A systematic approach that uses screening criteria for potentially inappropriate medications, assesses signs and symptoms of drug-related causes, and includes monitoring of medication tapering and initiation of new drug therapies can effectively identify drug-related problems and manage their resolution. Patients presenting to the Bruyère Continuing Care Geriatric Day Hospital (GDH) in Ottawa, Ont, often display a constellation of symptoms that worsen their quality of life; medication review focuses on potential drug-related causes and steps to address them.
This case illustrates how medications might contribute to common, distressing geriatric symptoms. Despite patient sensitivity to medication changes, we were successfully able to stop several medications without worsening of symptoms for which the medications were being used. The case also emphasizes the importance of carefully monitoring the implementation of any new medication for possible adverse effects so that new medications can be stopped before another medication is added to treat their side effects.
Case
An 84-year-old woman was referred to the GDH for assessment of mobility and falls, mood, and cognitive changes. She was diagnosed with Parkinson disease earlier that year, and in the past couple of years had had a number of falls and near falls, during which she “felt her legs give way.” Her walking tolerance was diminished even with a 4-wheeled walker, and cognition had declined with slower processing speed. Her past medical history was relevant for a probable dementia secondary to Parkinson disease, benign positional vertigo, hemorrhagic stroke, diverticulosis, osteoporosis, osteoarthritis, degenerative disk disease, type 2 diabetes (diet controlled), glaucoma, and allergic rhinitis. The patient received help in all of her instrumental activities of daily living including medication management (by staff at the retirement home). Bloodwork revealed a vitamin B12 level of 195 pmol/L and calculated creatinine clearance was 38 mL/min (using Cockcroft-Gault equation with ideal body weight). The patient could not recall the names, dosages, or indications of her medications and stated she did not know “if they were doing any good.”
During the initial assessment, issues regarding cognition (Mini-Mental State Examination was 13 out of 30) and mood were highlighted in this university-educated patient; she described herself as feeling “demoralized” owing to her increasing physical deficits, her partner’s medical conditions, and a recent move to a retirement home. She also complained of nausea (particularly at mealtime and occasionally with vomiting) diminishing her appetite. Dizziness, dry mouth, itchy, watery eyes (which the patient found extremely bothersome), and hypotension (blood pressure as low as 77/50 mm Hg) were also a concern. She reported having 2 to 3 falls in the past month, with “a bad fall in the bathtub” where she hit her head and hurt her wrist. She had frequently interrupted sleep during the night; she was very fatigued and compensated with napping up to 4 hours a day. The GDH pharmacist, nurse, social worker, occupational therapist, physiotherapist, and speech language pathologist were consulted. The GDH pharmacist conducted a medication assessment, which included a 45-minute comprehensive interview with the patient, chart review, and communication with both the patient and the staff at the retirement home. Each medication was assessed for indication, effectiveness, safety, compliance, and patient understanding.1 The results of the initial part of this assessment are outlined in Table 1.
History of medication experience: Patient is allergic to valdecoxib and morphine.
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Signs and symptoms were assessed to determine potential drug causes and drug-related problems were identified. 2 The complete medication assessment is outlined in Table 2.
