Running head: PHARMACOTHERAPY

Case Study: Pharmacotherapy for and Elderly Adult

 Patient Characteristics

The patient is a 76-year-old male that has a past medical history of hypertension, atrial

fibrillation, coronary artery disease, osteoarthritis, and diabetes. Unfortunately, the patient has

stopped visiting his primary care physician after a stroke three years ago since he no longer feels

unwell. The patient is currently taking several medications to manage his multiple comorbidities:

nifedipine (30mg), hydrochlorothiazide (25mg), acetaminophen (4000mg), simvastatin (30mg),

glipizide extended release (10mg), and warfarin (2mg). Additional over the counter medications

being taken by the patient include coenzyme Q10 (CoQ10; 200mg BID), garlic (2000mg),

ginkgo biloba (500mg), glucosamine (1500mg), ginseng (200mg), and omega 3 fish oil (8g).

Today, in clinic, his blood pressure was 160/95, his International Normalized Ratio (INR) was

1.5, and his serum blood glucose was 260. On physical exam, edema was noted in his lower

extremities and these appear to be abrupt changes.

 Physiological

Collectively, the physical characteristics of this patient are that his illnesses are

uncontrolled. The blood pressure is elevated in the stage II hypertensive range and the edema is

suggestive developing heart failure (Boron & Boulpaep, 2016). Moreover, his blood sugars are

significantly elevated, even for postprandial values. As per Boron and Boulpaep (2016), a

diabetic patient with appropriate management should have a fasting level of 80-30 mg/dl (4.4–

7.2 mmol/L), a one to two hour postprandial value of less than 180 mg/dl (10.0 mmol/L), and

hemoglobin A1c (HbA1C) of less than 7%. Lastly, the patient is taking multiple herbal
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supplements that were not reviewed (presumptively) by a qualified health care provider and

therefore, could cause drug-drug interactions that worsen the patient’s condition.

 Social and Psychological

Although not explicitly stated, one could argue that the patient is suffering from several

social and psychological issues that may negatively impact his well-being. Masters (2018)

reported that elderly patients who state that they stopped visiting their healthcare provider due to

an absence of sick perceptions may have socioeconomic limitations that impede their ability to

obtain healthcare. These individuals may find it difficult to admit that they do not have the

means to pay for their healthcare and will otherwise state that they stopped seeking medical

services due to continued wellness. It is unlikely that the patient did not experience any adverse

side effects from his lack of medical care and thus, one could argue that there are underlying

social issues limiting this patient’s ability to access quality and affordable healthcare.

It must also be mentioned that a history of stroke can affect the cognitive capacity of an

elderly patient. Boron and Boulpaep (2016) stated that a stroke can decrease the critical thinking

and analytic skills of a patient, which is further exacerbated by old age. Thus, the patient may not

possess the mental capacity to appropriately evaluate his health and determine if continued

medical intervention is necessary. It is likely that the patient’s age, in conjunction with the

history of stroke, has resulted in progressive dementia-like symptoms that limit his ability to

make appropriate decisions about his well-being.

 Patient Diagnosis

The patient diagnosis in this situation is not entirely clear. There are several

pathophysiologic mechanisms that could contribute to gradual lower extremity edema in the
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setting of diabetes, hypertension, and coronary artery disease. The most likely patient diagnosis

would be acute cardiac failure followed by diabetic nephropathy. The history of coronary artery

disease, stage II hypertension, diabetes, and stroke are suggestive of widespread atherosclerotic

changes that may decrease the perfusion of cardiac myocytes leading to progressive worsening

of cardiac function (Boron & Boulpaep, 2016). Less likely would be diabetic nephropathy due to

sustained, elevated blood glucose. Significantly elevated blood glucose can cause damage to the

juxtaglomerular apparatus, resulting in the loss of proteins and a shift in oncotic pressure (Boron

& Boulpaep, 2016). The absence of any other peripheral edema, such as in the hands, and the

lack of gastrointestinal upset makes acute cardiac failure the more probable diagnosis. If acute

cardiac failure is suspected, immediate intervention is needed to decrease the likelihood of

myocardial infarction and death.

