Multi-morbidity and Complex Care — Written Clinical Reasoning

SAQ 1 — Integrated and Prioritised Management of the Multi-morbid Older Patient After a Fall (25 marks, 35 minutes)

Prompt: Outline your integrated and prioritised management plan for Mrs O'Brien, addressing: (a) the assessment of the fall and the modifiable risk factors; (b) the structured medication review using STOPP/START and Beers, including the drugs to deprescribe, the drugs to start, and the tapers required; (c) the integrated approach to her cardiovascular conditions (HFrEF, AF) and diabetes in the setting of CKD; (d) the goals-of-care and advance care planning discussion; and (e) the coordination of her discharge and follow-up. Anchor the entire plan to her stated priorities (independence at home). [1]

Model Answer

(a) Assessment of the fall and the modifiable risk factors (4 marks): [1]

Mrs O'Brien has had a mechanical fall and I would approach it systematically, looking for modifiable risk factors rather than accepting "she just tripped". The multi-factorial falls assessment covers: a detailed history of the fall (the circumstances, any preceding symptoms of syncope or presyncope, any loss of consciousness, any witnessed seizure, any head strike and loss of consciousness, the recovery); a full medication review (see below); a cardiovascular examination (postural blood pressure, heart rate and rhythm, carotid sinus hypersensitivity testing if indicated, any valvular lesion); a neurological examination (gait, balance, cognitive assessment, signs of parkinsonism or stroke); a vision and hearing assessment; a foot and footwear check; and a functional assessment (ADLs, IADLs, gait speed, the Timed Up and Go test, and a review of the home environment with the occupational therapist). [1]

The modifiable risk factors I will look for specifically in Mrs O'Brien include: orthostatic hypotension (from the ACE inhibitor, the diuretic, and the SGLT2 inhibitor); urinary frequency or nocturia leading to night-time mobilisation (from the diuretic and the SGLT2 inhibitor); cognitive impairment affecting judgement and hazard awareness; the benzodiazepine (temazepam) causing sedation and impaired postural reflexes; the anticholinergic (oxybutynin) causing cognitive impairment, blurred vision, and constipation with straining; visual impairment; and environmental hazards (loose rugs, poor lighting, no grab rails). Each identified factor is addressed in the plan below. [1]

(b) Structured medication review using STOPP/START and Beers, including deprescribing, additions, and tapers (7 marks): [1]

I will reconcile the medication list first — obtaining the best possible medication history from the patient, her family, the GP, the community pharmacist, and the previous discharge summary, and confirming each drug, dose, frequency, and indication. I will then apply the STOPP/START version 3 criteria and the 2023 AGS Beers Criteria to identify potentially inappropriate medications (STOPP) and prescribing omissions (START) [9] [8].

Drugs to deprescribe: [1]

1. Oxybutynin 5 mg three times daily — a potent anticholinergic on the Beers Criteria list of drugs to avoid in older adults and in dementia/cognitive impairment. It worsens cognition, causes blurred vision (a falls risk), constipation, and urinary retention. It is the highest-priority deprescribing target. The plan is to taper it (reduce to twice daily for 1 to 2 weeks, then once daily for 1 to 2 weeks, then alternate day for 1 week, then stop) to avoid anticholinergic withdrawal, with monitoring for return of overactive bladder symptoms. If urinary symptoms recur, I would switch to a non-anticholinergic option (mirabegron, or conservative measures).
2. Temazepam 10 mg at night — a benzodiazepine on the Beers Criteria and STOPP list, associated with falls, fractures, cognitive impairment and delirium in older adults. It is a major contributor to her falls risk. The plan is a supervised taper (reduce by 10 to 25 per cent every 1 to 2 weeks, consider diazepam substitution if withdrawal symptoms emerge), combined with cognitive behavioural therapy for insomnia and sleep hygiene measures. This is a medium-term taper, not an abrupt cessation [10].
3. Atorvastatin 40 mg — she is on a statin for secondary prevention (post-hip fracture is not a statin indication per se, but she has type 2 diabetes and likely a vascular risk; I would review the original indication). In a mildly frail 82-year-old, the time-to-benefit for primary prevention may exceed her life expectancy, but if she has established cardiovascular disease the statin should be continued. I would discuss this with her as part of the goals-of-care conversation.

