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Problematic Pharmacological Management in a Geriatric Patient

Mrs. A’s pharmacological management presents several problematic issues common in elderly patients that likely contributed to her current presentation and her daughter’s concerns about her declining functional status. The confusion, fatigue, irritability, and obsessive-compulsive behaviors Mrs. A has exhibited over the past 2-3 months strongly suggest medication-related adverse effects or toxicities. Elderly patients like Mrs. A are at much higher risk for these types of issues due to age-related pharmacokinetic and pharmacodynamics changes.

Physiologic changes associated with aging alter how the body handles medications. Decreases in lean body mass, total body water, renal blood flow, and hepatic metabolism all impact drug absorption, distribution, and elimination. Additionally, increased body fat and decreased serum albumin concentrations affect the volume of distribution for many drugs. The blood-brain barrier also becomes more permeable with age, raising central nervous system sensitivity to medications that can cause cognitive impairment and psychiatric symptoms (Knox et al., 2022). Mrs. A’s complaints about the lace curtains appearing soiled or moldy could represent a medication-induced visual disturbance or a psychiatric adverse effect.

From a pharmacodynamics perspective, aging is associated with increased sensitivity to medications, especially those that act on the central nervous system, like digoxin. Alterations in homeostatic mechanisms, receptor numbers, and receptor affinities all contribute to an exaggerated response in the elderly, even at normal therapeutic doses. With multiple underlying medical conditions like Mrs. A has, it becomes extremely challenging to achieve an appropriate risk-benefit ratio with pharmacological therapy as side effects and toxicities become more likely.

Geriatric Pharmacokinetic Changes

The primary pharmacokinetic changes in elderly patients that can impact drug disposition include decreased renal and hepatic function. Mrs. A, at 71 years old, almost certainly has an age-related decline in glomerular filtration rate and liver function that alters how medications are absorbed, distributed, metabolized, and eliminated from her body. Reduced renal clearance of digoxin and furosemide likely led to elevated serum levels, increasing her risk of toxicity. The slower hepatic metabolism of piroxicam may have caused drug accumulation. Higher paracetamol levels could also occur with impaired clearance (Freo et al., 2021). These pharmacokinetic changes, combined with her multiple comorbidities, increase Mrs. A’s sensitivity to medications with a small therapeutic window.

Impact of Renal and Hepatic Function Changes

Specifically, Mrs. A’s worsening chronic heart failure likely decreased her renal perfusion further, reducing the excretion of furosemide and digoxin. Higher circulating cardiac glycoside levels from the digoxin may have contributed to her fatigue, confusion, and irritability. Elevated furosemide levels could also be causing electrolyte abnormalities and dehydration, exacerbating her mental status changes (Colalillo et al., 2023). Her osteoarthritis and advanced age alter acetaminophen pharmacokinetics by decreasing glucuronidation and sulfate conjugation, raising serum concentrations, and increasing the risk of hepatotoxicity. The piroxicam she takes daily has a long half-life and requires dosage reduction in elderly patients; steady-state accumulation is likely causing gastrointestinal side effects, as her antacid use indicates.

Polypharmacy Issues

The phenomenon of polypharmacy, using multiple medications concurrently, compounds the individual drug issues for geriatric patients. The more medications prescribed, the higher the risk of side effects, interactions, and nonadherence. Mrs. A’s regimen of six routine medications is quite complex, especially considering her age, multiple chronic diseases, and emerging dementia. Simplification would be prudent through DE prescribing unnecessary or high-risk medications and dosage reductions when possible.

Potential Side Effects and Interactions

Potential side effects and interactions from Mrs. A’s regimen are concerning. Digoxin can cause visual disturbances, confusion, and gastrointestinal symptoms like nausea and vomiting at elevated levels. Furosemide increases the risk of electrolyte abnormalities and dehydration. High-dose NSAID use raises risks of gastrointestinal bleeding, renal impairment, and cardiovascular events. Paracetamol hepatotoxicity is more likely with reduced dosing in the elderly. Drug-drug interactions like compromised effectiveness of digoxin and furosemide due to electrolyte disturbances and additive nephrotoxicity from combining diuretics, NSAIDs, and digoxin also present risks.

Improving Pharmacological Management

Several strategies could have improved pharmacological management in this case. First, using pain medications like acetaminophen and NSAIDs judiciously and with scheduled limitations due to toxicity risks (Nadeau & Lawhern, 2022). Second, piroxicam dose and frequency should be reduced to avoid accumulation. Third, closely monitoring digoxin and furosemide levels given reduced renal clearance. Fourth, minimize total medications through indication review and use non-pharmacologic approaches first when reasonable. Finally, clear communication about intended effects, possible side effects, and symptoms requiring prompt reporting may have identified issues earlier.

Educational Strategies

Several educational strategies could have improved Mrs. A’s outcomes in this case. First, providing clear counseling on her medication regimen, dosing instructions, and potential adverse effects would allow for earlier recognition of issues. Teaching Mrs. A’s family about key symptoms like confusion, fatigue, and changes in behavior to watch for is also essential.

Step two is the education of Mrs. A and her family about the hazards of polypharmacy in older adults and the value of medication reconciliation, which is critical. The process of going through each medicine, what it has meant for, the targets it should reach, and monitoring should be done is crucial. The issue of DE prescribing abuse must also be discussed, including an explanation of how drugs that are only good for their well-being can be used. The last recommendation is that patients get educated on the use of non-pharmacological therapies that can be used in place of or added to medications for the treatment of chronic pain. In addition to medical treatment through physical therapy, occupational counseling, cognitive behavioral therapy, and pain management strategies, patients can also utilize non-medical approaches. A pharmacist and an interprofessional team should be indispensable for the education and medication programs applied to highly complex elderly cases.

Conclusion

In summation, polypharmacy, dominated pharmacokinetics, deadly drug interactions, and incompatibilities in prescriptive drugs have profound effects on the health of our geriatric patients. Careful medication reconciliation, lab-prescribing drugs for patient profiles, controlled doses, monitoring drug levels, patient counseling, and non-pharmacological therapies are crucial to enhance the outcomes of this population. The intervention emphasizes collaboration among all the healthcare teams to avoid pharmacologic management, which is usually the primary cause of problems among elderly patients like Mrs. A.

REFERENCES

Colalillo, E. A., Rogu, P. J., Wierzbicki, J., & Colalillo, E. (2023). Recurrent Mental Status Changes in a Patient With Chronic Alcoholic Cirrhosis Taking Diuretics: A Case Report. Cureus15(11).

Freo, U., Ruocco, C., Valerio, A., Scagnol, I., & Nisoli, E. (2021). Paracetamol: A review of guideline recommendations. Journal of clinical medicine10(15), 3420.

Knox, E. G., Aburto, M. R., Clarke, G., Cryan, J. F., & O’Driscoll, C. M. (2022). The blood-brain barrier in aging and neurodegeneration. Molecular psychiatry, 27(6), 2659-2673.

Nadeau, S. E., & Lawhern, R. A. (2022). Management of chronic non-cancer pain: a framework. Pain Management12(6), 751-777.

 

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