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Lindsey TheriotMarch 5, 2014Case Study 5: Polypharmacy of the ElderlyUnderstanding the Disease and PathophysiologyIdentify each of the medical diagnoses for Mr. Kaufman.Metabolic Alkalosismild dehydrationtype 2 DMRenal insufficiencyIdentify which if these may affect cardiac function, liver function and renal function.Cardiac function- dehydration, Metabolic Alkalosis, Type 2 DMLiver function- dehydration, Type 2 DMRenal function- dehydration, Type 2 DM, renal insufficiency, Metabolic AlkalosisAre there also normal changes in renal function that occur with agingYes, with increasing age comes a normal decrease in renal function; which is not always due to the same cause, it is dependent on the individual. Define polypharmacy. Do you think that Mr. Kaufman's medications represent polypharmacy? Why is polypharmacy a concern in the elderly?A. Polypharmacy is administering multiple drugs to one individual at one time. I do believe Mr. Kaufman's medications represent polypharmacy because he is taking multiple medications at once and he is also taking the wrong dosage of the medications. Polypharmacy is a concern in the elderly because they are often prescribed multiple medications together and their absorption, metabolism, distribution and excretion abilities tend to decline with age; which can lead to harmful interactions between the drugs.II. Understanding the Nutrition Therapy 5. Describe the potential nutritional complications secondary to pharmacotherapy.Some nutritional needs will increase as a result of pharmacotherapy. Certain foods will have to be eliminated from the diet due to possible drug-nutrient interactions. There might also be a need for a decrease of foods and nutrients due to pharmacotherapy. 6. Describe the potential effect of nutrition on the action of medications. Nutrition affects drug dissolution, absorption, metabolism and excretion; such as if a patient was dehydrated he or she would not be able to absorb the medication properly and it would not be as effective as it is intended to be. III. Nutrition AssessmentA. Evaluation of Weight/Body Composition7. Mr. Kaufman is 5'5'' tall and weighs 196lbs. Calculate his body mass index. How would you interpret this value? Should any adjustments be made in the interpretation to account for his age?BMI is 32.6. ((196 X 703) / (652)) Mr. Kaufman is categorized as obese since his body mass index is greater than 30. Age is not a factor when calculating body mass index.8. Calculate Mr. Kaufman's percent usual body weight. Interpret the significance of this assessment.((current body weight/ usual body weight) X 100) = 93% UBW. Mr Kaufman's percent usual body weight of 93% shows that he has lost weight, when comparing is current weight to his usual body weight.9. In an older individual, what specific changes occur in body composition and energy requirements that may need to be taken into consideration when completing a nutritional assessment?A. In an older individual, typically their percent body fat increases, bone density decreases and muscle mass decreases. Elderly individuals require a decrease in energy needs as a result off body composition changes. Calculation of Nutrient Requirements10. Calculate energy and protein requirements for Mr. Kaufman. Identify the formula/ calculation method you used and explain the rationale for using it. What factors should you consider when estimating his requirements?Energy- (9.99 X 89 kg) + (6.25 X 139.7 cm) - (4.92 x 85) + 5 = 1349 X 1.4(a.f.) X 1 (i.f.)= 1889 calories/day. Mifflin St. Joer was used because it take into account weight, height, age; which allows adjusted body weight to not be used. B. Protein- (.8 X 89 kg) = 71.2 grams/day. This equation used .8 as a variable because the patient has no injury requiring an elevated protein need. C. When estimating his requirements, his age, weight, height, and activity and injury factor should be considered to get the right amount of nutrients needed. Also, basal metabolic rate reduces with age and it is a factor in the Mifflin St. Joer method so that is another reason that equation was used to assess caloric needs. C. Intake Domain11. Mr. Kaufman's daughter expressed concern regarding his fluid intake. Is this a common problem in aging? Explain. Decreased fluid intake is a common problem when it comes to the elderly because they tend to not drink as much as they did when they were younger. Their desire and quench for fluids decrease as they age.12. There are several ways to estimate fluid needs. Calculate Mr. Kaufman's fluid needs by using at least two of these methods. How do they compare? From your evaluation of his usual intake, do you think he is getting enough fluids?A.