Drugs to start or to confirm (START criteria): [1]

1. I would confirm she is on appropriate bone protection (alendronate weekly, calcium-vitamin D) — she is, and this is appropriate after her previous hip fracture.
2. I would confirm her HFrEF therapy is optimised — she is on a beta-blocker (bisoprolol), an ACE inhibitor (ramipril), an MRA (spironolactone), a diuretic (frusemide), and an SGLT2 inhibitor (empagliflozin). This is good foundational therapy; I would confirm the doses are at guideline-recommended targets and that her renal function and potassium tolerate them.
3. I would consider whether she needs iron studies and a ferritin (if iron-deficient, intravenous ferric carboxymaltose has evidence in heart failure, AFFIRM-AHF). [1]

Drugs to dose-adjust for renal function: [1]

1. Apixaban 5 mg twice daily — the dose reduction criteria for apixaban are two of: age 80 or more, weight 60 kg or less, creatinine 133 micromol per litre or more. She meets one criterion (creatinine 138) and is borderline on age (82). If she meets only one criterion, the dose remains 5 mg twice daily; if her weight is 60 kg or less, the dose reduces to 2.5 mg twice daily. I would confirm her weight and document the dose calculation. [1]

(c) Integrated approach to HFrEF, AF, and diabetes in CKD (6 marks): [1]

The integrated approach recognises that several of her conditions share a cardio-renal-metabolic pathway and that some treatments benefit multiple conditions simultaneously. [1]

1. The SGLT2 inhibitor empagliflozin is the prototype multi-morbidity drug — it benefits her HFrEF (EMPEROR-Reduced, PMID 32865378), her CKD (DAPA-CKD for the class, PMID 32975395), and her diabetes (EMPA-REG OUTCOME, PMID 26378978). She should remain on it unless a specific contraindication arises (euglycaemic ketoacidosis, recurrent urinary sepsis, volume depletion that cannot be managed).
2. Heart failure — continue the foundational four (beta-blocker, ACE inhibitor, MRA, SGLT2i) with the diuretic for symptom control. Monitor renal function and potassium (the ACEi and the MRA will raise both); an acceptable creatinine rise is up to 30 per cent from baseline, and an acceptable potassium is up to 5.5 mmol per litre. If hyperkalaemia is persistent, I would consider a potassium binder (patiromer or sodium zirconium cyclosilicate) to enable continuation of the disease-modifying drugs rather than stopping them.
3. Atrial fibrillation — continue the apixaban at the dose-adjusted level, and confirm the rate is controlled (her resting heart rate of 68 in AF is well controlled on the bisoprolol).
4. Diabetes — individualise the HbA1c target. Her current HbA1c of 58 mmol per mol is reasonable, and I would not intensify. In a mildly frail 82-year-old, the target should be 58 to 70 mmol per mol (7.5 to 8.5 per cent), prioritising the avoidance of hypoglycaemia (which causes falls, confusion, arrhythmia) over tight control. Metformin 1000 mg twice daily is at the upper end of the safe dose for an eGFR of 35; I would review it if her renal function declines further (the TGA and international guidelines recommend reducing the metformin dose at eGFR below 30 and stopping at eGFR below 15).
5. Avoid NSAIDs — the triple whammy (ACEi plus diuretic plus NSAID) would precipitate AKI; any pain should be managed with paracetamol, topical agents, and non-pharmacological measures.
6. Blood pressure — her current blood pressure of 135/75 is well controlled on the ramipril and the bisoprolol, with contribution from the frusemide; I would not intensify the antihypertensive regimen in advanced age given the falls risk (SPRINT confirmed more adverse events with intensive targets in older patients) [3].

