What is the appropriate comprehensive care plan for a patient with chronic pain, insomnia, constipation, protein-calorie malnutrition, and a history of rhabdomyolysis and metabolic encephalopathy?

Comprehensive Care Plan for Geriatric Patient with Multiple Chronic Conditions

Nutritional Management Priority

This patient's protein-calorie malnutrition requires immediate intensive nutritional intervention with oral supplements, weekly monitoring, and consideration of enteral support if oral intake remains inadequate, as malnutrition directly increases mortality, infection risk, and impairs rehabilitation capacity in geriatric patients. 1

Immediate Nutritional Actions

• Continue current oral supplementation (house supplement with documented percentage intake) and appetite stimulant (mirtazapine), as oral nutrition with fortified supplements is the first-line approach before considering tube feeding 1
• Protein requirements should be 1.2-1.5 g/kg/day given age, malnutrition severity, and multiple chronic conditions—significantly higher than the 0.8 g/kg/day for healthy adults 1
• Weekly weights for 4 weeks, then monthly to track response, with albumin and total protein monitoring every 3-4 months 1
• If oral intake remains insufficient after 7-10 days of intensive supplementation, consider nasogastric or gastric tube feeding before progressing to jejunal or parenteral routes 1

Critical caveat: The ESPEN guidelines emphasize that nutritional restoration in elderly patients is slower and less complete than in younger adults, requiring concurrent physical rehabilitation to restore muscle mass 1

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Pain Management Strategy

Continue hydrocodone-acetaminophen PRN for chronic dorsalgia, as current stable renal function (Cr normal) and liver enzymes support safe intermittent use, but intensify bowel regimen and monitor closely for narcotic bowel syndrome given opioid exposure. 1, 2

Pain Management Protocol

• Gabapentin should be considered as first-line adjunct for any neuropathic component, titrating to 2400 mg/day in divided doses, which also improves sleep scores 1
• Non-pharmacologic interventions are mandatory: physical therapy, heat application, repositioning, and cognitive behavioral therapy to reduce opioid dependence 1
• Document pain levels and functional impact at each visit to justify continued opioid use and assess for dose escalation patterns suggesting tolerance or narcotic bowel syndrome 2
• If pain control deteriorates or opioid requirements increase, consult pain specialist to evaluate for narcotic bowel syndrome and consider supervised opioid taper 1, 2

Major pitfall: Abrupt opioid discontinuation in physically dependent patients causes severe withdrawal, uncontrolled pain, and increased mortality risk—any taper must be gradual (10-25% dose reduction every 2-4 weeks) 2

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Metabolic Encephalopathy Prevention

Maintain aggressive hydration, avoid all anticholinergic and sedating medications, and complete pending metabolic workup to prevent rhabdomyolysis recurrence, as repeat episodes significantly increase mortality. 3

Metabolic Monitoring

• Discontinue cyclizine permanently—this anticholinergic agent reduces peristalsis and can precipitate or worsen pseudo-obstruction and encephalopathy 3
• Complete ordered metabolic panel including CK, TSH, vitamin levels to identify reversible causes of prior encephalopathy 1
• Daily orientation assessment and behavioral monitoring by nursing staff to detect early cognitive changes 1
• Ensure adequate fluid intake (oral or IV supplementation if needed) to prevent dehydration-related metabolic decompensation 1

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Constipation Management in Opioid Context

Escalate bowel regimen prophylactically given opioid use: continue current senna-docusate combination, add scheduled polyethylene glycol (not just PRN), and monitor for bowel movement every 48-72 hours maximum. 1

Bowel Protocol

• Scheduled stimulant laxative (senna) plus osmotic agent (polyethylene glycol) is superior to either alone in opioid-induced constipation 1
• Avoid high-dose secretory laxatives early as they can worsen electrolyte imbalances, particularly hypokalemia 3
• If no bowel movement in 72 hours, escalate to suppository or enema rather than increasing oral laxatives indefinitely 1
• Document bowel movement frequency on medication administration record to track regimen effectiveness 1

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Insomnia and Behavioral Management

Continue melatonin and mirtazapine while avoiding all anticholinergic sedatives; consider sleep hygiene consultation and rule out pain, nocturia, or medication-related causes of nighttime agitation. 1, 3

Sleep Optimization

• Minimize overnight care disruptions (consolidate vital signs, medication administration) to preserve sleep architecture 1
• Assess for undertreated pain as nocturnal pain commonly disrupts sleep and may manifest as agitation in elderly patients 1
• Trazodone PRN is acceptable as it lacks significant anticholinergic effects, unlike diphenhydramine or hydroxyzine which must be avoided 3
• Physical therapy and daytime activity improve nighttime sleep quality and reduce behavioral disturbances 1

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Multidisciplinary Care Coordination

This patient requires intensive interdisciplinary team management with a designated care coordinator, as multiple chronic conditions with competing treatment demands significantly increase mortality without coordinated care. 1, 4, 5

Team Structure and Communication

• Assign single care coordinator (typically nurse or social worker) to help patient prioritize competing demands and ensure treatment plan coherence 5
• Nutrition counseling should occur every 1-2 months given active malnutrition, with more frequent contact if intake deteriorates 1
• Quarterly interdisciplinary team meetings including physician, nursing, dietitian, pharmacy, and social work to update comprehensive care plan 1
• Patient and family must participate in care planning to ensure goals align with patient values and capabilities 1, 5

Key principle: Elderly patients with multimorbidity desire individualized care plans that acknowledge their unique constellation of problems and shifting priorities, requiring flexible support systems that respond to changing needs 5

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Monitoring Schedule and Reassessment Triggers

• Weekly labs for 4 weeks (CBC, CMP, CK) to ensure metabolic stability post-hospitalization 1
• Monthly nutritional assessment including weight, dietary intake documentation, and albumin/prealbumin if available 1
• Immediate reassessment required if: new confusion, decreased oral intake >48 hours, no bowel movement >72 hours, uncontrolled pain, or acute illness 1
• Quarterly comprehensive review of all medications, nutritional status, functional status, and care plan effectiveness 1