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Prescribing for the Vulnerable Older Adult – Case Discussion: Mr. Robert Jacobs
Mr. Robert Jacobs, an 82 year old black, married man lives in his own home with the support of his wife
and a son who lives nearby. They have come to your office today for a follow-up visit.
Mr. Jacobs and his wife have recently returned from an extended 2-month stay with their daughter’s family
in Florida. While he was in Florida, Mr. Jacobs was evaluated in the emergency room for an episode of
dizziness and delirium. Although there are no records available today about this ER visit, Mrs. Jacobs
reports that her husband was diagnosed with and treated for a urinary tract infection. The ER physician
also adjusted some of Mr. Jacob’s medication. You last saw Mr. Jacobs, four-months ago.
Problem List in Your Chart
Medications/Doses Listed in Your Chart
Vascular Dementia
Benign Prostate Hypertrophy
Hypertension
Osteoarthritis
Chronic Renal Failure
Congestive Heart Failure
Type II Diabetes
Donepezil (Aricept) 5 mg Once a Day
Terazosin (Hytrin) 4 mg q HS
HCTZ 25 mg Once a Day
Lisinopril 20 mg Once a Day
Tolterodine (Detrol) 2 mg Twice a Day
Acetaminophen 1000 mg Four times a day
Glipizide 10 mg Twice a Day
Rosiglitazone (Avandia) 4 mg Once a Day
Aspirin 81 mg Once a Day
Today’s History
Mr. Jacobs is still experiencing dizziness and is unsteady when he walks, but he has not had any falls. His
wife says that he still is more confused than prior to the UTI and seems to be sleeping more during the day.
The patient is also having trouble with urinary frequency, knee pain, and his appetite is not good.
Your nurse has completed a MMSE today with a score of 17/30 (22/30 six months ago)
Physical Examination
Reported Changes in Medications
Weight 159 pounds (168 pounds, last visit)
BP 140/70 sitting (110/60 standing)
Apical pulse 78, regular, sitting
Increase: Donepezil (Aricept) to 10 mg Once a Day
Increase: Terazosin (Hytrin) to 6 mg q HS
New: Celecoxib (Celebrex) 200 mg Once a Day
Apical pulse 90, regular, standing
RR 18 and comfortable
1+ ankle edema, osteoarthritis-knees
LE Neuro – Strength, NL; mild rigidity,
no cogwheeling, Romberg – SL. sway,
decreased sensation lt. touch and vibration
Gait slow, antalgic, poor balance with nudge
Heart S4, 2/6 systolic murmur at base
Lung clear
Abdomen no organomegaly or masses
Rectal rubbery enlarged prostate
New: Risperidone (Risperdal) 0.5 mg Once a Day
Laboratory Work (from this am)
Na 140 mmol/L, K 5.2 mEq/L, glucose 180 mg/dl
Creatinine 2.5 mg/dl (1.9, last visit)
BUN 32 mg/dl (25, last visit)
LFTs normal
Hemoglobin 11.5 g/dl (12.0, last visit)
Urine analysis - negative
For discussion
Which of Mr. Jacobs’s current signs and symptoms can be attributed to his medications?
What changes in Mr. Jacobs’s medication regimen would you consider today and during future visits?
Prescribing for the Vulnerable Older Adult – Case Discussion: Mrs. Janet Andrews – Part One
Mrs. Janet Andrews, an 86 year old white, widow lives in own home with the support of her daughter who
lives nearby. They have come to your office today for a follow-up visit.
Mrs. Andrews has recently been discharged from a 3-week stay in the nursing home after a hospitalization
for elective right hip replacement surgery that was complicated by an episode of pneumonia, rapid atrial
fibrillation and some congestive heart failure. You last saw Mrs. Andrews, one-month ago when you
completed her pre-operative evaluation in your office.
Pre-operative diagnoses
Pre-operative medications
Atrial fibrillation
Osteoarthritis
Irritable bowel
Hypertension
Anemia
Recurrent UTI’s
Chronic renal insufficiency
Previous surgery: Left total hip replacement
Digoxin 0.125 mg QD
Enalapril (Vasotec) 5 mg BID
Warfarin 4 mg QD
Aspirin 325 mg QID prn pain
HCTZ 50 mg QD
Trimethoprim/Sulfa (Bactrim DS) 1 q HS
Tylenol PM q HS, may repeat x 1
Dicyclomine (Bentyl) 10mg po TID
Today’s History
Mrs. Andrews is able to walk comfortably and but is only slowly regaining her pre-operative stamina. She
is still using a walker for distances. Her daughter reports that her mother seems more confused than usual.
