Polypharmacy is a very important issue in elderly patients because most of these patients suffer from many conditions, and thus, they are likely to combine many drugs. The purpose of this paper is to present a case study of an elderly patient, who is demonstrating issues of polypharmacy. The patient in this case is a 70-year-old Caucasian female, who is suffering from a number of conditions and is taking four prescription drugs on a regular basis and six OTC drugs. Demographic information, medications, teaching plan and follow-up visits in regard to this patient are discussed.
There is no consensus definition of polypharmacy; however, in practice, it is defined as the use of more drugs than clinically indicated, regardless of the appropriateness of medication use. In other words, polypharmacy may be used to indicate the unnecessary use of drugs. Most of the definitions that have been raised focus on the complexity of a clients conditions, various medications prescribed, and the number of medications. Irrespective of the definition, polypharmacy is a very crucial issue in older adult patients. The individual selected demonstrate issues of polypharmacy in that she is taking a lot of medications and suffers from many conditions as well. The patient is taking four prescription drugs on a regular basis and six OTC drugs. The patient is also suffering from hypertension and obesity.The patient in this case is a 70-year-old Caucasian female, who is suffering from a number of conditions and is taking four prescription drugs on a regular basis and six OTC drugs. Demographic information, medications, teaching plan and follow-up visits in regard to this patient are discussed.
There is no consensus definition of polypharmacy; however, in practice, it is defined as the use of more drugs than clinically indicated, regardless of the appropriateness of medication use. In other words, polypharmacy may be used to indicate the unnecessary use of drugs. Most of the definitions that have been raised focus on the complexity of a clients conditions, various medications prescribed, and the number of medications. Irrespective of the definition, polypharmacy is a very crucial issue in older adult patients. The individual selected demonstrate issues of polypharmacy in that she is taking a lot of medications and suffers from many conditions as well. The patient is taking four prescription drugs on a regular basis and six OTC drugs. The patient is also suffering from hypertension and obesity.
Demographic Information of the Patient
History of the Present Illness: The patient is 70-year-old Caucasian female. She came to wellbeing visit associated with follow up on her hypertension and obesity. She states feeling just fine.” She brought medication bottles lisinopril and HCZT to the appointment. Additionally she has BP journals with BP numbers running between S: 122-125, and D: 78-82. She confirmed taking four prescription medications as prescribed on a regular basis with excellent results. Patients reports to have lost 7 lbs in the past three months by walking every day and swimming two times a week and a lowfat diet. She states I feel much better and will continue a healthy lifestyle.”
Past medical history includes: Illness: Hypertension -age 46, Hyperlipidemia age 46, Hypothyroid age 50. OA- age 68. Medication: Prescription: Lisinopril, 10 mg, HCZT, 12.5 mg,
Crestor 20 mg, and levothyroxine 88mcg. OTC medication: Vit D3, BI-FLEX, Mg, Preservision, and Tums. Surgeries: Hernia repair in 2004 and obesity. Allergies: NKA. Immunization: up to date. Screening: Pap smear/mammo – 5 years ago, mammo, colonoscopy nine years ago all w/o any finding.
Social History: Patient is living together with her husband in two bedroom apartment two blocks from their older daughter. She has three children- two daughters age 46 and 44 and one son age 37. She has two grandchildren aged from 5 to 4. She volunteers one time a week at VNA clinic, a non-profit organization. Actively participates in church activities together with her husband. She walks with her husband two times a week for 60 minutes. She visits a swimming pool twice a week. Sleeps typically 6-7 hours a night. She cooks at home but likes to visit restaurants. Denies use of alcohol, street or other recreational drugs. Never smoked. Due to high cholesterol and blood pressure, she was advised to reduce fat and salt from her diet.
Ethnic Culture: Culture influences someones beliefs about medications, illness, and health. It also influences how individuals respond physiologically to drugs, comply with prescribed drugs and interact with healthcare providers. Regarding the patient selected in this paper, culture may have influenced decision-making concerning medication usage because Caucasian patient highly expect that their condition will be healed, or manageable, through powerful medications and technology. As a matter of fact, Caucasian patients expect to leave the providers office with a prescription.
Since the client belongs to federally sponsored drug discount program, she decided to choose a pharmacy program that enabled her to get the medication at a fixed discounted price. Each of the prescribed drug cost $4 on a monthly basis. She decided to choose this program because it allowed her to get all her drugs at a fixed price.
The client takes lisinopril 10 mg, one tablet every morning at 10 AM for blood pressure management. Lisinopril belongs to the classification known as angiotensin-converting enzyme (ACE) inhibitors. It function by reducing the chemicals that tighten the blood vessels, allowing blood to flow smoothly.it is normally used to control blood pressure but not to cure it. Side effects associated with lisinopril include heartburn, nausea, insomnia, anxiety, sexual dysfunction, tingling or burning pain in the feet or hands, excessive tiredness, cough, headache, and dizziness. Lisinopril ought not to be taken with potassium supplements because it may result in rising blood potassium levels to harmful levels. Combining lisinopril with HCZT may increase the risk of hypercalcemia.
