The Need for Ongoing Medication Review in the Elderly Population

An essential principle in the practice of geriatric medicine is the need to scrupulously and frequently review the patient’s current list of medications. The necessity for this practice cannot be overstated. Very frequently, the causes of a change in a patient’s health status or level of cognition are likely the result of a change in the patient’s medication regimen. This change may result in an adverse drug reaction or may result in the development of a drug-drug interaction. The following case report illustrates this point and the need for ongoing review of medications. Case Presentation Mrs. TC is an 85-year-old widow who lived in an apartment adjacent to her daughter since her husband’s death seven years earlier. For the past year, she had a companion for several hours daily to assist with domestic chores and on shopping trips. She remained independent in all her activities of daily living (ADLs), but required some assistance from her daughter in balancing her checkbook and paying her bills. She has a past medical history significant for hypertension, constipation, hemorrhoids, and degenerative joint disease. Mrs. TC fell in her bedroom during the night and sustained a right hip fracture. She underwent a right hip open reduction internal fixation (ORIF), which was complicated by postoperative confusion. She was discharged from the hospital to our facility for subacute rehabilitation with a new diagnosis of dementia. Her medications upon admission included amlodipine 10 mg once daily, extended-release metoprolol 50 mg once daily, hydrochlorothiazide 12.5mg once daily, omeprazole 20 mg once daily, calcium 500 mg with vitamin D twice daily, and a multivitamin supplement. After a successful first week of rehabilitation therapy, Mrs. TC’s participation and endurance in therapy began to wane. She appeared more confused and was less able to follow directions. She was noted to be hypotensive, with a resting blood pressure of 86/50 and a pulse of 76. Despite the discontinuation of all of her antihypertensive medications, Mrs. TC’s blood pressure remained at approximately 110/50, and she was not able to participate any further in a skilled rehabilitation program due to orthostasis and an inability to follow commands because of a new baseline level of cognitive impairment. Following extensive discussions with her family, Mrs. TC’s daughter decided to transfer her mother to long-term care for several months, as her significant decline in ADLs presented difficulty in caring for her mother’s needs at home, and time was needed to consider options for her mother’s long-term care needs. A medical workup was commenced to determine the cause of the new-onset orthostatic hypotension and confusion in an 85-year-old patient with a prior history of severe hypertension. A brain computed tomography (CT) scan revealed mild atrophic changes. An electrocardiogram (EKG) was done, and was unchanged when compared with her pre-operative EKG several weeks earlier. Serum electrolytes as well as a thyroid-stimulating hormone (TSH), B₁₂, and folate level tests were within normal limits. Further scrutiny of the patient’s medications administration record failed to provide any cause for this recent change in the patient’s status. Several days later, I became aware of an ointment with an unfamiliar label on the patient’s dresser. When I questioned this, the patient’s aide explained that this was a hemorrhoidal ointment that the patient had begun using prior to her hospitalization. The patient’s daughter had brought it from home and had asked her mother’s private aide to apply it to the patient’s rectum twice daily. The ointment had been prescribed by the patient’s gastroenterologist several weeks earlier, shortly before the patient’s fall at home. Although she was aware that all medications and treatments must be prescribed and dispensed by nursing staff, she apologetically stated that she hadn’t mentioned this ointment earlier as “it was just a hemorrhoid cream.” In fact, the ointment in question was a nifedipine-based compound prescribed for symptomatic relief of rectal fissure and the pain associated with it. Following the discontinuation of the newly-discovered nifedipine-based ointment preparation, Mrs. TC’s blood pressure returned to normal levels, and she was once again able to participate in physical therapy. Over the course of the next week, her cognitive status improved dramatically, returning to her prior baseline functional status. She completed her rehabilitation therapy and subsequently returned to her apartment in the community. Discussion There is clinical evidence in the medical literature supporting the use of topical nifedipine in the treatment of anal fissures. However, there have been no cases reported in the literature related to the development of hypotension associated with its usage. In one study, application of topical nifedipine was shown to promote healing of chronic anal fissure with efficacy that approached the success rate for patients undergoing internal lateral sphincterotomy.¹ Other studies have supported the use of topical nifedipine in healing chronic anal fissures at 6 weeks; however, there is concern about recurrence of fissures in the long term.^2,3 The case of Mrs. TC illustrates several key principles of geriatric medicine. The importance of comprehensive medication reconciliation in the elderly patient is a primary component of good geriatric care. This process must take place across the spectrum of healthcare delivery, whether in the office-based setting, the acute care setting, or in long-term care. Patients may visit different physicians for specific complaints and obtain new prescription medications from each physician, without the knowledge of the patient’s primary care physician. Often, upon discharge from an acute or subacute care facility, medications may have been added or removed from the patient’s regimen. The clinician cannot assume that this information will be conveyed by the patient on a subsequent visit. Secondly, the case of Mrs. TC emphasizes the importance of asking patients and families about all medications and preparations that the patient is currently taking. In order for a physician to effectively manage the geriatric patient, accurate and up-to-date information must be elicited from the patient or family member at each visit; these must include prescription items, ophthalmological preparations, over-the-counter preparations, and herbal supplements. Finally, this case illustrates the fundamental rule of geriatric pharmacology that “anything can cause anything.” Physicians must be vigilant in noting a temporal relationship between the initiation of a new medication and the onset of a new complaint or symptom. The incidence of an adverse drug reaction is significantly elevated in the elderly population. This results from several factors that affect the pharmacokinetics, including alterations in drug absorption and distribution, prolonged rates of metabolism, and delays in elimination causing elevated serum drug levels and the potential for drug-drug interactions. The physician must keep in mind that the most seemingly benign medications, such as aspirin or acetaminophen, can cause serious adverse reactions when misdosed. In the case of Mrs. TC, what was perceived to be a “benign” hemorrhoidal cream resulted in significant orthostatic hypotension and cognitive impairment due to cerebral hypoperfusion. The author reports no relevant financial relationships.