NUR 545 Module 8 Older Adult Assessment Example

Nine Bottles on the Table: An Older Adult Assessment of Cognition, Function and Medication Safety

[Student Name]

Southern New Hampshire University

NUR 545: Advanced Health and Literacy Assessment

Older Adult Assessment

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Nine Bottles on the Table: An Older Adult Assessment of Cognition, Function and Medication Safety

For older adults living alone, the ability to take medicines correctly depends on reading, numeracy, memory, eyesight and routine, and a problem with any one of them can look like nonadherence. This paper assesses a composite 82-year-old at a community health center who came for a routine diabetes visit and was asked to bring all her medicines. It combines a brown-bag medication review, a check against the American Geriatrics Society Beers Criteria, cognitive screening with the Mini-Cog and an assessment of instrumental activities of daily living. It argues that her risk comes less from any single drug than from a regimen too complex for her current memory, and that the safest plan removes medicines rather than adding teaching.

The Patient and the Brown Bag

The patient, a retired school cafeteria worker, lives alone in a second-floor apartment; her daughter visits on Sundays. She reads comfortably and manages her own mail but says numbers "get jumbled" lately. Table 1 lists what she brought.

Table 1

Brown-Bag Medication Review

Note. Composite patient.

Checking Against the Beers Criteria

The 2023 Beers Criteria identify medicines that are potentially inappropriate for most older adults (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Four of hers fall into that category. Diphenhydramine is strongly anticholinergic and is associated with confusion, constipation and falls in older adults; the criteria recommend avoiding first-generation antihistamines. Sulfonylureas such as glipizide carry a high risk of prolonged low blood sugar in older adults and are recommended against as first- or second-line therapy. Proton pump inhibitors should be avoided beyond eight weeks unless there is a clear high-risk indication, which the review did not find. And aspirin should not be started for primary prevention in older adults, with deprescribing considered for those already taking it. Amlodipine is not on the list, but its likely link to her ankle swelling is worth reviewing.

Cognitive Screening

Because she described numbers getting jumbled and was taking a duplicated medicine, the nurse asked permission to do a brief memory check, framing it as routine for everyone her age. The Mini-Cog combines recall of three words with a clock drawing (Borson et al., 2000). Only one of the three words came back to her, and her clock had all twelve numbers but the hands pointed to 11 and 10 rather than ten past eleven. Under the Mini-Cog's scoring approach, recall of one or two words with an abnormal clock is a positive screen for possible cognitive impairment. A screen is not a diagnosis, and the result needs follow-up with a fuller evaluation, including a check for reversible contributors. Two of those were already in the bag: nightly diphenhydramine and episodes of low blood sugar can both impair memory.

Function and the Glucose Meter

Instrumental activities of daily living, such as managing money, shopping, using transportation and handling medicines, are usually the first abilities to decline when cognition changes (Lawton & Brody, 1969). She manages shopping and cooking independently, has recently let her daughter take over bills after missing two payments and no longer drives at night. For medicines, she keeps the bottles on the kitchen table and "remembers" whether she has taken them; she does not use an organizer.

Her glucose meter's memory told the most important story. Over two weeks, four morning readings were between 52 and 64 mg/dL. She had not recognized these as low because she "felt a bit off" but not shaky. Taking glipizide from two bottles on some days, with a small supper, explains them, and repeated hypoglycemia in an older adult risks falls, confusion and cardiac events.

Health Literacy in This Patient

Her difficulty is not reading. She read every label aloud accurately. It is numeracy and memory: keeping track of which of nine bottles she has taken today, noticing that two bottles contain the same drug and interpreting a meter reading of 58. A handout would not solve any of these. What helps is fewer medicines, packaging that shows whether a dose was taken and a single simple rule for low sugar, taught by teach-back and practiced with her meter (Brega et al., 2015).

Plan

The plan, agreed with the patient and, at her request, discussed with her daughter by phone, has five parts. First, stop glipizide today, remove both bottles and review glucose control at follow-up. Second, taper and stop diphenhydramine, replacing it with sleep hygiene measures she chose. Third, stop aspirin and begin tapering omeprazole, with instructions for what to do if heartburn returns. Fourth, consolidate all remaining prescriptions at one pharmacy, which will supply weekly blister packs labeled by day and time, so a missed dose is visible. Fifth, refer for a fuller cognitive evaluation after two to four weeks off diphenhydramine and without hypoglycemia, since both may be affecting her memory. The regimen falls from nine medicines to five scheduled ones.

Teaching focused on one rule for low sugar, taught with her meter and checked by teach-back: "If the meter says under 70 or you feel off, drink the small juice box from the fridge door, sit down for 15 minutes, check again and call us." She explained it back in her own words and showed where the juice boxes would be kept.

Conclusion

The brown bag revealed what a chart could not: a duplicated sulfonylurea causing silent morning lows, a nightly anticholinergic and two medicines without a current reason. The Mini-Cog and a functional history suggested memory changes that make a nine-drug regimen unsafe, while also pointing to reversible contributors. For this patient, the most effective health literacy intervention was not a better explanation but a simpler regimen that asks less of her memory and numeracy, supported by packaging, one clear rule and follow-up.

References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive "vital signs" measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15(11), 1021-1027. https://doi.org/10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6

Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., Cifuentes, M., Albright, K., & West, D. R. (2015). AHRQ health literacy universal precautions toolkit (2nd ed., AHRQ Publication No. 15-0023-EF). Agency for Healthcare Research and Quality.

Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3, Pt. 1), 179-186. https://doi.org/10.1093/geront/9.3_Part_1.179