Case Study #2: Pharmacology/Medication Management
Directions:
Read the assigned chapters in the course textbooks (for the week’s covered by
this case study). Read the following information (statement and scenario).
Answer the questions at the end of the Scenario for M.M. using your textbooks,
the supplemental readings and other sources that you find to support your
statements. This case study should use the APA guidelines (title page (with
author notes), body (with your specific headings/subheadings),
citations/references, and graphs/tables/charts as appropriate). Please spell and
grammar check your submission prior to submitting via Blackboard –
Communications – Course Messages. No other forms of submission will be
accepted or graded.
Older Adults are often prescribed at least one medication to treat chronic health
conditions (Robnett & Chop, 2015, p. 172). As, often Older Adults are taking multiple
medications, there is a risk of preventable adverse effects (Center for Disease Control
and Prevention, 2012; Robnett & Chop, 2015; pp.179-183). Efforts to prevent these
adverse events require coordinated and managed healthcare interventions to include
medication management (Robnett & Chop, 2015, pp. 183-184) with healthcare
professionals (Centers for Disease Control and Prevention, 2012). Additionally, Older
Adults need to be monitored as their health changes to incorporate these considerations
into prescribing practices based upon current research (Administration on Aging, n.d.).
References
Administration on Aging. (2011, Jan 31). “Prescription Drug Options for Older Adults:
Managing your medicines.” Eldercare locator. Retrieved from
http://www.eldercare.gov/Eldercare.NET/Public/Resources/Brochures/docs/Elder
careMedicareBrochure.pdf
Centers for Disease Control and Prevention. (2012, Oct 2). “Medication Safety Program:
Adults and Older Adults Adverse Drug Effects.” Retrieved from
http://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html
Robnett, R.H. & Chop, W. (2015). Gerontology for the Health Professional. Burlington:
MA: Jones & Bartlett.
U.S. Department of Health and Human Services/National Institute on Aging. (2009,
Sept). “Clinical Trials and Older People.” Retrieved from
https://www.nia.nih.gov/health/publication/clinical-trials-and-older-people
Scenario
•
M.M. is a 70 year old female who has been diagnosed with the following health
conditions:
o Hypertension (diagnosed at 35 years old)
o Hypothyroidism (diagnosed at 50 years old)
o Arrhythmia (diagnosed at 68 years old)
o Macular Degeneration (diagnosed at 70 years old)
o Parkinson’s disease (diagnosed at 65 years old)
o Arthritis (diagnosed at 55 years old)
o Edema (diagnosed at 68 years old)
•
The following medications have been prescribed:
o Synthroid (generic: Levothyroxin Sodium) – Refill 30 tabs/1x per month
o Inderal (generic: Propranolol) – Refill 30 tabs/1x per month.
o Lasix (generic: Furosemide) – Refill 60 tabs/1x per month.
o Percocet – Refill 30 tabs/1x per month
o Lucentis – Refill 90 tabs/1x per month
o Sinemet (Levodopa/Carbidopa) – Refill 30 tabs/1x per month.
o Hydrochlorothiazide (HCTZ) – Refill 90 tabs/1x per month.
•
M.M. is often busy and doesn’t always remember to take her medications as
prescribed. She often may take extra to “catch up” when she forgets.
•
M.M. often has a glass of wine with dinner when she goes out with her daughter
(at least once a week).
•
M.M. is living in an assisted living facility with 8 other residents.
•
M.M. has Medicare and a Medigap supplement for her insurances.
•
M.M. has meals prepared by the facilities staff, based upon recommendations
from the registered dietitian.
•
When possible, M.M. goes on the scheduled trips that the assisted living facility
frequently schedules to museums, shopping excursions and other points of
interest.
•
M.M. is considered underweight for her height (96 lbs. for 5’4”). A normal weight
would be between 110-140 lbs.
Questions for Case Study
1. What concerns do you have for M.M. regarding medication management?
(Note: Explain what conditions may lead to adverse drug effects.)
