I Found this today in one of the blogs I follow. An example of how 10 minute care with your practitioner is not holistic care. Of why it is really up to the practitioner how much time you need for a visit. An example of the consequences of treating symptoms instead of root cause:

Background

An 88-year-old woman visited her cardiologist. She was prescribed amlodipine to manage her systolic blood pressure, which was measured at 150. Subsequently, she developed edema and was prescribed Lasix (furosemide) along with potassium supplements.

Due to experiencing incontinence, she was given oxybutynin. She then started experiencing dizziness and was prescribed meclizine. Following this, she developed dysphagia and began to aspirate. As a result, she lost 45 pounds over the course of five months.

Unfortunately, she then suffered a fall, breaking her humerus and incurring a subdural hematoma (SDH). The family decided to sue and ultimately won the case.

Question

What did the cardiologist do wrong?

Case review and explanation

This patient presented with a systolic blood pressure (SBP) of 150 mmHg and was prescribed amlodipine. Shortly after, she developed edema and was prescribed Lasix (furosemide) along with potassium supplements, complicating her treatment regimen and increasing the complexity of her care. As these medications were introduced, the possibility of adverse effects and drug interactions should have been carefully evaluated. The principle of avoiding polypharmacy, especially in elderly patients, is crucial to minimize the risk of interactions that can lead to severe outcomes.

Instead of addressing the root cause of symptoms like dizziness and incontinence with comprehensive assessments, symptomatic treatments such as meclizine and oxybutynin were administered. This approach potentially obscured underlying issues and led to further complications, including dysphagia and significant weight loss. In managing elderly patients, therapeutic strategies should prioritize addressing the underlying condition with minimal medication use and exploring non-pharmacological interventions as first-line treatments.

Ultimately, the patient’s complex medication regimen and the lack of a coordinated approach led to adverse outcomes, including a fall resulting in a humerus fracture and subdural hematoma (SDH). Evaluating medication necessity, duration, and efficacy through ongoing assessments could have prevented many of these complications. Engaging in a thorough review of the patient’s complete medication profile, including over-the-counter drugs, and focusing on therapeutic rather than preventive measures tailored to the patient's age and condition, might have offered a more favorable outcome. The family’s decision to pursue legal action, resulting in a successful case, underscores the importance of careful medication management in vulnerable populations.

Guidelines for Proper Medication Prescribing, Prevention of Polypharmacy, and Medication Reduction

(Avoid Too Many* Practice Mnemonic)

Alternatives: Use non-pharmacological therapies whenever possible (e.g., warm milk instead of a sleeping agent).

Vague history or symptoms: Do not treat vague symptoms with drugs (e.g., vague gastrointestinal “upset” with H2 blocker).

OTC: Over-the-counter drugs do count as drugs.

Interactions (drug-drug, drug-disease)

Duration: If possible (e.g., symptomatic drugs), decide on the duration of therapy. If there is no positive effect after the trial period, stop before adding another medication.

Therapeutic vs. preventive: Depending on life expectancy, preventive drug therapy may not benefit the patient. In general, therapeutic drugs should have priority over preventive drugs.

Once a day vs. BID, TID, QID:  In general, once a day improves compliance, but may be more expensive than TID or QID drugs.

Other MDs

Money issues

Adverse drug effects of other drugs: Do not treat adverse drug effects with a different drug if the offending agent can be stopped or changed.

Need: Does the person really need medication now?

Yes/No: Refers to compliance. Is the person taking the current medication?

* Adapted from: Flaherty, Joseph H., M.D., and Nina Tumosa, Ph.D., Saint Louis University Geriatric Evaluation Mnemonic Screening Tools. Saint Louis University School of Medicine Division of Geriatric Medicine and the Geriatric Research, Education, and Clinical Center St. Louis VA Medical Center, n.d.