Case Scenario - Polypharmacy

Case Scenario - Polypharmacy

Aims of the session

To focus on managing polypharmacy in the elderly and the issues that this and similar cases raise.

Background Information

·  Mrs. Elsie Dale, 85y Female, widowed

·  17y old grand-daughter, Anne lives with her

·  Newly diagnosed Dementia.

·  History of Type II Diabetes (now on insulin)

·  Recently discharged from hospital after a chest sepsis & infected leg ulcer.

·  Multiple new medications

·  New Social Care Package – TDS carers.

·  DN input BD for insulin, INR’s and leg ulcer management (occasionally refusing to let DNs enter the house)

·  Daughter (Next of Kin) away on holiday

Medical Problems

Date / Problem
15-Oct-2014
15-Oct-2014 / Leg ulcer
Chest infection and Sepsis – hospital admission
18-Aug-2014 / Anxiety with Depression
04-Jun-2014 / Decompensated cardiac failure
23-May-2014 / Impaired left ventricular function
18-Mar-2014 / Urinary incontinence
18-Mar-2014
21-Jan-2015 / Osteoporotic vertebral collapse
Dementia, Alzheimer’s Type
05-Mar-2012
16-Jan-2012 / Venous eczema
Paroxysmal AF – Anticoagulation started
12-Jun-2010 / Exacerbation of COPD- admitted to hospital
03-Nov-2009 / Knee osteoarthritis NOS
31-Jan-2007 / Chronic kidney disease stage 3
08-Dec-2005 / Type 2 Diabetes Mellitus
11-Dec-2002 / COPD
07-Jun-2002 / Urge incontinence / pelvic floor exercises- cystoscopy showed irritative bladder
27-Feb-2002
16-Dec-2001 / Essential hypertension
Gout

Medications

Acute

Drug Dosage Quantity

Ibuprofen 400mg One To Be 56 tablet

Three Times

Daily PRN

Repeat

Drug / Dosage / Quantity
Bisoprolol 1.25mg tablets
Warfarin 5mg
Warfarin 3mg / One To Be Taken Daily
ASD
ASD / 56 tablet
100 tablet
100 tablet
Aspirin 75mg tablets / One To Be Taken Daily / 56 tablet
Bumetanide 1mg tablets / One To Be Taken on Alternative Days / 28 tablet
Omeprazole 20mg gastro-resistant capsules / One To Be Taken Each Morning / 56 capsule
Citalopram 10mg tablets / One To Be Taken Daily / 56 tablet
Zerobase 11% cream / Use PRN / 500 gram
Atorvastatin 10mg tablets / One To Be Taken Daily / 56 tablet
Laxido Orange oral powder sachets / 1 sachet mixed with water SD / 90 sachet

Donepezil 10mg tablets 1 to be Taken Daily 56 tablets

Hydroxyzine 10mgs tablets 1 to be Taken at night 56 tablets

Ramipril 5mgs tablets 1 to be Taken Daily 56 tablets

Co-codamol 8/500 tablets 1-2 tablets QDS PRN 112 tablets

Novomix 30 flexpen 22u am/ 18u pm 100units/mls

Freestyle light testing strips ASD 50 strips

Salbutamol 100mcgs/dose inhaler 2 puffs prn/qds 1 inhaler

Tiotropium bromide

180mcg inhalation powder capsule 1 capsule daily 56 capsules

Metformin 500mgs tabs 1 to be Taken TDS 168 tablets

Diazepam 2mg 1 TDS PRN 28 tablets

Allevyn Gentle Border ASD 20dressing

Dressing 15cm x 15cm

Aquacel Ag Dressing 5cm x 5cm ASD 5 dressing

Tubigrip Elasticated Support

Bandage Stockinette 10cm x1m ASD 3m

Allopurinol 100mg 1 to be Taken Daily 56 tablets

Solifenacin 5mg 1 to be Taken Daily 56 tablets

Past Medication

Gliclazide 80mgs tabs 1 to be Taken BD 56 tablets

Last investigations (1 month ago):

HBA1c: 78, U&E: Na 133, K 5.1, Ur 11.2, Cr 132, eGFR: 56 ml/min Stage 3

FBC: Hb 11.2, MCV 78, Plt 156, WCC 4.9

INR (3 weeks ago): 3.2. (Patient refused INR blood test due 1w ago)

Other healthcare information

·  Pharmacy Notes: Elsie’s notes red-flagged at the pharmacy as not ordering repeat

medications regularly

·  Hand held social care notes record that seems doesn’t always take her medication as prescribed and sometimes won’t let carers in or eat the food they prepare.

·  DNs records – slow healing ulcer, using dressings advised by hospital on discharge; sometimes refuses BMs, insulin and INRs

Areas for Discussion/Decision Making

1) In a patient who has newly been diagnosed with dementia, what issues does the list of medication raise?

2) How would you ensure compliance?

3) Who else would you like to be involved in the management of this patient’s medications?

4) Are there any medications that you would consider stopping? How would you organise it?

5) Which tablet/s do you think Mrs Dale would be most and least willing to stop?

Please discuss the pros and cons of each decision above

6) What other questions/anxieties has this case and discussion raised for you?

Further Discussion (Time permitting)

1 week later the GP on-call visits the patient following a request from the DN who visited her earlier in the day concerned that the patient has developed diarrhoea and vomiting.

Entry from EMIS records from visiting GP:

Problem Viral Gastroenteritis

History 2d hx of vomiting with loose brown stool, says no blood, no abdo pain, initially feverish, now settled. Taking insulin although ?missed insulin last night as refused to let carer and DN into the house. Says stopped vomiting, now only loose stool x5-6/day, no mucus. No hx of diverticulitis. No wt loss, reduced eating since being unwell, drinking better now, says passing urine, able to produce sample

Examination Pleasantly confused 8/10, Temp 37.4, pulse 66 bpm, irreg, BP 106/64

BM 18.6

Abdo – soft, non-tender. No peritonism. BS N, PR refused.

Urinalysis – Ketones trace, nil else

Comments Imp: Viral Gastroenteritis

DNs to watch BMs, patient encouraged to drink plenty fluids

Area for Discussion

What medications would you stop/change during this acute illness and how would you ensure

that this happens?