2. What individuals/agencies should be involved in addressing these
concerns? (Note: Who should be included in the discussion or be
consulted regarding medication management?)
3. How would you develop an intervention/care strategy of reducing the
potential risks for M.M. experiencing an adverse drug reaction? (Note:
What steps should be taken to reduce drug interactions and preventable
adverse reactions).
4. What can M.M. do to reduce the potential for an adverse drug effect? (Note:
What changes may be necessary to reduce preventable adverse drug
reactions?)
5. What other agencies can assist with improving M.M.’s medication
adherence to minimize adverse medication effects? (Note: Think about
what types of devices or tools are available to remind Older Adults to take
their medication or applications to prevent adverse drug interactions.)
6. What processes or procedures are necessary to safeguard M.M. from
experiencing an adverse drug interaction or effect?
Sponsored by:
Donald W. Reynolds Foundation
Arizona Geriatric Education Center
February 2011
ELDER CARE
A Resource for Interprofessional Providers
Depression in Older Adults – Pharmacotherapy
Jeannie Kim Lee, Pharm D, BCPS, College of Pharmacy, University of Arizona
Depression in older adults is a common, but frequently
underdiagnosed and undertreated, condition. Depression
goes further than personal suffering of older patients. It
also causes family disruption, increased use of healthcare
services, a decline in functional abilities, and increased risk
of death from suicide.
A previous edition of Elder Care reviewed the
epidemiology, risk factors, and diagnosis of depression.
This edition focuses on pharmacotherapy with
antidepressant medications.
There has been limited research on the use of
antidepressant medication in geriatric populations, as the
majority of clinical trials of antidepressants have been
conducted in younger individuals. Thus, clinicians have to
extrapolate from studies conducted in younger individuals
who do not exhibit the co-morbidities and polypharmacy
that often complicate treatment decisions for older
patients. Available research does, however, show that
older adults benefit most from aggressive treatment meaning that it is started early (within 2 weeks) and
continued longer than in younger adults.
Management Goals
The goals for treating geriatric depression include
symptom resolution, relapse prevention, enhanced
functional capacity, lower risk of suicide, and reduced use
and costs of health services. Treatment should be
individualized based on: (1) history of depression, (2) past
response, (3) severity of illness, (4) concurrent diseases and
medications.
For example, if a patient has a history of depression and
reports past response to a particular agent, consideration
should be given to prescribing that same medication again.
Similarly, if there is a family history of depression, the
antidepressant response of family members should be
considered in selecting a medication for the patient’s
current episode of depression.
Severity of disease is also a consideration. Although
combination therapy with multiple antidepressants should
generally be avoided to reduce the risk of adverse drug
effects, combination therapy may be needed for severe
episodes of depression. Finally, concurrent disease, such
as conditions causing chronic pain, should be managed
effectively, and if the patient is taking a medication that
can cause depression (see Table 1), the need for such
medication should be reassessed and the drug
discontinued if possible.
Table 1. Medications That Can Cause Depression
Class
Examples
Antibiotics
ampicillin, dapsone, isoniazid,
metronidazole, nitrofurantoin,
sulfonamides, tetracycline
Anticonvulsants
carbamazepine, ethosuximide,
phenobarbital, phenytoin, primidone
Antihypertensives
clonidine, methyldopa, propranolol
Anti-Parkinsons
amantadine, bromocriptine, levodopa
Antipsychotics
fluphenazine, haloperidol
Cardiac medications
digoxin, procainamide
Chemotherapies
azathioprine, bleomycin, cisplatin,
cyclophosphamide, doxorubicin, vinblastine, vincristine
Gastrointestinal agents
cimetidine, metoclopramide,
ranitidine
Hormones
glucocorticoids, estrogen-progestin
Sedatives/anxiolytics
barbiturates, benzodiazepines
Stimulant withdrawal
amphetamines, caffeine,
methylphenidate
TIPS FOR ANTIDEPRESSANT THERAPY IN OLDER ADULTS
Recognize and treat early to alleviate overuse of health services.