The client takes HCZT 12.5 mg, one tablet every morning at 10 AM for blood pressure management. HCZT belongs to the classification known as diuretics. It is used to treat edema and hypertension. HCZT functions by making kidney get rid of unnecessary fluid and salt, leading to increased urine output. HCZT decreases the elimination of lithium by kidneys and may cause lithium toxicity. Non-steroidal anti-inflammatory drugs lower the effects of HCZT by reducing the blood pressure. HCZT may raise the levels of blood sugar levels, calling for adjustments in the doses of drugs used to treat diabetes. Taking corticosteroids together with HCZT can increase the risk for lower levels of blood potassium as well as other electrolytes. Colestipol and cholestyramine may reduce the absorption of HCZT from the GI tract by binding to it. The side effects of HCZT include mild and severe rashes, anaphylaxis, jaundice, pancreatitis, electrolyte disturbances, abdominal pain, nausea, impotence, light sensitivity, low blood pressure, and weakness. Combining HCT with tums may also increase the risk of hypercalcemia.
The client takes Crestor 20 mg, every evening at 6 PM for the management of high cholesterol. Crestor belongs to the classification referred to as HMG-CoA reductase inhibitors, also known as statins. It decreases the levels of cholesterol in the blood by inhibiting HMG-CoA reductase. Crestor and other statins lower blood LDL cholesterol levels and total blood cholesterol. Side effects of Crestor include muscle pain, diarrhea, vomiting, nausea, and headache. Severe side effects include kidney failure, muscle breakdown, and liver failure. Other important side effects associated with Crestor include amnesia, forgetfulness, memory loss, confusion, and memory impairment.
The client takes levothyroxine 88 mcg, every morning before breakfast at 7 AM for the management of hypothyroid. Levothyroxine is a synthetic form of the primary thyroid hormone known as the thyroxine. The thyroid hormone assists in maintaining body temperature, utilization of food, and brain function, among others, in adults. It is used to treat hypothyroidism. The common side effects for Levothyroxine include fever, weight loss, vomiting, diarrhea, insomnia, headache, nervousness, heat intolerance, excessive sweating, increases pulse or heart rate, and chest pain. If diabetic patients start taking levothyroxine or discontinues taking it, there is need to decrease or increase the dosage for antidiabetic drug or insulin. When combining levothyroxine and tums, thyroid function should be monitored. Administration of the two drugs should be done 4 hours before oral calcium salts are taken. Combining levothyroxine with tums may decrease thyroid hormone efficacy.
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The client takes Vitamin D3 every morning per mouth, and its cost is $ 4.30. Vitamin D3 is commonly referred to as the cholecalciferol. In the body, it is usually broken down together with Vitamin D2 into its active form calcitriol. Calcitriol functions by improving the absorption of phosphorus and calcium in the body. It also stops the loss of phosphorus and calcium from kidneys, causing them to be absorbed back in the body to retain satisfactory levels. Vitamin D is used for the treatment hypoparathyroidism. Vitamin D ought not to be taken with mineral oil because it slows down its absorption and reduces its effectiveness. Thiazide diuretics have to be used with caution in individuals suffering from hypoparathyroidism and taking Vitamin D because they can increase calcium levels. Side effects of Vitamin D include hypercalcemia, weakness, weight loss, constipation, vomiting, and nausea. The combination of Vitamin D3 and HCZT taken together with thiazide may increase the risk of hypercalcemia
The client takes chondroitin and glucosamine daily per mouth with the lunch and costs $30. Chondroitin and glucosamine are naturally occurring substances that are used to help in maintaining healthy joints. Their combination is mostly used as a nutritional supplement in individuals with OA and should not be used as a replacement for the medication prescribed by a provider. Chondroitin and glucosamine are normally sold as an herbal supplement and should be obtained from a trustworthy source to reduce the risk of contamination. Side effects associated with chondroitin and glucosamine include diarrhea, heartburn, upset stomach, mild nausea, skin rash and gastrointestinal upset. Individuals who are allergic to shellfish are not supposed to take glucosamine. Recent studies also indicate that glucosamine is capable of increasing insulin levels in diabetic individuals.
