What is the optimal management plan for an elderly patient with multiple comorbidities including AFib, hypertension, hyperlipidemia, CAD, CHF, hypothyroidism, and a history of falls, currently undergoing rehabilitation?

Optimal Management of Elderly Patient with Multimorbidity in Skilled Nursing Facility

Continue the current comprehensive rehabilitation program with PT/OT/ST as prescribed, while implementing a personalized, domains-based approach that prioritizes fall prevention, medication optimization to reduce polypharmacy burden, and careful monitoring of anticoagulation given the high bleeding risk from dual antiplatelet therapy plus anticoagulation. 1

Framework for Multimorbidity Management

This patient exemplifies the challenge of managing atherosclerotic cardiovascular disease (ASCVD) with multiple comorbidities in an elderly individual. The 2022 ACC Expert Consensus emphasizes that simply "stacking" Class 1 guideline recommendations leads to polypharmacy, increased adverse events, treatment burden, and therapeutic confusion—particularly problematic in older adults. 1 A domains-based assessment framework should guide all management decisions, evaluating medical conditions, mental/emotional status, physical functioning, and social/environmental factors. 1

Critical Domain Assessments Needed

Mobility and Fall Risk Assessment:

• Formal fall risk assessment is mandatory given the history of multiple falls and rib fractures. 1 The ACC guidelines specifically note that fall risk directly impacts management of antiplatelet, anticoagulant, and antihypertensive therapy. 1
• Implement the Timed Up and Go test: patient stands from chair, walks 10 feet at normal pace, turns, returns, and sits down—times ≥12 seconds indicate increased fall risk requiring intervention modification. 1
• Alternatively, use the Johns Hopkins Fall Risk Assessment Tool evaluating age, fall history, continence, medications, support equipment use, mobility, and cognition. 1

Functional Status:

• Apply the Katz Index of Independence in Activities of Daily Living to formally assess bathing, dressing, toileting, transferring, continence, and feeding capabilities. 1 This informs the level of support required and discharge planning trajectory.

Mental Health Screening:

• Administer Patient Health Questionnaire-2 for depression screening and Generalized Anxiety Disorder-2 for anxiety assessment. 1 Both use simple 4-point scales from "not at all" to "nearly every day." 1
• This is particularly important as the patient is on lorazepam, which increases fall risk and should be critically evaluated for deprescribing. 1

Cardiovascular Management Optimization

Heart Failure with Preserved Ejection Fraction

The current regimen of carvedilol and lisinopril is appropriate for diastolic CHF management. 2 However, several refinements are needed:

• Diuretic therapy must be carefully titrated to relieve congestion while avoiding aggressive diuresis that worsens renal function in elderly patients with CKD. 2 Monitor daily weights and adjust furosemide based on fluid status, not by rote scheduling.
• Regular monitoring of BNP and troponin is essential in elderly heart failure patients to guide therapy optimization. 2 The current plan lacks specific biomarker monitoring intervals.
• Frailty assessment should be incorporated, as it is present in >70% of heart failure patients over 80 years and fundamentally affects treatment decisions. 2

Atrial Fibrillation and Anticoagulation

The combination of apixaban (anticoagulation) plus aspirin and clopidogrel (dual antiplatelet therapy) creates substantial bleeding risk that must be actively managed. 3

• Triple therapy with oral anticoagulation plus dual antiplatelet agents increases absolute major bleeding risk significantly, and major bleeding is associated with up to 5-fold increased mortality risk following acute coronary syndrome. 3
• Given the patient's fall history and rib fractures, the bleeding risk is further amplified. 1 Fall risk directly impacts the safety of anticoagulation therapy. 1
• If the patient is >1 year post-PCI for CAD, strongly consider discontinuing dual antiplatelet therapy and maintaining anticoagulation alone. 3 The duration of triple therapy should be minimized to reduce bleeding complications.
• Beta-blocker therapy (carvedilol) is appropriate first-line rate control for atrial fibrillation in patients with heart failure and hypertension. 2

Hypertension Management

Current blood pressure readings of 135/90 mmHg represent Grade 1 hypertension requiring intervention. 4

• Target blood pressure should be 120-129 mmHg systolic if well tolerated, with individualization based on frailty status. 4
• However, aggressive blood pressure lowering must be balanced against fall risk and orthostatic hypotension in this elderly patient with documented falls. 1 Monitor for dizziness or lightheadedness with position changes.
• The current regimen of lisinopril and carvedilol is appropriate, but doses may need titration based on tolerance and fall risk assessment results.