 Pharmacokinetics & Pharmacodynamics

The most important pharmacokinetic and pharmacodynamic principles that must be

considered are reducing blood pressure, increasing cardiac output, and improving the patient’s

diabetic state. The pathophysiology of acute and chronic cardiac failure involves a decrease in

myocardial contractility that offsets the Frank-Starling mechanism from its equilibrium.

Skidmore-Roth (2018) reported that lower extremity edema is a result of an imbalance in the

Starling equation. The Starling equation takes into consideration the oncotic and hydrostatic

pressure in blood vessels and the interstitium. Any significant change in the protein content or

vessel pressure can cause changes in fluid flow. In the setting of acute cardiac failure, fluid backs

up in the venous system and myocytes are unable to generate sufficient contractile force to

adequately propagate fluid through the arterial system (Boron & Boulpaep, 2016). This causes a

gradual increase in hydrostatic forces and fluid pressures overcome oncotic pressures, causing
PHARMACOTHERAPY 3

fluid to flow into the interstitium. The increased fluid in the interstitium can be observed on

physical exam as peripheral edema. Typically, medications such as hydrochlorothiazide and

nifedipine can prevent heart failure by increasing the excretion of fluid in the kidney and

relaxing vascular smooth muscle, respectively (Boron & Boulpaep, 2016). Unfortunately, those

medications were not sufficient to prevent acute heart failure in this patient and additional

therapeutics may be required.

The patient’s history of diabetes, in conjunction with the new onset heart failure, warrant

the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers

(ARB). These medications are effective in relaxing vascular smooth muscle and lowering blood

pressure, thereby improving blood flow (Skidmore-Roth, 2018). Moreover, ACE inhibitors and

ARBs dilate the efferent and afferent glomerular arterials to reduce glomerular hydrostatic

pressure and renal filtration fraction (Arcangelo et al., 2017). These confer renal protection due

to the decreased perfusion of the kidneys, which is important in diabetic patients owing to the

risk of nephropathy. The appropriate pharmacological endpoint in this patient is the

improvement of their acute heart failure by increasing perfusion by increasing cardiac function.

 Potential Drug Interactions

There are several potential drug interactions based on the patient’s current

pharmaceutical regimen. Leite, Martins, and Castilho (2016) reported that warfarin has several

dietary and herbal contraindications that can decrease its effectiveness as an anticoagulant.

Leafy, green vegetables have been shown to decrease the effectiveness of warfarin due to the

high concentration of vitamin K. Vitamin K inactivates warfarin and high concentrations of the

substance can decrease the therapeutic range of warfarin, which is typically between 2 and 3 for

patients with chronic atrial fibrillation (Arcangelo et al., 2017). Furthermore, several herbal
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substances, such as CoQ10, garlic, ginkgo, and ginseng can decrease serum concentrations of

warfarin. Unfortunately, the effect these herbal substances have on warfarin are not entirely

understood besides a reduction in serum concentrations (Leite, Martins, & Castilho, 2016). Other

medication side effects are simvastatin and nifedipine, and hydrochlorothiazide and glipizide. In

short, these drug-drug interactions cause inappropriate increases or altered actions of the

pharmacologic agents that can potentially worsen the patient’s condition (Arcangelo et al.,

2017).
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Appropriateness of Pharmacological Agent

