Case Study 1 Advanced Pharmacology solution – Mrs. A is a 71 year old widow

Mrs. A is a 71 year old widow with CHF and osteoarthritis who has recently been exhibiting quite unusual behavior. Her daughter is concerned about her mother’s ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a dementing illness. Over the last two to three months Mrs. A has become confused, easily fatigued and very irritable. She has developed disturbing obsessive/compulsive behavior constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly moldy. Her prescribed medications are:(Advanced pharmacology case study sample)

• Furosemide 40 mg daily in the morning
• Digoxin 250 micrograms daily
• Paracetamol 500 mg, 1-2 tablets 4-hourly PRN
• Piroxicam 20 mg at night
• Mylanta suspension, 20 ml PRN
• Coloxyl 120 mg, 1-2 tablets at night

Assignment Questions and Instructions

1. Critically discuss this case study in terms of the problematic nature of this patient’s pharmacological management.
2. Outline some pharmacokinetic changes in the geriatric population that may affect drug disposition.
3. Outline how changes in renal and hepatic function may affect treatment strategies.
4. In the drug regimen presented above – discuss potential side effects and potential interactions, if any?
5. Your response should include a discussion of the problems of polypharmacy as it is related to this case study and the assessment/management and educational strategies which could have been implemented to improve the outcome of Mrs. A.

Instructions

• Prepare and submit a 3-4 page paper [total] in length (not including APA formatted title and references pages).
• Answer all the questions above.
• Support your position with examples.

Advanced pharmacology case study sample

The World Health Organization (WHO) estimates that one in every nine adults is aged 60 years or more. By 2050, this proportion is projected to increase to one in every five people accounting for approximately 50% of the total growth in the world population (Gagli & Sharma, 2014). The two researchers further note that the aforementioned demographic transition presents a significant challenge for healthcare systems since elderly age is significantly associated with multiple chronic diseases ranging from heart disease, diabetes, arthritis, amongst others(Advanced pharmacology case study sample). Subsequently, the elderly population is related to taking several medications, usually daily, commonly called polypharmacy (Nguyen et al., 2020). Suffice it to say that this may lead to unnecessary drug use and accompanying side effects. As such, it is imperative the problems of polypharmacy(Advanced pharmacology case study sample). To achieve the objective, the paper utilizes the selected case study of Mrs A, a 71-year-old woman diagnosed with congestive heart failure (CHF) and osteoarthritis and, of late exciting, unusual behavior indicative of the development of a dementing illness. The patient has six prescribed medications, namely Furosemide 40mg daily, Digoxin 250 micrograms daily, Paracetamol 500mg, where she takes 1 or 2 tablets four hours, and Mylanta suspension 20ml on a pro re nata(PRN) basis as the need arises. Additionally, Mrs. A also has to take Piroxicam 20mg and Coloxyl 120 mg at night. (Advanced pharmacology case study sample)

Problematic Nature of Mrs. A’s Pharmacological Management

Healthcare experts acknowledge that polypharmacy is associated with functional decline, with study findings demonstrating that increased prescription medication is linked to decreased physical functioning and decreased ability to perform instrumental activities of daily living (ADLs). The clinician offering care to geriatric patients on polypharmacy should take caution as multiple drugs are required to treat the various diseases prevalent in common with advancing age, which in Mrs. A’s case is CHF and osteoarthritis and the emerging of dementia over the last two months(Advanced pharmacology case study sample). Take, for example, the Furosemide, a water pill, or type of diuretic used to manage fluid retention (edema and swelling emanating from CHF). It improves renal functions by getting rid of unwanted water and salt, making it easier for blood flow. However, if the patient develops other age-related kidney problems, the Furosemide dosage lower than 80 mg would be ineffective in the CKD becomes advanced. While Digoxin 250 micrograms taken daily may help treat CHF and improve the patient’s quality of life by decreasing its symptoms and preventing hospitalizations, there is a need for the provider to frequently evaluate the patient’s digoxin, potassium and magnesium levels(Advanced pharmacology case study sample). The two drugs used to relieve the pain, namely paracetamol to relief pain and Piroxicam as a non-steroidal anti-inflammatory drug (NSAID), mean the latter can be used for osteoarthritis, reduce the swelling, and treat pain. The use of Mylanta suspension 20 ml though PRN could be the case of a prescribing cascade whereby the signs and symptoms of an adverse drug reaction are misinterpreted to be a disease leading to a new treatment. Finally, coloxy 120 mg tablets swallowed at night would help prevent constipation by drawing water into the stool. The clinician is required to exercise caution when deprescribing unnecessary medication to limit polypharmacy. To prevent polypharmacy, medication reconciliation at the patient’s care transition, eliminate duplicate medication, and asses for drug-drug interactions. Initiating patient education strategies on polypharmacy would ensure patient safety, decrease hospitalizations, and lower healthcare costs.(Advanced pharmacology case study sample)

Pharmacokinetic Changes in the Geriatric Population That May Affect Drug Disposition

