Risk Safety and Pain Management for the Elderly Patient

Scenario #2

An 82-year-old male (R.L) is admitted to your care after falling at home. R.L. is alert and reports that he has bilateral knee pain and needs more pain medication. He lists Tramadol and Lortab as the two medications that work best for the pain and takes both regularly. His wife states that this has been a problem for over a year and that “he doesn’t do much because his knees hurt”. R.I. stated that he also takes a statin, antihypertensive medication, Metformin, and a PPI . He appears compliant with his medications. Surgical history includes a CABG three years ago. His BMI is 30.3. He has Medicare Parts A, B, D, plus a Medicare supplement.

Introduction

The aging process is normal and it is something that every human beings will all experience. During the aging process our bodies will go through a variety of changes whether it is subtle or profound. The aging population does have specific interest of certain needs that should be met. Mentally and physically the older person are no longer agile as they were younger. In the case study above, shows how an elderly man has presented with so many challenges in his life. As the nurse practitioner is important to launch an initiative to tackle these challenges and conceptualize solutions in order for this patient have the optimal care. There are four topics that should be address for this 82-year-old man such as polypharmacy, falls and fall risk safety, pain management and Medicare D.

Polypharmacy

The elderly population are often prescribed multiple medications due to multiple comorbidities. 

Merriam-Webster’s definition of polypharmacy is the practice of administering or using multiple medications especially concurrently (as in the treatment of a single disease or of several coexisting conditions) (Merriam- Webster.com, n.d.). Polypharmacy is a growing issue within the healthcare system and it is an issue that should not be ignored. As we get older, the body goes through many changes, and these changes can affect the therapeutic level of drugs. These can then lead to many risk factors; shortness of breath, hypertension, fall risks, dependency instrumental activities of daily living, poor self-reported health, decrease in lower extremity function, and tension between patient and provider . Each person reacts differently to a drug, but most go through the same biological bodily changes (at different times) as we get older, and these changes can produce a chain of event that can alter medication absorption.  The patient R.L. takes Tramadol, Lortab, statin, antihypertensive medication, Metformin and a PPI. As the nurse practitioner the patient would be advised about the drug interactions between Tramadol Hydrochloride ER (tramadol) and Lortab (acetaminophen / hydrocodone). It is not advisable for the patient to combine Tramadol with another narcotic due to side effects such as light-headedness, dizziness, sedation, nausea, vomiting, constipation, sweating, and pruritus respiratory depression, sedation and nausea. According to a study PPI have recently been associated with clinically relevant side effects as well as interactions with other drugs. Moreover, it has been reported that PPIs might interfere with cholesterol metabolism. Indeed, PPIs may increase statin action since both drugs are metabolized by the same P450 cytochromes (CYP3A4, CYP2C19). PPIs may act as an agonist for liver X receptor (LXR), which is associated with cholesterol metabolism (Barkas et al 2015). Also antihypertensive and Lortab are known to cause dizziness, bradycardia, and lightheadedness. 

Intervention:

Complete a thorough assessment of the patient’s medication because older adults are not good historians. It is important to ask the right question to get a complete list of all of their medications including over-the-counter drugs. In addition, educate the patients on side effects of the medication.  As the nurse practitioner, reviewing the medications such be done often. A lot of times the elderly population forget about the side effects and run the risks of drug to drug interactions. A simple intervention could be medication adjustments such as discontinuing the narcotics for NSAIDs to avoid opioid dependency. Another tool that should be incorporated as a clinician is the Beers Criteria that is use as a guide when it comes to prescribing medications.  On the Beers criteria, it informs the clinician on drugs that generally should be avoided in older adults. Drugs to be avoided in combination with specific comorbidities. Drugs to be used with caution and drug-drug interactions that should be avoided in elderly. Drugs to be avoided or dosage reduced with varying levels of kidney function (Chandrappa, & Rajarathna, 2019).Since the patient appears compliant with his medication, another tool to use is the Assessing Care of Vulnerable Elders (ACOVE). ACOVE allows the provider the choice of medication, monitoring parameters, a maintenance list of medications and drug regimen reviews (Ham et al, 2014). As a nurse practitioner my goal is to practice safe medication administration by utilizing the tools available in order to give quality care.