Medication care plan
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On review of the medications and recognizing that they might be contributing to the patient’s dizziness, low blood pressure, nausea, fatigue, and low mood, the following changes were made: bisoprolol, candesartan, betahistine dihydrochloride, cetirizine, dimenhydrinate, and rosuvastatin were discontinued. We changed trazodone to be used on an as-needed basis and stopped metoclopramide, eventually adding domperidone 4 times daily to the regimen. With these changes, nausea and vomiting resolved and her blood pressure rose to within the desired target range. We added vitamin B12 and calcium secondary to deficiencies and frequent falls. We tried 2 antidepressants at low doses but found these caused more dizziness and falls and subsequently stopped them. Over time, the patient’s participation in group activities increased, her energy level improved and her mood was judged to be improved with counseling by our social worker; additional follow-up with the geriatric psychiatrist was recommended. In addition, a recommendation was made for the neurologist to follow up with tapering levodopa after metoclopramide was stopped. Given the risk of swallowing difficulties in the setting of Parkinson disease, the patient was provided with strategies for safe eating, drinking, and pill swallowing by the team’s speech pathologist; however, with ongoing cognitive deficits, carry-over of this education was limited. While at the GDH, the patient received physiotherapy twice a week, including balance exercises, gait and transfer training, and cardiovascular conditioning on a stationary bicycle. In parallel with this, she received falls prevention education from various members of the interdisciplinary team. Her balance and mobility improved slightly, with a change in Berg Balance Score from 35 out of 56 to 38 out of 56 and an increase in 6-minute walking distance from 180 m to 200 m. Her confidence with transfers increased, but she continued with poor safety awareness. There was no worsening of vertigo, and eye tearing resolved. Chronologic steps taken to implement the action plan are outlined in Box 1 and a final medication list is presented in Box 2.
Discussion
When trying to determine whether the patient’s medications were contributing to her symptoms, we considered the following.
Using screening criteria to identify “inappropriate” medications
Worsening of symptoms associated with Parkinson disease is a well-known side effect of metoclopramide. This is highlighted in both the Beers and the STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) criteria, explicit criteria used to identify potentially inappropriate medication use in the elderly.3,4 It was unclear whether our patient began metoclopramide before or after Parkinson disease was diagnosed; nevertheless, the potential worsening of parkinsonian symptoms was an important consideration.5,6 Metoclopramide was stopped and the patient was monitored for worsening nausea, vomiting, and bloating. Nausea improved (as other medication doses were being reduced) but recurred several weeks later, so domperidone was started at a low dose with good effect (in addition to other ongoing changes to reduce drug-induced nausea). The risk of metoclopramide use concurrently with Parkinson disease can be easily identified by health care professionals using screening criteria (such as Beers or STOPP) or with the use of a computer program for drug interactions7; incorporating these strategies into medication assessment either at the time of prescribing or dispensing would help in identifying medications considered to be “inappropriate” in the elderly. After stopping metoclopramide, we sent an interoffice speedy memo to the patient’s neurologist regarding the possibility of tapering levodopa; the patient was asked to follow up with the specialist regarding this matter, and a description of the events was included in her medication chart, which was copied to the family doctor on discharge.
Intervention timeline:Initial pill burden = 20 pills daily; initial number of medications = 14; final pill burden = 16 pills daily; final number of medications = 10.
Week 1
No new medication changes
Week 2
No new medication changes
Week 3
Reduce betahistine dihydrochloride to 8 mg twice daily
Week 4
No new medication changes
Week 5
Stop bisoprolol
Stop metoclopramide
Week 6
Start 1200 μg of vitamin B12 daily
Stop candesartan
Reduce betahistine dihydrochloride to 8 mg daily
Week 7
Stop betahistine dihydrochloride
Stop cetirizine
Start calcium carbonate antacid twice daily
Stop routine blood glucose checks
Week 8
Start 7.5 mg of mirtazapine at bedtime
Reduce trazodone to 25 mg at bedtime
Week 9
No new medication changes
Week 10
Hold rosuvastatin for 1 week, then reassess
Start 5 mg of domperidone 4 times daily
Stop dimenhydrinate
Stop mirtazapine
Week 11
Stop trazodone
Start 5 mg of citalopram daily
Week 12
Stop citalopram