Assure an adequate trial (at least 6 weeks) after titrating first-line agent to therapeutic dose.
Avoid combination regimen if possible to reduce the risk of adverse effects.
Work with psychiatrists, psychologists, counselors, pharmacists, and social workers on pharmacotherapy, self-care,
behavioral changes, support systems, etc.
ELDER CARE
Continued from front page
Pharmacotherapy
Up to 75% of depressed older patients respond to pharmacotherapy. A guideline for treatment of late-life depression
was developed by the Prevention of Suicide in Primary
Care Elderly: Collaborative Trial (PROSPECT) group. The
recommended first-line antidepressant is a selective serotonin reuptake inhibitor (SSRI). The initial dose should be half
the usual adult dose, with slow titration to the target dose, if
tolerated.
If an adequate response to a first-line drug is not seen after
at least 6-8weeks of therapy at target dose, then switch to
a different first-line agent or to a second-line agent (see
Table 2). Third-line drugs, such as aripiprazole (Abilify)
and buspirone (Buspar), are reserved for augmenting the
response to a first- or second-line therapy. Other drugs
(see Table 3) should be avoided in older adults.
To prevent relapse, continue therapy for 6 months after initial remission. Patients at high risk for relapse (those who
have had two or more depression episodes, or depression
lasting more than two years) need continued therapy for at
least two years. Many clinicians would recommend indefinite treatment.
Table 3. Antidepressants to Avoid in Older Adults
Medication
Problems in Older Adults
Amitriptyline (Elavil)
anticholinergic, sedating, hypotensive
Amoxapine
anticholinergic, sedating, hypotensive,
extra-pyramidal side effects.
Doxepin (Prudoxin)
anticholinergic, sedating, hypotensive
Imipramine (Tofranil)
anticholinergic, sedating, hypotensive
Maprotiline
seizure, rash
Protriptyline (Vivactil)
anticholinergic, can be stimulating
St. John’s Wort
multiple drug interactions including
SSRIs, photosensitivity at 2-4g/day
Trimipramine (Surmontil) anticholinergic, sedating, hypotensive
Table 2. Commonly Used Antidepressants: Initial Geriatric Dose, Target Dose, and Geriatric Considerations
First-Line Medications
Initial Dose Target Dose
Geriatric Considerations
Citalopram (Celexa)
10-20 mg
20-60 mg Fewer adverse effects compared to other agents; GI distress may limit adherence; may
cause weight gain or loss; decreased sexual function possible; generic available
Escitalopram (Lexapro)
5-10 mg
10-20 mg Fewer adverse effects compared to other agents; GI distress may limit adherence; may
cause weight gain; decreased sexual function possible; more costly, no generic
Fluoxetine (Prozac)
5-10 mg
20-60 mg Last-line among SSRIs due to long half-life (parent drug and metabolite); CNS effects, GI
distress, hyponatremia, sexual dysfunction possible; weight gain or loss; generic available
Paroxetine (Paxil)
5-10 mg
10-40 mg More adverse effects compared to other SSRIs – CNS effects, ACH side effects, GI distress,
tremor, hyponatremia, sexual dysfunction possible; weight gain or loss; generic available
Sertraline (Zoloft)
25 mg
50-200 mg Less adverse effects compared to other agents; GI distress, sexual dysfunction and tremor
may limit adherence; may cause weight gain or loss; generic available
Bupropion (Wellbutrin)
50-100 mg
300-450 mg Mild GI distress possible; no effect on sexual function; effective for smoking cessation; CNS
effects, tachycardia and weight loss may limit adherence; generic available
Duloxetine (Cymbalta)
20 mg
40-60 mg CNS effects, ACH side effects, GI distress may limit adherence; weight loss and decreased
sexual function possible; more costly, no generic
Mirtazapine (Remeron)
7.5 mg
15-45 mg Severe sedation (effective in concurrent insomnia), ACH side effects, Hypotension, and
large weight gain (effective in concurrent anorexia) can be seen; generic available
Venlafaxine (Effexor)
25-75 mg
Second-Line Medications
75-225 mg CNS effects, ACH side effects, GI distress, and dose-related hypertension may limit adherence; weight loss and decreased sexual function possible; generic available
CNS = central nervous system, ACH = anticholinergic side effects, GI = gastrointestinal
References and Resources
Alexopoulos GS, et al. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry
2009; 166: 882-90.
