Amber D. is a 76-year-old African American female living with her children in the suburbs. The patient has a history of two infarctions, and her primary diagnoses are congestive heart failure, hypertension, osteoarthritis, and hyperlipidemia. She has no recorded history of medication allergies. She takes:
- Metoprolol Succinate (50 mg) by mouth once a day after a meal;
- Omeprazole (20 mg) by mouth once a day after a meal;
- Lisinopril (suspension 10 mg) by mouth once a day in the morning;
- Furosemide (40 mg) by mouth after breakfast;
- Aspirin (325 mg) by mouth twice a day;
- Acetaminophen (50 mg) twice a day in chewing tablets;
- Tramadol (50 mg) by mouth in case of severe pain;
- Atorvastatin Calcium (20 mg) once a day orally with food;
- Potassium chloride (20 mEq) by mouth twice a day;
- Multivitamin orally once a day.
Geriatric patients experience age-related changes in pharmacokinetics and pharmacodynamics. In particular, patients may experience changes in absorption, distribution, metabolism, and excretion (Höchel, 2019). When speaking about absorption, age-related changes are associated with decreased first-pass metabolism, which has a significant effect on high extraction drugs (Sera & Uritsky, 2016). Such changes call for decreased doses of high extraction drugs to decrease the chances of possible adverse effects (Sera & Uritsky, 2016). At the same time, older adults have decreased blood albumin concentration, which calls for adjusting doses of highly
protein-bound high extraction drugs (Sera & Uritsky, 2016). Additionally, older adults have decreased the clearance of drugs excreted by the kidneys, which means that care providers should decrease the doses or frequency of renally excreted drugs (Sera & Uritsky, 2016). In short, care providers should take into consideration age-related changes as they may significantly impact the occurrence of side effects.
Beers Criteria Application
American Geriatric Society (AGS) created an explicit list of medications that should be avoided by older patients generally or under certain circumstances. This list is commonly called AGS Beers Criteria. When applying this list to Amber D’s case, there are at least two changes that should be made based on the latest updates from AGS. First, the administration of aspirin in doses higher than 325 mg a day is associated with gastrointestinal bleeding or peptic ulcer disease in patients aged 75 and older (AGS, 2019). Additionally, aspirin as a method for primary prevention of cardiovascular diseases should be used with caution (AGS, 2019). Thus, I would recommend dismissing aspirin and replacing it with close blood pressure control as a primary prevention method for the patient. Second, I would recommend avoiding Tramadol, as it is associated with an increased risk of hyponatremia in older adults (American Academy of Family Physicians, 2020). At the same time, opioids increase the chance of severe respiratory depression (American Academy of Family Physicians, 2020). There, I would recommend replacing it with non-steroidal anti-inflammatory drugs (NSAIDs) (Ali et al., 2018).
Apart from conventional treatment, there is complementary and alternative medicine (CAM) that can be used to improve patient outcomes. As an NP, I have two major CAM regulation problems that I need to overcome. First, I am not sure about when CAM is appropriate for geriatric patients. I am not sure when it is ethical to offer CAM to patients and when such treatment can actually help. Second, I am unaware of collaboration mechanisms with CAM providers. For instance, I am not sure how to find a suitable manual therapist to lower back pain.
At the same time, I will need to assess medication reconciliation to avoid errors, such as duplicating, incorrect dosing, or drug interaction problems. According to Fink (2018), there are various strategies for medication reconciliation, including collaboration with pharmacists, working with IT to create technological solutions, or conducting focused conversations with patients. Since I have gained much experience in research, I think that the best strategy to assess medication reconciliation is to review the latest evidence and best practices. This strategy will help me adhere to the principles of evidence-based care.
Ali, A., Arif, A., Bhan, C., Kumar, D., Malik, M., & Sayyed, Z. (2018). Managing chronic pain in the elderly: An overview of the recent therapeutic advancements. Cureus.
American Academy of Family Physicians. (2020). Beers criteria for inappropriate medication use in older patients: An update from the AGS. American Family Physician, 101(1), 56-57.
American Geriatrics Society. (2019). Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. QIO Program. Web.
Fink, J. (2018). 7 strategies to improve medication reconciliation. MedScape.
Höchel, J. (2019). Does everything get slower with age? Pharmacokinetics in the elderly. Drug Research, 69(S 01), S7-S8.
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.