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Polypharmacy, Chronic Constipation, and Medication Reconciliation

4/16/2009
Mrs. Greene is an 89-year-old woman admitted to a long-term care facility after a short hospitalization for congestive heart failure and pneumonia. In addition to these conditions, she has a history of Type 2 diabetes, hypertension, progressive dementia (currently moderate), GERD, and chronic constipation. Mrs. Greene is non-ambulatory and dependent for transfers. Her appetite is fair and she is incontinent of urine. She had complained of chronic constipation prior to her most recent hospitalization. She is a former school teacher and a widow of 9 years, a non-smoker, and a social drinker (< 1 drink per day).

Vital statistics upon admission

Height: 61"
Weight: 144 lbs (up from 142 in hospital)

BP/Pulse (today):
BP: 188/68
Pulse: 79 regular, respirations 16 and non labored

BP/Pulse (prior to discharge from hospital):
BP: 128/54
Pulse: 82 regular, respirations 14 non labored

Lab results

A1C 8.6 (8 months ago)
TSH 1.2
T4 1.2
Calculated GFR: Scr 1.6mg/dl
CrCl: 25 mls/min (using the Cockcroft-Gault equation)

Physical exam

Well-built, well-nourished female in no acute distress.
HEENT: poor dentition
Neck: supple, No JVD
Lungs: Clear, poor effort
Heart: Regular
Abdomen: Soft, non-tender
Extremities: slight edema (1-2+)

Medications

Furosemide: 20mg daily
Levothyroxine: 50 micrograms daily
Sertraline: 25mg daily
Famotidine: 20mg at bedtime
Donepezil HCl: 5mg at bedtime
Insulin glargine: 20 units at bedtime
Sliding Scale Insulin per protocol
GlucernaŽ: at bedtime and as a snack with a sandwich
Docusate sodium: 300mg q AM
Bowel protocol: (LTC specific)
Note: She has no known drug allergies

Questions to consider:

1. How should the consultant pharmacist begin the drug regimen review process for this resident?

Chronic Constipation in LTC: The Medication Regime Review (MRR) and F-Tags

2. What medications could be affecting her ability to have a "normal" bowel movement?

Polypharmacy and Constipation

3. What medications could be affecting the resident's overall health by exacerbating a chronic disease or condition?

Polypharmacy and Constipation

4. What would the first steps be in "improving" this resident's care?

Nonpharmacologic Management of Chronic Constipation in the Elderly

Pharmacologic Management of Chronic Constipation in the Elderly

5. Are there resources that can be used to provide a common sense approach to this case?

Treatment Adherence in the Elderly: A Case Management Perspective

Review previous topics and cases to consider your responses.
Dr. Brodeur will provide other possible answers.

Case contributed by:

Michael R. Brodeur, PharmD, CGP, FASCP
Associate Professor
Department of Pharmacy Practice
Albany College of Pharmacy
Albany, NY









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The E-IMPACCT (Elderly IMProvements & Advances in Chronic Constipation Treatment) educational initiative is sponsored through a collaboration of ASCP, AKH Inc., and Medical Communications Media, Inc.

Supported by an educational grant from Sucampo Pharmaceuticals, Inc. and Takeda Pharmaceuticals North America, Inc.

 

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