move depression treatment to an SSRI, fluoxetine, which lacks these anticholinergic and pressor effects, and to swap haloperidol for risperidone, an atypical antipsychotic with a gentler side effect profile. Bisacodyl covers the current constipation.
Step 4: The rejected options fail because tweaking the antihypertensives leaves the offending psychotropics untouched, a laxative alone is purely symptomatic, and blanket withdrawal with steroids has no basis and risks harm.
\[\boxed{\text{Change imipramine and haloperidol to fluoxetine and risperidone, add bisacodyl}}\]
Step 2: Imipramine, a tricyclic, is the chief culprit. Its alpha blocking action produces orthostatic hypotension, and its potent anticholinergic effect slows the gut and aggravates constipation. Haloperidol layers on more anticholinergic effect. Together they explain the symptoms.
Step 3: The rational substitution is to move depression treatment to an SSRI, fluoxetine, which lacks these anticholinergic and pressor effects, and to swap haloperidol for risperidone, an atypical antipsychotic with a gentler side effect profile. Bisacodyl covers the current constipation.
Step 4: The rejected options fail because tweaking the antihypertensives leaves the offending psychotropics untouched, a laxative alone is purely symptomatic, and blanket withdrawal with steroids has no basis and risks harm.
\[\boxed{\text{Change imipramine and haloperidol to fluoxetine and risperidone, add bisacodyl}}\]
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