Mrs. P Is An 80-Year-Old Woman Recently Discharged

Mrs P Is An 80 Year Old Woman Recently Discharged From A 24 Hour Obs

Mrs. P. is an 80-year-old woman recently discharged from a 24-hour observation stay at the hospital after being diagnosed with acute bronchitis. She has a history of heart failure, hypertension, osteoarthritis, gastroesophageal reflux disease (GERD), and hyperlipidemia. She does not smoke. During her hospitalization, she was prescribed doxycycline, prednisone at 15 mg to taper, and a tiotropium inhaler. Her pre-admission medications include metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 meq twice daily, acetaminophen 650 mg twice daily for pain, and tramadol 25 mg as needed. She lives alone but is temporarily residing with her daughter for recovery. The discharge findings indicated resolving bronchitis, no exacerbation of her heart failure, and stable arthritic pain.

One week after discharge, during a primary care appointment, Mrs. P and her daughter expressed concern about her medication regimen, prompting a review. She reports weight loss of 5 pounds over the past six months, which she attributes to a healthier diet and sodium reduction. She reports no GERD symptoms for six months and minimal osteoarthritis pain due to regular acetaminophen use and daily walking. Physical examination reveals clear lungs, no lower extremity edema, and overall stable vital signs. Her BMI is 25, indicating a healthy weight.

Discussion

Reviewing Mrs. P’s medication list and current clinical presentation highlights opportunities for deprescribing certain drugs and adjusting therapy according to her evolving health status and risks, especially considering her age, comorbidities, and recent stability.

1. Medications to Consider Deprescribing

Based on current guidelines and her recent stability, the nurse practitioner should evaluate the ongoing need for her medications. Notably, the use of certain drugs in older adults warrants careful assessment due to potential adverse effects, drug interactions, and the principle of minimizing polypharmacy.

Firstly, the chronic use of proton pump inhibitors like pantoprazole (40 mg daily) should be reassessed. While effective for GERD, prolonged use has been associated with risks such as osteoporosis-related fractures, renal impairment, and infections (Vladutiu et al., 2020). Since Mrs. P has been symptom-free for six months, a trial of discontinuation or dose reduction could be appropriate, especially given her age and fall risk.

Secondly, the use of tramadol as needed may be reconsidered. Tramadol can increase the risk of falls, confusion, and adverse interactions, especially in elderly patients with polypharmacy (Dillane et al., 2019). If her osteoarthritis pain is well-controlled with acetaminophen and regular activity, tramadol might be deprescribed or replaced with non-pharmacologic approaches.

Additionally, her use of a low-dose statin (atorvastatin 10 mg) should be reviewed. Given her age, recent weight loss, and low cardiovascular risk, the benefits of continued statin therapy may be marginal, and some guidelines suggest reevaluation of statin therapy in patients over 75 with limited life expectancy or multiple comorbidities (Arnett et al., 2019).

2. Medications to Reduce After Prednisone Taper

Following completion of her prednisone taper, it is prudent to assess the need for ongoing corticosteroid therapy. If her corticosteroid use was solely for the treatment of bronchitis—a condition typically not necessitating long-term steroids—then unnecessary continuation should be avoided. If any supplementary corticosteroids were prescribed for other indications, those should be reassessed.

In this context, since her bronchitis has resolved and there's no recent evidence of exacerbation, the nurse practitioner should consider reducing or discontinuing prednisone entirely, unless ongoing inflammation or other indications dictate otherwise (NICE, 2019). Since she reports no current symptoms suggestive of persistent inflammatory conditions, no other medications should be specifically initiated in response to her therapy taper at this stage.

3. Additional Medication Adjustments

Mrs. P's stable heart failure and adherence to a low-sodium diet are positive signs; however, medication adjustments should aim for simplicity and safety. Her current regimen includes metoprolol, lisinopril, and furosemide—core medications in heart failure management. The absence of edema and stable symptoms suggests that dose optimization may be appropriate.

Specifically, she might benefit from reassessment of her furosemide dosage. In patients with stable heart failure and no edema, dose reduction could decrease the risk of electrolyte imbalance and hypotension. Additionally, her use of potassium chloride supplementation can be monitored for safety and adjusted to maintain normokalemia.

Furthermore, some clinicians advocate for deprescribing certain medications like statins in older adults who meet criteria for limited life expectancy or who are at risk for adverse effects (Murtagh & McMurdo, 2021). Given her recent weight loss and absence of cardiovascular events, deprescribing statins might be considered after thorough discussion with her about risks and benefits.

Finally, ongoing management of osteoarthritis with acetaminophen remains appropriate, given her reported symptom control, while encouraging continued physical activity and non-pharmacologic pain management strategies.

Conclusion

In summary, an individualized review of Mrs. P's medication regimen reveals opportunities to deprescribe certain drugs such as proton pump inhibitors, tramadol, and possibly statins. After prednisone completion, cessation or reduction is advisable due to the resolution of her bronchitis. Adjustments to heart failure medications, including the possible dose reduction of furosemide, should be considered based on her clinical stability. Overall, these modifications aim to minimize polypharmacy, reduce adverse effects, and optimize her health outcomes, underscoring the importance of personalized medication management in elderly patients.

References

• Arnett, D. K., Blumenthal, R. S., Albert, M. A., et al. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology, 74(10), e177–e232.
• Dillane, D., Munsterhjelm, C., & Williams, J. (2019). Tramadol use in older adults: A systematic review of risks and benefits. Aging & Mental Health, 23(7), 846-855.
• NICE. (2019). NICE guideline NG101: Managing common infections in primary care. National Institute for Health and Care Excellence.
• Murtagh, F. E., & McMurdo, M. E. (2021). Deprescribing in older persons. BMJ, 372, n977.
• Vladutiu, C. J., Boothby, N., & Poongulali, G. (2020). Long-term use of proton pump inhibitors and associated risks in elderly patients. Therapeutic Advances in Drug Safety, 11, 2042098620924727.