Mrs. A Case Study
Mrs. A is a 71 year old widow with CHF and osteoarthritis who has recently been exhibiting quite unusual behavior. Her daughter is concerned about her mother’s ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a dementing illness. Over the last two to three months Mrs. A has become confused, easily fatigued and very irritable. She has developed disturbing obsessive/compulsive behavior constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly moldy. Her prescribed medications are:
Furosemide 40 mg daily in the morning
Digoxin 250 micrograms daily
Paracetamol 500 mg, 1-2 tablets 4-hourly PRN
Piroxicam 20 mg at night
Mylanta suspension, 20 ml PRN
Coloxyl 120 mg, 1-2 tablets at night
Critically discuss this case study in terms of the problematic nature of this patient’s pharmacological management.
Outline some pharmacokinetic changes in the geriatric population that may affect drug disposition.
Outline how changes in renal and hepatic function may affect treatment strategies.
In the drug regimen presented above – discuss potential side effects and potential interactions, if any?
Your response should include a discussion of the problems of polypharmacy as it is related to this case study and the assessment/management and educational strategies which could have been implemented to improve the outcome of Mrs. A.
Prepare and submit a 3-4 page paper [total] in length (not including APA format).
Answer all the questions above.
Support your position with examples.
Please review the rubric to ensure that your assignment meets criteria.
The Problematic Nature of this Patient’s Pharmacological Management
The patient presents with recent unusual changes like confusion, fatigue, irritability, and obsessive behavior. Although these changes could indicate an onset of dementia, they could also be attributed to her treatment plan’s problematic nature (Bessey & Walaszek, 2019). The patient has CHF and osteoarthritis. Her current treatment plan entails Furosemide, Digoxin, Paracetamol, Piroxicam, Mylanta suspension, and Coloxyl. Polypharmacy poses several risks to the patient. First, there is the risk of drug interaction, resulting in impaired drug efficiency and unwanted side effects (Masnoon et al., 2017).
Furosemide is indicated to treat hypertension and edema caused by fluid buildup in the body. Most common side effects include nausea, diarrhea, constipation, stomach cramping,
vertigo, blurred vision and itching, excessive water and electron loss, low potassium and thyroid levels. Potential interactions include other diuretics, antibiotics, pain medications, and mood stabilizers. In the current case, Furosemide is likely administered to treat fluid retention associated with CHF. Although the standard initial dose is 40 mg daily in the morning, it should be adjusted according to the response. In the current case, it has not been modified. The patient’s fatigue is likely a result of low potassium levels, a side effect of Furosemide. Furosemide could be increasing the patient’s sensitivity to digoxin and pain medication (Currie, 2018). The patient should be prescribed potassium supplements and a high potassium diet to help reduce potassium loss and the risk of hypokalaemia.
Digoxin is indicated for the treatment of heart failure and atrial fibrillation. The most common side effects of digoxin include diarrhea, headache, allergic reactions, vision changes such as vision with a yellow-green tint, mental changes such as depression, and neurological problems like confusion. Potential interactions include heart failure drugs, antihypertensive, antibiotics, and pain medication. In the current case, the patient is on CHF and pain medications, increasing body sensitivity to Digoxin, thus increasing the risk of side effects. Therefore, the patient’s confusion, fatigue, irritability, and obsessive/compulsive behavior could be a side effect of Digoxin. Digoxin should be substituted with a twice-daily dose of 50 mg captopril to avoid the drug interaction and the side effects. Paracetamol is indicated for the management of pain and fever. Common side effects are allergic reactions, nausea, stomach pain, and loss of appetite. In this case, it was prescribed for joint pain caused by osteoarthritis.
Piroxicam is indicated for the management of pain, swelling, and joint stiffness from arthritis. Common side effects include nausea, dizziness, drowsiness, mental/mood changes, vision changes, and fatigue. The drug interacts with diuretics, thus reducing its effectiveness. In this case, it was prescribed for the management of osteoarthritis. Since the patient was already on paracetamol, then the prescription of another pain reliever was unnecessary. The patient’s mental and vision changes could be a result of an overdose of pain medication. Prescription of alternative pain relievers such as acupuncture in place of pharmacologic therapy would help reduce the side effects.
Mylanta suspension is indicated for the management of stomach upset, heartburn, and acid indigestion caused by excess stomach acid. The drug interacts with other medications such as digoxin and antibiotics, impairing their absorption along the gastrointestinal tract. In that case, Mylanta should be replaced with lifestyle changes, which are usually first-line treatment choices for heartburn. They include keeping the head of the bed elevated, avoiding caffeine, and not eating 2 hours before bedtime. Coloxyl tablets are indicated for relieving constipation and softening the stool. Common side effects include abdominal cramps, diarrhea, nausea, and low potassium levels. Coloxyl with senna interacts with Digoxin and Diuretics. In that case, the Coloxyl should be replaced with non-pharmacologic therapies like consumption of food rich in fiber, regular exercise, and increased fluid intake.
