Care home resident with multimorbidity

Case summary

Background (age, sex, occupation, baseline function)

82-year-old man
Recently transferred to local care home following long hospital admission
Previously:
- 20 years ago he suffered a lumber discectomy and decided to retire at 62 after a long career in business
- In retirement, he lived alone in a remote location
Three children but none are local

History of presentation/reason for review

Medication review following admission to care home (change of care setting)

Current medical history and relevant co-morbidities

Admitted to hospital seven months ago following a fall at home
- Fractured right neck of femur and repaired with dynamic hip screw
- Confused post operatively which resolved but remained cognitively impaired
- Concerns raised at time of admission, house noted to be in a mess, no food in house and general state of ill repair
- Family do not live locally and had not seen him recently
- Diagnosed with dementia and unable to return home due to combination of mobility and cognitive impairment
- No welfare power of attorney and long wait in hospital for guardianship to support discharge
Little medical contact in year prior to admission
Suspected transient ischaemic attack (TIA) with transient speech upset - five years ago
Hypertension - five years ago
Type 2 Diabetes Mellitus diagnosed - five years ago
Bowel cancer leading to right hemicolectomy - 10 years ago
Lumbar discectomy L4/5 - 20 years ago
Hard of hearing

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

Allergies or adverse drug reactions: nil

Currently prescribed:

Adcal-D3® 750mg/200IU caplets: two caplets twice a day
Amlodipine 10mg tablets: one tablet daily
Aspirin 75mg dispersible tablets: one tablet daily
Atorvastatin 80mg tablets: one tablet daily
Folic acid 5mg tablets: one tablet daily
Gabapentin 300mg capsules: three capsules three times a day
Gliclazide 80mg tablets: one tablet twice a day
Lisinopril 10mg tablets: one tablet daily
Lisinopril 20mg tablets: one tablet daily
Lorazepam 500micrograms tablets: one tablet at night
Omeprazole 20mg capsules: one capsule daily
Paracetamol 500mg tablets: two tablets four times a day
Sertraline 100mg tablets: one tablet daily

Over the counter medicines: nil

Lifestyle and current function

Clinical Frailty Score (Rockwood) 7 - severely frail - completely dependent for all personal care
Assistance of one needed to transfer. Stand aid hoist needed when tired
Assistance of one to mobilise with walking aid
Can communicate simple conversation. Often disorientated to place
Catheter (since hospital admission) and occasional faecal incontinence
Eats well but needs prompting and supervision

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

Has enjoyed video conference contact with family who had not been in touch for a while
Lots of foreign travel over his life and enjoys talking about this
He is not keen to mobilise and prefers to be sedentary
Initially he did not leave his room and engage with others but slowly engaging more and appears to enjoy that
No current issues with pain

Observations, examinations and results

Note: local laboratory reference ranges may vary

Bloods updated recently

Weight 54kg, Height 177cm, BMI 17kg/m²
BP 110/60 mmHg
Creatinine 82 micromol/L (60-120 micromol/L), calculated creatinine clearance 39 ml/min
HbA1c 38 mmol/mol (5.6%)

Most recent relevant consultations

None recently as he has been in hospital for seven months

7 steps: Person specific issues to address

1. Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

Support and encourage independence and interaction where possible
Ensure symptoms are well controlled

2. Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

Drugs that have essential replacement functions (e.g. levothyroxine)
Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

No drugs considered essential

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use
with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

Gabapentin: indication not clear and may no longer be needed. Risk of sedation and confusion
Lisinopril and amlodipine: tight blood pressure control, likely to be over treated. Target BP control should consider comorbidities and frailty using a person-centred approach
Gliclazide: tight HbA1c, therefore likely over treated
Sertraline: unclear indication, may be possible to withdraw
Atorvastatin: likely commenced after possible TIA several years ago, likely limited effect now
Lorazepam: unclear indication, may be possible to withdraw
Folic acid: may no longer be needed
Review indications for all medications in old notes/records

4. Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific issues to address

Recent hip fracture and no investigations recorded for osteoporosis. Consider if life expectancy sufficient for time to benefit from treatment. In this case may be too short. Note: if considering bisphosphonate treatment need to assess dental health
Assess pain control. Is paracetamol still needed as regularly as four times a day?

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

appropriate individual targets e.g. HbA1c, BP
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers (e.g. hypokalaemia)
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

Risk of hypoglycaemia with tight blood glucose control
Risk of falls and increased harm with tight blood pressure control
Risk of sedation and increased confusion with gabapentin
Risk of sedation and increased falls with lorazepam
Medication Sick Day Guidance: ensure staff have clear information on medication to withhold (in this case lisinopril and gliclazide if continuing)

6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
- over-ordering
- disposal
Water pollution

Person specific issues to address

All medicines are formulary choices
Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

7. Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

Stop lorazepam
Stop Review HbA1c after three months
Consider stopping atorvastatin due to limited life expectancy
Reduce and stop lisinopril and amlodipine
Reduce gabapentin gradually and assess pain control
Reduce and stop sertraline, if agreed
Change calcium/vitamin D supplement to a once daily preparation
Low BMI and history of acute on chronic poor nutrition. Encourage continued focus on nutrition in care home. Look for old weights in notes/records. Assess Malnutrition Universal Screening Tool (MUST) score
Potential for improvement in physical and cognition with improved nutrition, encouragement to mobilise and interaction in care home activities.
Discuss changes with appointed guardian

Key concepts in this case

Transfer to long-term care is an important change of care setting and is a trigger for medication review
Frail older adults frequently have a range of conditions with diagnosis often made when younger and fitter. Treatment targets are likely to change with time and caution is needed to prevent over treatment
Improvements in function can be made with non-drug interventions especially in adults who have become deconditioned due to illness or social isolation. Consider nutrition as a reversible cause of decline in function
Ensure all medications have a valid current indication
Sedatives should be avoided especially for long-term use
Reduced time in medication administration can free time for other activities for the individual and staff that may be more beneficial
Social health is important, and care plan should involve exploration of individual’s interests and enjoyments