Patient A is 82 years of age with a history of congestive heart failure, glaucoma, hypertension, and osteoarthritis. Her current medications are furosemide, potassium, lisinopril, metoprolol, aspirin, timolol maleate opthamic solution (Timoptic), acetaminophen (as needed), multivitamin, and a calcium/vitamin D supplement (800 IU daily). She has an appointment with a new orthopedic physician. During the appointment, the patient complains of persistent arthritic pain in her knee. The physician prescribes the nonsteroidal anti-inflammatory drug (NSAID) meloxicam (7.5 mg per day) for pain and inflammation.

Comments and Discussion : From the orthopedic standpoint, prescription of meloxicam is good practice, as it should help to ameliorate patient A's symptoms. However, from a cardiac standpoint, this is a risky approach due to the potential side effect of fluid retention and its effect on the heart. In general, NSAIDs can be dangerous for an individual of Patient A's age. NSAIDs (including meloxicam, but also over-the-counter options like ibuprofen) have been issued "black box" warnings by the U.S. Food and Drug Administration (FDA) for the increased risk of:

Patient A has a good working relationship with her primary care provider, who has instructed her to contact him regarding any changes in her medication regimen. She calls her physician prior to taking the medication, and he advises her not to take the NSAID. Instead, he devises a pain management plan that minimizes the potential risks. Previously, Patient A was taking acetaminophen as needed, averaging up to one dose daily. This is increased to twice daily extended-release acetaminophen (650 mg). For breakthrough pain, tramadol 25 mg every four hours (as needed) is prescribed. Another option considered was the topical anti-inflammatory diclofenac sodium 1% topical gel, which would have fewer side effects than systemic agents. Aside from pharmacotherapy, the patient is scheduled with a physical therapist to create a safe exercise plan, including strengthening and range-of-motion exercises.

Patient B is a man, 78 years of age, who resides in a nursing facility. One year ago, he fell and fractured his left hip and underwent surgical repair. He returned to the nursing facility, completed rehabilitation, and regained most of his prior function. After the surgery, Patient B was prescribed warfarin to prevent deep vein thrombosis (DVT) after surgery.

During a routine survey, a state surveyor discovers that Patient B is still being administered warfarin. After further investigation, it is discovered that the warfarin was never discontinued after the appropriate duration after the hip fracture repair. The surveyor considers warfarin an unnecessary drug, and a citation (F757) is issued. After contacting the attending physician, the warfarin is promptly discontinued.

Comments and Discussion : Patient B 's case is an example of using the right drug but not using it for the correct duration. After orthopedic surgery, warfarin is usually indicated for approximately two to three months or until activity/ambulation has increased to a point that the risk of DVT is reduced. There is a substantial burden of treatment with warfarin, including weekly evaluations of prothrombin time/international normalized ratio (PT/INR), adverse reactions, interactions, and increased risk of bleeding and brain hemorrhage, especially for patients with a history of falls.

There is shared responsibility for this error between the prescriber/healthcare provider and the facility. The provider did not follow through and discontinue the medication when it was no longer needed, and the facility nursing staff should have realized that the drug was no longer necessary and approached the provider for an order to discontinue. The nursing facility could have called the orthopedic physician for orders and duration of warfarin treatment after surgery. When a medication is started, the stop date for that medication should be considered and established. The consultant pharmacist could have intervened as well.

Patient T is a man, 84 years of age, who resides in a long-term care facility. He has been diagnosed with congestive heart failure, hypertension, arthritis, and hyperlipidemia and has a history of two myocardial infarctions (eight and two years previously). He requires minimal assistance with his activities of daily living and remains ambulatory with a cane. His usual medications are:

At baseline, he takes 10 medications/supplements.

Patient T is transferred to the emergency department for increased shortness of breath. He is diagnosed with bronchitis and spends 24 hours in the hospital for observation before being transferred back to the long-term care facility for ongoing care. At the care facility, the receiving practitioner reviews the medication list from the hospital:

Including the as-needed medications, Patient T is currently prescribed 17 drugs. Physical assessment reveals an elderly debilitated man who is in no acute distress (Table 3). He is alert and oriented and answers questions appropriately. His intake of food and fluids has been poor since his return from the hospital, and he is using oxygen per nasal cannula at 2 L/minute.

As noted, Patient T's new diagnosis is bronchitis, and he does not appear to be having an exacerbation of his CHF. The first step in medication reconciliation is to discontinue any as-needed medications ordered in the hospital that are no longer necessary. Haloperidol is frequently used to treat delirium in geriatric patients in the hospital setting, but it is considered inappropriate for this use in long-term care facilities. Secondly, duration should be established for levofloxacin and prednisone. The receiving practitioner contacts the ordering physician and determines the levofloxacin should be continued for seven days and the prednisone continued for two weeks with a plan for tapering to discontinue. A pulmonary consultation follow-up is scheduled in two weeks, during which the pulmonologist will determine the duration of the inhalation drugs started during the hospitalization. The oxygen therapy was also acquired during the hospitalization, and serial oxygen saturation readings will be used to determine whether Patient T will require long-term oxygen therapy.

As discussed, the reduction or discontinuation of medications should be done cautiously, generally one medication at a time. The provider reviews the drugs the patient usually takes, evaluating for polypharmacy or any prescribing problems with the drugs ordered (Table 4).

When reconciling the medication regimen, the first step is to identify the clinical indication for each medication. There are no obvious inappropriate prescribing practices in Patient T's record, and in a patient with multiple comorbidities, polypharmacy may become the standard. However, attempts at medication reduction and discontinuation should be attempted.

His primary care provider discusses the medication regimen with the patient and his daughter, who is his healthcare surrogate. They express interest in attempting to reduce the number of medications Patient T is taking.

The provider discontinues tramadol and writes orders to taper off omeprazole by giving every other day for 10 days, then stopping. The aspirin dose is reduced to 81 mg every day, and the atorvastatin is reduced to 10 mg daily with a plan for serial lipid measurements.

The ongoing dosages of furosemide and potassium are determined by the level of heart failure. When patients decline and lose weight, adjustments to diuretic dosages are required to prevent subsequent dehydration. Older patients are at increased risk of falls and complications due to orthostatic hypotension, and if the patient is dehydrated, the effects are more profound and potentially dangerous. Measurement of orthostatic vital signs will help to determine the appropriate dosage of metoprolol, lisinopril, and even furosemide. After the reconciliation, omeprazole and tramadol are discontinued and the dosages of several drugs are reduced (Table 5).

Comments and Discussion : Mr. T's case shows an example of multiple comorbid conditions and polypharmacy. There are no obviously inappropriate drugs, and each medication has a clinical indication consistent with evidence-based medicine. This makes medication reduction and reconciliation difficult.

When medication regimens are adjusted, the patient should be monitored and re-evaluated regularly to detect any adverse reactions. In some cases, a trial dosage reduction or discontinuation of a medication, with close monitoring of the patient response, is necessary.

Medication reduction in the elderly should be done slowly and conservatively to prevent rebound effects. Manufacturer and FDA recommendations should be followed for tapering to reduce or discontinue medications. The provider must refer to packaging inserts and information.