Feb 5 2018 – Polypharmacy Case
Download Document: Recommendations Feb 5 2018
Date: February 5, 2018
PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise establish a provider-patient relationship between any ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.
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75-84 y.o. female on several medications to manage her CHF, Diabetes, HTN, Hypercholesteremia, Thyrotoxicosis, Mild pancytopenia, and recent Stroke in July 2017. New concerns regarding drug safety, possible support from CCAC and management of her current medications.
Summary of Recommendations:
- Full medication review to clarify exact indications for each medication (e.g., review all CVS medications in particular). Particular medications mentioned to review:
- Assess indications for dual antiplatelet therapy (Clopidogrel & ASA)
- Digoxin – Obtain digoxin levels of patient. Consider lowering dose if medication is indicated for management of CHF.
- ISDN – is this medication treating patient’s HTN/angina?
- Prior to starting patient on Aldactone, consider what NYHA Class patient falls under as current guidelines recommend Aldactone in Class III or higher.
- Metformin –tight control of glucose may not be needed in this patient (higher HbA1C in older patients is acceptable), can consider lowering current dose.
- Vitamin D & Calcium – new data may suggest that this treatment may not be beneficial in prevention of falls and fractures (Refer to JAMA Meta-analysis in Dec 2017)
- Check iron levels –if normal may consider removing ferrous fumarate from medications.
- Methimazole –
- Reassess thyroid status of patient. If patient is euthyroid may need to readjust dosage of other medications (i.e. beta blocker and digoxin)
- Medication could be reason for elevated LFT and anemic status.
- Discuss goals of treatment with patient – is patient more concerned with life longevity, symptom reduction, functionality, well-being, etc. Refer to: Tinetti “Patient Priority Directed Decision Making and Care for older adults with Multiple chronic conditions”
- Safety risks of being at home and taking medications:
- Phillips lifeline: provides drug dispensing machines if patient has difficulty administering her medications correctly.
- Request Occupational Therapy for home assessment and to optimize energy
- Consider referral to Palliative Care CCAC services for her CHF.
- Refer to Telehome Care Services –service offered to CHF patients Review blood pressure medications– refer to JNC8 guidelines on optimal BP target for patient based on age and comorbidities.
- JNC8 CHF Blood Pressure Algorithm. http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
- Lifeline Phillips Medication dispension service https://www.lifeline.ca/en/shop-lifeline/health-solutions/medication-dispensing-service/
- Effect of vitamin D in falls. https://jamanetwork.com/journals/jama/article-abstract/2667071?redirect=true
- Tinetti “Patient Priority Directed Decision Making and Care for older adults with Multiple chronic conditions”. Clinics Ger Med 2016 http://www.geriatric.theclinics.com/article/S0749-0690(16)00013-6/abstract