Geriatric Prescribingand

Medication Reductionin the Elderly

G EO R G E W. B R E T T M D

C H I E F M E D I C A L O F F I C E R

C A P STO N E P E R FO R M A N C E SYST E M S

Dr. Brett is Chief Medical Officer for Capstone Performance Systems providing expert Medicare Risk Adjustment Services to PACE and similar organizations.

Dr. Brett serves as Vice-Chair of the Clinical Advisory Committee for CareKinesis – a PACE-centric medication management and distribution pharmacy.

Capstone Performance Systems and Carekinesis are members of Tabula Rasa HealthCare.

Disclosures

Understand the Seriousness of Polypharmacy in Frail Elderly

Understand the cause of Adverse Drug Events (ADE’s)

Learn about strategies to minimize number of medications being taken by the elderly.

Purpose of this Session

5

Joyce Hesselberth New York TImes

“All substances are poisons; there is none which is not a

poison. The right dose differentiates a

poison from a remedy.”

Paracelsus

(1493-1541)

Occupation: alchemist, physician,

astrologer, and general occultist

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“The administration of more medicines than are clinically indicated, representing unnecessary drug use”

(Montamat 2004)

Often Defined as using > 5 Medications.

Polypharmacy: A Serious Threat to the Elderly

Prevalence of PolypharmacyDefined as > 5 prescription Medications

2000: 8.2%

2006 Medicare Part D

2012: 15%

Biggest Increase: Antihyperlipidemics, Antidepressants, PPI’s, and Muscle Relaxants.

JAMA. 2015;314(17):1818-1830

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Polypharmacy doesn’t start and end with your Prescriptions

42% of Patients don’t tell the Provider about the Complementary and

Alternative Medicines they were using (CAM)

JAMA Intern Med. 2016;176(4):545-546

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My Pet Peeve….

Where was it written

That when a person turns 65 years old

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My Pet Peeve….

Where was it written

That when a person turns 65 years old

That what arrives in the mail

Is their Medicare Card

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My Pet Peeve….

Where was it written

That when a person turns 65 years old

That what arrives in the mail

Is their Medicare Card

And

Their First Prescription for Omeprazole?

13

Chronic Use of PPI’s isassociated with

1. Osteoporosis

2. Hip Fractures

3. Clostridia Dificile Colitis

4. Community Acquired Pneumonia

5. Dementia1. Based on mouse studies, reason felt to be an increase

in Beta Amyloid in the Brain

14

JAMA Neurol. 2016;73(4):410-416

PRACTICAL: More Drugs = higher costs = Risk of outspending the Part D Bid

QUALITY: Maintaining compliance with CMS Prescription Drug Benefit Manual:

Chapter 9 – Part D Program to Control Fraud Waste and Abuse

PATIENT CARE: More Drugs = Adverse Drug Events

Polypharmacy…. What’s the big deal?

Scope of Polypharmacy

40% of Community Dwelling elders take 4-9 medications per day

20% of Community Dwelling elders take 10 or more medications per day.

Older adults are seven times more likely to have a hospitalization for a adverse drug event than younger persons

NEJM; 365:2002-12

Scope of Polypharmacy

• Sheer number of medications being taken“Shock and Awe”

• Drug – Drug Interactions

• Medication Adherence

• Cost to Participant.Co-PaysCoverage Gap: Refills fall off at the end of the year.(Not an issue for PACE Participants)

Coumadin 9mg dailySynthroid 88 mcg dailyMiralax 17 gms dailyBeano 5 tabl po TIDKCL 20 meq TIDMag Oxide 400 BIDFloranex 1 tab QIDFlomax 0.4 BIDProscar 5 mg dailyArmodafinil 300 dailySenna 2 tablet dailyMiacalcin I spray dailyNorco 5/300 q 4 hr prnVoltaren Gel 1% QID

