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MMI Scenario 8
Irene, 80 has been booked into your morning medication review clinic having been already seen by the GP last week, as a result of a fall she sustained in her garden. You have been tasked to review her medication and conduct a falls prevention management plan for Irene. What issues are important to explore? What other resources are available for us to use to support Irene?
Example Answer
Patient ICE: (ideas, concerns and expectations)– it is important to ascertain Irene’s perspective of the fall and reflect on her values and feelings towards the fall. Does she remember how the fall happened? How did she fall? What was the contributing/aggravating factors which caused the fall? Where and how did she fall exactly? This will give us a better picture of how we can work with Irene to prevent the fall.
Medication Review: As a clinical pharmacist, it is prudent we review her medications, identifying her anti-cholinergic burden (ACB) and medications which need to be reviewed in terms of needs and indication, potentially omitting the medication if Irene is in partnership with this.
Falls risk assessment: It is important to switch/highlight drugs which are most likely to increase dizziness/falls e.g. high dose TCAs, anti-muscarinic for bladder incontinence.
Fracture risk assessment: As Irene may be at risk of secondary falls, it is important to carry out fracture risk assessment (Qfracture/FRAX) to validate her osteoporosis risk and support us to refer to an integrated bone health and falls clinic.
Nutrition: She should be given Vitamin D + Calcium, or just Vitamin D 800-1000IU daily to support her bone strengthening. It may be appropriate to suggest a bone profile blood test to highlight any other deficiencies.
Referral to multidisciplinary teams: With Irene’s consent she should ideally be referred to a multi-disciplinary team for therapeutic input in aim of falls prevention. This may include the following, physiotherapist for muscle + bone strengthening exercises, occupational therapist to support her physical health and home environment to prevent slips and trips. Optician to have her eyes checked in case vision may be a confounding issue. Hearing checked by audiology in case of any hearing loss/imbalance. It may also require input from community dietician in case Irene’s diet is poor which may need more structure. Lastly, we could spare her of incontinence medications, by referring to community continence and bladder and bowel service.
Voluntary sector input: We should also signpost Irene to patient support groups and voluntary sector organisations e.g. Age UK, IndependentAge.org
Medication Review: As a clinical pharmacist, it is prudent we review her medications, identifying her anti-cholinergic burden (ACB) and medications which need to be reviewed in terms of needs and indication, potentially omitting the medication if Irene is in partnership with this.
Falls risk assessment: It is important to switch/highlight drugs which are most likely to increase dizziness/falls e.g. high dose TCAs, anti-muscarinic for bladder incontinence.
Fracture risk assessment: As Irene may be at risk of secondary falls, it is important to carry out fracture risk assessment (Qfracture/FRAX) to validate her osteoporosis risk and support us to refer to an integrated bone health and falls clinic.
Nutrition: She should be given Vitamin D + Calcium, or just Vitamin D 800-1000IU daily to support her bone strengthening. It may be appropriate to suggest a bone profile blood test to highlight any other deficiencies.
Referral to multidisciplinary teams: With Irene’s consent she should ideally be referred to a multi-disciplinary team for therapeutic input in aim of falls prevention. This may include the following, physiotherapist for muscle + bone strengthening exercises, occupational therapist to support her physical health and home environment to prevent slips and trips. Optician to have her eyes checked in case vision may be a confounding issue. Hearing checked by audiology in case of any hearing loss/imbalance. It may also require input from community dietician in case Irene’s diet is poor which may need more structure. Lastly, we could spare her of incontinence medications, by referring to community continence and bladder and bowel service.
Voluntary sector input: We should also signpost Irene to patient support groups and voluntary sector organisations e.g. Age UK, IndependentAge.org