NUR 616 Module 9 Final Project Example

Final Project: A Priorities-Based Care Plan for a 78-Year-Old Man With Diabetes, Chronic Kidney Disease, Heart Failure and Eleven Medications

[Student Name]

Southern New Hampshire University

NUR 616: Primary Care of Adults and Gerontological Patients

Final Project

[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.

Final Project: A Priorities-Based Care Plan for a 78-Year-Old Man With Diabetes, Chronic Kidney Disease, Heart Failure and Eleven Medications

Clinical guidelines are written one disease at a time, but older adults rarely have one disease. A 78-year-old with diabetes, kidney disease and heart failure who follows every applicable guideline can end up on a dozen medicines, with targets that raise the risk of the harms he most fears. The American Geriatrics Society has argued that care for such patients should start from their preferences, weigh the evidence for people like them and consider the burden of treatment (American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity, 2012). This final project applies that approach to a man on eleven medicines. It argues that organizing the plan around his priorities leads to fewer drugs, safer targets and treatment he is more likely to continue.

Patient Presentation

Mr. J., 78, a retired machinist, shares a small house with his wife. Type 2 diabetes was diagnosed 20 years ago; he also has kidney disease at stage 3b, with an eGFR of 38 and albuminuria of 180 mg/g, heart failure with an ejection fraction of 35% after a myocardial infarction five years ago, knee osteoarthritis, benign prostatic hyperplasia and peripheral neuropathy. In the past three months he has had two episodes of sweating and confusion with fingerstick glucose readings of 52 and 58 mg/dL, both before lunch, and two falls at home, one when getting up at night to urinate.

Medications: insulin glargine 20 units at bedtime, glipizide 10 mg twice daily, metformin 500 mg twice daily, carvedilol 12.5 mg morning and evening, lisinopril 10 mg daily, spironolactone 25 mg daily, furosemide 40 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily, tamsulosin 0.4 mg daily, gabapentin 300 mg three times daily, omeprazole 20 mg daily for eight years without a clear indication and over-the-counter naproxen 220 mg once or twice daily for his knees.

Examination: blood pressure 124/70 mm Hg seated and 106/62 standing with dizziness; pulse 62; weight 88 kg, up 2 kg from last month; bibasilar crackles; 1+ ankle edema. Timed Up and Go 16 seconds. He could not feel the monofilament at four sites on each foot. Labs: A1c 6.4%, potassium 5.3 mmol/L, creatinine 1.8 mg/dL, hemoglobin 11.6 g/dL, B12 normal.

Priorities: asked what matters most, he said he wants to be "steady on my feet" to walk his granddaughter down the aisle at her wedding in April and to keep tending his vegetable garden. He dislikes the number of pills and his wife worries about the low sugars.

Assessment

The central problems are not the diagnoses themselves but the harms of his treatment. First, hypoglycemia from overtreated diabetes. His A1c of 6.4% is below the range appropriate for an older adult with multiple chronic illnesses and neuropathy, for whom the ADA standards suggest a target below 8.0% and advise reducing medicines that cause hypoglycemia (American Diabetes Association Professional Practice Committee, 2024). Glipizide, a sulfonylurea, carries a high hypoglycemia risk that rises as kidney function falls, and the 2023 Beers Criteria recommend avoiding sulfonylureas in older adults in favor of safer alternatives (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).

Second, falls with orthostatic hypotension, driven by the combination of furosemide, tamsulosin and carvedilol, worsened by gabapentin at a dose too high for his kidney function and by neuropathy and nocturia. Third, worsening heart failure and kidney function aggravated by naproxen: NSAIDs cause sodium retention and reduce renal blood flow, and the Beers Criteria advise avoiding them in heart failure and in people with a creatinine clearance below 30, which he is approaching. His raised potassium reflects spironolactone and lisinopril in the setting of reduced kidney function, with naproxen adding to it. Fourth, long-term omeprazole without a continuing indication, which the Beers Criteria advise stopping after eight weeks unless a clear reason exists.

