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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?