From Greg Gahm, MD

RW is a 102-year-old black female with primary diagnoses of Atrial Fibrillation, HTN, Cardiomegaly, PVD, generalized weakness, hypothyroidism, dyslipidemia and hyperthyroidism (yes, her most recent PCC list of diagnoses contains both hypo- and hyperthyroidism!) She has a remote history of a single DVT associated with a Pulmonary Embolus.

Despite her age and the occasional low stage pressure ulcer, she seems to be doing fairly well other than just slowing down a bit. Her most recent BP is 156/90, pulse 60 and pulse ox of 93. She requires assistance with many ADLs and has some swallowing problems requiring a diet of regular texture, thin consistency. Her BIMS is 7 and PHQ-9 is 1. She has no complaints and is not in pain.

Medications include:

  • Metoprolol ER 75 mg qd
  • Amiodarone 200 mg qd
  • Aspirin 81 mg qd
  • Atorvastatin 20 mg qhs
  • Warfarin 2 mg qd (dose changes every month or so)
  • Lidoderm patch to sacral area qd
  • Omeprazole 40 mg q am (GERD)
  • Protein Liquid 30 ml qd
  • Tapazole 5 mg qd
  • Acetaminophen 650 mg tid
  • Lasix 20 mg qod
  • Viscous Lidocaine Solution 15 cc po q 6 hours “as needed for pain”
  • Lactulose, Dulcolax, Senna qd prn
  • Maalox Max Suspension 400-400-40 30 ml q 6 prn heartburn
  • TUMS q 2 hours prn heartburn

What would you recommend to the provider? How strong would your recommendation(s) be?

(Posted by HLeMaster for Dr. Greg Gahm)

102-year-old black female – what would you recommend?

One thought on “102-year-old black female – what would you recommend?

  • June 1, 2015 at 2:53 pm

    1. At age 102, there is no excuse for keeping this poor lady on Amiodarone! It does not matter who started her on it, for what reason or how long ago! She does not have life-threatening ventricular arrhythmias now and since she made it to 102, almost certainly never did! STOP THE AMIODARONE!

    Among the 100+ common side effects in the elderly is hyperthyroidism, undoubtedly the reason which she is being kept on Tapazole! The other thing to remember is that the AFFIRM Trial comparing rate with rhythm control for Atrial Fibrillation clearly demonstrated that the two approaches had statistically equivalent outcomes, but there were far more side effects using the rhythm control approach. There is not and never has been an expert panel or group recommending that both rhythm and rate control be used in patients. Once the Amiodarone is discontinued, the TSH should be monitored about every 6 weeks for 3-6 months until a new baseline is established, likely after the Methimazole has been tapered and discontinued.

    2. Anticoagulation: is still recommended for the AF, but from the global view it is probably time to consider using just Aspirin , not any form of anticoagulation. This patient does not and likely never did have an indication for using both an anticoagulant and an anti-platelet agent . The evidence shows that there are only 3 indications to support concurrent use where intended benefits exceeded adverse effects / increased risk of bleeding:

     Mechanical Valve patients with a low bleeding risk;
     Acute Coronary Syndrome; and
     Recent Coronary Stents or Bypass Surgery

    My recommendation for this patient would be to discontinue the Lovenox –> Warfarin and continue the aspirin only (there is only a 1% per year decrease in strokes using anticoagulation instead of an antiplatelet agent).

    3. At age 102, it is time to stop the statin!!!

    4. Based on recent evidence that Lidocaine Patches are no more effective than placebo patches (but are very expensive), it is time for the Lidoderm to go away.

    5. It is unlikely that she truly has ‘GERD’ or needs a PPI. Acid production is cut nearly in half by the age of 80 in most seniors. Who knows how much acid one makes at age 102, but it is almost certainly not enough to warrant placing her at increased risk for bacterial pneumonia, C Diff, hip fractures, low magnesium and B12 and decreased absorption of other medications.

    6. I do not know what clinical benefit 20 mg of Lasix every other day is providing, so might take a closer look at it to see if it is really still necessary.

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