What is the best approach to manage the care of an older adult patient with essential hypertension, chronic pain, depression, and osteoporosis, on a complex medication regimen, with vitamin D deficiency and mildly elevated liver enzymes?

Management of Complex Polypharmacy in an Older Adult with Multimorbidity

This patient requires immediate comprehensive medication review with systematic deprescribing, prioritizing patient-centered goals over disease-specific guideline adherence, as applying multiple single-disease guidelines to older adults with multimorbidity is cumulatively impractical and potentially harmful. 1

Immediate Priority Actions

Medication Reconciliation and Risk Assessment

• Conduct an urgent medication review focusing on the 19 active medications (excluding PRN medications), as patients taking 5 or more medications average 1 significant drug problem, and this patient is taking nearly 4 times that threshold 1
• Identify potentially inappropriate medications using a multidisciplinary team approach involving the primary physician, pharmacist, and nursing staff 1
• The current regimen includes multiple high-risk medications for older adults: morphine sulfate ER, oxycodone-acetaminophen (both scheduled and PRN), pregabalin, duloxetine, and oxybutynin—all of which increase fall risk, cognitive impairment, and adverse events 1, 2

Address Vitamin D Deficiency Immediately

• The patient's 25-OH Vitamin D level of 18 ng/mL indicates deficiency (goal >30 ng/mL), yet she is only receiving 50,000 IU monthly, which is inadequate 3
• Increase vitamin D3 supplementation to 2,000-4,000 IU daily (or 50,000 IU weekly for 8 weeks, then 1,000-2,000 IU daily maintenance) to achieve sufficiency, as vitamin D deficiency causes muscle weakness, increases fall risk, and compromises osteoporosis treatment efficacy 3
• The current monthly dosing of 50,000 IU provides only approximately 1,667 IU daily equivalent, which is below the 800-1,000 IU minimum needed for maintenance 3

Systematic Deprescribing Approach

Pain Management Optimization

This patient is on an excessive and dangerous opioid regimen with multiple overlapping pain medications:

• Morphine sulfate ER 15 mg every 12 hours (scheduled)
• Oxycodone-acetaminophen 5-325 mg at bedtime (scheduled)
• Oxycodone-acetaminophen 5-325 mg every 6 hours PRN
• Pregabalin 75 mg three times daily
• Lidocaine patches
• Topical menthol-methyl salicylate

Recommended deprescribing strategy 1:

• Eliminate the scheduled bedtime oxycodone-acetaminophen immediately—there is no justification for both scheduled long-acting morphine AND scheduled short-acting oxycodone 1
• Reduce morphine sulfate ER to 7.5 mg every 12 hours and reassess pain control weekly, with goal of further reduction or discontinuation 1
• Continue pregabalin 75 mg three times daily for neuropathic pain, as this is appropriate dosing 1
• Retain topical agents (lidocaine patches, menthol-methyl salicylate) as they have minimal systemic effects
• Keep PRN oxycodone-acetaminophen but limit to maximum 2 doses daily with strict monitoring of total acetaminophen intake (<3 grams/24 hours) 1

Anticholinergic Burden Reduction

• Discontinue oxybutynin 5 mg every 8 hours immediately—this is a high-risk anticholinergic medication in older adults that increases fall risk, cognitive impairment, and delirium 1, 2
• If overactive bladder symptoms persist after discontinuation, consider behavioral interventions first (timed voiding, fluid management) before any pharmacologic alternative 1

Cardiovascular Medication Review

Current regimen:

• Amlodipine 10 mg daily
• Aspirin 81 mg daily
• Simvastatin 40 mg daily (but only taking 20 mg according to order)
• Nitroglycerin PRN

Assessment 1, 4:

• Amlodipine 10 mg is appropriate for this patient's blood pressure control, though elderly patients have 40-60% increased AUC and may require lower doses 4
• Clarify the simvastatin dosing discrepancy—order states 40 mg tablet but "give 20 mg," which creates confusion and medication error risk 1
• Continue aspirin 81 mg daily for CAD secondary prevention 1
• Monitor for drug interactions: amlodipine increases simvastatin exposure by 77%, increasing myostatin toxicity risk (note CPK is already low at 27 U/L, below normal range) 4

Respiratory Medications

• Continue albuterol HFA and ipratropium-albuterol nebulizer PRN for COPD/asthma management—these are appropriate 1

Gastrointestinal Medications

Current regimen includes excessive bowel management:

• Senna-S twice daily (scheduled)
• GlycoLax (polyethylene glycol) daily (scheduled)
• Milk of Magnesia PRN

Recommended approach 1:

• Reduce to single scheduled agent: Continue GlycoLax 17 grams daily only
• Discontinue scheduled Senna-S—the combination of scheduled stimulant laxative plus osmotic laxative is excessive 1
• Retain Milk of Magnesia PRN for rescue use only (no BM in 3 days)
• Note: Opioid reduction will decrease constipation burden significantly 1

