Chronic Care Management

After an initial examination of the medication list, I try to envision Mrs. X based on the SPICES assessment and my own 30 years of geriatric experience.  This is an 80-year-old female who has lived her entire life eating rich foods high in cholesterol and fat.  She is probably short and plump.  She has not been sleeping and likely exhibits physical behaviors which have been labeled as “psychotic” in nature.  She hasn’t been eating well and has had a significant weight loss, despite her plump appearance.  She has tremors in her hands which make it hard to hold utensils and cups, but she has lost weight because she has had anorexia, not due to the tremors.  She is incontinent and has constipation.  She is confused, usually agitated, and she probably cries inappropriately.  She is ambulatory, but she is weak. She will have some bruises and skin tears on her arms and legs due to the falls, but she doesn’t have any pressure wounds, yet. Chronic Care Management Essay.

Although Mrs. X is very ill, there is no question that some of her current ailments are related to her polypharmacy.  There are 21 medications on Mrs. X’s medication list.  Unfortunately, the use of more than five medications daily (polypharmacy) is commonly seen in elderly patients (Masnoon, Shakib, Kalisch-Elliot, & Caughey, 2017).  At first glance, it is notable that many of the medications on Mrs. X’s list work in similar ways and place Mrs. X at higher risk for side effects or adverse reactions.  Also, some of these medications have the same ingredients as others, increasing the risk of overdose. Chronic Care Management Essay Some of the listed medications are even contraindicated for elderly patients (Maher, Hanton, & Hajjar, 2014).

A plan of care is needed that should include medication reconciliation, education regarding her medications, review by a pharmacy consultant, and initiation of gradual dose reductions.  Medication education should include a description of the each medication currently taken.  Altace is an ACE (angiotensin-converting-enzyme) inhibitor and is used to treat high blood pressure (Hypertension) and heart failure (Wolters, 2011).  Adalat is a calcium channel blocker and is used to treat high blood pressure (Wolters, 2011).  Cardizem LA is also a calcium channel blocker and is used to treat high blood pressure (Wolters, 2011). Chronic Care Management Essay Lasix is a diuretic used to treat fluid retention caused by heart failure (Wolters, 2011).  Hydrochlorothiazide is also a diuretic and is used to treat fluid retention and hypertension (Wolters, 2011).  Baby aspirin is a blood thinner, as well as a nonsteroidal anti-inflammatory, and is used to reduce the risk of heart attack by thinning the blood (Wolters, 2011).  Lipitor is a statin drug and is used to treat high cholesterol and triglyceride levels (Wolters, 2011).  Synthroid is a hormone used to treat hypothyroidism (Wolters, 2011).  Tylenol is an analgesic used to treat minor aches and pains (Wolters, 2011).  Benadryl is an antihistamine with a sedating effect that is used to treat seasonal allergies (Wolters, 2011).  Aleve is a nonsteroidal anti-inflammatory drug used to treat arthritis pain (Wolters, 2011).  Amrix is a muscle relaxant used to treat pain and stiffness caused by muscle spasms (Wolters, 2011). Chronic Care Management Essay Glucosamine is an amino sugar and is used to treat arthritis pain.  Amitriptyline is an antidepressant and is used to treat sleeplessness associated with depression (Wolters, 2011).  Paxil is a selective serotonin reuptake inhibitor and is used to treat depression (Wolters, 2011).  Oxazepam is a sedative and is used to treat insomnia associated with depression (Wolters, 2011).  Tylenol PM is a combination drug that contains both Benadryl and Tylenol.  Prilosec is a proton pump inhibitor used to treat gastroesophageal reflux disease (GERD) (Wolters, 2011).  Fiber laxative is a bulk-forming laxative used to treat constipation by increasing the bulk of the stool causing movement in the intestine.  It also increases the amount of water in the stool making the stool softer (Wolters, 2011).  Colace is a sulfonic acid which is also used to increase the amount of water in the stool making it softer and easier to pass (Wolters, 2011).  Multivitamins are prepared with multiple dietary minerals and nutritional elements and are used as dietary supplements and often stimulate the appetite. Chronic Care Management Essay.