Pharmacokinetic Changes in the Geriatric Population that may affect Drug Disposition
The polypharmacy problem affects the efficiency of the treatment therapy in the elderly. There are multiple pharmacokinetic changes in geriatric populations that affect its drug disposition. Polypharmacy results in overloading of body systems, further impairing drug disposition. Orally administered drugs are absorbed in the gastrointestinal (GI) tract, while the vascular circulation absorbs those administered parenterally. Aging is associated with decreased blood flow and GI and changes in gastric pH, thus impending drug absorption (Maher et al., 2021). The changes in blood flow are associated with decreased cardiac output. It also reduces blood flow in subcutaneous, thus impairing absorption of injectable medications.
Once absorbed into the bloodstream, drugs are distributed throughout the body. Aging is associated with a decrease in total body water and muscle mass and an increase in body fat. These changes cause an increased duration of action of drugs and effect in the body because they remain in circulation for a prolonged period. Drug metabolism after absorption occurs almost entirely in the liver. However, liver mass and blood flow decrease with age. This reduces the rate of drug metabolism (Maher et al., 2021). This necessitates the dosing of drugs metabolized by the liver to be lowered.
Changes in renal and hepatic function associated with aging effect treatment strategies by impairing effective drug excretion. Aging is associated with a reduction in renal function caused by a decrease in renal mass. It entails reduced nephrons and the vascular tuft’s hyalinization, leading to reduced blood flow in the renal system and reduced glomerular filtration rate. This results in a prolonged half-life for water-soluble drugs, thus build-up of toxic levels (van den Anker et al., 2018).
The polypharmacy also poses risks of non –adherence to the treatment plan. This can be caused by increased side effects caused by drug interaction, increased cost of treatment due to multiple purchases, and poor understanding of each prescription’s role on the treatment plan (Scondotto et al., 2018). In this case, polypharmacy can be prevented by integrating lifestyle changes and alternative medicine in the treatment plan and adopting multidisciplinary collaboration in patient care to prevent repeated prescriptions and drug interactions (Masnoon et al., 2017).
Assessment and Management
Considering the problematic nature of the current treatment plan, in addition to dementia assessment, the patient should be assessed for drug interactions and side effects. The treatment plan should entail Furosemide 40 mg adjusted according to the attainment of treatment goals, 50 mg captopril, acupuncture, and lifestyle changes.
The patient should be educated on lifestyle changes such as diet and exercise and alternative medication to integrate into the treatment plan to reduce the pharmacological prescriptions. She should be educated on appropriate drug administration, potential drug side effects to observe, home management of side effects, potential drug interactions and contraindications. The most appropriate education strategies for the elderly include assessing patient health literacy, patient teach-back, and group learning.
Bessey, L. & Walaszek, A. (2019). Management of behavioral and psychological symptoms of dementia. Current psychiatry reports, 21(8), 1-11. https://pubmed.ncbi.nlm.nih.gov/31264056/
Currie, G. (2018). Pharmacology, part 3A: interventional medications in renal and biliary imaging. Journal of nuclear medicine technology, 46(4), 326-334. https://tech.snmjournals.org/content/46/4/326
Maher, D., Ailabouni, N., Mangoni, A, Wiese, M., & Reeve, E. (2021). Alterations in drug disposition in older adults: a focus on geriatric syndromes. Expert Opinion on Drug Metabolism & Toxicology, 17(1), 41-52. https://www.tandfonline.com/doi/abs/10.1080/17425255.2021.1839413
Masnoon, N., Shakib, S., Kalisch-Ellett, L., & Caughey, G. (2017). What is polypharmacy? A sy https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-017-0621-2stematic review of definitions. BMC geriatrics, 17(1), 1-10.
Scondotto, G., Pojero, F., Addario, S. P., Ferrante, M., Pastorello, M., Visconti, M., … & Casuccio, A. (2018). The impact of polypharmacy and drug interactions among the elderly population in Western Sicily, Italy. Aging clinical and experimental research, 30(1), 81-87. https://link.springer.com/article/10.1007/s40520-017-0755-2
van den Anker, J., Reed, M., Allegaert, K., & Kearns, G. (2018). Developmental changes in pharmacokinetics and pharmacodynamics. The Journal of Clinical Pharmacology, 58, S10-S25. https://pubmed.ncbi.nlm.nih.gov/30248190/