geriatric case studies
Patient Case (N.H. continued from above) 4. To maintain and improve function in N.H., which one of the following interventions should be implemented? A. Add a calcium and vitamin D supplement. B. Add simvastatin 10 mg/day. C. Add warfarin. D. Assess for incontinence and treat with anticholinergic agents.
4. Answer A Efforts to maintain bone and muscle strength are important for N.H. Most people who are older do not consume a diet rich in calcium or vitamin D. In addition, because N.H. resides in a nursing home, she will have less sun exposure and is more likely to be deficient in vitamin D.
3. Based on your assessment of age- and disease-related changes in N.H., which one of the following areas of pharmacotherapy should be addressed first? A. Diabetes treatment. B. Alzheimer's disease treatment. C. Hypertension treatment. D. Stroke prevention.
3. Answer A The diabetes treatment should be addressed promptly. Because N.H. has considerable renal insufficiency, she does not meet the prescribing guidelines for metformin. Use of metformin in individuals with impaired renal function increases the likelihood of lactic acidosis. In addition, glyburide is partly eliminated in the kidney, has duration of effect of about 24 hours, and is not recommended for elderly patients with poor renal elimination.N.H. could be experiencing periods of hypoglycemia that contribute to her dizziness.
Patient Case 1. N.H. is an 85-year-old woman who resides in a nursing home. She weighs 65 kg. Her medical history is significant for type 2 diabetes mellitus, hypertension, and moderate dementia, likely attributable to vascular changes. Two years ago, she had a cerebrovascular accident, and 1 year ago, she had a right hip fracture. Her regularly scheduled medications include glyburide 10 mg/day, lisinopril 10 mg/day, metformin 500 mg 2 times/day, donepezil 10 mg/day, aspirin 81 mg/day, and a multivitamin daily. Her as-needed medications include zolpidem 5 mg/day as needed for sleep, meclizine 25 mg ½ tablet 3 times/day as needed for dizziness, and the house bowel regimen. When recommending medication changes for this patient, which one of the following functional assessments is most important to evaluate? A. IADLs. B. Assessment for depression. C. Assessment for gait and balance. D. Assessment for pressure sores.
1. Answer C This patient is typical of an older person in a nursing home with many chronic diseases requiring drug management. At this time, she has several risk factors for falls including a history of fall with hip fracture; diseases such as diabetes, dementia, and hypertension; dizziness; and use of several drugs. An assessment for gait and balance would help determine the severity of her risk.
10. This patient is medically assessed, and reversible causes of her hyper-vocalization are ruled out. Which one of the following represents the best approach to treating her behavioral symptoms? A. Implement a behavioral approach. B. Add valproic acid. C. Increase the dose of quetiapine. D. Add citalopram.
10. Answer A Hyper-vocalization is a difficult behavior to address. In general, medications are not very efficacious in this case. Increasing the dose of quetiapine would likely result in increased sedation in the patient. Although the behavior might decrease during periods of sedation, the behavior often returns when the patient adjusts or developsa tolerance to the sedative properties. The other drug choices, adding valproic acid or citalopram, do not have much evidence of effectiveness in the literature. A behavioral approach is the best method to try in this patient. Types of interventions that could be effective include those that create a soothing, serene environment for the patient, such as soft music. Activities appropriate to the patient's level of cognition might also be helpful as a distracting mechanism as well as a way to improve interactions. Reassurance by staff is also particularly helpful so that the patient feels more comforted- often, moving a patient from his/her room and closer to the nurses' station will help a patient feel less alone and less afraid.
Patient Case 11. A 65-year-old woman reports worsening problems with stress incontinence. She is unable to participate in physical activities, and she has decreased social engagements. She has hypertension and has been advised not to take α-agonists. Which one of the following is the best course of action at this time? A. A trial of topical estrogens. B. Instruction in exercises to improve pelvic floor muscle strength. C. Referral to a urogynecologic surgeon for evaluation. D. Administration of tolterodine.
11. Answer C In a postmenopausal woman, stress incontinence that affects daily function should be evaluated by a surgeon with expertise in urogynecology. Data showing the efficacy of available drug therapy for stress incontinence are limited. Kegel exercises can be helpful in improving the strength of muscles in the pelvic floor, but they are seldom sufficient to treat stress incontinence.
Patient Case 12. A.W. is an 85-year-old man who presents to his physician with LUTS. A digital rectal examination confirms the diagnosis of BPH, and the physician schedules a further work-up including a prostate ultrasound, which indicates his prostate volume is 31 g. A.W.'s score on the AUASI is 15. Which one of the following therapies is best at this time? A. Watchful waiting. B. Finasteride. C. Tamsulosin. D. Finasteride plus tamsulosin.
