Frailty with multimorbidity

Background (age, sex, occupation, baseline function)

• 87-year-old female
• Lives at home with her husband

History of presentation/reason for review

• Referred for medication review due to combination of frailty and multiple medicines

Current medical history and relevant co-morbidities

• Cerebrovascular disease
  • Vascular dementia - two years ago
  • Stroke (partial anterior circulation) - five years ago. Good recovery with mild left arm weakness main residual deficit
• Ischaemic heart disease
  • Atrial fibrillation - five years ago
  • ECHO (preserved LV function) - five years ago
  • STEMI (thrombolysed) - 15 years ago
• Lumbar vertebral fracture - eight years ago. DXA confirmed osteoporosis
• Hypertension – 20 years ago
• Type 2 diabetes mellitus – 20 years ago
• Hypothyroidism – 27 years ago

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

Allergies or adverse drug reactions (ADRs): nil

Currently prescribed: 

• Adcal-D3® 1500mg/400iu tablets: two tablets daily
• Alendronic acid 70mg tablets: one tablet once a week
• Atorvastatin 80mg tablets: one tablet daily
• Clopidogrel 75mg tablets: one tablet daily
• Digoxin 125microgram tablets: one tablet daily
• Edoxaban 60mg tablets: one tablet daily
• Gliclazide 80mg tablets: two tablets twice a day
• Indapamide 2.5mg tablets: one tablet daily
• Levothyroxine 100microgram tablets: one tablet daily
• Levothyroxine 50microgram tablets: one tablet daily
• Metformin 500mg tablets: two tablets three times a day
• Mirtazapine 30mg tablets: one tablet at night
• Omeprazole 20mg capsules: one capsule daily
• Paracetamol 500mg tablets: two tablets four times a day
• Perindopril 4mg tablets: one tablet daily
• Tolterodine MR 4mg capsules: one capsule daily
• Zopiclone 7.5mg tablets: one tablet at night

Over the counter medicines: nil 

Lifestyle and current function

• Clinical Frailty Score (Rockwood) 7 (severely frail) - dependant on husband for personal care
• Mobility limited due to shortness of breath and joint pain
• Unsteady on feet, uses stick if walking outside
• Husband assists with showering and manages to dress with prompts from him
• Steadily worsening memory and needing regular re-orientation by husband
• Tendency to become much more confused with acute illness/infection
• Continence an issue. Needs assistance from husband to get to toilet
• Needs a lot of encouragement to eat and drink
• Only leaves the house to attend hospital clinics or GP appointment
• Non-smoker and no alcohol
• Husband has COPD with one hospital admission in the last year

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

• Main concern is bladder and incontinence issues
• Attends clinic with husband, who worries about her failing health. He underplays the large amount of care he provides - ‘we cope’
• Managing medicines is becoming more difficult and it can be a struggle to persuade her to take them

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• Marked cognitive impairment and poor short-term memory apparent
• Weight 43kg, Height 157cm, BMI 17kg/m²
• BP 102/56mmHg sitting, 84/40mmHg standing
• Pulse 56bpm (irregularly irregular)
• Urea and Electrolytes: Creatinine 118micromol/L (60-120micromol/L), calculated creatinine clearance 20ml/min
• Urine albumin/creatinine ratio 5mg/mmol (in diabetes ACR>3.5mg/mmol in women is considered clinically significant)
• HbA1c 34mmol/mol (5.3%)

Most recent relevant consultations

• Out of hours review after fall one month ago, no bony injury
• Suspected urinary tract infection three months ago, treated empirically with antibiotics

Person specific issues to address

• Continence
• Burden of medication
• Improvement in function where possible

 

Person specific issues to address

• Levothyroxine: check thyroid function tests to ensure correct dose 

 

Person specific issues to address

• Edoxaban and clopidogrel: no indication for combination. High bleeding risk in combination
• Alendronic acid: completed eight years treatment. Further years of treatment of questionable benefit. Note CrCl 20ml/min, therefore alendronic acid not appropriate. Cognition/frailty will influence choice of other bone protection
• Zopiclone: night sedation, long-term use not recommended
• Mirtazapine: antidepressant with sedative effects
• Atorvastatin: consider ongoing benefit of high dose statin.

 

Person specific issues to address

• Consider and discuss how medicines are being managed as with such a large list of medicines, adherence may be difficult
• Tolterodine: continence major issue therefore review effectiveness and stop if not beneficial
• Shortness of breath affecting mobility. Consider if uncontrolled heart failure or other treatable cause
• Consider ongoing therapeutic management of osteoporosis in context of frailty

 

Person specific issues to address

• High risk combination of edoxaban and clopidogrel: excessive blood thinning
• Edoxaban dose too high. Reduce to 30mg as weight less than 61kg. Note reduced renal function and not licensed when CrCl less than 15 ml/min
• Diabetes:
  
  • blood glucose control too tight.
  • Hypoglycaemia more likely with gliclazide and could be contributing to episodes of confusion and variable cognitive function.
  • Metformin: low creatinine clearance, therefore not indicated
• Blood pressure control too tight with postural drop, review perindopril and indapamide. Note perindopril indicated for reno-protection in T2DM
• Zopiclone and mirtazapine: risk of falls and sedation
• Levothyroxine without recent TFTs. Check to ensure correct dose
• Digoxin in presence of excessive bradycardia. Reduce dose and consider checking digoxin levels due to impaired renal function
• Alendronic acid: not indicated with eGFR less than 35 ml/min
• Tolterodine: anticholinergic and concern over worsening cognitive function
• Paracetamol: reduce dose as weight less than 50kg

Medication Sick Day Guidance: advice given for perindopril and gliclazide (if continued)

 

Person specific issues to address

• All medicines are formulary choices 
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Stop:
  • alendronic acid
  • clopidogrel
  • metformin
  • perindopril and indapamide. Note before stopping perindopril, ensure symptoms are not due to heart failure. Aggressive treatment of albuminuria outweighed by potential problems with low blood pressure
• Reduce:
  • Paracetamol to 500mg four times a day
  • Digoxin and check level. Stop if pulse remains less than 65bpm
  • Gliclazide or stop with follow up
  • Atorvastatin or stop to reduce tablet burden
  • Zopiclone. Discuss the risk and benefit of night sedation and option to gradually reduce with an aim to stop
• Review mirtazapine: check indication and efficacy and withdraw if unclear
• Review levothyroxine dose: check TFTs
• Review tolterodine and trial stopping to assess effectiveness
• Discuss oral calcium/vitamin D supplement and option of alternative formulation
• After drug holiday, careful consideration needed of risk and benefit of continuing osteoporosis treatment
• Ask about bowel function as could be affected by medication
• Referral or signposting for management of low body weight and nutritional needs
• Complete falls assessment
• Consider carer stress and support available. Provide detail of local support services