What is the optimal care plan for an elderly patient with AFib, hypertension, hyperlipidemia, CAD, CHF, hypothyroidism, and recent falls, admitted for debility, weakness, and an 11th rib fracture?

Optimal Care Plan for Elderly Patient with Multiple Comorbidities, Falls, and Rib Fracture

This patient requires immediate initiation of osteoporosis pharmacotherapy with oral bisphosphonate (alendronate or risedronate), systematic fall risk reduction through medication optimization (particularly deprescribing the newly added trazodone and lorazepam), vitamin D 800 IU daily, and structured multidisciplinary rehabilitation with aggressive early mobilization. 1

Immediate Priorities: Fracture Prevention and Fall Risk Reduction

Osteoporosis Treatment - Critical Gap in Current Management

The most urgent intervention missing from this care plan is pharmacological osteoporosis treatment. This patient has sustained a fragility fracture (11th rib) with multiple falls, which mandates systematic fracture risk evaluation and treatment. 1

• Initiate oral bisphosphonate therapy immediately: Alendronate or risedronate are first-choice agents because they reduce vertebral, non-vertebral, AND hip fractures, are well-tolerated, low-cost, and have extensive clinical experience. 1
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, zoledronic acid (IV) or denosumab (subcutaneous) are alternatives. 1
• Treatment duration should be 3-5 years minimum, longer if high risk persists. 1
• Ensure adequate calcium intake (1000-1200 mg/day) combined with vitamin D 800 IU/day - this reduces non-vertebral fractures by 15-20% and falls by 20%. 1
• Avoid high-pulse dosages of vitamin D as they paradoxically increase fall risk. 1

Medication Optimization - Addressing Polypharmacy and Fall Risk

The recent addition of trazodone 50 mg QHS represents a significant medication error in this high-fall-risk patient and should be discontinued immediately. 1

• Trazodone creates multiple dangerous interactions: Combined with escitalopram (serotonin syndrome risk) and apixaban (bleeding risk), while simultaneously increasing fall risk through sedation. 1
• Psychotropic medications carry an odds ratio of 1.7 for falls - this patient already has multiple fall risk factors without adding sedating medications. 1
• Lorazepam discontinuation was appropriate and should not be reversed; benzodiazepines dramatically increase fall and cognitive impairment risk in elderly patients. 1
• For insomnia management, prioritize non-pharmacological interventions: sleep hygiene, scheduled toileting, pain control with current lidoderm/acetaminophen regimen, and addressing hearing aid placement. 1

Review and optimize all medications through a deprescribing lens: 1

• Metoprolol and irbesartan: Monitor for orthostatic hypotension contributing to falls; blood pressure lowering increases instability and falls in older people. 1
• Lasix 20 mg BID: Short course is appropriate for current edema, but prolonged use increases fall risk (OR 1.1 for diuretics). 1
• Apixaban: Continue for AFib, but recognize increased bleeding risk with any fall - document bleeding checks each shift as currently ordered. 1
• Polypharmacy (≥4 medications) is itself a major fall risk factor - this patient is on 10+ medications. 1

Fall Risk Assessment and Intervention - Structured Approach

This patient has multiple high-risk fall factors requiring systematic intervention beyond current "fall precautions." 1, 2

The strongest fall risk factors present in this patient: 1

• Muscle weakness (RR 4.4) - primary admission diagnosis
• History of multiple falls (RR 3.0) - documented recent falls
• Gait deficit (RR 2.9) - requiring rollator, deconditioning
• Use of assistive device (RR 2.6) - rollator dependence
• Impaired ADLs (RR 2.3) - admission for ADL decline
• Age >80 (RR 1.7) - if applicable to this elderly patient
• Polypharmacy - documented 10+ medications

Implement evidence-based multicomponent fall prevention: 1, 2, 3

• Aggressive physical therapy with early mobilization - begin immediately, not just "continue current frequencies." Early postfracture physical training and muscle strengthening are critical. 1, 4
• Balance training must continue long-term beyond acute rehabilitation to prevent future falls. 1, 4
• Environmental assessment: Ensure call light within reach, adequate lighting, clear pathways, bathroom safety equipment, appropriate footwear. 1
• Vision and hearing optimization: Bilateral hearing aids must be placed every morning and removed at night - hearing impairment itself increases fall risk. 1, 2
• Timed Up and Go test should be performed to objectively measure fall risk and track improvement. 2

Cardiovascular Management in Context of Multimorbidity

Heart Failure and Fluid Management

Current CHF management is appropriate but requires careful monitoring given fall risk from diuretics and antihypertensives. 1

• Continue irbesartan and metoprolol for diastolic CHF. 1
• Monitor for orthostatic hypotension - check lying and standing blood pressures given recent BP elevation (171/97) and multiple antihypertensive agents. 1
• Lasix 20 mg BID through specified end date is reasonable for current +1 BLE edema, but reassess need for continuation. 1
• 1500 mL fluid restriction continues. 1
• Weight monitoring q72h is appropriate - alert for >2-3 lb increase. 1

