Caring for the Aging in the Community
John Andraos; Arlene Dies; Chantal B. Lecuyer; and Andrea Nykipilo
Background
This is an interprofessional Problem Based Learning (iPBL) case created for health professions students’ education. Students will work together in interprofessional groups to identify knowledge gaps and fill them in. Students will also learn from each other about each member’s roles in patient care.
Learning Objectives:
By the end of the iPBL, students will be able to:
- Demonstrate collaborative practice by identifying the need to include additional healthcare professionals
- Demonstrate clear and thorough communication skills in an interprofessional team
- Assess a client’s medical history, medication, and clinical presentation
- Describe factors that impact a person’s ability to manage their medications
- Describe the impact memory loss has on those living independently
- Create a comprehensive care plan for the patient, while showing awareness of community resources
This iPBL involves three meetings of the group with a tutor to facilitate. A new piece of the case will be revealed in each session and students will collaborate to create an interprofessional action plan for an elderly man currently living alone. Each student should take responsibility for their own learning and contribute to the learning of the group. Some research between meetings is expected with information brought back to the group to help progress work in the subsequent session.
This case is geared towards students from the following health professions disciplines:
- Pharmacy (2nd year students)
- Medical student (3rd year students)
- Nursing (3rd year students)
Day 1
Bruce Adams is an 81 year old male who lives at home alone. He was married for 57 years to his wife Mary, who passed away three months ago. Recently, Bruce has been struggling a bit with his medications and finds it hard to remember which ones to take and at which times, and with keeping track of which medications he has already taken. Bruce drove himself to the pharmacy today and asked for a refill of one of his medications. He shows the pharmacist a bottle containing pills of varying shapes and colours.
Bruce’s medication list is listed below.
| Drug Name & Strength | Directions |
| Metformin 500 mg | Take 2 tablets twice daily |
| Warfarin 5 mg | Take 1 tablet at bedtime |
| Gliclazide 60 mg | Take 1 tablet once daily |
| Metoprolol 25 mg | Take 1 tablet twice daily |
| Ramipril 10 mg | Take 1 capsule once daily |
| Atorvastatin 80 mg | Take 1 tablet at bedtime |
| Hydrochlorothiazide 25 mg | Take 1 tablet once daily |
| Rabeprazole 20 mg | Take 1 tablet twice daily |
| Tamsulosin 0.4 mg | Take 1 tablet once daily |
| Zopiclone 7.5 mg | Take 1 tablet at bedtime |
The pharmacist reviews his record, and sees that one week ago, he filled one month’s worth. When asked about this, he has no response and looks puzzled. Bruce’s pharmacy is part of an integrated care clinic with his primary physician and a primary care nurse onsite. During his visit to the pharmacy today, the pharmacist decides to involve the interprofessional team to help create an action plan to help Bruce.
A quick review of his file shows his medical history includes: type II diabetes, hypertension, atrial fibrillation and benign prostate hyperplasia. The pharmacist chats with Bruce and finds out that he fears that what is happening to him with his medications will mean that he has to leave his beloved home, which carries many fond memories of his life with Mary. In fact, he has been so worried, that he has not been sleeping well and his appetite has been low. He also says that he has been feeling dizzy and off-balance at times. The pharmacist suggests that Bruce makes an appointment with his physician and he agrees. He is asked to bring all his medications to this appointment, including: prescriptions, over-the-counter medications, supplements, vitamins, herbal medicines, creams, and inhalers.
Day 1: Tutor Probes
Questions that tutors can use if the discussion stalls.
- What in Bruce’s medical history would impact his ability to care for himself and continue to live independently?
- Are there concerns with how Bruce made it to the pharmacy today? Elaborate on why or why not.
- What other healthcare professions would you involve at this point?
- What do you know about aging and memory loss?
- Would you expect a patient with Bruce’s medical history to be on so many medications?
- Do any of Bruce’s disease processes impact memory, balance, or sleep?
- Where and how could a person be tested for memory loss?
- What impact would Bruce’s low appetite have on his medical conditions?
- What do you know about hypertension (HTN) and its management?
- What are the symptoms associated with Benign Prostate Hyperplasia (BPH)?
- How could Bruce’s diagnosed BPH contribute to his health issues?
- What do you know about atrial fibrillation and how to manage it?
- What are contributing factors to sleep disturbances?
- What are the different types of sleep disorders?
Day 1:Wrap-Up Questions
Questions to ask at the end of the session, before students are presented with the next set of information.
- Summarize what could be contributing to Bruce’s current situation (including drugs, health conditions, etc.).
- What other information about Bruce and the situation do you think you would need to have before starting to make a plan for Bruce?
- Other than his health professional team, who should be involved in Bruce’s care at this stage?
- What alternative medication packaging can be considered? Would a bubble pack be appropriate for Bruce, and if so, what would that look like?