Drug Name Class Mechanism Metabolism Interactions

Simvastatin HMG CoA Competitive Cytochrome Nifedipine;
reductase inhibitor of P450 3A4 Dietary
inhibitors HMG CoA system in the
reductase liver
Hydrochlorothiazid Diuretic Decreases Excreted Glipizide
e (HZT) reabsorption of unchanged in
sodium in the the air and
distal
convoluted
tubule and may
alter peripheral
vascular
resistance
Nifedipine Calcium- Calcium channel Cytochrome Simvastatin;
channel blockers inhibitor causing P450 3A4 Dietary
peripheral system in the
arterial liver
vasodilation
Acetaminophen Analgesic and Unknown; May NAPQI in the
antipyretic decrease liver
generation of
prostaglandins
Glipizide ER Sulfonylurea Partial blockage Cytochrome Warfarin; HZT
of potassium P450 3A4
channels in beta system in the
cells of liver
pancreatic islets
of Langerhans
Warfarin Anticoagulant Inhibits Cytochrome Glipizide;
synthesis of the P450 P1A2, Dietary; CoQ10;
C1 subunit of 3A4, and Garlic; Ginkgo;
vitamin K carbonyl Ginseng
epoxide reductases
reductase
Table 1: Pharmacologic overview of prescribed medications
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Nursing Intervention
Educate the patient about
their disease status
Obtain history about previous
stroke
Obtain history about previous
cardiac disease
Recommend the ministration
of an ACE inhibitor with
ARB and discontinuation of
nifedipine
Instruction for use of a home
blood glucose monitor
Educate on proper diet and
use of herbal supplements
Recommend a periodic
increase in warfarin and
Nursing Care Plan
Rationale
The patient suffers from
multiple comorbidities that
are life-threatening if not
properly managed
Cognitive deficits may be
present that limits the
patient’s ability to care for
themselves
Determine if the patient has
ever suffered from heart
attack warning signs, i.e.
chest pain, jaw tingling, arm
numbness, and/or shortness
of breath
The patient’s blood pressure
is excessively high and the
nifedipine has multiple drug-
drug interactions with the
current regimen
The patient’s blood sugar
needs assessed daily to
determine if changes to their
diabetic medications are
necessary
Some diets and herbal
supplements can lessen the
efficacy of warfarin
The patient’s INR must be
within a therapeutic range to
6
Evaluation
Regular follow-up visits will
allow for frequent physical
exams and lab monitoring to
evaluate decreases in blood
pressure, lipids, and serum
glucose
If a mini mental status exam
demonstrates deficiencies,
and the patient is unable to
complete activities of daily
living, then discussions about
skilled nursing may be
necessary
Thorough history collection
will allow for the evaluation
of the extent of the patient’s
past cardiac history and their
current symptoms
Drug-drug interactions that
alter the efficacy of other
medications can worsen their
cardiac health. Moreover,
addition of these medications
can decrease kidney damage
associated with diabetes in
hypertensive patients
Uncontrolled diabetes can
worsen atherosclerotic
disease and cause myocardial
infarction and stroke
The patient has a history of
atrial fibrillation and must
remain in the therapeutic INR
range of 2 to 3
Weekly INR measurements
must be conducted until there
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weekly INR measurements prevent recurrent stroke in the INR is stabilized in a

until stabilized setting of atrial fibrillation therapeutic range. At that
point, INR measurements can
be conducted monthly.
Table 2: Nursing intervention strategies

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics

for advanced practice: A practical approach, (4th ed.). New York, NY: Wolters Kluwer.

Boron, W. F., & Boulpaep, E. L. (2016). Medical physiology, E-book. Saint Louis, MO: Elsevier

Health Sciences.

Leite, P., Martins, M., & Castilho, R. (2016). Review on mechanisms and interactions in

concomitant use of herbs and warfarin therapy. Biomedicine & Pharmacotherapy, 83, 14-

21. doi: https://doi.org/10.1016/j.biopha.2016.06.012

Masters, K. (2018). Role development in professional nursing practice. Burlington, MA: Jones &

Bartlett Learning.

Skidmore-Roth, L. (2018). Mosby's 2019 nursing drug reference, E-book. Saint Louis, MO:

Elsevier Health Sciences.