Chapter 7: Geriatrics: Falling Frannie Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Identify medications listed as Beers List drugs, and describe the reason they may be inappropriate in older adults.

• Discuss common geriatric syndromes, including falls, dizziness, syncope, and urinary incontinence, and identify ways to prevent exacerbations of these conditions.

• Establish goals for the treatment of pain, urinary incontinence, and allergic rhinitis in older adults based on patient-specific characteristics and comorbid disease states.

• Describe ways to prevent falls in older adults.

• Provide appropriate patient counseling to help seniors minimize the cost of their medications.

PATIENT PRESENTATION

Chief Complaint

“I get so dizzy when I stand up, and I don’t have control of my bladder.”

HPI

Fran Jones is an 87-year-old woman who presents to your pharmacotherapy clinic today reporting dizziness and urinary incontinence. She was referred by her PCP for a polypharmacy consult and an adverse drug event review. She reports having fallen last night after getting out of the bed to use the bathroom. She states that her hip is hurting where she fell on it. She admits to being “very blue” often and has crying spells when she discusses her husband who passed away last year.

PMH

• Osteoporosis

• Nonvalvular atrial fibrillation, no h/o VTE

• Seasonal allergic rhinitis

• Early onset Alzheimer’s dementia diagnosed 2 years ago

PSH

• One cesarean section

FH

• Noncontributory

SH

Mrs Jones reports having just started taking Ginkgo biloba to help with memory and taking “lots” of Tylenol since her fall. She does not remember the other meds she is taking, and her daughter fills her pill box. She denies using any tobacco or alcohol. She has lived alone since her husband passed away 6 months ago. She is very concerned about paying for medications. She says the last time she was at the pharmacy, the pharmacist said something about being in a “donut hole.” She has a Medicare Part D plan.

Meds

• Warfarin 2 mg Mon–Wed–Fri–Sun and 4 mg Tue–Thu–Sat

• Alendronate 70 mg PO once weekly

• Diphenhydramine 25 mg PO TID for allergies

• Acetaminophen OTC Extra Strength 1–2 PO PRN pain

• Metoprolol succinate 50 mg PO every morning

• Donepezil 5 mg PO every morning

• G. biloba PO every morning

All

• NKDA

ROS

Reports occasional bladder incontinence and hip pain where she fell as well as a runny nose from allergies; denies heartburn, chest pain, or shortness of breath

Physical Examination