Psychiatric Medications

• Continue duloxetine 20 mg twice daily for depression—this is appropriate dosing and addresses both depression and chronic pain 1
• Continue Zofran PRN for nausea/vomiting

Osteoporosis Management

• Continue alendronate (Fosamax) 70 mg weekly—this is appropriate for osteoporosis treatment 3
• Ensure adequate calcium and vitamin D supplementation (addressed above) to maximize bisphosphonate efficacy 3
• Current calcium carbonate-vitamin D 500-200 mg-unit daily is inadequate; increase to calcium 1,200 mg daily total (including dietary sources) 3

Laboratory Abnormalities Requiring Action

Mild Anemia

• Hemoglobin 11.8 g/dL (low) with normal MCV, MCH, MCHC suggests anemia of chronic disease 5
• Check iron studies, B12, and folate to rule out nutritional deficiencies
• Consider contribution from chronic NSAID use (if any) or GI blood loss

Low Creatinine

• Creatinine 0.54 mg/dL (low) likely reflects sarcopenia and low muscle mass, common in older adults with chronic pain and limited mobility 5
• eGFR 92 mL/min/1.73m² is reassuring for kidney function
• This patient may be more sensitive to renally cleared medications despite "normal" eGFR 4

Low Total Protein and Albumin

• Total protein 6.1 g/dL (low) and albumin 3.6 g/dL (low-normal) suggest poor nutritional status or chronic inflammation 5
• Obtain nutritional assessment and consider dietary supplementation
• Low albumin affects protein binding of highly bound drugs like amlodipine (93% protein bound), potentially increasing free drug levels 4

Lipid Panel

• Total cholesterol 138 mg/dL, LDL 74 mg/dL, HDL 41.7 mg/dL (low)
• LDL is at goal for CAD (<100 mg/dL), but low HDL increases cardiovascular risk 1
• Current simvastatin dose appears adequate for LDL control

Hypertension Management

• Current blood pressure is not provided in the data, but patient is on amlodipine 10 mg daily for essential hypertension 1
• Target blood pressure for this elderly patient should be <140/90 mmHg, individualized based on frailty status 1
• Amlodipine monotherapy is appropriate for elderly patients and those with multiple comorbidities 1, 4
• Monitor for peripheral edema, a common side effect of dihydropyridine calcium channel blockers 4

Patient-Centered Goals of Care

Shift from disease-specific to patient-centered approach 1:

• Primary goals should be: maintaining functional independence, controlling pain adequately without oversedation, preventing falls, preserving cognitive function, and reducing treatment burden 1
• Life extension may be less important than quality of life and symptom control in this 79-year-old with multiple comorbidities 1
• Engage patient and family in collaborative goal-setting to align treatment with patient values and preferences 1

Multidisciplinary Team Coordination

Implement team-based care 1:

• Pharmacist: Conduct comprehensive medication review, identify drug-drug interactions, monitor for adverse effects
• Nursing: Assess functional status, fall risk, pain control, medication adherence
• Physical therapy: Evaluate mobility, fall risk, and implement fall prevention strategies
• Dietitian: Address nutritional deficiencies (low albumin, vitamin D deficiency)
• Primary physician: Coordinate care, make final prescribing decisions, communicate with specialists

Monitoring Plan

After implementing medication changes 1:

• Week 1-2: Daily assessment of pain control, sedation, fall risk, bowel function
• Week 4: Reassess pain scores, functional status, medication adherence
• Month 3: Repeat vitamin D level (goal >30 ng/mL), CBC, comprehensive metabolic panel
• Ongoing: Monitor for withdrawal symptoms from opioid reduction, anticholinergic discontinuation effects

Critical Safety Warnings

• This patient is at extremely high risk for falls due to polypharmacy (19 medications), opioids, pregabalin, duloxetine, and oxybutynin 1, 2
• Cognitive impairment risk is elevated from anticholinergic burden (oxybutynin) and CNS depressants (opioids, pregabalin) 1, 2
• Drug-drug interactions are likely given the complexity of the regimen—amlodipine increases simvastatin levels, multiple CNS depressants potentiate sedation 4
• Approximately 47% of patients continue medications after care transitions without clear indication—active deprescribing planning is essential 2

Common Pitfalls to Avoid

• Do not apply single-disease guidelines without integration—this leads to contradictory recommendations and polypharmacy 1, 6
• Do not assume all medications are necessary because they were prescribed by specialists—each medication should have a clear, current indication 1
• Do not delay deprescribing due to fear of withdrawal or disease worsening—the harms of polypharmacy often outweigh these risks 1
• Do not ignore patient preferences—some patients prioritize alertness and function over complete pain control 1
• Do not forget to reassess at every care transition (hospital admission, discharge, nursing home placement) 2, 5