12. Answer C Pharmacologic therapy targeted at reducing urethral sphincter pressure has proved effective in reducing BPH symptoms. Tamsulosin is an α-adrenergic blocker with more specific activity for the genitourinary system. Postural hypotension can still occur with all α-adrenergic blockers, so patients should be monitored when therapy is initiated. Finasteride, an α-reductase inhibitor, and combination therapy with these agents are recommended when there is evidence of large prostate size.
Patient Case 13. W.F. is an 85-year-old man who presents to his physician with pain from hip OA. He also has hypertension,coronary artery disease, and BPH. For his OA, W.F. has been taking acetaminophen 650 mg 3 times/day. W.F. reports that acetaminophen helps, but he still experiences pain that limits his ability to walk. Which one of the following is the best next step in analgesic therapy for W.F.? A. Change the analgesic to celecoxib. B. Add hydrocodone. C. Change the analgesic to ibuprofen. D. Add glucosamine
13. Answer B The American Geriatrics Society recommends treatment with opioids for OA when older patients do not respond to initial therapy with acetaminophen. The NSAIDs and COX inhibitors are seldom considered when a thorough assessment of the patient shows that the risk of treatment (gastrointestinal bleeding and
Patient Case 14. F.A. is a 55-year-old woman with rheumatoid arthritis. On diagnosis 1 year ago, F.A. had an RF titer of 1:64,signs and symptoms of inflammation in the joints of both hands, and about 45 minutes of morning stiffness.She began therapy with methotrexate, and she is presently receiving 15 mg every week, folic acid 2 mg/day,ibuprofen 800 mg 3 times/day, and omeprazole 20 mg/day. At today's clinic visit, F.A. reports a recurrence of her symptoms. Radiographic evaluation of her hand joints shows progression of joint space narrowing and bone erosion. Which one of the following is the next step in therapy for F.A.? A. Administer etanercept. B. Administer hydroxychloroquine. C. Add prednisone bridge therapy. D. Change to leflunomide.
14. Answer A This is an example of a young woman with indicators of poor prognosis with rheumatoid arthritis (positive RF, young age, many symptoms) who has not responded to therapy with methotrexate. Although the next treatment step is not entirely clear, her best choices would be between combination DMARD therapy and a biologic agent. Leflunomide would not be preferred because its efficacy is similar to methotrexate. Hydroxychloroquine would not be recommended as sole therapy for someone who has not responded to methotrexate. Etanercept has a response in 60%-75% of patients whose therapy with methotrexate has failed. Glucocorticosteroids are used as adjunctive therapy for the first several months of treatment with a disease-modifying agent.
2. Your further evaluation of N.H. reveals that she has not used any of her as-needed medications in 2 months. In addition, her laboratory results reveal the following: fasting plasma glucose 90 mg/dL, sodium 138 mEq/L, potassium 4.5 mEq/L, chloride 102 mEq/L, CO2 25 mEq/L, blood urea nitrogen 30 mg/dL, SCr 1.8 mg/dL, and TSH 4.0 mU/L. Which one of the following pharmacokinetic parameters is most likely to be changed in N.H.? A. Oral absorption. B. Distribution. C. Metabolism. D. Renal excretion.
2. Answer D Renal elimination is usually the most significantly changed pharmacokinetic parameter in older people. In this patient, her advanced age and diseases will also add to her loss of renal function. Using the Cockcroft- Gault equation, N.H.'s estimated creatinine clearance is 24 mL/minute. Creatinine clearance = [(140 − 85)65/(72 × 1.8)] × 0.85
Patient Case 5. An 85-year-old woman is assessed at a memory loss clinic to determine the cause of her dementia. Her most recent score on the MMSE is 24/30. Present diagnoses include Parkinson disease, hypothyroidism, and OA of both knees. She has had these conditions for more than 10 years, is stable, and is independent in her ADLs. Her present medications include carbidopa/levodopa continuous release, trihexyphenidyl, celecoxib, levothyroxine, docusate, and bisacodyl. Which one of the following medication changes is best to consider first? A. Add donepezil 5 mg/day. B. Slow dosage reduction of carbidopa/levodopa. C. Slow dosage reduction and discontinue trihexyphenidyl. D. Replace celecoxib with acetaminophen.
