Table 2.

Medication care plan

DRUG-RELATED PROBLEM	ACTION PLAN	MONITORING
Medications that might contribute to hypotension, dizziness, and falls: Metoprolol (which might also contribute to bradycardia) Amlodipine (which might also contribute to ankle edema) Furosemide (also contributing to hypokalemia) Nitroglycerin patch	One at a time: Taper metoprolol to 25 mg/d, then to 12.5 mg twice daily, then stop Taper amlodipine to 2.5 mg/d, then stop Taper furosemide to 20 mg/d for 1 wk, then stop if no worsening of ankle edema (nurse to fit for compression stockings) Taper nitroglycerin patch to a single 0.4-μg patch on for 12 h, off for 12 h Nurse to provide education about behavioural strategies to manage orthostatic hypotension	HR BP (target 120/60 mm Hg to 140/90 mm Hg) Angina or shortness of breath Ankle edema Potassium level
Current analgesic regimen not controlling pain (VAS score 7–9 out of 10); consider increasing acetaminophen and switching to a different opioid	Stop acetaminophen with codeine Increase acetaminophen to 1000 mg 3 times daily Try 30 mg of plain codeine 3 times daily as needed (with pain diary) If not effective, stop codeine and try 0.5 mg hydromorphone 3 times daily and titrate up gradually Start controlled-release hydromorphone when regular-release daily dose is equivalent to 3 mg	VAS Effect on function Nausea, constipation
Risk of falls increased with Zopiclone Oxazepam Escitalopram	Taper to 2.5 mg of zopiclone every night for 3 wk, then stop Taper oxazepam to 15 mg every night for 2–3 wk, then to 10 mg every night for 2–3 wk, then to 5 mg every night for 2–3 wk, then to 5 mg at bedtime every other day or as needed until able to stop Assess need for continuing escitalopram Counsel patient on switching to decaffeinated drinks to make it easier to reduce need for sedatives	Rebound insomnia (tends to peak within a few days after dose reduction or stopping) Anxiety, mood
Known osteoporosis and history of vertebral fracture (only taking 1000 IU/d of vitamin D with continuing low vitamin D level); patient would benefit from the following: increasing vitamin D dose (also reduces fall risk); calcium supplementation; and bisphosphonate therapy	Increase vitamin D to 3000 IU/d Assess calcium intake from diet and select supplement of patient’s choice Discuss with physician and patient benefit of bisphosphonate addition	Constipation, nausea Compliance and esophageal irritation with bisphosphonate
Anemia (hemoglobin 115 g/L) secondary to low ferritin levels (18 μg/L), might be contributing to fall risk, dizziness Needs iron treatment	Restart polysaccharide iron complex 150 mg/d	Constipation, gastrointestinal side effects
Risk of bleeding with combination of clopidogrel and escitalopram	Reassess need for continuing escitalopram (discuss with patient before any changes)	Bruising, bleeding gums, blood in stool
Risk of developing serotonin syndrome with combination of escitalopram and hydromorphone	Reassess need for continuing escitalopram (discuss with patient before any changes)	HR, BP, pulse, hyperthermia, agitation, tremor
Pantoprazole might not be needed and might also decrease absorption of iron and increase atorvastatin levels	Switch to 10 mg/d of rabeprazole for 2 wk, then stop (provide written information about treating rebound heartburn)	Rebound heartburn (for up to 4 wk after stopping)
Vitamin C not adding benefit and contributing to pill burden	Stop vitamin C	NA

BP—blood pressure, HR—heart rate, NA—not applicable, VAS—visual analogue scale.