Polypharmacy

case – case discussion – 10 mints

BEFORE YOU READ THAT I WANT YOU TO KNOW THAT YOU DON’T HAVE TIME TO SAY THE WHOLE
INFORMATIONS MENTIONED HERE. BUT YOU HAVE TO THAVE THE KNOWLEDGE TO SUPPLY
PERFECT INFO IN ORGANISED WAY JUST IN CASE YOU WERE ASKED OR YOU ALLOWED TO
COMPLETE THE WHOLE SCENARIO.

DDx for the case ..

• According to the onset of the symptoms, more likely it’s an acute delirium. That
delirium could be caused by different causes. Medical and Psychological ..

Medical causes like ..
• Infections – inside CNS (meningitis or encephalitis) or outside CNS (sepsis).
• Electrolyte imbalance – Hyponatremia can cause neurological symptoms and psychosis.
• Uncontrolled chronic illness – (hyper-hypoglycaemia, Hypo-hyperthyroidism)
• Malignancy – Inside CNS (brain tumours) – outside CNS (Melanoma easily metastasis to
the brain .. Colon cancer)
• Vitamin deficiency (Vit B12, lack of dietary intake) – Vitamin E – Thiamine
Alcohol intake (toxicity – withdrawal symptoms)
• Head Trauma – Fall
• Vision or hearing problems

Psychological causes like ..
Depression, Schizophrenia (acute psychosis), Acute Mania, Bipolar disorder
Simple feeling of loneliness

Approach to the case

Please, cut it into phases

Phase ONE > before giving you the medications.

You will analyse the main complaint of the patient > Onset, course, duration, Timing, What
makes it worse, what makes it better, what are the associations ( MENTION to them that
you are going to exclude the emergency situation which requires immediate intervention or
referring to the hospital because Acute delirium has a potential emergency nature ).

Associations could be > Fever, previous head trauma, falls, cough, pain, nausea or vomits,
rashes, blurring of vision.

Then go to RED FLAGS (very important) > Weight loss, Night sweats, Lumps or bumps in the
body, Change in bowel habits, Change in nature, colour, or amount of urine, Chronic cough
especially with haemoptysis, Voice change, Suspicious skin lesions (Melanoma).

Then ask about things that might be affecting that age group ( take it from up to down ) ..
Brain functions (weakness or TIAs or Strokes), Eyes problems, Ear problems, Nose (snoring
OR OSA), swallowing problem, Thyroid, Chest, …….. etc .. till the joints and DON’T FORGET
forgetfulness and mental functions.
Then check quickly … for Past history of chronic illnesses, and previous Medications
Then HEADS >>> (focus on Home support and Depression status)
Then SADMA (Smoking + Alcohol) .. DON’T ASK DRUGS >> be reasonable please.
GIVE > Geriatric Depression Scale + MMSE examination + FRAT (Falls Risk Assessment Tool)


Phase TWO > After giving you Diseases and Medications.

Ø Tell the panel that you wanna ASK the patient further questions regarding
COMPLICATIONS of chronic illness he gave you.
Ø Ask > Are that all medications or there are other medications at home.
Ø Ask > prescribed by one doctor or more than one doctor.
Ø Ask > Verbal consent from the patient to contact the other doctors/specialists
regarding her condition (if needed).
Ø Get the medications out ONE BY ONE and ask about >
o COMPLIANCE of each medication.
o ADHERENCE to each medication.
o Possible COMPLICATIONS that might caused by that medications.

Phase THREE > Management Plan

- Explain to the patient what are you going to with her + Reassurance.
- Clarify to the patient the indication for each medication (as far as the patient can
retain)
- Start GP CARE PLAN > this plan is created to set up a therapeutic goals to be
achieved on a time frame.
- The plan is composed of 3 parts ..
o Life style modification and Psychotherapy > This includes discussing SNAP
guide + involving ACAT (Aged care assessment team), your supervisor, clinical
pharmacist + we might need other allied health (optometrist, podiatrist,
exercise physiologist, dietitian, psychologist)
o DISCUSSING MEDICATIONS (Which is the main reason for the visit) .. You
should mention about CEASE PROTOCOL (6 Qs you have to know them by
HEART) + Discussing with your supervisor + Clinical pharmacist + relevant
registrar before Replacing or Cease any medication. + Mention WEBSTER
PACK + Mention HOME MEDICATION REVIEW.
o PREVENTIVE HEALTH and future plans > arrange for screening programs,
vaccinations, other laboratory investigations, imaging.
- BEFORE THE PATIENT LEAVES > Tell the panel that I need to discuss with the patient
in the next visits …
o Advanced directive care plan.
o Safety at home > occupational therapist
o How to minimize risk of falls.