Restart trazodone 25 mg at bedtime
Stop rosuvastatin
Week 13
Change trazodone to 25 mg at bedtime only if needed
Medication schedule at discharge
Morning (around 8 am)
5 mg of domperidone
2 tablets of 100/25 mg of levodopa-carbidopa
1000 IU of vitamin D
Calcium carbonate tablet
1200 μg of vitamin B12
0.05 mg of levothyroxine
40 mg of pantoprazole
1 drop of 0.5% timolol in both eyes
150 mg of risedronate once a month
Afternoon (around 12 pm)
5 mg of domperidone
2 tablets of 100/25 mg of levodopa-carbidopa
Calcium carbonate tablet
Supper (around 5 pm)
5 mg of domperidone
2 tablets of 100/25 mg of levodopa-carbidopa
Bedtime (around 10 pm)
5 mg of domperidone
1 drop of 0.5% timolol in both eyes
25 mg of trazodone when needed
Assessing signs and symptoms of drug-related causes
Bothersome symptoms such as nausea, anorexia, dry mouth, fatigue, and dizziness can severely affect an elderly person’s quality of life. Drugs that might potentially be contributing to any of these symptoms were identified by reviewing the side effects of each and considering their pharmacologic mechanisms; they were assessed for continued indication and, if possible, tapered and stopped. Betahistine dihydrochloride was tapered and stopped with no return of vertigo; subsequently it was believed that the original dizziness might have been due to balance impairment and not true vertigo. Cetirizine was stopped with no worsening of the eye symptoms for which it had been started (watery eyes inexplicably resolved by end of GDH admission). Dimenhydrinate was stopped and an attempt was made to stop trazodone, but the patient eventually required a small as-needed dose for occasional insomnia. The patient’s dry mouth improved. Finally, rosuvastatin was briefly stopped to determine its effect on nausea and eventually it was completely stopped because of lack of clear indication and because nausea improved without it (albeit during the time period domperidone was started). With resolution of nausea, a recommendation was made to the family physician to attempt a domperidone taper in the future. Notwithstanding the improvement in the patient’s nausea, she continued to have anorexia, perhaps related to residual mood difficulties.
Low systolic and diastolic blood pressure measurements might have been contributing to the patient’s fatigue and dizziness (and hence risk of fall) and might have also been associated with an increased risk of cardiovascular events and mortality.8 Antihypertensive medication frequently contributes to hypotension, as the absorption, distribution, metabolism, and excretion of these drugs change considerably as people age.9,10 We identified an appropriate target blood pressure range for her age (120/60 mm Hg to 150/90 mm Hg) and found the patient consistently had blood pressure readings in the low end or below this range.8 We also considered the possibility that the combination of oral bisoprolol and topical timolol might have had an additive effect in contributing to depressive symptoms such as fatigue.11 We gradually stopped her antihypertensives (for which there were no other compelling indications) and her blood pressure eventually rose and stabilized in the appropriate target range.8
Monitoring the initiation of new drugs
Depression can have a serious effect on morbidity and quality of life in older people. Given age-related changes in pharmacokinetic and pharmacodynamic parameters, as well as adverse events associated with antidepressants, careful attention must be paid to choosing and using an antidepressant.12,13 Minimizing β-blocker therapy (or other medications that can contribute to depression) might help, but we also considered treatment in this patient. In collaboration with the geriatric psychiatrist, we tried a low dose of mirtazapine; however, the patient reported more dizziness and worsening balance within 2 days of starting the medication and, as a result, it was stopped. Next, we tried 5 mg of citalopram; however, within 2 days of initiating therapy, the patient again had increased dizziness and reported 2 falls over a weekend. The patient had been warned (verbally and in writing) about this potential when we started the citalopram. She brought her concerns to the attention of the staff at the retirement home; however, the person she spoke with denied that a new medication had been started. The patient persisted in questioning the addition of citalopram when she returned to the GDH and we confirmed with the staff at the retirement home that the medication had been started. This highlights the importance of involving patients in monitoring the effects of medication and of engaging them so that they feel empowered to question the appearance of potential drug-induced problems. The citalopram was stopped; dizziness improved over the next few days. The patient was reluctant to try another antidepressant and instead continued to receive counseling from the social worker at the GDH; follow up was planned with the geriatric psychiatrist.