The client takes magnesium 250 mg every morning per mouth, and the cost is $ 3.99. Magnesium is a mineral supplement that is used for the treatment of magnesium deficiency, high blood pressure, dyspepsia, and constipation. It is also used for the conditions such as heart attack, heart valve disease, low levels of good cholesterol, high levels of bad cholesterol, irregular heartbeat, and chest pain. Side effects associated with magnesium include diarrhea, vomiting, nausea, stomach upset, and many more. Some antibiotics, such as aminoglycoside, quinolone, tetracycline, and bisphosphonates, interact with magnesium, and this affects their effectiveness. Taking magnesium nitrate together with lisinopril requires that renal function and electrolytes to be monitored as this combination may increase the risk of nephrotoxicity. Renal function and electrolytes also need to be monitored if magnesium citrate is combined with hydrochlorothiazide. This combination may increase the risk of electrolyte abnormalities, seizures, QT prolongation, cardiac arrhythmias, and nephrotoxicity.
The client takes PreserVision 1 tablet every morning per mouth for the management of macular degeneration, and costs $18.99. PreserVision is an antioxidant supplement that has select minerals and vitamins at levels that are high than ordinary multi-vitamins. This supplement may not be received through diet alone. It is used to slow up the macular degeneration and the vision loss associated with it. It contains generic medications such as ascorbic acid, zinc oxide, vitamin E, beta-carotene, cupric oxide, and many others. Some of the common side effects associated with this supplement include stomach upset, headache, dizziness, and diarrhea.
The client takes Tums 500mg PRN PO for heartburn and costs $5.99. Tums is used to enhance the intake of calcium in persons whose diets are low in calcium. It is used as part of the regime for treating and preventing osteoporosis in people with low levels of calcium in their diets. It is also used as an antacid to treat minor stomach upset. Tums interact with some antibiotics such as tetracycline and quinolone, affecting their absorption into the body. Tums reduces the acidity in the stomach, and this affects the absorption of iron from the intestine. The combination of tums and Vitamin D3 may increase the risk of hypercalcemia. Side effects associated with tums include thirst, dry mouth, decreased appetite, vomiting, and nausea.
The client takes Tylenol 650 mg bid or as needed for the management of OA and costs$3.99. Tylenol belongs to the classification of drugs known as antipyretics and analgesics. It is used for the relief of pains and aches as well as fever. Its mechanism of action is not yet known. Without a direction from a provider, it should not be used for more than ten days. Side effects are very rare with Tylenol, but it may cause serious skin reactions and hypersensitivity reactions. The potential for Tylenol to harm the liver is raised if it is taken together with drugs that may also harm the liver or with alcohol .
The clients prescriptions are usually sent online to Wal-Mart, and she picks up by herself. The pharmacy provides 90 days supplies and automatic refills. She stores medications in upper cabinet in the kitchen. The only notable physiological change that may affect some medications is the possible decrease in renal failure. Some medications may be affected by changes in renal function, but the doses of renal-adjusted medication may not be affected for all elderly patients. The healthcare provider potential actions that may be indicated for these medications with this patient include taking some medications at different times, avoiding the combination of various drugs, and possibly withdraw of unnecessary medications.
Concerns and Teaching Points
The main concerns that could help prevent polypharmacy include drug interactions, adverse drug effects, lack of patient adherence, inappropriate treatment, inadequate monitoring, inappropriate drug selection, and drug ineffectiveness. Most of these concerns will be addressed in the teaching plan below.
The client is using four prescribed drugs and six OTC drugs. This increases the risk of adverse reaction, especially because she is an older adult. There could be a development of irrational polypharmacy because the client is using OTC dietary supplements and herbal preparations. Therefore, the teaching plan will focus on the following areas: adverse effects of each medication, dietary supplements, medication adherence, and drug interaction. The main goal of the patient education will be to help the client manage her medication and prevent polypharmacy. Face-to-face teaching will be conducted, and the client will be provided with printed education materials that include images and illustrations of the content being taught. The methodology that will be used to teach the client is teach-back. The teaching will be simplified to advise the client to avoid combining OTC medications with prescription medications, especially for the management of OA.
The education components will focus on the clients specific medications. Other areas that the teaching will focus on include: the importance of taking along a medication list to her provider, when to call the provider with medical related concern, and how to keep a medication list in an easy to get location in the event of an emergency. In the post-test follow-up visits, the patient will be asked to demonstrate understanding of the areas taught using her words. She will be asked to teach back the information, using her words, till I will be comfortable that they understand it. The client will demonstrate all the areas taught.
Summary of the Follow-up visit
The content of the teaching session will concentrate on the information about each medication, potential side effects and interaction of each medication, importance of involving the provider with question or concern, potential drug-related concerns that require emergency care, importance of medication adherence, and importance of filling her prescription at one pharmacy. Teaching instructions will be provided using simple language, and my teaching will be reinforced with printed teaching aids. These teaching aids will be printed in an easy-to-read format. The teach-back methodology will be used. The evaluation of clients learning will concentrate on knowledge gained and changes in the number of medications taken by the client.