Advancing age is associated with functional impairment of many regulatory processes that offer functional integration between cells and organs. One key feature is the inability to maintain homeostasis under physiological stress conditions. Most importantly, critical pharmacokinetic and pharmacodynamics changes occur with advancing ageas kidney and liver clearance. Similarly, there is an increase in the volume of distribution of lipid-soluble medications leading to an extension of elimination half-life. At the pharmacodynamics level, alterations include increased sensitivity to several drugs like anticoagulants, cardiovascular and psychotropic medications (Sera & Uritsky, 2016). For example, cardiovascular changes include decreased elasticity of the main blood vessels. Similarly, renal mass decreases with age, while intra- renal vascular alterations occur to the vascular tuft’s hyalinization, resulting in decreased blood flow. Lastly, aging is accompanied by neuroendocrine response alterations that lead to psychosocial and physical stress.(Advanced pharmacology case study sample)

How Changes in Renal and Hepatic Function May Affect Treatment Strategies

Tan et al. (2015) observe that age-related changes in the liver are marked by a decrease in the organ’s volume spanning between 20% and 40% during an adults’ lifespan. This means there is a link between advancing age and declining drug clearance. Subsequently, the physician has to consider the impact of hepatic changes in bioavailability and hepatic clearance(Advanced pharmacology case study sample). The prescriber should start slow and go slow on Mrs. A, just like in all other non-emergency geriatric patients. Reduced renal function (RRF) results from reduced responsiveness of the renin-angiotensin (RAS), leading to lowered renin release as a response to appropriate stimuli (Chen et al., 2019). RRF significantly impacts the treatment of a geriatric patient since it slows the elimination of renally excreted drugs, leading to increased blood levels and increased risk of ADR, which may or may not go undetected. In the case of Mrs. A, the prescription of NSAIDs and diuretics should be limited as they can reduce renal functions.(Advanced pharmacology case study sample)

Potential Side Effects and Potential Interactions

Although polypharmacy may be required to treat and effectively manage each of the geriatric patient’s presenting symptoms, they can lead to side effects, which include but are not limited to loss of appetite, confusion, weakness, and dizziness. When drug interactions occur, they may change how the patients’ medications work or increase the risk of severe side effects. Specific drug interactions include chest pain and lower back or side pain(Advanced pharmacology case study sample). However, these side effects are rare. On the other hand, digoxin may cause nausea and vomiting, with paracetamol causing a severe allergic reaction. Piroxicam may also cause stomach upsets and Mylanta causing constipation. The patient is, therefore, advised to inform the physician if the reactions become severe. A study conducted by Moore (2015) demonstrated that concomitant use with antihypertensive like Furosemide and NSAIDs like paracetamol had reduced diuretics’ efficacy. This is because NSAIDs administration inhibits renal prostaglandins and increased fluid retention.(Advanced pharmacology case study sample)

In conclusion, it is essential to acknowledge that the evaluation of polypharmacy is a significant concern among geriatrics to avoid all the likely adverse effects. The multidisciplinary healthcare team must conduct a comprehensive medication review and risk assessment to devise ways of reducing polypharmacy and the accompanying side effects. The identification and avoidance of polypharmacy would lead to improved patient outcomes among geriatric populations. It is imperative to understand the impact aging has on clinical pharmacology to enhance quality prescribing. (Advanced pharmacology case study sample)

References

Chen, F., Zuo, Z. L., Huang, F. Y., Xia, T. L., Huang, B. T., Chai, H., & Huang, D. J. (2019). Influence of age on the effect of reduced renal function on outcomes in patients with coronary artery disease. BMC public health, 19(1), 205.(Advanced pharmacology case study sample)

Dagli, R. J., & Sharma, A. (2014). Polypharmacy: a global risk factor for elderly people. Journal of international oral health: JIOH, 6(6), i.

Kaas Oldenburg, L. I., Dalhoff, K. P., Sandoval, L. Ø., & Vermehren, C. (2020). The Risk of Drug-Drug Interactions with Paracetamol in a Population of Hospitalized Geriatric Patients. Journal of Pharmaceutics, 2020.

Moore, N., Pollack, C., & Butkerait, P. (2015). Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Therapeutics and clinical risk management, 11, 1061.(Advanced pharmacology case study sample)

Nguyen, T., Wong, E., & Ciummo, F. (2020). Polypharmacy in Older Adults: Practical Applications Alongside a Patient Case. The Journal for Nurse Practitioners, 16(3), 205-209.

Sera, L., & Uritsky, T. (2016). Pharmacokinetic and pharmacodynamic changes in older adults and implications for palliative care. Progress in Palliative Care, 24(5), 255-261.(Advanced pharmacology case study sample)

Tan, J. L., Eastment, J. G., Poudel, A., & Hubbard, R. E. (2015). Age-related changes in hepatic function: an update on implications for drug therapy. Drugs & aging, 32(12), 999-1008.