Other drug-related problems
The need for ongoing proton pump inhibitor therapy was reviewed (especially in light of low vitamin B12 levels), but plans to taper the patient’s pantoprazole were not carried out at the GDH owing to the many other ongoing medication changes. A recommendation was made to the family doctor to pursue proton pump inhibitor tapering. With regard to adding a cholinesterase inhibitor for her Parkinson dementia, we elected to focus on the deprescribing of other medications to try to improve her nausea and dizziness, along with trying antidepressant therapy for her mood. We recommended the family doctor pursue dementia treatment in collaboration with the patient’s neurologist if the patient’s nausea remained stable and anorexia improved. The patient was also asked to follow up with her neurologist regarding options to lower the levodopa dose now that metoclopramide was stopped. Reducing the number of unneeded medications, and those potentially causing adverse effects, allowed us to feel comfortable adding to her pill burden with vitamin B12 and calcium. Finally, the patient was encouraged to stop her routine blood glucose monitoring, as her diabetes was well controlled with diet.14 All medication changes, rationale for changes, outcomes, and recommendations were documented in plain language in a “medication chart” for the patient, a copy of which was forwarded to the family doctor on discharge from the 12-week program.
Conclusion
This case highlights the importance of considering whether a patient’s medications are contributing to his or her symptoms before initiating a new diagnosis or adding another drug. By using screening criteria, medications that are potentially inappropriate can quickly be identified. After identifying the potential drug-related causes of presenting symptoms (such as nausea, dizziness, low blood pressure, depression), the next question—is this drug still needed?—can be asked, and then steps can be taken to gradually reduce doses and monitor for improvement of symptoms. Monitoring the initiation of new drugs and engaging the patient in monitoring for relevant, potentially serious adverse effects—or indeed, any change in function following drug initiation—is vital to reducing drug-related morbidity. Finally, this case also underlines the benefits of an interdisciplinary team-based approach in managing patient symptoms with nonpharmacologic interventions, such as counseling or psychotherapy for a mood disorder when a trial of antidepressants has failed.
Acknowledgments
Financial support for this project is provided by the Bruyère Academic Medical Organization.
Notes
EDITOR’S KEY POINTS
Use the Beers or STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) screening criteria to identify “inappropriate” medications for the elderly.
When considering a patient’s new symptoms, always ask yourself, “Can this symptom be caused by a drug?” After identifying the potential drug-related causes of presenting symptoms (eg, nausea, low blood pressure, depression), then begin to gradually reduce medication doses and monitor for improvement of symptoms.
Involve patients in monitoring side effects when new medications are started and engage them so that they feel empowered to question the appearance of potential drug-related problems.
POINTS DE REPÈRE DU RÉDACTEUR
Utilisez les critères de dépistage Beers ou STOPP (Screening Tool of Older Persons’ potentially inappropriate) pour identifier les ordonnances de médicaments possiblement «inappropriés» pour les aînés.
Lorsque vous examinez les nouveaux symptômes d’un patient, demandez-vous toujours si ces symptômes peuvent être causés par un médicament. Après avoir cerné les causes du symptôme potentiellement reliées à un médicament (p. ex. nausée, hypotension, dépression), commencez alors à réduire graduellement les doses du médicament et surveillez si les symptômes s’améliorent.
Faites participer les patients à la surveillance des effets secondaires lorsque de nouveaux médicaments sont ajoutés et mettez-les à contribution de manière à ce qu’ils se sentent en mesure de poser des questions lorsque surviennent des problèmes possiblement reliés aux médicaments.
This article is one of several prepared as part of a collaboration among the Bruyère Continuing Care Geriatric Day Hospital, the CMAJ, Canadian Family Physician, and the Canadian Pharmacists Journal to assist clinicians in the prevention and management of polypharmacy when caring for elderly patients in their practices.
Footnotes
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↵* Instructions, discussion questions, and worksheets on identifying drug-related problems and developing an interprofessional medication care plan and planning interventions are available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.
Competing interests
None declared
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