The patient is also having trouble with constipation, poor sleep, and her appetite is not good.
Physical Examination
Post-operative medications
Weight 110 pounds (118 pounds, last visit)
BP 100/60 sitting (135/80 last visit)
Apical pulse 50, regular (70-75, irregular, last visit)
RR 18 and comfortable
No peripheral edema
Well-healed right hip surgical scar
Digoxin 0.125 mg QD
Enalapril (Vasotec) 5 mg BID
Warfarin 4 mg QD
Aspirin 325 mg QID prn pain
HCTZ 50 mg QD
Trimethoprim/Sulfa (Bactrim) DS 1 q HS
Tylenol PM q HS, may repeat x 1
Valdecoxib (Bextra) 10 mg QD
Amiodarone (Cordarone) 400 mg po BID
Oxycodone 5 mg po q 4 prn pain
Ferrous sulfate 325 mg po TID
Dicyclomine (Bentyl) 10 mg po TID
Laboratory Work (from 2 days ago)
Digoxin level 1.9 ng/ml
Electrolytes – normal
Creatinine 3.1 mg/dl (2.2, last visit)
BUN 55 mg/dl (41, last visit)
Hemoglobin 8.2 g/dl (11, last visit)
INR 3.1 (2.5, last visit)
Serum iron – low
TIBC - normal
For discussion
Which of Mrs. Andrew’s current symptoms can be attributed to her medications?
What changes in Mrs. Andrew’s medication regimen would you consider today and during future visits?
Prescribing for the Vulnerable Older Adult – Case Discussion: Mrs. Janet Andrews – Part One
Mrs. Janet Andrews, an 86 year old white, widow lives in own home with the support of her daughter who
lives nearby. They have come to your office today for a follow-up visit.
Mrs. Andrews has recently been discharged from a 3-week stay in the nursing home after a hospitalization
for elective right hip replacement surgery that was complicated by an episode of pneumonia, rapid atrial
fibrillation and some congestive heart failure. You last saw Mrs. Andrews, one-month ago when you
completed her pre-operative evaluation in your office.
Pre-operative diagnoses
Pre-operative medications
Atrial fibrillation
Osteoarthritis
Irritable bowel
Hypertension
Anemia
Recurrent UTI’s
Chronic renal insufficiency
Previous surgery: Left total hip replacement
Digoxin 0.125 mg QD
Enalapril (Vasotec) 5 mg BID
Warfarin 4 mg QD
Aspirin 325 mg QID prn pain
HCTZ 50 mg QD
Trimethoprim/Sulfa (Bactrim DS) 1 q HS
Tylenol PM q HS, may repeat x 1
Dicyclomine (Bentyl) 10mg po TID
Today’s History
Mrs. Andrews is able to walk comfortably and but is only slowly regaining her pre-operative stamina. She
is still using a walker for distances. Her daughter reports that her mother seems more confused than usual.
The patient is also having trouble with constipation, poor sleep, and her appetite is not good.
Physical Examination
Post-operative medications
Weight 110 pounds (118 pounds, last visit)
BP 100/60 sitting (135/80 last visit)
Apical pulse 50, regular (70-75, irregular, last visit)
RR 18 and comfortable
No peripheral edema
Well-healed right hip surgical scar
Digoxin 0.125 mg QD
Enalapril (Vasotec) 5 mg BID
Warfarin 4 mg QD
Aspirin 325 mg QID prn pain
HCTZ 50 mg QD
Trimethoprim/Sulfa (Bactrim) DS 1 q HS
Tylenol PM q HS, may repeat x 1
Valdecoxib (Bextra) 10 mg QD
Amiodarone (Cordarone) 400 mg po BID
Oxycodone 5 mg po q 4 prn pain
Ferrous sulfate 325 mg po TID
Dicyclomine (Bentyl) 10 mg po TID
Laboratory Work (from 2 days ago)
Digoxin level 1.9 ng/ml
Electrolytes – normal
Creatinine 3.1 mg/dl (2.2, last visit)
BUN 55 mg/dl (41, last visit)
Hemoglobin 8.2 g/dl (11, last visit)
INR 3.1 (2.5, last visit)
Serum iron – low
TIBC - normal
For discussion
Which of Mrs. Andrew’s current symptoms can be attributed to her medications?
What changes in Mrs. Andrew’s medication regimen would you consider today and during future visits?