Falls and fall risk safety

The topic of falls would be something that should be address because it is the patient’s chief complaint.  Falls are very common in the older population and are the reason for older adults to be hospitalized.  According Sharif et al., (2018) a fall is an accidental events in which a person falls when his/her center of gravity is lost and no effort is made to restore balance or when this effort is ineffective (p.1).  At least a third of older persons living at home will fall at least once a year, and about 1 in 40 will be hospitalized (Ham et al., 2014). As the nurse practitioner, it is our duty to investigate what could be causing R.L.’s fall at home and look at all the possible variables.  Some risks factors to look out for are history  of  falling, use  of  assistive  devices,  environmental hazards such as poor lightening, and various health conditions, including  muscle  weakness, vertigo,  gait  and balance impairments, visual and hearing disorders, cognitive and sensory impairments, orthostatic hypotension, cardiovascular medications, and osteoporosis (Sharif et al, 2019). Clearly R.L. is on cardiovascular medications as listed above. Also, he stated that he has bilateral knee pain which indicates that R.L. would have gait and balance impairment. Therefore, it is essential that a thorough assessment is performed in order to get a better understanding of what could be contributing to him falling at home.

Interventions:

A post fall assessment should be performed in order to figure out what might have cause the fall and to determine possible differential diagnosis (Ham et al, 2014). Also, a Mini-Mental State Examination would be performed to rule out any cognitive disorders. It is important to note that R.L. is on narcotics and antihypertensive drugs that could have caused confusion. In addition evaluate for any urinary tract infections that can cause confusion which lead to his fall. According to the American and British Geriatric Societies” older adults who report a single fall should be evaluated for mobility impairment and unsteadiness using a simple observational test with those who demonstrate mobility problems or unsteadiness” (Ham et al., 2014). 

An important tool to nurse practitioner should incorporate is STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative. The Centers for Disease Control and Prevention (CDC) created the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative, based on American Geriatric Society Guidelines to assist healthcare providers in preventing older adult falls (Bergen & Eckstrom, 2018). STEADI allows nurse practitioners to screen older patients for fall risk, assessing at-risk patients to identify modifiable risk factors, and intervening by recommending evidence-based strategies (Bergen & Eckstrom, 2018). Educating the patient and his wife is vital because informing a family member could potentially save his life. The patient R. L. does have risk factors such multiple medication so it would be important to review each medication and making sure that he continues to adhere to his medications. Another thing a nurse practitioner should do is to find out if there any environmental hazards at home such as no rails or grab bars in bathroom, uneven carpeting, multiple stairs and lack of assistive devices that might be contributing to his fall. It is important to conduct a home safety assessment to correct changes necessary in order to prevent future falls.

Pain Management

Often times pain are poorly reported in the older population because they feel that it is part of the aging process. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Ham et al., 2014). Yet in many older adults, pain is often left untreated or underestimated by clinicians.  Pain are poorly controlled in the elderly population due to difficult communication or fear of side effects of medications when there a comorbidities (Ham et al., 2014). The patient R.L. has had bilateral knee pain which seems to be persistent due to the request of additional pain medication. Based on the patient’s statement he has been taking Tramadol and Lortab for over a year that could imply opioid dependency.

Intervention

Acccording to Ham et al., (2014)

Diet and Exercise

• Barkas, F., Elisaf, M., Rizos, C. V., Klouras, E., Kostapanos, M. S., & Liberopoulos, E. (2015). Proton pump inhibitors and statins: a possible interaction that favors low-density lipoprotein cholesterol reduction? Hippokratia, 19(4), 332–337.
• Bergen, G., & Eckstrom, E. (2018). Building the evidence base for falls prevention: The CDC’S STEADI initiative. Innovation in aging, 2(Suppl 1), 237. doi:10.1093/geroni/igy023.882
• Chandrappa, S., R., D., & Rajarathna, K. kavitharajarathna@gmail. co. (2019). Assessing prescriptions for potentially inappropriate medications using Beer’s criteria in elderly in-patients at a tertiary care hospital. Journal of ICT Research & Applications, 9(2), 145–149. https://doi-org.proxy.ulib.uits.iu.edu/10.5455/njppp.2019.9.1236011122018
• Merriam-Webster.com. (n.d.). Retrieved from www.merriam-
• webster.com/dictionary/polypharmacy: http://www.merriam-webster.com/dictionary/polypharmacy
• Sharif, S. I., Al-Harbi, A. B., Al-Shihabi, A. M., Al-Daour, D. S., & Sharif, R. S. (2018). Falls in the elderly: assessment of prevalence and risk factors. Pharmacy Practice (1886-3655), 16(3), 1–6. https://doi-org.proxy.ulib.uits.iu.edu/10.18549/PharmPract.2018.03.1206