Case ReportPractice

Reducing fall risk while managing hypotension, pain, and poor sleep in an 83-year-old woman

Barbara Farrell, Salima Shamji and Nafisa Ingar
Canadian Family Physician December 2013; 59 (12) 1300-1305;

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Tables

  • Table 1.

    History of medication experience: Medication history was relevant for amitriptyline and gabapentin, both of which were stopped in summer 2011 possibly to reduce fall risk, as well as iron supplements, which the patient had stopped taking on her own. The patient was allergic to acetylsalicylic acid (which caused a rash), possibly allergic to penicillin, and possibly allergic to rofecoxib (the patient said she was unaware of penicillin and rofecoxib allergies).

    MEDICATIONREASON FOR USE (IF KNOWN)KNOWLEDGE, EFFICACY, COMPLIANCE, GOALS, SAFETY ASSESSMENTDURATION (IF KNOWN)
    5 mg of ramipril every morning
    Half a 5-mg amlodipine tablet twice daily    		Hypertension
    Hypertension

    • BP at GDH in first 4 visits ranging from 92/52 mm Hg to 110/64 mm Hg; 1 episode of orthostatic hypotension (from 110/64 mm Hg lying down to 88/50 mm Hg standing)

    • No dry cough; has some ankle swelling

    		Many years
    Many years
    Half a 50-mg metoprolol tablet twice dailyCAD and CABG (remote)

    • Heart rate 56 beats/min at time of assessment

    • Is followed by cardiologist

    		About 30 y
    0.4-mg nitroglycerin patch; 2 on at 9 am and off at 10 pm, rotating siteAngina (remote)

    • If forgets to remove, gets headache and is reminded to remove patch

    • Has difficulty differentiating chest pain and arthritis pain

    		About 30 y
    0.4 mg of nitroglycerin spray as neededAngina (remote)

    • Last used previous summer, does not carry regularly

    • Has difficulty differentiating chest pain and arthritis pain

    		2.5 y
    75 mg of clopidogrel every morningCAD, CABG, possible mild stroke

    • No bruising or bleeding reported

    		Many years
    40 mg of furosemide every morningUnknown

    • Does not know why furosemide started (some ankle edema; sleeps with 2 pillows)

    • Potassium level 4.1 mEq/L (at GDH admission)

    		Unclear
    80 mg of atorvastatin at bedtimeCAD, CABG, possible mild stroke

    • Does not complain of muscle ache

    • Does not drink grapefruit juice

    		2 y (40 mg for many years previously)
    10 mg of escitalopram every morningDepression, possible anxiety

    • Helps with mood; reports previous panic attack when old pharmacy would not refill; worries about stopping suddenly

    • Has nausea after lunch and sleep difficulties

    		About 6 mo
    5 mg of zopiclone at bedtimeInsomnia

    • Sleep not improving (reports going to bed at about 9 pm and waking at midnight with difficulty getting back to sleep)

    • Intends to try nonpharmacologic measures for sleep hygiene

    		1 y
    2, 10-mg tablets of oxazepam at bedtimePossible anxiety

    • Patient thinks it was prescribed for anxiety after open-heart surgery

    		About 30 y
    1000 IU of vitamin D dailyOsteoporosis (midthoracic vertebral compression)

    • Is seen by specialist

    • Vitamin D level 76 nmol/L (at GDH admission)

    		NA
    200 mg of hydroxychloroquine sulfate at supperRheumatoid arthritis

    • Helps with arthritis but does not remove pain completely

    • Is seen by specialist

    		NA
    30 mg of codeine with acetaminophen twice daily as neededPain

    • Pain in left torso and ribs, radiating left hip pain

    • Throbbing pain throughout night; limits sleep, mobility, and function

    		NA
    500 mg of acetaminophen 4 times dailyPain

    • VAS score of 9 out of 10 on admission and 6-7 out of 10 with acetaminophen and codeine in combination and regular acetaminophen

    • Patient states she “could not do without acetaminophen”

    		NA
    40 mg of pantoprazole every morningNausea

    • States it is helpful in reducing nausea

    		NA
    Polyethylene glycol eye drops as neededEye lubrication

    • Uses effectively for dry eyes

    		NA

    • BP—blood pressure, CABG—coronary artery bypass grafting, CAD—coronary artery disease, GDH—Bruyère Continuing Care Geriatric Day Hospital, NA— not available, VAS—visual analogue scale.

  • Table 2.

    Medication care plan

    DRUG-RELATED PROBLEMACTION PLANMONITORING
    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/dConstipation, gastrointestinal side effects
    Risk of bleeding with combination of clopidogrel and escitalopramReassess 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 hydromorphoneReassess 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 levelsSwitch 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 burdenStop vitamin CNA

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

  • Week 1

    • Hold acetaminophen with codeine

    • Increase acetaminophen to 1000 mg 3 times daily

    Week 2

    • Stop acetaminophen with codeine

    • Start codeine 30 mg 3 times daily as needed

    • Increase vitamin D to 1000 IU 3 times daily

    • Add calcium carbonate antacid in the morning and at lunch

    Week 3

    • Change codeine to 30 mg 3 times daily regularly

    • Decrease metoprolol to 12.5 mg twice daily

    Week 4

    • Stop codeine

    • Start 3 mg/d of controlled-release hydromorphone

    • Start polysaccharide iron complex 150 mg/d

    Week 5

    • Stop metoprolol

    • Decrease amlodipine to 2.5 mg/d

    Week 6

    • Stop amlodipine

    • Add 0.5 mg hydromorphone 3 times daily (total hydromorphone 4.5 mg/d)

    • Patient asked to keep pain diary

    Week 7

    • Increase controlled-release hydromorphone to 4.5 mg/d (continue 0.5 mg 3 times daily as needed)

    • Decrease zopiclone to 2.5 mg at bedtime

    Week 8

    • Decrease furosemide to 20 mg/d

    • Stop controlled-release hydromorphone 4.5 mg and 0.5 mg of hydromorphone

    • Start 3 mg of controlled-release hydromorphone twice daily (total hydromorphone 6 mg/d)

    • Reduce nitroglycerin patch to a single 0.4-μg patch daily

    Week 9

    • Stop pantoprazole

    • Start 10 mg/d of rabeprazole

    • Stop zopiclone

    • Stop furosemide

    • Continue 20 mg of oxazepam at bedtime

    Week 10

    • Stop rabeprazole

    • Restart 40 mg/d pantoprazole

    • Stop vitamin C

  • am

    • 5 mg of ramipril

    • A single 0.4-mg nitroglycerin patch

    • 75 mg of clopidogrel

    • 40 mg of pantoprazole

    • 10 mg of escitalopram

    • 3 mg of controlled-release hydromorphone

    • 1000 IU of vitamin D

    • Calcium carbonate tablet

    pm

    • 2, 500-mg acetaminophen tablets

    • 1000 IU of vitamin D

    • Calcium carbonate tablet

    pm

    • 200 mg of hydroxychloroquine sulfate

    • 2, 500-mg acetaminophen tablets

    • 1000 IU of vitamin D

    pm

    • 80 mg of atorvastatin

    • 2, 500-mg acetaminophen tablets

    • 2, 10-mg oxazepam tablets

    • 3 mg of controlled-release hydromorphone


    Nitroglycerin spray when needed
    Polyethylene glycol eye drops when needed

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Reducing fall risk while managing hypotension, pain, and poor sleep in an 83-year-old woman
Barbara Farrell, Salima Shamji, Nafisa Ingar
Canadian Family Physician Dec 2013, 59 (12) 1300-1305;
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