Prescribing for the Vulnerable Older Adult – Case Discussion: Janet Andrews – Part II
A Brief Recap:
During the last visit, one month ago, we discussed potential inappropriate medications for Mrs. Janet
Andrews, an 86 year old white, widow who lives in her own home with the support of her daughter. Mrs.
Andrews had been discharged from a 3-week stay in the nursing home after a hospitalization for elective
right hip replacement surgery that was complicated by an episode of pneumonia, rapid atrial fibrillation and
some congestive heart failure. At her last visit Mrs. Andrews was able to walk comfortably and but was
only slowly regaining her pre-operative stamina. She continues using a walker for distances. Her daughter
reported that her mother seemed to be more confused than usual. The patient was also having trouble with
constipation, poor sleep, and her appetite was not good.
Since her last visit, one month ago, you have discontinued the following medications:
Co-Trimoxazole DS 1 q HS
Tylenol PM qHS, may repeat x 1
Dicyclomine 10mg po three times a day
Aspirin 325 mg four times a day when need for pain
Valdecoxib (Bextra) 10 mg once a day
Amiodarone 400 mg po twice a day
Since her last visit, one month ago, you have reduced the dose the following medications:
HCTZ from 50 mg once daily to 25 mg once daily
Ferrous sulfate 325 mg po from three times a day to once a day
Since her last visit, one month ago, you have prescribed the following new medications:
Acetaminophen 500 mg tablets two tablets 4 times a day for osteoarthritis, plus capsaicin topical cream
applied when needed for additional arthritis pain control in knees or feet.
Her current medication lists with associated active diagnosis are:
Diagnoses
Current Medications
Atrial fibrillation
Osteoarthritis of the knee
Hypertension
Anemia
Digoxin 0.125 mg once daily
Warfarin 4 mg po once daily
Acetaminophen 500 mg two tablets four times a day
Enalapril 5 mg twice a day
Ferrous sulfate 325 mg po once daily
Other past medical problems not currently requiring treatment are:
Recurrent UTI’s
Constipation
Dehydration
Today’s History
Mrs. Andrews and her daughter present at your office today for a follow-up visit. Weight loss continues to
be a problem. She is more withdrawn and continues to have trouble walking. Her daughter complains that
she can not sleep through the night and that she has increasing agitation and anxiety. She seems to bruise
rather easily. Confusion continues, but has improved since she stopped using Tylenol PM, dicyclomine,
and oxycodone. She has occasional leaking of urine mostly because of difficulty getting to the toilet.
Tylenol and when needed capsaicin cream reduce (but do not eliminate) pain in her knees and feet. Pain
quality is a dull aching and rather constant, but worse in the morning. On a scale of 10, her pain is reported
as 5, limiting her ability to accomplish Instrumental Activities of Daily Living. Activities of Daily Living
are intact except for occasional leaking of urine.
After attending a seminar at the senior center on dietary supplements, she has started taking Ginkgo Biloba
to “improve her memory” and garlic for her hypertension; kava kava for her agitation and anxiety,
glucosamine/chondrotin for her osteoarthritis and St Johns Wort for the “blues”.
Today’s Physical Examination
Weight 108 pounds (110 pounds two months ago; 118 pounds three months ago)
BP 120/70 sitting; 115/65 standing (100/60 sitting one month ago and 135/80 three months ago)
Apical pulse 50, regular (no change from last visit); increases to 55 when standing
RR 18 and comfortable
No peripheral edema
Well-healed right hip surgical scar
Gait, slow and labored but otherwise normal.
Laboratory Work (from 2 days ago)
Digoxin level 1.9 ng/ml (same as one month ago)
Electrolytes – within normal limits (same as one month ago)
Creatinine 2.2 mg/dL (two months ago was 3.1 mg/dl, now back to her baseline after decreased HCTZ)
BUN 38 mg/dL (two months ago was 55 mg/dl; three months ago was 41 mg/dl)
Hemoglobin 9.2 g/dl (was 8 g/dL one month ago slowly returning to baseline of 11g/dL three months ago)
INR 3.3 (was 3.1 one month ago and 2.5 three months ago)
Serum iron – low normal; TIBC - normal
Total cholesterol 140 mg/dL
Albumin 3.0g/dL
For discussion
Which of Mrs. Andrew’s current symptoms can be attributed to her continuing and new medications?
What changes in Mrs. Andrew’s medication regimen would you consider today and during future visits?
What new problems may be occurring and how should they be managed?