5. Answer C This patient has mild-moderate dementia in addition to Parkinson disease. Although some patients with Parkinson disease develop dementia, many do not. This patient has been stable for some years. When evaluating her cognitive loss, it is important to limit the use of any drug that could contribute to confusion. Anticholinergics such as trihexyphenidyl can cause confusion. Because this drug is likely part of the patient's Parkinson disease treatment, the dose should be slowly reduced, and the patient should be monitored for exacerbationsof her Parkinson disease.
Patient Case 6. An 87-year-old man with Alzheimer's disease began therapy with rivastigmine. He has been titrated up to rivastigmine 6 mg 2 times/day. His family notes improvement in his functional ability but reports that he is experiencing nausea and vomiting that seem related to rivastigmine. Which one of the following is the best course to take? A. Advise the patient to take his drug with an antacid. B. Add prochlorperazine 25 mg by rectal suppository with each rivastigmine dose. C. Discontinue rivastigmine and initiate memantine 5 mg twice daily. D. Change rivastigmine to the daily patch that delivers 9.5 mg/day
6. Answer D Rivastigmine is a potent inhibitor of acetyl and butyl cholinesterase, leading to significant cholinergic adverse effects such as nausea, vomiting, and diarrhea. These adverse effects can be diminished by a slow-dosage titration of the drug. In addition, when a patient is at his/her full therapeutic dose, use of the transdermal delivery system will generate even plasma concentrations and lessen the incidence of cholinergic adverse effects. Based on the maintenance dose achieved of 12mg of rivastigmine, this man can be changed to the 18-mg patch that delivers 9.5 mg/day.
Patient Case 7. R.A. is a 75-year-old woman with Alzheimer's disease who has been treated with donepezil 10 mg/day for about 3 years. When she initiated therapy, her MMSE was 21/30, and her present MMSE is 17/30. R.A. is living at home with her husband. She cannot perform most IADLs but can perform most ADLs with cueing. R.A.'s husband asks about changing her drug treatment to help maintain her function. Which one of the following is the best course of action? A. Change her treatment from donepezil to rivastigmine. B. Stop donepezil. C. Add memantine 5 mg/day. D. Add vitamin E 400 units 2 times/day.
7. Answer C Over 3 years, R.A. has declined 4 points on her MMSE, which suggests a treatment response to donepezil. Furthermore,R.A. is still able to live at home with her husband, and she has maintained some function in her basic ADLs. Because she has benefited from acetylcholinesterase inhibitor use, it should not be abruptly discontinued. Evidence from clinical trials with memantine shows that an additional treatment response can be observed when memantine is added to donepezil therapy. Memantine should be initiated at 5 mg/day and increased every 2 weeks until the full therapeutic dose is achieved (10 mg 2 times/day).
Patient Cases 8. You are evaluating the medication profile of an 87-year-old female nursing home resident. She resides in a secure advanced dementia unit. Her medical history includes dementia probably caused by Alzheimer's disease, Parkinson disease, and OA. She requires assistance with all ADLs including total assistance with bathing and dressing and help with feeding. She ambulates with the assistance of a four-wheeled walker. Her medication regimen includes donepezil 10 mg/day, memantine 10 mg 2 times/day, carbidopa/levodopa 25/100 mg 4 times/day, oxybutynin extended release 5 mg/day, quetiapine 25 mg 2 times/day, and a multivitamin supplement daily. The patient's MMSE score is 5/30, and her GDS is 4/15. When reviewing the nursing notes, there are several references to the patient continuously crying out, "Help me, help me." Which one of the following additional information is necessary in assessing this patient? A. The Brief Psychiatric Rating Scale. B. Functional Assessment Staging. C. An evaluation of incontinence. D. Framingham Risk Assessment.
8. Answer C This patient has several issues related to her medication regimen. Patients in late stages of dementia (as evidenced by an MMSE of 5/30) will develop a functional incontinence caused by their loss of cognition and inability to recognize toileting needs. Oxybutynin is an anticholinergic agent useful in treating overactive bladder rather than functional incontinence, and it also has pharmacologic properties that oppose the action of donepezil. A review of the patient's incontinence history will help determine whether this drug is efficacious in the treatment of her UI.
9. Which one of the following recommendations would reduce inappropriate medications? A. Change carbidopa/levodopa to a continuous-release formulation. B. Discontinue oxybutynin. C. Discontinue memantine. D. Reduce quetiapine to 12.5 mg 2 times/day.
9. Answer B Discontinue oxybutynin. This drug is classified as an inappropriate drug on the basis of Beers consensus criteria In addition, oxybutynin is highly anticholinergic and may lead to confusion in older patients. If the patient does have overactive bladder (rather than functional incontinence), alternative medications can be used that more specifically target the bladder musclewith less potential for central nervous system effects.