Pharmacology - Polypharmacy case study

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The Subject Learning Outcomes demonstrated by successful completion of the task below include:

a) Identify and discuss the general principles of pharmacology including pharmacokinetic concepts and pharmacodynamics and their application to pathophysiological states.

b) Explain and apply quality & safety frameworks to the use of therapeutic medicines in clinical practice

c) Compare and contrast the mechanisms of action, therapeutic uses, adverse effects, interactions, contraindications and routes of administration of different drug groups.

d) Deduce the factors contributing to individual variability and determine dosage individualisation strategies to control variability in drug response including lifespan aspects of drug therapy and population groups with specific needs.

e) Identify and justify utilisation of evidence-based reference resources relating to integrative pharmacology to identify, prevent and clinically manage polypharmacy, potential adverse drug reactions, interactions and toxicity to ensure safe practices.

g) Explore and apply professional, legal and ethical issues surrounding the safe prescription and administration of medications.

In this assessment, you will review the case of a patient who is on multiple medications and answer a series of short answer questions related to polypharmacy (1500 words).

Rosa has been admitted to the Geriatric Evaluation Management (GEM) ward following a functional decline at home and urinary tract infection (UTI). Prior to admission, an on-call GP visited Rosa at home, because she had been feeling unwell with symptoms of urinary frequency, dysuria and urge incontinence for a few days.

The GP diagnosed a UTI and prescribed trimethoprim 200 mg BD for 3 days.

Rosa deteriorated the following day with symptoms of confusion, nausea and unsteady gait. Rosa’s husband called an ambulance, resulting in a subsequent visit to an emergency department (ED), where she was transferred to the GEM ward for further assessment and management.

Patient Details
Name: Rosa Ferarri	Age: 86
Allergies: None	Language Italian (limited English)
Medical Past History
· Coronary heart disease (CHD) · Asthma · Anxiety · Insomnia	· Moderately impaired left ventricular systolic function on ECHO · Hypertension (HT) · Partial deafness (L) ear
Social History
· Lives with husband · Supportive sons x2	· Smokes 10 cigarettes daily · Drinks 4-6 standard alcoholic beverages per week
Results
· BP 170/80 mmHg · Respiratory Rate 26 per minute (rest) 36 on exertion · Sp02 94% on Room Air	· U&Es all within normal range · Pulse 91 bpm regular
Current Medications
· Omeprazole 20 mg once daily · Simvastatin 40 mg at night · Clopidogrel 75 mg once daily · Bisoprolol 2.5 mg once daily · Amlodipine 10 mg once daily	· Furosemide 40 mg once daily · Temazepam 10mg PRN at night · Salbutamol Inhaler 4 puffs PRN · Trimethoprim 200 mg BD for 3/7
Admitting Diagnosis
· UTI · Functional decline
Clinical Handover 07:00am
Night shift report Rosa was irritable and unsettled overnight, she was given 15mg Temazepam at 02:20am as prescribed PRN for insomnia. Night shift nursing staff tell you that they have recently paged the medical officer to review and request a telephone order for nebulised salbutamol 5mg, as they think Rosa is experiencing an exacerbation of asthma as she’s a little breathless. Rosa is drowsy and unable to co-ordinate using the salbutamol, and the uncoordinated use of the puffer had no effect on her symptoms of breathlessness. Rosa shows increased used of accessory muscles, is breathless at rest, and this becomes worse with any exertion. She needed assistance x2 to be propped up in bed and she was sliding down the bed. Night shift observed persistent issues with peripheral pitting oedema, and lower limbs leaking serous fluid at times. Night shift document suspecting Rosa shows signs of early dementia, she is confused and irritable, with a GCS of 12 (eyes open to speech, verbal responses are confused and she moves to localised pain).