(kg body weight x 30 ml) = 89kg X 30 ml = 2670 ml/dayB.(1 ml X kcal needs) = 1889 ml/dayC. Using the first method resulted in a higher needs per day. He is obviously not getting enough fluids because his levels showed he was dehydrated and his daughter even stated that he is not drinking much. 13. Evaluate Mr. Kaufman's usual intake for both caloric and protein intake. How does it compare to the MyPyramid recommendations?According to MyPyramid it is recommended he have 5 1/2 ounces of protein a day and he is consuming over that amount daily. His calorie intake is lines with the recommendations except for his carbohydrate intake; which is too high, especially since he is a type 2 diabetic.14. From the information gathered within the intake domain, list Mr. Kaufman's possible nutrition problems using the diagnostic term. A. Excessive carbohydrate intakeB. Inadequate fluid intakeC. Inadequate calcium intake15. Do you think Mr. Kaufman needs to take a multivitamin? In general, do needs for vitamins and minerals change with aging? What references would you use to determine recommended amounts of the micronutrients?Yes, I would recommend Mr. Kaufman needs to take a multivitamin because his potassium, calcium and magnesium levels are low. Needs for vitamins and minerals do increase with age because patients tend to have decreased intake and absorption ability. MyPlate and lab values will be sued as references for recommended micronutrients. D. Clinical Domain16. Mr. Kaufman was diagnosed with mild metabolic alkalosis and dehydration. What is metabolic alkalosis? Read Mr. Kaufman's history and physical. What signs and symptoms does the patient present with that may be consistent with metabolic alkalosis and dehydration? Explain. A. Metabolic alkalosis is when the pH of tissue is elevated beyond the normal range of 7.35-7.4; this is the result of decrease hydrogen ion concentration, leading to increased bicarbonate. The patient's signs of dehydration is the fact that he does not drink much when given a beverage and that his electrolyte levels are off. His recent state of confusion can be from metabolic alkalosis and dehydration. Metabolic alkalosis could have caused decreased potassium levels and his high pH of 7.47. The patient's his osmolality of 310 is indicative of dehydration. Dehydration causes low fluid levels which lead to the increased osmolality and confusion.17. What laboratory values support his medical history of renal insufficiency? What laboratory values support this diagnosis of metabolic alkalosis? What are consistent with dehydration? What laboratory values support his medical history of type 2 diabetes mellitus? Renal insufficiency evident by BUN high at 32, creatinine high at 1.5, albumin low at 3.4 and CO2 high at 31.Metabolic alkalosis is shown by a pH high at 7.47, potassium low at 3.4, pCO2 high at 46, HCO3 high at 32 and CO2 high at 31.Dehydration is from a high osmolality of 310 and a high CO2 level of 31. LaboratoryNormalMr. Kaufman's ValueAlbumin 3.5-5 g/dL3.4 HPotassium3.5-5.5 mEq/L3.4 LOsmolality285-295 mmol/kg/H2O310 HGlucose70-110 mg/dL172 HBUN8-18 mg/dL 32 HCreatinine0.6- 1.2 mg/dL1.5 HHbA1c3.9-5.2 %8.2 HpH7.35-7.457.47 HpCO235-45 mm Hg46 HCO225-30 mmol/L31 HHCO324-28 mEq/L32 H18. Using he following table, list all the medications that Mr. Kaufman was taking at home. Identify the function of each medication. (Information derived from ) MedicationFunctionDrug-Drug InteractionDrug-Nutrient InteractionDiovan Type 2 DM, Nephropapthy treatmnent, antihypertensiveTaking with NSAIDs may end in kidney failureTaken with potassium supplement may result in hyperkalemiaPrilosecAntiulcer, antigerd, antisecretoryIf taken with aspirin or zocor, prilosec could be badly affectedReduces Ca