Protonix 40 mg dailyReglan 10 dailLactase 3 tab TIDAndrogel 1 pakt topically dailyZetia 10mg dailyCardizem 300mg dailyAtenolol 25 mg dailyOscal w D 1000 dailyAlphagan 0,1% 1 gtt BIDAtorvastatin 40mg dailySingulair 10mg HSDuoNebs inhaled QIDColace 200 mg BIDHumalog SQ TIDLevemir SQ BIDZofran 4 mg q4 hr prn

“Shock and Awe”78 yr old man admitted to our local Nursing Home 4/18/2014

Adverse Drug Events (ADE’s)

Any new symptom or sign

in the elderly,

should be considered to be a Adverse Drug Reaction

until proven otherwise

BMJ 1997; 315: 1096-99

Adverse Drug Events

RISK OF ADVERSE DRUG EVENTS:

◦2 Medications: 13%

◦5 Medications: 58%

◦7 or more Medications 82%

Interventions to Improve the Appropriate Use of Polypharmacy for Older People

The Cochrane Library 2012 Issue 5

In-Patient Care Setting:◦ Affects 2,000,000 hospitalizations a year

◦ Increases Length of Stay by 1.7 – 4.6 days

◦ Quality of life during that hospital stay?

Out-Patient Care Setting:◦ Causes over 3,500,000 Office Visits

◦ Causes 1,000,000 Emergency Room Visits (Underestimate)

◦ Causes 125,000 Hospital Admissionshttp://health.gov/hai/ade.asp

Impact of Adverse Drug Events

During the 45 Day Post Discharge Window◦ Adverse Drug events (ADEs) occurred frequently

◦ More than half occurred within 14 days

◦ ADE’s occurred in ONE IN FIVE Discharges

◦ One Third of the ADE’s were preventable

◦ The more severe events were the most preventable

◦ Only a “small portion” of the identified ADE’s were the result of medications on the Beer’s List

JAGS 61: 1894-99, Nov 2013

Post-Hospitalization and ADE’s

“Start Low, Go Slow”

“My Clinical Experience”

Drug - Drug Interaction Tables

Beers Criteria, (and presumably STOPP)

“ADEs are common and often preventable in older adults…Beers criteria medications play a small role in these events, suggesting that efforts to improve quality and safety of medication use…must extend beyond a singular focus on Beers criteria medications.”

Kanaan et. al: J Am Geriatric Society 61:1894 – 1899, Nov 2013

Current Tools to Avert ADE’sDon’t Work

Problems with PHARMACOKINETICS:

What your body does to the drug

Problems with PHARMACODYNAMICS:

What the drug does to your body

Problems with ALLERGIES

Cause of Adverse Drug Events

Problems Arising from Problems with Pharmacokinetics

Nearly half of hospitalizations for ADE’s involved adults ≥80 years of age, which was 3.5 times as high as adults 65-69 years of age…“Two Thirds of these hospitalizations were due to Unintentional Overdoses.”

Budnitz DS et al. Emergency Hospitalizations for ADE’s in

Older Americans. NEJM 2011; 365: 2002-12

Adverse Drug Reactions

Participant Adherence? Perhaps to some degree

Pharmacokinetics“What your body does to a drug.”

Whole purpose of “drug metabolism” is to water-solubilize the drug so it can be excreted

Why Unintentional Overdoses?

Medication Changes and Adverse Drug Events: Patient Errors

•Patient Related Errors leading to ADE’s

•Cohort study of over 30,000 Medicare enrollees.

•Reasons for Adverse Drug Reactions•Modifying the Medication Regimen: 41.9%• Administering the medication (31.8%)

• Failure to follow clinical advice re: medication use: 21.7%

J. Am Geriatric Soc 2007:55:271-276

Participant Adherence?

Perhaps to some degree

Pharmacokinetics“What your body does to a drug.”

Whole purpose of “drug metabolism” is to water-solubilize the drug so it can be excreted

Why Unintentional Overdoses?

Pharmacogenomics:

Are the Drug Metabolizing genes from Parents functional? Nonfunctional?