Some of his medicines have strong evidence for outcomes he cares about. Carvedilol, lisinopril and spironolactone reduce death and hospitalization in heart failure, and statin and aspirin therapy after his myocardial infarction are appropriate. An SGLT2 inhibitor, not currently prescribed, would benefit his heart failure and kidney disease at once, carries little hypoglycemia risk and could replace glucose-lowering drugs that do.

Plan

Glucose: stop glipizide. Reduce glargine to 14 units at bedtime. Continue metformin 500 mg twice daily, the maximum appropriate at his eGFR. Start empagliflozin 10 mg daily for heart failure and kidney protection; its modest glucose-lowering effect will be monitored with fingersticks before breakfast and lunch for two weeks, with a target A1c below 8.0%. Heart failure and volume: continue carvedilol and lisinopril. Reduce spironolactone to 12.5 mg daily because of his potassium. Keep furosemide at 40 mg for now, since he is mildly overloaded, and reassess in one week after naproxen is stopped and empagliflozin begins, as both change fluid balance. Pain: stop naproxen and start diclofenac 1% gel to both knees four times daily. Falls: reduce gabapentin to 300 mg twice daily, adjusted for kidney function, and move tamsulosin to bedtime with advice to pause, seated, for a slow count of thirty before getting up at night; referral to physical therapy for strength and balance and a home safety check with night lights and a bedside urinal. Omeprazole: step down to alternate days for a fortnight before stopping, with instructions to report heartburn. Continue atorvastatin and aspirin.

Monitoring: basic metabolic panel and weight in one week; fingerstick log review by phone in two weeks; clinic visit in four weeks with orthostatic blood pressure, Timed Up and Go and a review of any hypoglycemia or falls; A1c in three months.

The Result in Numbers

The plan stops four medicines, glipizide, naproxen, omeprazole and, in effect, the high gabapentin dose, adds one with benefits across two of his conditions and reduces three doses. His regimen falls from eleven oral and injected medicines to nine, with the drugs most likely to cause hypoglycemia, fluid retention and falls removed. The changes are sequenced so that no more than two affect fluid balance in the same week.

Communicating the Plan

Mr. J. and his wife received a written list of what to stop, what to change and what to continue, with the reason for each in plain language. They were told that his sugar goal is being loosened on purpose to prevent the lows, that the new pill protects his heart and kidneys and that the knee gel is safer for his heart than the tablets. They were asked to bring every bottle to the next visit. The patient priorities approach, in which care decisions are aligned with what patients say matters most, has been studied in older adults with multiple chronic conditions; in a nonrandomized comparison, it was associated with trends toward less treatment burden and more shared prescribing decisions, although the differences did not reach statistical significance (Tinetti et al., 2019). For Mr. J., framing every change around walking at the wedding made the plan easier to accept.

Limitations

Most trials behind his heart failure and kidney drugs enrolled younger participants with fewer conditions, so their benefits are extrapolated to him. Deprescribing trials in multimorbidity are few, and the plan relies on pharmacology and consensus criteria as much as on randomized evidence. The plan will be adjusted if his heart failure worsens or his glucose rises above target.

Conclusion

Mr. J. was being harmed by treatment aimed at numbers rather than at him. Starting from his priority to be steady on his feet, relaxing his glucose target, removing four drugs that were causing low sugars, fluid retention and falls and adding one with benefits across his conditions produces a safer, simpler plan. Whether it worked will show in his fingerstick log and his kidney tests, but above all in whether he walks his granddaughter down the aisle.

References

American Diabetes Association Professional Practice Committee. (2024). 13. Older adults: Standards of care in diabetes, 2024. Diabetes Care, 47(Suppl. 1), S244-S257. https://doi.org/10.2337/dc24-S013

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

American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60(10), E1-E25. https://doi.org/10.1111/j.1532-5415.2012.04188.x

Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Internal Medicine, 179(12), 1688-1697. https://doi.org/10.1001/jamainternmed.2019.4235