CASE STUDY: Medication Review and Reconciliation Service
BEFORE – Patient Setting and Current Medications
Patient: Harold S., 92-year-old male
Primary Diagnosis: Congestive Heart Failure (CHF), NYHA Class III
Secondary Diagnoses: Type 2 Diabetes Mellitus, Iron Deficiency Anemia
Current Status: Uses 2L oxygen via nasal cannula as needed for shortness of breath, lives at home with daughter as primary caregiver
Current Medication List (Before Review):
- Atorvastatin 80mg daily
- Metformin 1000mg twice daily
- Glipizide 10mg twice daily
- Furosemide (Lasix) 40mg twice daily
- Ferrous Sulfate 325mg three times daily
- Lisinopril 10mg daily
- Metoprolol 50mg twice daily
- Aspirin 81mg daily
- Omeprazole 20mg daily
- Docusate 100mg twice daily
- Multivitamin daily
- Melatonin 3mg at bedtime
AFTER – Medication Review and Reconciliation Report
COMPASSION CROSSING, LLC – MEDICATION REVIEW REPORT
Date: [Current Date]
Patient: Harold S., Age 92
Reviewed by: Peter M. Abraham, BSN, RN, EOLD
CURRENT MEDICATIONS ANALYSIS
1. Atorvastatin 80mg daily
- Intended Benefit: Lower cholesterol to prevent cardiovascular events
- Absolute Risk Reduction: 2-3% over 5 years for primary prevention in the elderly
- Side Effects: Muscle pain, liver problems, memory issues, increased fall risk
- Recommendation: DISCONTINUE – Limited benefit in 92-year-old with CHF; high dose increases fall risk and muscle weakness
2. Metformin 1000mg twice daily
- Intended Benefit: Blood sugar control in Type 2 diabetes
- Absolute Risk Reduction: 1-2% reduction in HbA1c
- Side Effects: GI upset, lactic acidosis risk with kidney/heart problems
- Recommendation: REDUCE DOSE to 500mg twice daily due to CHF and age-related kidney function decline
3. Glipizide 10mg twice daily
- Intended Benefit: Blood sugar control
- Absolute Risk Reduction: 0.5-1% reduction in HbA1c
- Side Effects: Hypoglycemia, weight gain, increased fall risk
- Recommendation: REDUCE to 5mg twice daily – high hypoglycemia risk in elderly
4. Furosemide (Lasix) 40mg twice daily
- Intended Benefit: Fluid removal for CHF management
- Absolute Risk Reduction: Symptom relief, not mortality benefit
- Side Effects: Dehydration, electrolyte imbalance, kidney problems
- Recommendation: CONTINUE AS IS but monitor kidney function and electrolytes monthly
5. Ferrous Sulfate 325mg three times daily
- Intended Benefit: Treat iron deficiency anemia
- Absolute Risk Reduction: Variable based on iron levels
- Side Effects: Constipation, GI upset, drug interactions
- Recommendation: REDUCE to 325mg daily – lower dose equally effective with fewer side effects
6. Lisinopril 10mg daily
- Intended Benefit: Heart failure management, blood pressure control
- Absolute Risk Reduction: 4-6% mortality reduction in CHF
- Side Effects: Cough, kidney problems, high potassium
- Recommendation: CONTINUE AS IS – proven benefit in CHF
7. Metoprolol 50mg twice daily
- Intended Benefit: Heart rate control, CHF management
- Absolute Risk Reduction: 3-5% mortality reduction in CHF
- Side Effects: Fatigue, low blood pressure, breathing problems
- Recommendation: CONTINUE AS IS – essential for CHF management
8. Aspirin 81mg daily
- Intended Benefit: Cardiovascular protection
- Absolute Risk Reduction: 0.3% stroke reduction in the elderly
- Side Effects: Bleeding risk, GI upset
- Recommendation: DISCONTINUE – bleeding risk outweighs minimal benefit at age 92
9. Omeprazole 20mg daily
- Intended Benefit: Stomach acid reduction
- Absolute Risk Reduction: Variable
- Side Effects: Nutrient malabsorption, bone fractures, kidney problems
- Recommendation: TAPER OFF over 2 weeks – reduce to every other day for 1 week, then stop
10. Docusate 100mg twice daily
- Intended Benefit: Prevent constipation
- Absolute Risk Reduction: Minimal evidence of effectiveness
- Side Effects: Minimal
- Recommendation: REPLACE with increased fiber and fluids; use senna 8.6mg as needed
11. Multivitamin daily
- Intended Benefit: Nutritional supplementation
- Absolute Risk Reduction: No proven benefit for the elderly
- Side Effects: Minimal
- Recommendation: CONTINUE AS IS – low risk, potential benefit
12. Melatonin 3mg at bedtime
- Intended Benefit: Sleep aid
- Absolute Risk Reduction: Variable
- Side Effects: Daytime drowsiness, increased fall risk
- Recommendation: REDUCE to 1mg or discontinue – high fall risk
SUMMARY OF RECOMMENDATIONS
DISCONTINUE IMMEDIATELY:
- Atorvastatin 80mg daily
- Aspirin 81mg daily
TAPER OFF:
- Omeprazole: Reduce to every other day for 1 week, then stop
REDUCE DOSAGE:
- Metformin: Reduce to 500mg twice daily
- Glipizide: Reduce to 5mg twice daily
- Ferrous Sulfate: Reduce to 325mg daily
- Melatonin: Reduce to 1mg at bedtime
CONTINUE AS-IS:
- Furosemide 40mg twice daily
- Lisinopril 10mg daily
- Metoprolol 50mg twice daily
- Multivitamin daily
MEDICATION CHANGES:
- Replace Docusate with Senna 8.6mg as needed for constipation
MONITORING RECOMMENDATIONS:
- Monthly kidney function and electrolyte monitoring
- Blood sugar monitoring with diabetes medication changes
- Iron levels in 3 months
- Blood pressure monitoring with medication changes
FOLLOW-UP:
Two follow-up calls were included within 30 days to address questions or concerns about medication changes.
IMPORTANT NOTE: These are recommendations only. Before implementation, all medication changes must be discussed with and approved by the patient’s healthcare providers.
This case study demonstrates how medication review can identify potentially inappropriate medications in elderly patients, reduce polypharmacy risks, and focus on medications that provide the most benefit with the least harm. We’re here to help you during this difficult time. Schedule a free conversation with Nurse Peter to see how we can support you or someone you care about.