Competitive Inhibition:

Genes are functional, but multiple drugs are vying for it simultaneously

Up/Down Regulation:

Gene is functional, but another drug is inducing more gene to be produced or inhibiting its use

Impaired Renal Function

Pharmacokinetics and Unintentional Overdoses leading to ADR’s

Pharmacogenomics

Currently, there are 58 known Cytochrome P-450 enzymes (CYP’s) that are known to metabolize drugs.

Only a handful are clinically significant

60-70% of Drugs are metabolized by◦ CYP2C9, CYP2C19, CYP2D6, and CYP3A4

That is fine if the CYP’s are functioning….but what if there are mutations to these enzymes that are responsible for eliminating drugs from the body?

As with all proteins (enzymes) DNA codes for the production of all the CYP’s.

Most frequent error events are Single Nucleotide Polymorphisms (“SNP’s”).

These SNP’s can lead 3 Metabolic Phenotypes◦ Poor Metabolizers◦ Extensive (Normal) Metabolizers◦ Ultra-Rapid Metabolizers

Inheriting two SNPs that code for fast metabolism of CYP3A4 can lead to devastating consequences when taking codeine which would then be highly converted to morphine

Pharmacogenomics

30% of the population have mutations of the genes that code for CYP2C19 making them poor/slow metabolizers

Clopidogrel needs CYP2C19 to be converted to its active form

Therefore 30% of your participants receiving Clopidogrelare not benefiting from its effects?

If you don’t test, how are you to know?

Pharmacogenomics:

Each Drug needs one CYP to be metabolized.

What if Multiple Drugs taken at the same time are metabolized by the same CYP? Which one gets metabolized? Which one “wins?”

The drug with the highest Affinity Coefficient for the CYP.

Other Meds are left behind Toxic Levels ADE’s

Competitive Inhibition

Isoenzyme conceptCYP Substrates Inhibitors Inducers

1A2 Theophylline, caffeine, imipramine, mexiletine

Quinolones Cigarette smoking

2A6 Coumarin, nicotine Diethyldithiocar-bamate

2C9 NSAID, losartan, irbesartan, S-warfarin, celecoxib

Sulfaphenazole Rifampin

2C19 Omeprazole, R-warfarin

2D6 Codein, antiarrhythmics, b-blockers, anti-H1, SSRI

Quinidine

2E1 Alcohol, chlorzoxazone Alcohol

3A4 CCB, anti-H1 2nd, BZD, cyclosporin, HMG CoA

Macrolides, imidazoles

Rifampin, phenytoin

Affinity conceptCYP3A4

Inhibitors Substrates Inducers

DRUG – DRUG INTERACTIONS

Greater than 80% of Drug - Drug Interactions involve the Cytochrome P-450 System (CYP)

Analysis based on multiple 2x2 Comparisons is obsolete and often inappropriate

There are now software/tools developed to predict the correct dose to start at in a Poly-Medicated Participant

How Prescribing is EvolvingPreference Precision

Preference Based Era Evidenced-Based Era Precision Based Era

The Clinician’s Best Insight

The Clinician’s Best Insight

Population-basedAlgorithms.

