medication care planning: the frame around the pieces of the puzzle!

Community • Professional Academic

Detailing in GP offices Medication knowledge • Polypharmacy Medication review

Hospital • MedRec Best possible medication history • 48/6 Assess 6 areas w/i 48 hr • Polypharmacy Medication review

Residential Care

• MedRec Best possible medication history • CLeAR Appropriate antipsychotic use • Polypharmacy Medication review

Transition in Care

Patient

Case Scenario: Fervid Trimble

Fervid Trimble was an active and sociable 87-year-old widowed woman, with no history of dementia.

• She resides in an independent-living apartment in a multi-care-level seniors’ complex.

• She uses a cane or walker for mobility.

• She has a stepdaughter who lives nearby and sons and daughters-in-law who live within a 2-4 hour drive.


Fervid had been on the following medications for what appears to be the associated indications:

• Hydrochlorothiazide - history of hypertension

• Warfarin - started in 1997 for atrial fibrillation

• Timolol eye drops- high intraocular pressure and risk of glaucoma

• Refocoxib (Vioxx)- for hip and leg pain (previous surgery to leg).


After a bout of influenza and dehydration treated at the local hospital ER she is discharged the following day to recuperate for a few days in the nursing care unit of the complex. Soon after moving in, the following med change is made:

• Tramadol (Ultram) for pain (substituted for Vioxx)

• Tylenol is added for pain

• Claritin D – sinus draining


She is prescribed the following additional medication for what appears to be the associated indications:

Digoxin – rapid heart beat

Nitrofurantoin (Macrobid)- urinary tract infection

She is also seen by the Geriatric Psychiatrist:

• Zoloft is prescribed for depression.


A few weeks later, she is seen again by the visiting Geriatric Psychiatrist as she is having hallucinations and the following medication change is made:

• Citalopram (Celexa)- to replace Zoloft.


Two months later, however, Fervid has not recuperated but is increasingly delusional, somnolent, hallucinating, and she has became bedridden. She was diagnosed by the visiting psychiatrist with vascular dementia and Donepezil (Aricept) was suggested. Instead of following this course of action, the family asks for a medication review as they suspect delirium from a drug adverse event called serotonin syndrome, from the Celexa and Ultram combination, not dementia for which Fervid had no antecedent history. The physician refuses to meet and the med review only occurs 4 months later when the physician leaves the facility and a Nurse Practitioner becomes involved.


Fervid recovers cognitively after the serotonergic drugs were stopped.

However, she cannot return to the hoped-for accommodation in an assisted living suite because too much mobility and function has been lost from being bedridden so long.

Residence administrators decide that she should remain in the higher care level long-term care unit.


In the 4 years Fervid is in the nursing care unit she has 3 hospital admissions: • One for a cranial bleed due to administering too high a dose of

Coumadin • One for a salivary gland infection (treated with antibiotics) and

dehydration • One for a stomach bleed and pneumonia (treated with

antibiotics). At the last admission, the following medications were started and continued on release: • Esomeprazole (Nexium) • Levofloxacin (Levagquin) • Diltiazem (Cardizem)


On return to the facility she is “mixed up, confused, upset, sometimes out of it, and sleeping a lot”, whereupon she is prescribed:

• Mirtazapine (Remeron) – for the above symptoms

• Nitrofurantoin (Macrodantin) – for a urinary tract infection

• And Warfarin (Coumadin) is restarted.

The Remeron is prescribed by a new facility physician who seems not to know Fervid’s history with anti-depressant medications.


She begins to display serotonin syndrome symptoms, similar to what had been seen some years ago.

Medications were reviewed and she recovers cognitively when Remeron is stopped, however her physical condition remains compromised.


It is of note that Fervid has also experienced a number of bouts of diarrhea, which further weakens her. She is diagnosed each time as having Clostridia Difficile infection for which she is prescribed:

• First: Metronidazole (Flagyl), then

• Vancomycin

She is seen by an infectious disease specialist who suggests a two week course of Vancomycin if there is another recurrence. It is also of note that there were others cases of C. Diff in that care facility where multiple transfers occur.


Fervid progressively weakens and declines and is assigned to hospice-level care after a family meeting with the doctor at the facility in the summer of 2008. She dies at the age of 92 years at the end of October 2008.


Questions for the panel:

1. Is this an unusual clinical scenario related to medications in the elderly? Why or why not?

2. From a care planning perspective in and across the care environments and given the focus of the new medication-related initiatives, how do you think that Fervid’s situation could have been prevented?


• Med rec and med review opportunities at admission

• Addition of meds by more than one physician plus what is the monitoring and review approach?

• Anticholinergic Claritin D

• Hospital as a med review opportunity over and above med rec plus transitions issues

• How is resident and family involved?

• New GP

• Multiple antibiotic courses, C. Diff; ?UTI Dx;


Question for the participant discussion:

“From a care planning perspective in and across the care environments and given the focus of the new medication-related initiatives, how do you think that Fervid’s situation

could have been prevented?”

medication care planning: the frame around the pieces of the puzzle!

Health & Medicine

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