Rehabilitation Program Optimization

The current PT/OT/ST schedule is appropriate and should continue as prescribed through the certification periods. 1

Evidence-Based Rehabilitation Principles for Elderly Patients

Cardiac rehabilitation is an essential component of contemporary management for patients with multiple presentations of CHD and heart failure, with benefits in elderly patients similar to younger patients. 1 However, specific modifications are required:

• Absolute levels of functional capacity in elderly patients are lower, and results may require longer program participation, particularly for those ≥75 years with significant comorbidities limiting mobility (arthritis, pulmonary disease, peripheral arterial disease). 1
• Increasing frequency and duration of exercise sessions should supersede increases in intensity to reduce potential for overuse injuries. 1
• Strength training is essential to improve neuromuscular function, muscular strength, endurance, and functional independence while reducing fall risk from musculoskeletal overuse. 1
• Participation in activities that increase socialization is paramount to combating isolation and depression. 1

Addressing Multimorbidity in Rehabilitation

Traditional cardiac rehabilitation focuses on single-disease management, but this patient requires personalized multimorbidity rehabilitation addressing her constellation of conditions. 1

• Approximately 50% of patients referred for cardiac rehabilitation have two or more comorbidities, and multimorbidity is a strong risk factor for both non-use and non-completion of rehabilitation programs. 1
• The rehabilitation plan must be individualized to address competing demands from multiple conditions rather than applying siloed disease-specific protocols. 1

Medication Optimization and Deprescribing

A critical medication review is needed to reduce polypharmacy burden and eliminate medications that increase fall risk or provide marginal benefit. 1

Priority Medications to Evaluate for Deprescribing

Lorazepam (Ativan):

• This benzodiazepine significantly increases fall risk in elderly patients and should be tapered and discontinued if possible. 1 The note indicates it is being held "due to fall risk," but the order remains active—this medication should be formally discontinued rather than held indefinitely.
• Alternative non-pharmacologic approaches for anxiety should be implemented, including behavioral interventions and increased social support. 1

Trazodone for Insomnia:

• While less problematic than benzodiazepines, trazodone can still increase fall risk through sedation and orthostatic hypotension. 1
• Evaluate whether sleep hygiene measures, pain control optimization, and treatment of underlying anxiety/depression could reduce or eliminate the need for this medication.

Dual Antiplatelet Therapy:

• As discussed above, if >1 year post-PCI, discontinue aspirin and/or clopidogrel to reduce bleeding risk while maintaining anticoagulation. 3

Ibuprofen PRN:

• NSAIDs should be avoided in patients with heart failure, CKD, and on anticoagulation due to increased bleeding risk and fluid retention. 4
• Continue acetaminophen and lidocaine patches for pain management instead.

Nutritional Management

The current supplementation with Ensure BID and Boost daily is appropriate for mild protein-calorie malnutrition. 1

• A lower-fat, whole-food, plant-forward diet can reduce and prevent morbidity in ASCVD and should be emphasized within the facility's dietary capabilities. 1
• Patients with heart failure and physical/cognitive impairments are at particular risk for malnutrition and require ongoing monitoring. 1
• Continue weekly weights and intake documentation as ordered.

Monitoring and Safety Protocols

The current Q-shift vital signs, fall surveillance, and safety monitoring are appropriate and should continue. 2, 4

Specific Monitoring Parameters

• Anticoagulation monitoring: Daily assessment for bleeding indicators (bruising, hematuria, melena, hemoptysis) given triple therapy risk. 2, 3
• Renal function: Monitor creatinine and eGFR regularly, as elderly patients with CKD are vulnerable to medication-induced renal deterioration. 2
• Cardiac biomarkers: Establish regular BNP monitoring schedule (monthly or with clinical changes) to guide heart failure therapy optimization. 2
• Fluid status: Daily weights, edema checks, and strict adherence to 1500 mL/day fluid restriction for CHF management. 2

Discharge Planning Considerations

The goal of discharge to independent/assisted living after therapy completion is appropriate, but requires structured assessment. 5

• Elderly patients with multimorbidities desire convenient access to providers, clear communication of individualized care plans, support from a single care coordinator, and continuity of relationships. 5
• Establish a primary care coordinator before discharge who can help prioritize competing demands and provide ongoing support. 5
• Assess whether the discharge environment can accommodate mobility limitations, medication management needs, and fall prevention strategies. 1, 5

Common Pitfalls to Avoid

• Avoid aggressive diuresis that worsens renal function in elderly patients with CKD and heart failure. 2
• Do not continue benzodiazepines indefinitely on "hold" status—make definitive decisions about deprescribing. 1
• Avoid prolonging triple antithrombotic therapy beyond necessary duration due to exponentially increased bleeding risk. 3
• Do not apply disease-specific guidelines in isolation without considering interactions and cumulative treatment burden. 1
• Avoid nighttime sedatives that increase fall risk when fall prevention is a primary safety concern. 1