Clinical Trials in Selected Cohorts

The Clinician’s Best Insight

Population-based Algorithms

AndIndividualized

Genomic information

andPatient - Specific

Criteria

Drugs’ Anticholinergic Burden

is

A Huge Risk to the Elderly

And these drugs are EVERYWHERE including OTC’S

Pharmacodynamics and ADE’s

Falls

Delirium

Drowsiness, Dizziness

Cognitive Impairment

Impulsive behavior

Constipation

Urinary Retention

Tachycardia, arrhythmias, increased angina

Decreased sweating – Hyperthermia

Mydriasis – Vision blurs leading to falls

Dry Eyes

Dry Mouth – Dental issues, teeth extraction

Tremors

Anticholinergic Effects of Medications

There is less Acetylcholine in the brain with aging

Poorer Drug Metabolism

Increased Permeability of the Blood Brain Barrier

Older Participants More Sensitive to Anticholinergic Effects

AGE (years) PREVALENCE

60 – 75 27%

≥ 75 90%

Drugs Aging 2013; 30: 321-330

Anticholinergic drugs are given to those who are most sensitive

to their adverse effect

Developed by Dr. Malaz Boustani, Indiana University for Aging Research ◦ 0 = No Anticholinergic Burden◦ 1 = Mild Anticholinergic Burden (e.g. Atenolol, Furosemide)◦ 2 = Moderate Anticholinergic Burden (e.g. Carbamazepine)◦ 3 = Severe Anticholinergic Burden (e.g. Amitriptyline, Quetiapine)

Score of 2: “Clinical Anticholinergic Effect” (e.g. Delirium)

Score of ≥3: “Clinically Impactful” (e.g. falls)

The effect of each drug’s ACB is CUMULATIVE

The higher the ACB score, the higher the adverse events.

Aging Health. 2008;4(3):311-20

Anticholinergic Cognitive Burden Scale (ACB)

Anticholinergics andCommunity Acquired Pneumonia

Population Based Study.

Age: 65 – 94

1,039 Cases of Pneumonia◦ 59% Occurred with Acute Use (Rx within 90 days of event)◦ 35% Controls

◦ 53% Occurred with Chronic Use (3 or more Rx within year)◦ 36% Controls

J Am Geriatr Soc. 2015 Mar;63(3):476-85.

Retrospective Cohort Study (Australian VA)

Admissions for Confusion◦ Drugs included if ACB ≥2◦ Excluded those with known dementia

If on two Anticholinergic Medications ◦ Adjusted Incident Rate Ratios(IRRs) 2.58

If on three or more Anticholinergics◦ Adjusted Incident Rate Ratios (IRRs): 3.98

Anticholinergics and Hospital Admissions for Confusion or Dementia

JAGS 62:1916 – 22, 2014

“Cumulative Use of Strong Anticholinergics and Incident Dementia”

Participants >65 years of age on anticholinergics

Mean follow-up was 7.3 years

23.2% developed dementia (79.9% was Alzheimer’s)

The higher the anticholinergic exposure the higher the risk◦ (Total Standardized Daily Dose “TSDD”)

JAMA Intern Med. 2015;175(3):401-407.

Anticholinergics NowAssociated With Dementia

Scope of Polypharmacy

• Potentially Inappropriate Medications

Beer’s Criteria Potentially Inappropriate Medications in Elderly

• Potentially Inappropriate medications because of• Drug-Disease interaction

• Drug –Syndrome interaction

• Leads to exacerbation of Disease or Syndrome

• Potentially Inappropriate Medications to be used with caution in the elderly

Scope of Polypharmacy

“Under-prescribing”◦ Participant who has polypharmacy is less likely to be prescribed a

much needed medication than participant taking 4 or less medications

Drugs Inhibiting other Drug’s Activation.◦ Different form of “Drug-Drug Interaction◦ Omeprazole and Clopidogrel

◦ Inhibition of CYP2C19 prevents Clopidogrel from being converted to its active form

◦ Paroxetine/Fluoxetine and Tamoxifen◦ Inhibition of CYP2D6 prevents Tamoxifen from being converted to its active

form, Endoxifen

Polypharmacy and Underprescribing

The more drugs a participant takes, the more likely an indicated prescription will not be prescribed

Br J Clin Pharmacol. 2008 Jan; 65(1): 130–133

Polypharmacy and Risk of30 Day Hospital Readmission

JAMDA 2013, Vol14. No 10; p761-67

What I’m saying is

We prescribe with precious little information about what is going to happen to that medication (pharmacogenomics, competitive

inhibition, pharmacodynamics issues)

andits effect after mixing with, on average, 10 other medications that

the PACE participant takes….

When we write prescriptions, do we really know what we are

doing?