absorption, iron and B12NeurontinModerate to severe restless leg syndrome, bipolar disorder, seizure control, pain relieverAspirin and Prilosec interfere with the effectiveness Should not be taken with alcohol and magnesium supplementsFurosemidehigh blood pressure, reduces swelling and fluid retentionTaking with aspirin can lead to high levels of aspirin Can reduce electrolytes, increase potassium, increase magnesium, decrease calciumZocorReduces triglyceride and cholesterol levelsMuscle toxicity could result from decreased elimination of the drugShould refrain from drinking fruit juices Isosorbide MonoPrevent anginaCalcium channel blockers can dramatically reduce blood pressureVitamin C can reduce effectiveness of drug TrazodoneAntidepressant, heterocydic, insomnia, aggression, panic attacksMAO inhibitors can lead to high blood pressure and confusion Eating food with drug can increase absorptionArpirinReduces the risk of MI, inhibits platelet aggregationAmount taken may differ when taken with other drugsIf taken for a long time iron deficiency and GI bleeding can occurSodium BicarbonateInhibits production of stomach acidDecreases the elimination of drugs by the liverSodium or magnesium toxicity can result from use of drugNPH insulin/ regular insulinIncreases the use of glucose in the blood Should not be taken with beta blockers, aspirin, alcohol, MAO inhibitors, or steroidsRegular eating patterns should continueMultivitaminUsed in the case of nutrient deficienciesOther drugs can alter this drugMisuse can result in toxicity 19. Identify all drug-drug interactions and then identify any drug-nutrient interactions for the medications.Drug-drug interaction1. Diovan- Taking with NSAIDs may end in kidney failure2.Prilosec- If taken with aspirin or zocor, prilosec could be badly affected3. Neurontin- Aspirin and Prilosec interfere with the effectiveness4. Furosemide- Taking with aspirin can lead to high levels of aspirin5. Zocor- Muscle toxicity could result from decreased elimination of the drug6. Isosorbide Mono- Calcium channel blockers can dramatically reduce blood pressure7. Trazodone- MAO inhibitors can lead to high blood pressure and confusion8. Aspirin- Amount taken may differ when taken with other drugs9. Sodium Bicarbonate- Decreases the elimination of drugs by the liver10. NPH insulin/ regular insulin- Should not be taken with beta blockers, aspirin, alcohol, MAO inhibitors, or steroids 11. Multivitamin- other drugs can alter this drug.B. Drug-Nutrient InteractionsDiovan- Taken with potassium supplement may result in hyperkalemiaPrilosec- Reduces Ca absorption, iron and B12Neurontin- Should not be taken with alcohol and magnesium supplementsFurosemide- Can reduce electrolytes, increase potassium, increase magnesium, decrease calciumZocor- Should refrain from drinking fruit juicesIsosorbide Mono- Vitamin C can reduce effectiveness of drugTrazodone- Eating food with drug can increase absorptionAspirin- If taken for a long time iron deficiency and GI bleeding can occurSodium Bicarbonate- Sodium or magnesium toxicity can result from use of drugNPH insulin/ regular insulin- Regular eating patterns should continueMultivitamin-Misuse can result in toxicity20. What medications are most likely to have contributed to the abnormal lab values and thus this diagnosis? Why?Prilosec is a diuretic so it could have led to the increased osmolality and increased CO2. The use of aspirin with the multitude of other drugs the patient is taking could be hazardous for health, especially iron deficiency and GI bleeding. A few of the other drugs Mr. Kaufman is taking are affected due to them being taken along with aspirin. The effectiveness of Zocor could be altered by the patient drinking fruit juice in the morning. Other than aspirin, Sodium Bicarbonate is the other main drug Mr. Kaufman is taking that is most likely contributing to his abnormal lab values. Mr. Kaufman's lab values showed elevated levels of pCO2, CO2, and HCO3; which was most likely caused by the sodium bicarbonate altering elimination of the other drugs he is taking and his excessive intake of sodium bicarbonate. The excessive absorption of sodium bicarbonate led to his diagnosis of metabolic alkalosis. 