# Situation: An 80-year-old woman with moderate Alzheimer disease is admitted to the medical ward for dehydration. She lives with her daughter. Her medications are donepezil 10 mg at bedtime and metoprolol 50 mg twice daily for hypertension. On day 2 she faints briefly while walking to the bathroom. Findings: heart rate 46/min and regular; blood pressure (BP) 124/72 mmHg lying and 118/70 mmHg after 3 minutes standing; capillary blood glucose 104 mg/dL (5.8 mmol/L). Which is the MOST likely contributor?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630425  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: An 80-year-old woman with moderate Alzheimer disease is admitted to the medical ward for dehydration. She lives with her daughter. Her medications are donepezil 10 mg at bedtime and metoprolol 50 mg twice daily for hypertension.

On day 2 she faints briefly while walking to the bathroom. Findings: heart rate 46/min and regular; blood pressure (BP) 124/72 mmHg lying and 118/70 mmHg after 3 minutes standing; capillary blood glucose 104 mg/dL (5.8 mmol/L). Which is the MOST likely contributor?

## 보기

1. Orthostatic hypotension caused by her continuing dehydration
2. Low blood glucose from her poor intake at meals and snacks
3. Slow heart rate from donepezil and metoprolol together **✔ 정답**
4. Progression of her Alzheimer disease affecting balance and gait

**정답: 3**

## 해설

Cholinesterase inhibitors such as donepezil can cause bradycardia and syncope, and beta blockers add to the effect. Her heart rate is 46/min, while her blood pressure falls only 6/2 mmHg on standing, short of the 20 mmHg systolic or 10 mmHg diastolic fall that defines orthostatic hypotension, and her glucose is normal. The nurse reports the finding before the next doses.

## 심화 해설

The most likely contributor
On day 2 she faints briefly while walking. Her heart rate is 46/min and regular, her blood pressure is 124/72 mmHg lying and 118/70 mmHg after 3 minutes standing, and her capillary glucose is 104 mg/dL (5.8 mmol/L). Cholinesterase inhibitors such as donepezil can cause bradycardia and syncope, and beta blockers such as metoprolol add to the effect. The slow heart rate from the two drugs together is the most likely contributor, and the nurse reports it before the next doses.

How the drugs combine
Donepezil increases acetylcholine by inhibiting its breakdown. Although the goal is to boost acetylcholine in the brain, the effect also reaches the heart, where increased vagal (parasympathetic) tone slows the sinus node and atrioventricular conduction. Metoprolol blocks beta-adrenergic stimulation of the heart, removing the sympathetic drive that would normally speed the rate. Together they can slow the heart enough to reduce cardiac output and cause fainting, especially in an older adult.

| Possible cause | Data | Conclusion |
| --- | --- | --- |
| Orthostatic hypotension | Fall of 6/2 mmHg on standing | Criterion not met |
| Hypoglycemia | Glucose 104 mg/dL (5.8 mmol/L) | Normal |
| Drug-induced bradycardia | Heart rate 46/min | Most likely |
| Alzheimer progression | Gradual course | Does not explain a sudden faint |

Why the other causes are ruled out
Orthostatic hypotension is defined as a fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; her fall of 6/2 mmHg does not meet this criterion, even though she was admitted for dehydration. Hypoglycemia is excluded by a normal capillary glucose. Progression of Alzheimer disease is gradual and does not explain a sudden faint with a heart rate of 46/min.

Nursing actions
The nurse ensures her safety, assesses her for injury from the faint, obtains an electrocardiogram if ordered, reports the bradycardia, and anticipates a review of donepezil and metoprolol before the next doses. Fall precautions are put in place, and she is assisted when walking.

Exam takeaway
Key point Donepezil plus a beta blocker can cause symptomatic bradycardia and syncope. Check the numbers against the definitions to rule out orthostatic hypotension and hypoglycemia.

## 임상 시나리오

Syncope on Donepezil and MetoprololFinding the real cause
Donepezil increases vagal tone and can slow the heart; metoprolol removes sympathetic drive. Together they can cause bradycardia of 46/min and fainting.

Her standing fall of 6/2 mmHg does not meet the orthostatic criterion of 20 systolic or 10 diastolic, and her glucose of 104 mg/dL is normal.

CautionReport the bradycardia before the next doses, check for injury, and put fall precautions in place.

## 핵심 개념

- **Donepezil** — A cholinesterase inhibitor that increases acetylcholine and is used for Alzheimer disease.
- **Bradycardia** — A heart rate slower than normal, in adults usually below 60/min.
- **Syncope** — A brief loss of consciousness caused by reduced blood flow to the brain.
- **Orthostatic hypotension** — A fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.

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