Submitted by: SOBREMONTE, Junelyn Aljona C.

Year & Section: BSN 3Y1-1B

Submitted to Mrs. Carol San Diego Date Completed:

COURSE TASK #4
Case Scenario: Medications and Aging

Ms. Espinosa is a 90-year-old Hispanic woman admitted to the hospital from her assisted living
facility. She has a history of hypertension and dementia and had a stroke and a myocardial infarction 3
years ago. She has also had insomnia for the past month. Ms. Espinoza is admitted due to an alteration in
her mental status. She has had a cold and a cough for a week, for she took Coricidin (acetaminophen and
chlorpheniramine) and Tylenol PM (acetaminophen and diphenhydramine). Her home medications
include monthly Nascobal (vitamin B12) injections; Toprol-XL ( metoprolol succinate), 100 mg daily;
Plentil (felodipine),10 mg daily; Allegra (fexofenadine),180 mg daily; Ecotrin (aspirin EC), 325 mg daily;
and Colace (docusate sodium), 100 mg daily. She also has a very unsteady gait.

Ms. Espinoza’s admitting diagnosis is pneumonia. The physicians order the following
medications: Lasix (furosemide), 20 mg IV push, x 1; Pepcid (famotidine), 20 mg bid; Ecotrin (aspirin
EC), 325 mg daily; Toprol-XL (metoprolol succinate), 100 mg daily; Colace ( docusate sodium),100 mg
daily; Allegra (fexofenadine), 180 mg daily; Levoquin (levofloxacin), 250 mg daily IVPB; Plendil
(Felodipine), 10 mg po daily; and Ambien (zolpidem), 5 mg at bedtime as needed

Questions

1. Which medication(s) may have contributed to Ms. Espinoza’s altered mental status? Make a drug
study of all the medications taken by Ms. Espinoza.

The medications which may have contributed to Ms. Espinoza’s altered mental status are Coricidin
(acetaminophen and chlorpheniramine), Tylenol PM (acetaminophen and diphenhydramine), Tropolol XL
(Metroprolol Succinate), Plendil (Felodipine), and Colace. Coricidin and Tylenol are both classified as
analgesics, these were used by the patient for one week in self-medicating cold and cough. Other home
medications are used by the patient for health maintenance, these includes Tropolol XL and Plendil, both
anti-hypertensive medications; and Colace classified as laxative.

According to studies, common medications used by elderly patients includes analgesics,

antihypertensive, and laxatives. These medications are all beneficial in relieving pain and in treating
diseases/illness. However, taking these medications together result in a drug-to-drug interaction which
can result in an adverse effect/alteration of mental health, such as hallucinations, dizziness, and
confusion. This can also lead to the alteration of pharmacodynamics and pharmacokinetics, considering
the decrease in hepatic blood flow and metabolism.
Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Drug Mechanism of Indication Contraindication Side-Effects Nursing

Action Consideration
Brand Name: Chlorpheniramine Used to treat Contraindi  fast,  Do not take more of
Coricidin blocks muscle responses headache, cated in patients pounding, Coricidin than is
(Acetaminophen in histamine and acts as runny nose, with systemic or uneven recommended.
and an antagonism of the sneezing, mastocytosis, heart beats.  Avoid drinking
Chlorpheniramine) constrictor effects of watery eyes, overactive thyroid  confusion, alcohol. It may
histamine on respiratory and pain or gland, closed angle severe increase your risk of
Classification: smooth muscle. fever caused glaucoma, high dizziness, liver damage while
(Acetaminophen) Acetaminophen blocks by allergies, blood pressure, or taking
Analgesic and pain impulse generation the common stenosing peptic drowsiness. acetaminophen.
Antipyretic peripherally and may cold, or the ulcer, blockage of  tremor,  If stomach upset
inhibit the generation of flu. the stomach or restless occurs, it may help
(Chlorpheniramine prostaglandin in the intestine, blockage muscle to take this
) CNS. of the urinary movements medication with food
Antihistamine bladder, enlarged  nausea, or milk.
prostate. pain in  In rare cases,
your upper acetaminophen may
stomach cause a severe skin
pain, reaction. Stop taking
itching, Coricidin and notify
loss of physician.
appetite


Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Brand Name: Thought to produce Mild to Contraind CNS:  Alert: Many OTC and
Tylenol PM analgesia by inhibiting moderate pain; icated in patients  Fatigue prescription products
(Acetaminophen) prostaglandin and other mild to hypersensitive to  Headache contain
substances that moderate pain the drug. acetaminophen; be
Therapeutic sensitize pain receptors. with CV: aware of this when
Classification: Drug may relieve fever adjunctive  hypertension calculating total daily
Use cautiously in
Analgesics through central action opioid dose.
patients with any  Hypotension
in the hypothalamic analgesics;  Tell patient not to use
type of liver
Pharmacologic heat-regulating center. fever GI: for marked fever,
disease and in
Class: Para- fever persisting
patients with long-  Nausea
aminophenol longer than 3 days, or
term alcohol use  Vomiting
derivatives recurring fever unless
because
Respiratory directed by prescriber.
therapeutic doses
can cause  Dyspnea
hepatoxicity. 
Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Brand Name: Vitamin B12 can be Used in B12 Contraindicated  Headache  Lab tests: Before
Nascobal converted to coenzyme deficiency in patients with  Nausea initiation of therapy,
(Cyanocobalamin B12 in tissues, and as such caused by hypersensitivity to  upset reticulocyte, and
) is essential for increased cobalt and/or stomach erythrocyte counts,
conversion of physiologic vitamin B12 or any  diarrhea Hgb, Hct, vitamin
Classification: methylmalonate to requirements of its excipients  runny nose, B12, and serum folate
Hormone and succinate and synthesis or inadequate [see Warnings and sneezing levels should be
synthetic of methionine from dietary intake. Precautions (5.2)].  sore throat determined; then
substitute; homocysteine, a reaction Anaphylactic repeated between 5
 swollen
Vitamin B12 which also requires shock and death and 7 d after start of
tongue
folate. In the absence of have been reported therapy and at regular
 dizziness
coenzyme B12, after parenteral intervals during
 weakness
tetrahydrofolate cannot vitamin B12 therapy.
 numbness or
be regenerated from its administration in  Monitor potassium
tingling
inactive storage form, 5- sensitive patients. levels during the first
 fever
methyltetrahydrofolate, 48 h
and a functional folate  joint pain
 Obtain a careful
deficiency occurs.  itching or
history of
rash
sensitivities.
 Therapeutic response
to drug therapy is
usually dramatic,
occurring within 48 h.
Effectiveness is
measured by
laboratory values and
improvement in
manifestations of
vitamin B12
deficiency.
 Obtain a complete
diet and drug history
and inquire into
alcohol drinking
patterns for all
patients receiving
cyanocobalamin to
identify and correct
poor habits.
 Notify physician of
any intercurrent
disease or infection.
Increased dosage may
be required.
Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Brand Name: A selective beta-blocker Hypertension Contraind CNS:  Do not confuse
Toprol XL that selectively blocks icated in patients  Fatigue metoprolol succinate
(Metoprolol beta1 receptors; Early hypersensitive to  Dizziness with metoprolol
Succinate) decreases cardiac Intervention in the drug and beta- tartrate. Do not
output, peripheral acute MI. blockers. CV: confuse Toprol XL
Therapeutic resistance, and cardiac  Bradycardia with Topamax, or
Classification: oxygen consumption; Stable Tegretol XR.
Use cautiously in  Hypotension
Antihypertensive and depresses renin symptomatic  Always check
patients with heart  Edema
secretion. heart failure, patient’s apical pulse
failure.
Pharmacologic cardiomyopathy GI: rate before giving the
Class: Selective  Nausea drug. If it is slower
Beta-Adrenergic When used to treat than 60bpm, withhold
 Diarrhea
Blockers MI, drug is drug or call prescriber
 Heart Burn
contraindicated in immediately.
Dose: patients with heart  Monitor blood
Respiratory
100mg/day rate less than pressure frequently,
 Dyspnea
45bpm, greater drug masks common
that first degree  Wheezing
signs and symptoms
heart block, of shock.
systolic blood Skin:
 Black Box Warning:
pressure less than  Rash When stopping
100mmHg, or 
therapy, taper dosage
moderate to severe over 1-2 weeks.
cardiac failure. Abrupt
discontinuation may
cause exacerbations
of Angina or MI. Do
not discontinue
abruptly even in
patients treated only
for hypertension.
 Instruct patient to take
drug exactly as
prescribed and with
meals.
 Tell patient to alert
prescriber if shortness
of breath occurs.

Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Brand Name: A dihydropyridine- Hypertension Contraind CNS:  Monitor blood

Plendil derivative calcium icated in patients  Headache pressure for response.
(Felodipine) channel blocker that hypersensitive to  Dizziness  Monitor patient for
prevents entry of calcium the drug.  Paresthesia peripheral edema,
Therapeutic ions into vascular smooth  Asthenia which appears to be
Classification: muscle and cardiac cells; both dose and age-
Use cautiously in
Antihypertensive shows some selectivity related. It is more
patients with heart CV:
s for smooth muscle common in patients
failure, particularly  Chest Pains
compared with cardiac  Palpitations taking higher doses,
those receiving
Pharmacologic muscle. especially those older
beta blockers.  Flushing
Class: than 60.
Calcium Channel  Tell patient to take
GI:
Blockers the drug without food
 Nausea
or with light meal.
 Abdominal
Dose:  Advise patient not to
Pain
10mg/day take drug with
 Constipation
grapefruit juice.
 Dyspepsia
 Advise patient to
continue taking drug
Respiratory
even when she feels
 Cough
better.
 Sneezing

Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Brand Name: A long-acting non- Seasonal Contraind CNS:  Instruct patient not to
Allegra sedating antihistamine allergic icated in patients  Fatigue exceed prescribed
(Fexofenadine) that selectively inhibits rhinitis hypersensitive to  Drowsiness dosage and to use
peripheral H1 receptors. the drug or its  Fever drug only when
Therapeutic components. needed.
Classification: EENT  Tell patient not to
Antihistamines  Otitis Media take antacid within 2
hours of this drug.
Pharmacologic GI:  Tell patient ODT
Class:  Nausea should be taken on an
Piperidines  Vomiting empty stomach.
 Dyspepsia  Instruct patient to let
Dose: ODT disintegrate on
180mg/day the tongue and then
Respiratory
 Cough swallow with or
 Rhinorrhea without water.


Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Brand Name: Thought to produce To reduce risk Contrain CNS:  Monitor elderly
Ecotrin analgesia and exert it of MI in dicated in patients  Agitation patient closely
(Aspirin EC) anti-inflammatory patients with hypersensitive to  Cerebral Edema because they may be
effect by inhibiting previous MI, the drug and in  Seizure more susceptible to
Therapeutic prostaglandin and unstable those with aspirin’s toxic effect.
Classification: other substances that angina, and NSAID-induced EENT  Advise patient to take
NSAID sensitize pain chronic stable sensitivity  Tinnitus drug with food, milk,
receptors. Drug may angina reaction, bleeding antacid, or large glass
Pharmacologic relieve fever through pectoris. disorder, or G6PD GI: of water to reduce GI
Class: central action in the Deficiency.  Pancreatitis reactive.
Salicylates hypothalamic heat-  GI Bleeding  Advise patient on a
regulating center. In low-salt diet as 1
Dose: low doses, drug also Skin: tablet of buffered
325mg/day appears to interfere aspirin contains
 Rash
with clotting by 553mg sodium.
 Urticaria
keeping a platelet-  Ibuprofen can
 Hives
aggregating substance interfere with the anti-
from forming. platelet effect of low

dose aspirin therapy.

Drug Mechanism of Action Indication Contraindication Side-Effects Nursing Consideration

Brand Name: Docusate is an anionic Used to treat Contraind  rash  Assess: cause of
Colace surfactant (i.e., a occasional icated in patients constipation - is fluid,
 itching/swelling fiber or exercise
(Docusate surface-active agent). constipation. hypersensitive to
(especially of the missing from
Sodium) It lowers the surface the drug or its
face/tongue/throat lifestyle; fluid
tension at the oil-water components, and
) balance.
Pharmacologic interface of the feces, patients with  Evaluate therapeutic
Class: allowing water and nausea and  severe dizziness
response (decreased
Laxative lipids to penetrate the vomiting.  difficulty in constipation).
stool. This helps to breathing  Drug should be
Dose: hydrate and soften the  Stomach pain discontinued if
Contraindicated in cramping, rectal
100mg/day fecal material,
patients with  diarrhea, or bleeding, nausea, or
facilitating natural
intestinal cramping vomiting occur. 
defecation.
obstruction or   Administer alone for
appendicitis. better absorption.
 Do not administer
within one hour of
other drugs, antacids,
or milk.
 Tablets/solution to be
taken with full glass
of water.

2. In addition to the drug regimen, does Ms. Espinoza have other risk factors for altered mental status?
Submitted by: SOBREMONTE, Junelyn Aljona C. Year & Section: BSN 3Y1-1B
Submitted to Mrs. Carol San Diego Date Completed:

Polypharmacy is the other risk factor for the altered mental status of Ms. Espinoza other than the
drug regimen. Polypharmacy is a concurrent use of multiple medication. This is most common in the
elderly. Use of multiple drugs increase the risk of drug interaction, adverse drug reaction, and adverse
drug event. It is also associated with numerous health risks and consequences in the elderly. Older
patients are at greater risk of adverse effects due to decreased renal and hepatic function, lower lean
body mass, reduced hearing, vision, cognition and mobility so it is important to identify those patients
who may be at risk of adverse health outcomes as a result of inappropriate polypharmacy.

According to the study conducted by Spandel Leszek, the use of multiple medications in geriatric
patients is associated with an increased rate of depressive symptoms.

3. Would you alter her drug regimen. Does Ms. Espinoza have any risk factors for altered mental status?

4. Would you alter her drug regimen in any way? If so, how?

(Answer for both number 3 and 4)

I will alter the drug regimen of Ms. Espinoza due to the risk factors posed by the use of multiple
medications. To do so, medication reconciliation at care transition should be conducted and duplicated
drugs should be eliminated. The patient’s diagnosis and current condition must be reviewed in order to
identify as to what the medications are for and why it is prescribed. Indications for every medication
will encourage safe prescribing, as the clinical use for the drugs should be correlated during instances
where polypharmacy exists. The drug-drug interaction, drug-disease interaction, and the dosage based
on the patient’s need and current condition must also be reviewed. It should also be noted that in the
process of reducing potential adverse drug effects caused by polypharmacy, there must be coordination
and communication with the physician/physician or medical staff.

Based on the protocol defined by Scott, et.al., medications can be evaluated in a

systematic personalized review process using a risk vs benefit analysis. The objective is to attempt to
simplify drug regimens while maintaining clinical efficacy. Tools or criteria that can be used include
the following: START (Screening Tool to Alert Doctors to Right Treatment) and STOPP (Screening
Tool of Older People's Potential Inappropriate Prescriptions).