Depression Age Page. National Institutes on Aging. http://www.nia.nih.gov/health/publication/depression
Gartlehner G, et al. Comparative benefits and harms of second-generation antidepressants. Ann Intern Med. 2008; 149:734-50.
Khouzam HR. The diagnosis and treatment of depression in the geriatric population. Compr Ther. 2009; 35:103-114.
Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. Journal of the American Geriatrics Society, 2007.
55: p. S247-S252.
ACOVE Quality Indicator: If a vulnerable elder is diagnosed with depression, then antidepressant treatment , psychotherapy, or electroconvulsive therapy should be
offered within 2 weeks after diagnosis unless there is documentation that within that period the patient has improved, or unless the patient has substance abuse or dependence, in which case treatment may wait until 8 weeks after the patient is in a drug- or alcohol-free state.
Interprofessional care improves the outcomes of older adults with complex health problems
Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD
Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP;
Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH
The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu
Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging
Running head: ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
1
APA Format Template: Title of Paper Goes Here Not Bold 12 pt. Font
Your Name
Old Dominion University
Author Note
Your contact information goes here. An Example is as follows:
Your Name, College of Health Sciences, Department of Community and Environmental Health,
Old Dominion University.
Correspondence concerning this article should be addressed to Your Name, College of Health
Sciences, Department of Community and Environmental Health, Old Dominion University,
Norfolk, VA 23529.
Contact: your name @odu.edu
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
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Title of Paper Repeated Exactly As It Appears On Title Page
To use this template, begin the body of your paper (your introduction) as the first
paragraph beneath the title. Note that APA does not use the Introduction header: just plunge in.
Add your text and delete the placeholder text used in the template. The rest of the text in this
template provides hints about properly generating all the parts of your APA-formatted paper.
APA style specifies that major components of the paper (abstract, body, references, etc.)
each begin on a new page with the heading centered at the top of the page. The body of the text
is typically divided into sections with headings such as Method, Results, and Discussion. For an
example of a paper properly formatted per the APA Manual, Sixth Edition, go to
http://www.apastyle.org/manual/related/sample-experiment-paper-1.pdf. Some papers have
multiple studies in them so the body could have multiple sections and subsections within it.
Sections can be further divided into subsections with headings. Use suitable
headings/subheadings for the topic discussed in each of the Case Studies. Unlike in earlier
editions of the APA manual, the sixth edition tells you to bold headings (but not the title above
or anything on the title page). Below are examples.
Heading Level 1
A Level 1 heading (centered, headline style caps, bold font, separate line) is used for a
major section of a paper such as the Background, Literature Review, or Discussion sections. A
Level 2 heading (flush left margin, headline style caps, bold font, separate line) would be used to
designate a subsection of a major section; a Level 3 heading (indented ½”, sentence style caps,
bold font, ends with a period, runs into paragraph text) designates a subsection under a Level 2
heading, and so on. Most student papers will use no more than three levels of headings.
The five levels of headings are shown below.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
Level 1: Major Section With Upper and Lowercase
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Heading Level 1
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Heading Level 1
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Heading Level 1
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
3
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
4
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Citations and References
Your papers should use the citation and reference formats shown in the APA Manual,
Sixth Edition. The (Author, Date) system of in-text citations is used to give credit to the words,
work, and ideas of others on which you are building your argument. The Reference section starts
on a separate page after the body text of the paper. If you need help formatting citations or
references, check out the APA Quick Reference Guide that is available on the School of Social
Work website: http://ssw.unc.edu/files/web/pdf/APA_Quick_Reference_Guide.pdf
About a References Section
An example of a References section is located further down in this template. Note that
APA uses the “hanging indent” style for references. The easiest way to create hanging indents is
to type each reference without worrying about the hanging indent. Then, when you are finished,
select all the references at once (and nothing else) and apply the hanging indent.