Prescribing in the ElderlyUnique Challenges:

◦Pre-marketing drug trials exclude elderly participants

◦Approved doses may not be appropriate for the elderly.◦ Special Pharmacokinetics:◦ Absorption, Distribution, Metabolism, Excretion

◦ Special Pharmacodynamics:◦ Physiologic Effects of the Drug

◦ Fraility:◦ What percent of participants have normal albumin?

“People in Clinical Trials don’t look like people

who take drugs”

Quote: Jerry Avorn, MD

Cerreta F et al. N Engl J Med 2012;367:1972-1974.

Polypharmacy: Who cares?

Medicare Part D: Fraud Waste and Abuse

Cost: PACE is a Medicare Part D Plan◦ Capitated payment through a “bid” process◦ PACE is therefore at risk for drug expenditures

Participant Adherence: Drug Misadventures◦ The more medications…◦ The more Different Schedules…◦ Equals the more mistakes in dosing◦ If a lower dose of med isn’t working, is it because a higher

dose is needed, OR because the participant was not taking it?

Etiology of Polypharmacy

Fear of Discontinuing Medications

Medications added to treat acute illness during hospitalization Continued upon discharge Not needed, or not needed in as high a dose Hospital Formulary Switches over home meds.

Care Delivery by Multiple Physicians Participant bounces from specialist to specialist each adding their specific Rx to the mix Each Specialist adding meds per their Clinical Practice Guidelines

Transitional Care: Poor Medication Reconciliation Major reason for 30 Day Readmission Rates

Etiology of Polypharmacy

Medication Prescribing CascadeNew drug prescribed to treat old drug’s side effects

Sharing of Medications and DiversionNo “short fills” for Narcotics

Use of Over the Counter Medications

Adherence to multiple Clinical Practice Guidelines

Prescribing Cascade

UpToDate

Etiology of Polypharmacy

Fear of discontinuing Medications◦ Physicians love to prescribe medications, hate to

discontinue medications◦ Wasn’t a good “Doctor Visit” if they left without a new Script!

◦ Lack of information as to why it was prescribed◦ “There must have been a good reason to Rx it.”

◦ Belief that the condition for which it was prescribed still exists today.◦ PPI’s for GERD or PUD

◦ Atypical Antipsychotics for dementia related behaviors

Etiology of Polypharmacy

Fear of discontinuing Medications ◦ Belief that discontinuing a medications will lead to

catastrophic events◦ Stopping isosorbide will cause an acute MI

◦ Stopping furosemide will lead to flash pulmonary edema.

◦ Participant who has donepazil restarted will not return to the functional level achieved before discontinuation.

◦ It was prescribed by a “specialist” who is “THE EXPERT” in the treatment of given disease entity.

Useful Tools to Potentially Identify Inappropriate Medications:

1. Beers Criteria

2. NCQA/HEDIS High Risk Medications

3. START/STOPP Criteria

Beers Criteria

Initially published in Archives Int. Medicine in 1991 by Mark Beers MD et al.

List of inappropriate medications in the Nursing Home Population (initially)

◦ Use for Quality Assurance Review

◦ Health Services Research

◦ Clinical Practice Guideline development

In 2011, AGS assumed responsibility for updating and revising Beers Criteria

Revised in 1997, 2003, 2012, and November 2015

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Beer’s Criteria 2015

1. Drugs that are Potentially Inappropriate

2. Drugs that are Potentially Inappropriate 1. Drug/Disease Interaction

2. Drug/Syndrome Interaction

3. Drug/Drug Interaction (new in 2015)

3. Drugs that should be used with Caution

4. Drugs whose dosage should be modified in the presence of renal impairment (new 2015)

JAGS 63:2227-2246

New to Beers 2015: Drug-Drug Interactions

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New to Beers:Dosage Adjustment in Renal Impairment

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Sample: Beers Criteria 2015

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START STOPPAge and Ageing 2007; 36:632-638

Int.J Clin Pharmacol Ther 2008;46 (2):72-83

START:◦Screening Tool to Alert doctors to the Right

Treatment

STOPP:◦ Screening Tool of Older Persons Potentially

Inappropriate Prescriptions

START/STOPPMore recent than the Beer’s Criteria

Organized by physiologic systems

References the following:◦ Drug – Class Duplication◦ Drug-Drug Interactions◦ Drug-Disease Interactions

Addresses Under-treatment of the elderly

START (n = 22)

STOPP (n = 65)

Stopping Medications “Comission versus Omission?”

