Care home resident with multimorbidity including dementia

Background (age, sex, occupation, baseline function)

• 78-year-old woman
• Resident in a care home
• Retired factory worker

History of presentation/reason for review

• Request from care home for medication review
• Due to the quantity of medicines, many in the morning, can often refuse all. For the past few weeks complaining of nausea and has been sick

Current medical history and relevant co-morbidities

• Peripheral oedema/ bilateral cellulitis - started on diuretic, follow up to titrate diuretic dose and check renal function to take place in primary care
• Type 2 diabetes mellitus: new diagnosis six weeks ago during hospital admission
• Fractured humerus - six months ago following a fall
• Mixed Alzheimer’s Disease / vascular dementia - moderately severe
• She does not have capacity to make decisions about her welfare and has a welfare power of attorney in place
  
  • She does not have capacity to make decisions about her welfare and has a welfare power of attorney in place

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drugs reactions (ADRs): nil

Currently prescribed: 

• Furosemide 40mg tablets: two tablets in the morning and one at lunchtime
• Furosemide 40mg if required for oedema - new this cycle as regular dose has been reduced by 40mg this cycle
• Laxido® sachets: one sachet up to twice a day as required
• Lorazepam 500 micrograms tablets: one tablet at teatime and one if required for agitation once a day
• Metformin 500mg tablets: two tablets twice daily - started six weeks ago
• Paracetamol 500mg tablets: two tablets four times daily
• Senna 7.5mg tablets: two tablets at night
• Tramadol 50mg capsules: one or two capsules three times daily

Recent acute medication:

• Fexofenadine 120mg tablets: one tablet daily for itchy rash. Taken three times in last two weeks - legs hot and itchy
• Metoclopramide 10mg tablets: one tablet up to three times daily for nausea two weeks ago - taken regularly three times daily
• Omeprazole 20mg capsules: one capsule daily: started two weeks ago
• Wound management products/ skin emollients

Over the counter medicines: nil

Lifestyle and current function

• Clinical Frailty Score (Rockwood) 7 (living with severe frailty)

From talking to care staff:

• She eats approximately two out of her three meals each day. She does not smoke and drinks rarely - one or two units of alcohol a month
• She has lost 10kg weight over the last six weeks and now weighs 96kg. Much of this has been fluid, as her legs are less swollen now and they are not weeping as much. She drinks plenty
• Her legs are sore much of the time. She will usually take analgesia when offered and can verbalise her pain
• She has had an injurious fall at least once in the past, but none in the care home
• Independent with a walking aid, but is slow due to the bandaging on her legs

“What matters to me” (ideas, concerns and expectations of treatment)

• She said her legs were sometimes sore and itchy and feel heavy and painful
• She feels sick a lot of the time

From talking to care staff:

• She has no problems swallowing food or drink. She likes paracetamol tablets halved but they stick in her throat. When given large tablets she chews these rather than swallowing them whole. This seems to be due to her dementia rather than due to her swallow
• Chewing medication seems to make her feel sick, and the number of tablets compounds this
• She refuses to take medicines a few times each week, or she takes some but not all of them. Staff are going back to try again at each medication round
• There has been no difference since starting metformin. The nausea seems to be related to the number of medicines
• Subjectively (the resident can verbalise pain) and objectively (using an observational pain score for people with dementia) the resident is in pain much of the time

Observations, examinations and results 

Note: local laboratory reference ranges may vary

Relevant results one month ago:

• Weight 96kg, Height 154cm, BMI 5kg/m²
• HbA1c 89mmol/mol (10.3%)
• Blood pressure 120/80mmHg, no postural hypotension
• Urea and electrolytes:
  • Urea 22.0mmol/L (2.5-7.8mmol/L)
  • Creatinine 62micromol/L (60-120 micromol/L), calculated creatinine clearance greater than 60ml/min
  • Albumin 33g/L (35-50 g/L)
  • K 3.5mmol/L (3.5- 5.3 mmol/L)
• CRP 15mg/L (0-10mg/L); Hb 122g/L (120-160 g/L)

Most recent relevant consultations

• On follow-up visit, U&E and results were within normal range. The oedema had improved and blood pressure normal

Person specific issues to address

• Sore itchy legs: improve analgesia
• Nausea and vomiting due to number and size of tablets

 

Person specific issues to address

• No current medication is essential but medicines to relieve symptoms and improve quality of life should be prioritised

 

Person specific issues to address

Review the need for:

• Omeprazole and metoclopramide recently started for nausea and vomiting
• Tramadol: not controlling pain but paracetamol often refused due to the size of the tablets
• Fexofenadine: for itchy sore legs
• Lorazepam: for stress and distress in the context of dementia
• Laxatives: for opioid induced constipation, aggravated by poor mobility and diet

 

Person specific issues to address

• Review pain management
• Reduce peripheral oedema
• Improve mood
• HbA1c to be checked three months after starting metformin

 

Person specific issues to address

Review need for:

• Metoclopramide: risk of adverse effects e.g. extra-pyramidal
• Omeprazole: increased risk of electrolyte disturbance
• Tramadol: increased risk of falls
• Lorazepam: increased risk of falls, potential to reduce from regular to as required use if less agitated once pain is managed
• Furosemide: review dose of and its effect on renal function
• Nausea: consider metformin as probable cause. A switch to MR preparation is not an option as she chews large tablets such as paracetamol and metformin. Option for liquid preparations
• Medication Sick Day Guidance: ensure staff have clear information on drugs to withhold (in this case prescription of furosemide and metformin) 

Person specific issues to address

• Metformin liquid more expensive than tablets but clinically justified
• Paracetamol capsules are less expensive than oral suspension, however still large capsules. Once pain is managed, could try capsules, however crunching capsules may cause nausea again
• Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

 

Agreed plan

• The proposed changes to medication were discussed and agreed with her welfare power of attorney
• Care staff will administer medication, monitor effect and her ability to take medication
• Stop metoclopramide, omeprazole once nausea resolves
• Reduce tramadol as regular paracetamol used
• Reduce lorazepam with aim to withdraw
• Change paracetamol, and metformin to liquid preparations
• Review furosemide, dose could reduce if increased mobility improves oedema
• Review fexofenadine, stop if itch resolves with oedema, or trial without
• Review laxatives, as mobility improves and tramadol reduced
• Medication dosing remained four times a day, this could be reviewed once leg pain has been managed to trial reduction in paracetamol frequency