Tables and Figures
Check with your instructor about whether you should embed tables and figures in the text
or attach graphic elements at the end of the paper. If your instructor asks that you attach tables
and figures on separate pages at the end of the text (typical format for papers being submitted for
publication) then the manuscript order is Title Page, Body Text, Reference Section, Appendix (if
any) , Tables, and Figures.
APA format for tables omits the gridlines. See the APA Quick Reference Guide for table
formatting rules. In addition, if you need instruction on creating tables in Word, you’ll find a
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
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variety of helpful videos posted on YouTube. I recommend the following tutorial for creating
tables in Word http://www.youtube.com/watch?v=0KVBaM4N3zw If you find a helpful
resource, please pass along the information to the Writing Support Team at
SoSWwritingsupport@gmail.com
Table 1
Correlations Among and Descriptive Statistics for Key Study Variables
Dist.
M (SD)
Sex
1.53 (.50)
Age
31.88 (10.29)
Income
2.60 (1.57)
Education
3.44 (1.06)
Relig.
1.21 (.30)
Dist. Intol.
3.75 (1.19)
Sex
Age
Income
Educ.
Relig.
Intol.
.07
-.09
.02
.14
.06
.08
.19*
.20*
.01
.04
-.14
-.09
-.29*
-.06
-.19*
Note. N’s range from 107 to 109 due to occasional missing data. For sex, 0 = male, 1 = female.
BHF = babies hoped for. Dist. Intol. = distress intolerance. Relig. = religiosity.* p < .05.
Using Headers in Word
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
6
Your paper’s page number and running head are located in the Header section of the
page. To edit the Header section, click on the “Insert” tab and choose the Header or Footer
option that looks like the figure below.
Selecting the Header icon will open a drop-down box; select “Edit Header” from the
bottom of the box. Enter your running head, and then close the Header section by clicking on the
red box at the far right of the Word ribbon.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
7
References
Ajournalarticle, R. H., & Seabreeze, R. M. (2002). Example of journal article reference
entry :Title of article goes here, sentence-style caps, no italics. Journal Title in Italics and
Headline Style Caps, 22, 236-252. doi:10.1016/0022-006X.56.6.893
B’authorsurname, I. M. (2010). Example of a book reference: Book title in sentence style caps
and italics. Publisher city, ST: Publisher. doi:10.1016/0022-006X.56.6.893
Cmagazinearticle, B. E. (1999, July). Note that names on this page also identify what kind of
source it is: Each source type has to be formatted in a different way. [Special issue].
Prose Magazine, 126 (5), 96-134.
Donlinemagazineornewsletterarticle, B. E. (1999, July). Did you notice alphabetical references.
[Special issue]. Hot Prose, 126 (5). Retrieved from http://www.hotprose.com
Gbookreference, S. M., Orman, T. P., & Carey, R. (1967). Writers’ book. New York, NY: Lu
Press.
O’encyclopedia, S. E. (1993). Words. In The new encyclopedia Britannica (vol. 38, pp. 745758). Chicago: Forty-One Books.
Qchapter, P. R., & Inaneditedvolume, J. C. (2001). Scientific research papers. In J. H. Stewart &
J. M. Kimmel (Eds.), Research papers are hard work but boy, are they good for you (pp.
123-256). New York, NY: Lucerne.
Rnewspaper articles without authors appear to sharply cut risk of schizophrenia. (1993, July 15).
The Washington Post, p. A12.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
Frugality
Amount that
Gets Spent
on Alcohol
8
Alcohol
Consumption
Figure 1. This simple path model, adapted from results in a Journal of Consumer Behaviour
paper, is an example of a figure.
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Formatting
Title Page
Citation
Outline