21.What does the HbA1c measure? What can this value tell you about Mr. Kaufman's overall control over his diabetes? HbA1c measures average blood glucose for the past three to four months. Mr. Kaufman's value is high at 8.2, which shows me that he has not been controlling his sugar and/or carbohydrate intake recently. 22. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term.Altered nutrition-related laboratory valuesOverweight/ObeseImpaired nutrient utilizationE. Behavioral-Environmental Domain23. List possible behavioral-environmental nutrition problems.A. The first behavioral-environmental nutrition problem is that Mr. Kaufman is on multiple medications and he does not know what they are all for and the correct dose he is suppose to be taking. His daughter stated that she is not fully aware of what he is taking because he is responsible for his own medicine, but that should not be happening; the daughter should be aware of what he is taking, how much should be taken and how often. Mr. Kaufman should also be able to make his own healthy meals if his daughter was not home and he had make his own meals. IV. Nutrition Diagnosis24. Select two high-priority nutrition problems and compare PES statements for each. A. Excessive energy intake related to usual diet of 12 ounces of egg beaters, bacon, toast, rice, potato and sweet tea multiple times during the day as evidence by a BMI of 32.6. B. Lack of nutritional knowledge related to excessive carbohydrate and sweet tea intake as evidence by HbA1c 8.2 %. V. Nutrition Intervention25. For each of the PES statements that you have written, establish an ideal goal (based on the sign and symptoms) and an appropriate intervention (based on the etiology).A. PES statement 1:a. Goal- Decrease weight by 5 pounds over the next month and inturn decrease body mass index towards a healthy number. b. Intervention- Tell the patient alternative beverages he can be eating to replace the sugar from the ice teas, such as diet coke, recommend eating either the rice or potato but not both. B. PES statement 2: a. Goal- Achieve stability of blood glucose levels. When the patient returns for his follow up appointment ask for an updated HbA1c test to see how the levels have been of the last few weeks. Goal is to decrease the HbA1c by three percent. b. Intervention- Recommend the patient monitor his blood glucose levels more frequently so he can see what foods increase and what decrease the levels. Educate the patient on what is considered a sugar and what is considered a carbohydrate, so his intake can decrease and his levels can become more stable.26. Would you make diabetes education a priority in your nutrition counseling for Mr. Kaufman? What methods might you use to help maximize his glucose control? How would you assess the patient's and daughter's readiness for change? A. Even though Mr. Kaufman has had diabetes for fifteen years he is still not able to keep his levels at a healthy range; so therefore I would definitely make diabetes education a priority in my nutrition counseling sessions. He has had some counseling in the past but there is still a lot he does not clearly know or understand fully so counseling would be beneficial for him. In order to maximize his glucose control I will recommend he take his blood sugar before and after every meal so he can learn what exactly elevated his levels and what decrease them. I will recommend he and his daughter keep a record of all the foods they notice cause a change in his blood glucose level. In order to assess the patient's and the daughter's readiness to change I will ask them both what their goals are, if they have any, and what they would like to do reach them. Theyboth already seem ready to change, evident by Mr. Kaufman losing weight since living with his daughter. They do not eat out, his daughter cooks all of his meals and he obviously tries to eat low sugar items. What I am gathering here is he and his daughter want to change but they are not educated properly on what diabetics should eat and what they should not eat a lot of; counseling sessions should help a lot. Lindsey TheriotMr. Kaufman's NCP:March 4, 20143:30 pmAssessment: 85 y.o. WM, weighs 196 lbs (89 kg), Usual body weight 195-225lbs, height 5'5'' (139.7 cm), BMI 32.6, percent UBW 