Atrial Fibrillation Management

• Continue apixaban for stroke prevention - benefits outweigh bleeding risks even with fall history. 1
• Continue metoprolol for rate control. 1
• Document bleeding assessments each shift given fall risk and trazodone interaction (if not discontinued as recommended). 1

Hypertension and CAD

• Blood pressure targets should be individualized considering fall risk from overtreatment - the 171/97 reading may not require intensification if it increases orthostatic symptoms. 1
• Continue aspirin for CAD. 1
• Monitor for exertional chest discomfort during therapy sessions. 1

Rehabilitation and Functional Recovery

Structured Rehabilitation Protocol

The current "continue PT/OT/ST at current frequencies" is inadequate - rehabilitation must be aggressive and goal-directed. 1

• Early finger and hand motion if any upper extremity involvement from falls. 4
• Aggressive muscle strengthening targeting lower extremities, core, and postural muscles. 1, 4
• Balance training as primary intervention - this must be intensive and continue long-term beyond discharge. 1, 4
• Gait training with rollator, progressing toward independence if possible. 1
• Functional task training for ADL recovery - bathing, dressing, toileting, transferring. 1

Rib Fracture Management

• Continue lidoderm patches and acetaminophen PRN - adequate pain control enables participation in rehabilitation. 1
• Encourage pulmonary hygiene and incentive spirometry to prevent pneumonia - chest injury in elderly exacerbates cardiopulmonary disease. 1
• Upright posture during activities. 1

Nutritional and Metabolic Optimization

Protein-Calorie Malnutrition

• Continue Ensure HP and Pro-Stat supplementation. 1
• Monitor weekly weights - malnutrition impairs fracture healing and functional recovery. 1
• Regular diet with thin liquids continues. 1

Thyroid and Metabolic Management

• Continue levothyroxine - TSH 0.37 is acceptable (slightly low but not requiring immediate adjustment). 1
• Continue current lipid therapy for hyperlipidemia. 1

Bowel and Bladder Management

Constipation Prevention

• MiraLax BID (powder formulation) and docusate are appropriate - constipation risk increases with reduced mobility and if trazodone continued. 1
• Monitor bowel movement pattern closely. 1

Urinary Management

• UA negative - macrobid discontinuation was correct. Avoid unnecessary antibiotic exposure per antimicrobial stewardship. 1
• Continue scheduled toileting for improving incontinence. 1
• Monitor for urinary symptoms that could indicate delirium or infection. 1

Cognitive and Psychological Management

Confusion and Delirium Prevention

• No confusion overnight - continue current approach of hearing aid placement, sleep hygiene, and neuro checks each shift. 1
• Avoid all sedating medications including the newly added trazodone. 1
• Maintain orientation cues and consistent care team. 1

Anxiety and Depression

• Continue escitalopram for anxiety disorder. 1
• Non-pharmacological anxiety management: Reassurance, family involvement, structured daily routine, adequate pain control. 1
• Do not add trazodone or reinitiate lorazepam - risks far outweigh benefits. 1

Multidisciplinary Coordination and Discharge Planning

Care Coordination Requirements

This patient requires a multidisciplinary team approach with clear role delineation and communication. 1

• Designate a local responsible lead to coordinate between rehabilitation medicine, cardiology, primary care, and orthopedics/rheumatology for osteoporosis management. 1, 4
• Pharmacist involvement for medication review and deprescribing recommendations. 5
• Physical therapy for intensive balance and strength training. 1, 4
• Occupational therapy for ADL training and home safety assessment. 1
• Nursing for daily monitoring, fall prevention, and medication administration. 1

Patient and Family Education

• Disease burden education: Explain osteoporosis, fall risk, and fracture prevention. 4
• Medication adherence: Discuss importance of bisphosphonate therapy and calcium/vitamin D. 1
• Fall prevention strategies: Home safety, appropriate footwear, assistive device use. 1, 2
• Treatment duration expectations: 3-5 years for osteoporosis therapy. 1
• Follow-up plan: Systematic monitoring for adherence and adverse effects. 1, 4

Discharge Planning

• Anticipate return to independent/assisted living once therapy goals achieved. 1
• Home safety evaluation before discharge - remove loose carpets, improve lighting, install bathroom safety equipment. 1, 2
• Outpatient follow-up: Primary care within 1-2 weeks, rheumatology/endocrinology for osteoporosis management within 4 weeks. 1, 4
• Continue balance training in outpatient setting - this is a long-term intervention, not just acute rehabilitation. 1, 4

Critical Pitfalls to Avoid

Common errors in managing elderly patients with multimorbidity and falls: 1

• Adding sedating medications for insomnia - trazodone should be discontinued immediately. 1
• Failing to initiate osteoporosis treatment after fragility fracture - this is a critical omission. 1
• Applying disease-specific guidelines without considering multimorbidity - blood pressure targets, for example, must account for fall risk. 1
• Inadequate deprescribing - polypharmacy itself increases fall risk. 1
• Short-term rehabilitation focus - balance training must continue long-term. 1, 4
• Ignoring time-to-benefit considerations - in patients with limited life expectancy, focus on symptom control and quality of life over long-term prevention. 1
• Undertreating pain - inadequate analgesia prevents rehabilitation participation. 1