Day 2
Case Info:
Since the last visit, Bruce has started bubble packs for his medications. His bubble pack sheet from his pharmacy is as follows:
| Drug Name & Strength | Time of day dosing | Qty | Directions | |||
| 0800 | 1200 | 1800 | 2200 | |||
| Metformin 500 mg | 2 | 2 | 112 | Take 2 tablets twice daily | ||
| Warfarin 5 mg | 1 | 28 | Take 1 tablet at bedtime | |||
| Gliclazide 60 mg | 1 | 28 | Take 1 tablet once daily | |||
| Metoprolol 25 mg | 1 | 1 | 56 | Take 1 tablet twice daily | ||
| Ramipril 10 mg | 1 | 28 | Take 1 capsule once daily | |||
| Atorvastatin 80 mg | 1 | 28 | Take 1 tablet at bedtime | |||
| Hydrochlorothiazide 25 mg | 1 | 28 | Take 1 tablet once daily | |||
| Rabeprazole 20 mg | 1 | 1 | 56 | Take 1 tablet twice daily | ||
| Tamsulosin 0.4 mg | 1 | 28 | Take 1 tablet once daily | |||
| Zopiclone 7.5 mg | 1 | 28 | Take 1 tablet at bedtime | |||
One week later, Bruce arrives for his clinic appointment with his physician. As requested, he brings his bubble pack. Upon arrival his weight and blood pressure are taken by the primary care nurse. Since his last appointment 6 months ago, Bruce has lost 8 lbs. His blood pressure reading today is 150/95. The nurse sets his medications aside for the doctor to review, and in doing so, notices that some bubbles from his packs are still filled with medications. During the appointment it is discovered that Bruce has not been taking his medications as prescribed. For this reason, the physician submits a request for Bruce to be assessed by the community nurse.
Day 2: Tutor Probes
Questions that tutors can use if the discussion stalls.
- What is the role of your profession in Bruce’s care at this point?
- What could be the consequences of missed doses for Bruce?
- What could be the consequences of using a narrow therapeutic window drug such as warfarin?
- What is International Normalized Ratio (INR)?
- What challenges could Bruce face in monitoring his INR while on warfarin?
- Do you think Bruce might have any financial barriers to fill his medications?
- What might you want ask Bruce to find out more about why he is having difficulty managing his medication? How could this help you decide on a plan to assist Bruce to set up a safe medication routine?
- What additional resources are available to assist Bruce with his bubble packs?
- What are the responsibilities of the patient when home care is initiated? Who is part of the home care team?
- What aspects of Bruce’s life may be affected by memory loss?
- What are the risk factors associated with HTN? What are the complications?
- What is considered a high blood pressure and how common is it? How frequently should someone with high blood pressure go for a blood pressure reading?
Day 2: Wrap-Up Questions
Questions to ask at the end of the session, before students are presented with the next set of information.
- What strategies would you use to help Bruce open up about how he manages his medications?
- Who should be involved in Bruce’s healthcare team at this stage? Are there any community resources that you would recommend?
- What tools could be used to assess Bruce’s need for assistance at home?
Day 3
Case Info:
The community nurse makes a visit to Bruce’s home because his physician has made her aware that he has not been adhering to his bubble packs. She will do some additional assessments to find out how he is managing living on his own.
Today is of particular importance to Bruce as it would have been his 60th wedding anniversary. He discloses to the nurse that he has not been cooking or eating as much since he lost his spouse, and that the last few weeks leading up to their anniversary have been particularly difficult. In fact, his neighbour Daphne, who checks in on him and brings meals to help out, has been visiting more frequently. Bruce shares that Daphne has voiced concern because she feels that he seems to be losing weight. Bruce is adamant that it is just a difficult time of the year for him and that Daphne is simply overreacting. The nurse asks questions to determine why he is not adhering to his bubble packs and finds out that even with the bubble packs, Bruce is having trouble remembering to take his medications correctly.
As part of the elderly patient exam, the community nurse completes an Instrumental Activities of Daily Living (IADL) and notes Bruce’s responses on file as seen below.
| Questions | Responses | Score 0 or 1 |
| Using the telephone | He has a landline, but does not remember the last time it was used | 0 |
| Shopping | He lives close to a little shopping mall where he is able to do his groceries and makes small purchases. Although prefers not to go out. | 0 |
| Preparing food | He has not been eating very well since his wife’s passing. His neighbour has been bringing over meals every now and then and will often bring him some groceries. | 0 |
| Housekeeping | Does light cleaning when he feels like it | 1 |
| Doing laundry | He is able to do his laundry | 1 |
| Using transportation | He drives his own vehicle | 1 |
| Handling medications | Struggling with this, his wife Mary helped him manage his medications and is now getting help from his Pharmacist | 0 |
| Handling finances | Mary was responsible for the finances, but he is learning with the help of the workers at the bank | 1 |
|
Score out of 8 |
4 | |
Day 3: Tutor probes
Questions that tutors can use if the discussion stalls.
- What risks are there for Bruce surrounding non-adherence to medications? (too much or too little)
- What do you believe could be contributing to Bruce’s lack of medication adherence?
- What other options, if any, could improve medication adherence?
- Clarify what role your profession would play in Bruce’s care.
- How/what would you communicate to Bruce’s circle of care?
- Who else might be involved in Bruce’s home care?
- What factors might affect Bruce’s ability or choice to seek support? Would cost be a factor?
- What community resources might be available for someone who is grieving the loss of a spouse?
- What resources are available in the community to assist Bruce to remain independent?
- Would knowing what kind of support system Bruce has be valuable information? If so, how? What kind of information would be important to know?
- What support would Bruce need, if any, with the passing of his spouse?
- What are the stages of the grieving process? What do they encompass?
- How could loss of his spouse affect Bruce’s diet/nutrition?
- How would you discuss diet/nutrition with Bruce? Which health care team member(s) should do this?
- In what ways could Bruce improve his eating/nutrition?
Day 3: Wrap-Up Questions
Questions to ask at the end of the session, before closing out the session and before students submit their final interprofessional action plans
- What does Bruce’s IADL score indicate?
- Summarize the resources that you feel Bruce would require to improve his ability to live on his own.
- Who would be part of Bruce’s home care team?
Bruce is a fictional character. This case was created for educational purposes.