93%, caloric needs are 1889 Kcal/day, protein needs are 71.2 g/day, lab values show albumin 3.4L, Potassium 3.4L, Osmolality 310H, Glucose 172H, BUN 32H, Creatinine 1.5 H, HbA1c 8.2 H, pH 7.47H, pCO2 46H, CO2 31 H, and HCO3 32H, pt. is retired, moved in with his daughter, son-in-law and two grandsons three years ago, medical diagnosis are Metabolic Alkalosis, renal insufficiency, mild dehydration, type 2 DM, usual diet consist of excess calories, carbohydrates but does eat fruits and vegetables and tries to eat low-fat and sugar-free snacks, current medications are a multivitamin, Diovan, Prilosec, Neurontin, Furosemide, Zocor, Isosorbide mono, Trazodone, Aspirin, Sodium Bicarbonate, NPH insulin/regular insulin. Diagnosis: Lack of nutritional knowledge related to excessive carbohydrate and sweet tea intake as evidence by HbA1c 8.2 %.Intervention: Recommend the patient monitor his blood glucose levels more frequently so he can see what foods increase and what decrease the levels. Educate the patient on what is considered a sugar and what is considered a carbohydrate, so his intake can decrease and his levels can become more stable. Goal is to decrease the HbA1c by three percent. Recommend alternatives for sweet tea and carbohydrate intake; such as diet coke. Monitor and Evaluation: Achieve stability of blood glucose levels. When the patient returns for his follow up appointment ask for an updated HbA1c test to see how the levels have been of the last few weeks. Goal is to decrease the HbA1c by three percent. Ask for the patient to bring in a 24-hour diet recall to assess his diet changes. Lindsey TheriotMarch 5, 2014AbstractBackground: Polypharmacy, which is prescribing more than three or four medications at one time to one individual, is becoming a known problem in the elderly community. It is more common than in younger people because the elderly have more chronic conditions than the young. Polypharmacy is known to cause multiple problems; such as increased morbidity and mortality rates and increased hospital visits and nursing home placements. The studies done on the medications prescribed to the elderly patients are typically done on younger individuals that do not have the same problems. Cost of prescriptions and amount give are continuing to increase. Purpose: The purpose of this study was to show the cost of medications and number of prescriptions give to those with diabetes in nursing homes. Methods/Analysis: To conduct this study the researchers used retrospective case notes review from 75 people who had unknown cases of diabetes and were currently living in nursing homes. This study was done in 2010 and during that time all of the nursing homes were visited. Information gathered included those with diabetes, total number of current resident and charts from those with diabetes were reviewed carefully. Patient's latest HbA1c was obtained from the hospitals records. Medication costs were collected by Mg and the Coventry Medicine Management TeamResults: The age range among the nursing homes was 55-102, average being 80.6. The residents were taking on average 6.7 medications (excluding those required). Three residents were taking twelve or more medications, 26 were taking eight to eleven, 34 were taking four to seven and twelve were taking zero to three. The average prescription cost for residents was $150. There were 18 residents who paid more than $160 per month on medications. The residents on glucose lowering therapy were being charged over $160 per month and over $160 a month for a special-order gliclazide liquid.Discussion: 84% of the residents in this study were found to be the victim of polypharmacy. It was found that cardiovascular disease prevention therapy is unnecessary and a waste of the resident's money, since it does not actually enhance life. More than a third of the residents were taking eight or more medications. ReferenceGadsby, R. R., Galloway, M. M., Barker, P. P., & Sinclair, A. A. (2012). Prescribed medicines for elderly frail people with diabetes resident in nursing homes-issues of polypharmacy and medication costs.?Diabetic Medicine,?29(1), 136-139. doi:10.1111/j.1464-5491.2011.03494.x ................
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