Homework answers / question archive / Prior to Mrs

Prior to Mrs

Writing

Share With

Prior to Mrs. P. being admitted to the observation unit for a diagnosis of bronchitis, she appears to have made some significant healthy lifestyle changes with her diet and exercise regimen. She currently has comorbidities of heart failure, hypertension, osteoarthritis, and hyperlipidemia. According to her report, she has eliminated her problem with GERD through her diet changes. Aside from the new medications prescribed for the acute onset of bronchitis, she is taking metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 mEq bid, acetaminophen 650 mg bid for pain, and tramadol 25 mg as needed. Both she and her daughter present today with concerns of the number of medications she is taking, and would like a review of those medications. Polypharmacy is a concern for many older adults and their caregivers, especially when there is the potential for adverse drug reactions as an outcome (Kennedy-Malone et al., 2019).

Congestive heart failure (CHF) is a serious condition, in which the heart does not pump blood around the body efficiently (Newman, 2021). If the heart becomes weakened and cannot supply the cells with enough blood, it can lead to fatigue and breathlessness. Everyday activities that used to be easy can become more difficult to accomplish (Newman, 2021). There are specific lifestyle changes can reduce the risk of heart failure or slow its progression. Some of those changes include: eating a healthy diet; maintaining a moderate weight and exercising regularly; getting enough quality sleep; drinking alcohol only in moderation; not smoking; and reducing stress as much as possible (Newman, 2021). Mrs. P. has already begun to make some of those healthier choices prior to her arrival for her visit, with success. The scenario above does not state the exact number of days that the antibiotic is prescribed for nor does it list the taper sequence for her prednisone. Assuming the prescribing physician did provide her with that information, we will address the medications to discontinue outside of those two particular ones. After she has completed the course of those previously mentioned prescriptions, I would first discontinue the inhaler, as she is asymptomatic and Spiriva has known side effects that can cause edema, myalgia, and arthralgia (Epocrates, n.d.), which she currently has under control, so there is no need to continue with a medication that can cause those recurring symptoms she has well managed at this time.

I would run labs on her to get a post hospital visit baseline of her CBC, CMP, and lipids, and depending on what her results were, would continue with deprescribing more of her medications. I would also have her record her daily blood pressure readings for morning and night, along with her pulse for a period of a month. If the pressures are well managed, and her pulse has become bradycardic, I would consider eliminating the beta blocker, and keeping her on the ace inhibitor. The furosemide and the potassium supplements can be eliminated by switching to spironolactone. One pill can effectively manage what the other two were doing. By changing to the potassium sparing diuretic, it will allow the patient to not have to use potassium replacement supplements while on the loop diuretic. Without an exacerbation of her heart failure, and the reduced sodium intake, she may be able to come off of the diuretics completely, until she does have an exacerbation. I would prefer to keep her on the one pill for cautious measures though. She may be satisfied with reducing the number of pills she is taking as opposed to eliminating all medications entirely.

Since she has both her GERD and her osteoarthritis under control, we can eliminate the omeprazole on a daily basis for her as well as the as needed tramadol. The final medication I would look to discontinue would be the atorvastatin.  Hyperlipidemia is an abnormally high levels of fats in the blood. The two major types of lipids found in the blood are triglycerides and cholesterol (Osborn, 2020). Triglycerides are made when your body stores the extra calories it doesn’t need for energy. They also come directly from the foods in your diet, like red meats and whole-fat dairy. A diet high in refined sugar, fructose, and alcohol also raises levels of triglycerides in the blood (Osborn, 2020). Mrs. P. has altered her diet and increased her activity level at her ALF, and I would expect to see somewhat of a natural decrease in her levels due to these changes. Even if the change in her lipid levels were not hugely changed, I would still consider discontinuing the statin. Statins are recommended for lowering cholesterol levels for many people who have a higher risk for cardiovascular disease, but much of the evidence for this is based on clinical studies done in people under the age of 75 (Radcliffe, 2019). For older adults it’s been less clear if the benefits of statins, which include preventing heart attacks and strokes, actually outweigh the side effects and associated risks of the medication, which include muscle and cognitive problems (Radcliffe, 2019). We can always monitor her labs again in three months to see the difference the medication changes have made, and if the patient is not happy with the results, or if she has an exacerbation of her heart failure before then, we can add back in the necessary medications to make sure all of her comorbidities are well managed. By listening to the patient and her concerns over her plan of care, if these changes do not prove to be beneficial, she may be more apt to heed future advice if and when medications are needed to be taken again. She will have seen that we are working with her, trying to accommodate her wishes, and if it works well for her, then we have a happier patient. If the repeat labs show that the reduction in medication therapies has not been effective, she may be amenable to taking a few extra pills on a daily basis for the benefit of her health. Attempting to bring her pill burden down from the original eleven prescribed medications to a more manageable three is a smart move for the older patient who is trying to eliminate polypharmacy in her daily life.