Table 2.

Medication care plan

DRUG-RELATED PROBLEM	ACTION PLAN	MONITORING
Medications that might contribute to cognitive decline symptoms and fall risk: Chlordiazepoxide Clidinium Amitriptyline (also contributing to QT prolongation with erythromycin and domperidone)	Stop chlordiazepoxide and clidinium (tapering not required owing to long benzodiazepine half-life Taper amitriptyline to 150 mg at bedtime and consult with geriatric psychiatrist regarding further tapering	Benzodiazepine withdrawal starting at 7–10 days, then for 6 weeks after stopping: insomnia, anxiety, etc Improvement in cognitive symptoms Improvement in anticholinergic symptoms (eg, dry mouth, constipation, dizziness)
Constipation-diarrhea cycle might be contributed to by periodic overuse of psyllium laxative and lactulose, followed by loperamide	Change to routine psyllium laxative 1 tbsp daily (each morning with water) and lactulose 1–2 tbsp every 2–3 days if no bowel movement Will provide IBS symptom diary	Bowel movements (IBS diary); need for loperamide
Might not require all 3 of erythromycin, domperidone, and pinaverium; risk of additive side effects (eg, diarrhea, nausea, vomiting, QT prolongation)	Once psyllium laxative and lactulose use is stable, consider tapering erythromycin Taper domperidone when effect of erythromycin is known Taper pinaverium once effect of above is known	Bowel movements (IBS diary) With domperidone tapering, monitor for worsening symptoms of esophageal spasms or reflux
Ongoing heartburn (with esophageal strictures); might need lansoprazole increase	Increase lansoprazole to 30 mg twice daily	Heartburn; use of calcium carbonate antacids
Half-capsule of acetylsalicylic acid, butalbital, codeine, and caffeine, and acetaminophen with codeine might be contributing to heartburn, constipation, dizziness, and confusion; limited effectiveness of each	Will discuss limiting acetylsalicylic acid, butalbital, codeine, and caffeine dosing with patient Reduce acetaminophen with codeine to 1 only for “tight band” headache	Esophageal spasms Headache
BP higher than target; might benefit from ramipril increase	Increase ramipril to 5 mg	Cough; serum creatinine and electrolyte levels in 1–2 weeks BP target < 140/90 mm Hg
At risk of additive side effects owing to overuse of 2 short-acting β2-agonists	Stop regular terbutaline inhaler and use only salbutamol inhaler as needed, with hand-grip attachment and antistatic valved holding chamber if necessary	Ability to use salbutamol inhaler

BP—blood pressure, IBS—irritable bowel syndrome.