Independently medications such as Benadryl, Paxil, Tylenol PM, and others are contraindicated for use in the elderly because they have adverse side effects such as increased delirium, behavioral problems, and increased risk for stroke.  Medications such as Prilosec can cause bone loss, fractures and even bowel infections such as Clostridium Difficile.  Nonsteroidal anti-inflammatory medications such as Aleve and baby aspirin could potentially promote fluid retention and exacerbate heart failure. Chronic Care Management Essay In addition to the side-effects/ adverse reactions that some medications can cause, there is also the potential for medications that work in a similar manner to increase other risks (Beers, 2015).  Antidepressant medications can lower blood pressure and if a patient also receives a fluid pill (diuretic), then this adds to the potential for extremely low blood pressure, which could cause falls or even be fatal.  Muscle relaxants and sedatives both cause increased sleepiness and are poorly tolerated by older adults.  Over-sedation and falls are a huge risk.  Even though CHF causes an excess of fluid, there is still a very real risk of dehydration (Haq, et.al., 2014).  Lasix, hydrochlorothiazide, bulk fiber laxative, and Colace all pull fluid out of the body for elimination either by urine or feces. A person can have edema when fluid is in all the wrong places, but still be dehydrated because the fluid is not in the right places (Haq, et.al., 2014).

It is important that medications are taken strictly as ordered and unnecessary medications should be discontinued (Masnoon, et.al., 2017).  Although there may be some adjustment with medication timing to meet a patient’s individual preferences, it is important that the medication regimen have a structured routine.  A pharmacist should be consulted to review medications monthly or as indicated to ensure that the lowest possible therapeutic dosages are given.  Laboratory monitoring will be critical in assessment of the status of medication levels and their effects on the body.  Other tests may also be needed such as an electrocardiogram, chest x-ray, or arterial doppler studies.  Physical, occupational, and speech therapies – as well as restorative nursing – will be needed to improve physical tolerance and endurance.  Nutrition will also be important.  Calorie intake, salt intake, and other vitamins and minerals will need to be monitored closely.  Daily weights and edema checks will be needed to monitor fluid gains and/ or losses (Haq, et.al., 2014).  Involvement in activities of daily living, social activities, and therapy activities, as well as a regular waking and sleeping routine, will be necessary to improve sleep patterns.  One of the more important interventions needed is the monitoring frequently for adverse reactions, side effects, and/or increased behaviors.  Regular assessments will be needed. Chronic Care Management Essay.

References

Masnoon, N., Shakib, S., Kalisch-Ellett, L., & Caughey, G.  (2017, October 10).  What is polypharmacy? A systematic review of definitions.  Biomed central geriatrics, 17, 230.  Retrieved from  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635569/

Wolters K. (Firm).  (2011). Nursing 2011 drug handbook.  Philedephia – Baltimore – New York – London.  Chris Burghardt Chronic Care Management Essay

Beers Criteria Update Expert Panel.  (2015). American geriatrics society 2015 updated Beers criteria for potentially inappropriate medication use in older adults.  Clinical Investigations.  Retrieved from  https://www.sigot.org/allegato_docs/1057_Beers-Criteria.pdf

Maher, Jr, R., Hanlon, J., Hajjar, E.  (2014). Clinical consequences of polypharmacy in elderly.  Expert opin drug saf.  Retrieved from  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864987/

Haq, M., Wong, C., Mutha, V., Anavekar, N., Lim, K., Barlis, P., & Hare, D.  (2014). Therapeutic interventions for heart failure with preserved ejection fraction:  A summary of current evidence.  World journal of cardiology, 6(2), 67-76.  Doi:  10.4330/wjc.v6.i2.67 Chronic Care Management Essay