If a Provider can prescribe a medication to treat a condition not fearing a possible adverse drug event, (e.g. a rash), knowing they will discontinue the medication should it occur…..

Why then….does a prescriber fear stopping medications (e.g. digoxin) when a frail elderly participant is having anorexia and weight loss over concerns of precipitating CHF or rapid Atrial Fibrillation knowing to restart if symptoms develop?

Risk of Discontinuing Medications.

Broad based studies on the subject are limited

26% of drug discontinuation resulted in worsening of the underlying disease state◦ Recurrence of angina◦ Re-elevation of blood pressure

4% were associated with withdrawal reaction◦ Beta-Blockers◦ Benzodiazepams

Arch. Int. Med 1997: 157:2205-2210

Discontinuing Medications

Tapering of medication preferable

Exceptions include◦ Dangerous signs or symptoms attributable to drug

◦ Clinical Inertia in the participant

◦ Future opportunities for drug modification limited

Rule of thumb:◦ Drugs can be tapered at the same rate at which they were

titrated up upon initiation.

Discontinuing Medications

Common Drugs Requiring Tapering◦ Opioids

◦ Beta-Blockers

◦ Clonidine

◦ Gabapentin

◦ Serotonin Uptake Inhibitors

◦ Serotonin-Norepinephrine Uptake Inhibitors

◦ Tricyclic Antidepressants

Strategies for Medication Reduction

Take time at Reassessment for critical review of all medications

Ask the participant if he/she would like their medication burden decreased.◦ Ask the participants if they feel they are taking too much medication.◦ You may be surprised!! Not everyone is in love with their medications

Be positive: Let the participant know that medication reduction will likely make them feel better

Reassure that you are looking out for exacerbation of symptoms and that the medication will be restarted in necessary

Strategies for Medication Reduction

What is the participant’s prognosis?

Is the medication really in keeping with the participant’s Goals of Care?◦ Is Medication burden an issue for someone in the functional or

palliative pathway.

◦ Is the medication appropriate given the participant’s overall prognosis?

Is the medication’s “time to benefit” such that it is unlikely to help a participant with perhaps limited life expectancy?

Strategies for Medication ReductionCheck for evidence of adherence. If not being used, why prescribe the medication?

◦ Are there several Salmeterol/Fluticasone (“Advair”) inhalers unused in the house?

◦ Are the number of pills remaining in the vials matching the refill date?

◦ Does the participant admit to not taking certain meds?

◦ For those participants on narcotics, has a random urine drug screen been done to rule out diversion?

78 y.o. Caucasian female admitted to the ACME PACE Program. She lives alone in a low income senior housing. She smoked 1 PPD for 40 years. She gets Meals on Wheels, and needs assistance with bathing and cueing for dressing. She walks with a walker and has occasional falls. Daughter comes by to check on her and pay her bills and take her shopping.

PMH: T.I.A. 2005, COPD, Diabetes Mellitus with neuropathy and occasional falls, Peripheral Arterial Disease, Venous Insufficiency, Hypertension, Major Depression with anxiety neurosis, and remote history of an M.I. She has mild dementia. She has incontinence and wears briefs.

She is in the Functional Pathway

Case Study

Vitals: BP=115/72: Pulse 52: RR=18:Temp 98.4: Wt. 108 lbs.

BMI: 18.9

General: Thin, frail and slightly disheveled in appearance.

HEENT negative. Carotids with soft bruits.

Chest with diminished breath sounds, but no wheezing or rhonchi. FVC normal. Cor: RRR without murmurs. Abdomen without masses. Ext +2 Edema. Absent peripheral pulses.

Neuro: diminished monofilament testing and positive Rhomberg.

She was oriented to person but not place nor time and exhibited recent memory impairment.

Case StudyExam

Hgb/Hct: 11.5/34%, WBC = 8,800, Plts = 230k

BUN/Creat = 36/1.3: Na+ = 130

GFR(Cockcroft-Gault) = 31ml/min

Hemoglobin A-1c = 7.1

LDL Cholesterol = 68

ALT = 65

AST = 38

Alk. Phos. = 101

Case StudyLaboratory Studies

1. Lisinopril 10 mg po daily

2. Amlodipine 5 mg po daily

3. Glyburide 5 mg po BID

4. Metoprolol 25 mg po BID

5. Metformin 500 mg po BID

6. Pregabalin 50 mg po BID

7. Aspirin 81 mg po daily

8. Lasix 20 mg po daily

9. Gabapentin 300 mg po QID

10. Timoptic ophth. drops

11. Fluticasone/Salmeterol 100/50: one puff BID

12. Clopidogrel 75 mg po daily

13. Donepezil 10mg po daily

14. Oxybutinin 5mg BID

15. Lorazepam 0.5 mg po TID

16. Spiriva DPI 18 mcg daily

17. Albuterol MDI Rescue inhaler

18. Nortriptyline 75 mg po daily

19. Lantus 10 units daily

20. Citalopram 10mg po daily

Case Study: Medications

•Does she need Lantus? Only 10 units a day?

•Should she be on Metformin? Has Stage IIIb CKD

•Does she need to be on Amlodipine? 1. Maximize one or the other antihypertensive meds2. Here, with DM and CKD, would maximize the ACEI

3. What is the target BP? Her BP is low and she is falling.

•Does she need both Gabapentin and Pregabalin?• How do you really know either is working?

•What is the Nortriptyline prescribed for? 1. Anticholinergic and has dementia2. Anticholinergic and incontinent despite the Rx3. If for neuropathy, already on 2 other meds for same.

Case Study Comments

•She is already incontinent but using Depends. • Is the Oxybutinin effective? Could dose be decreased?• Is her incontinence that much worse off the medication?• She is already demented!• What’s it doing to olfaction and importantly gustation? (Malnutrition?!?)

•Reason for Furosemide?• No history of CHF.• Not indicated for treating venous insufficiency

•Is Fluticasone needed with Salmeterol?• Already on Tiotropium. • Can she use the DPI correctly? Did anyone observe?

•What is the rationale for both ASA & Clopidogrel?• Even if “indicated.” She is falling. Risk for hemorrhage?

Case Study Comments

•Is there a need for Donepezil?• Did the family note improvement in cognition when it was started?

• She is possibly malnourished. Is it contributing to nausea/anorexia?

•Why on Glyburide?• GHB is 7.1. NPA Model Practice for DM would suggest maintaining

between 8-9.

• It is contraindicated in CKD

• Glipizide dose adjusted is more appropriate if needed.

•Does she need Lorazepam 0.5mg TID?• Can it be made prn? Can the dose be gradually reduced.

• She has history of falls.

Case Study Comments

Can the Metoprolol be weaned or dose reduced?◦ Resting pulse is 52.

◦ If for angina, has she been symptomatic? Is she active enough to get angina?

◦ If for BP, then, again, what is the target BP in this case?

◦ Also receiving Timoptic Ophthalmic drops = Beta Blocker as well

History of Depression on Citalopram.◦ Has she ever stopped taking her medication?

◦ Has a previous provider ever attempted to wean her off?

Case Study Comments

Participant Adherence:

Do we have any idea if she is taking her medications,

If so, is she taking them correctly?

Is she missing any doses?

Is she taking extra doses forgetting she already took her dose for the day?

Case Study Comments

96