(d) Goals-of-care and advance care planning discussion (4 marks): [1]

I would introduce the goals-of-care conversation early in the admission, in a quiet setting with her (and with her family or surrogate if she wishes). I would ask: "What do you understand about your illnesses and how they affect you? What matters most to you in the time ahead? What are the outcomes you would find unacceptable — for example, being in a nursing home, being on a breathing machine, being kept alive if you could not recognise your family? Who would you want to make decisions for you if you could not?" [1]

Based on the conversation, I would document her priorities (for Mrs O'Brien, the likely priority is to remain independent at home), the ceiling of treatment (likely ward-based care, not for ICU or CPR, given her frailty, her multi-morbidity, and her stated priorities), the resuscitation status (likely not for CPR, given the very low survival-to-discharge rate in this group), and the surrogate decision-maker (a family member or a formal guardian). [1]

I would document this in a shared record (an advance care directive, a goals-of-care form, and the hospital electronic record), communicate it to her GP and her family, and review it as her circumstances change. The goals of care anchor every treatment decision in the integrated plan [10].

(e) Coordination of discharge and follow-up (4 marks): [1]

I would arrange: [1]

1. A single coordinating clinician — Mrs O'Brien's GP will own the integrated care plan; I will communicate the plan and the medication changes by a detailed discharge summary and a direct phone call to the GP.
2. A Home Medicines Review by the community pharmacist within 2 weeks of discharge — the pharmacist visits her at home, reconciles all the medications (including those in the bathroom cabinet), and reports back to the GP.
3. A case conference within 2 to 4 weeks, including the GP, the community nurse, the pharmacist, the occupational therapist, the physiotherapist, and the family, to review the falls risk, the medication changes, the functional trajectory, and the goals of care.
4. An outpatient clinic review at 4 to 6 weeks to assess her renal function and potassium (after the ACEi, MRA and SGLT2i), her HbA1c, her functional trajectory, and the success of the deprescribing tapers.
5. Allied health input during the admission and after — occupational therapy for a home hazard assessment, physiotherapy for strength and balance training, and dietetics for the cardio-renal and diabetic diet.
6. A documented plan for future acute presentations — including the ceiling of treatment, the resuscitation status, and the medications to hold during acute illness (the sick-day rules: hold the ACEi, MRA, diuretic, metformin and SGLT2i during an acute illness with dehydration, sepsis or AKI; continue the beta-blocker and statin). [1]

The integrated plan is anchored to Mrs O'Brien's stated priority of remaining independent at home: the deprescribing of the falls-risk medications, the home hazard reduction, the strength and balance training, and the avoidance of treatments whose burden she cannot tolerate all serve this goal [2] [7].

SAQ 2 — Sick-Day Rules and Cardio-Renal Medication Management During Acute Illness in Multi-morbidity (10 marks)

Prompt: Mr David Chen is a 74-year-old man with heart failure with reduced ejection fraction, type 2 diabetes, stage 3 chronic kidney disease, and hypertension. He is admitted with a 3-day history of diarrhoea and vomiting from gastroenteritis, and is found to be hypotensive (blood pressure 95/55), tachycardic (heart rate 105 in sinus rhythm), and oliguric (urine output 20 mL per hour). His creatinine on admission is 220 micromol per litre (baseline 150) and his potassium is 5.6 mmol per litre. His medications on admission are bisoprolol 5 mg daily, ramipril 10 mg daily, spironolactone 25 mg daily, frusemide 40 mg daily, empagliflozin 10 mg daily, metformin 1000 mg twice daily, and atorvastatin 40 mg at night. Outline: (a) the medications to hold during this acute illness and the rationale; (b) the medications to continue and the rationale; (c) the plan for restarting the held medications; and (d) the patient education for future acute illness. [1]

Model Answer

(a) Medications to hold during this acute illness and the rationale (3 marks): [1]

1. The ACE inhibitor (ramipril), the MRA (spironolactone), and the diuretic (frusemide) — these are the renally-active drugs that cause or worsen AKI and hyperkalaemia in the setting of dehydration, hypotension, and reduced renal perfusion. The ACE inhibitor and the MRA are particularly dangerous in this setting because they block the renin-angiotensin-aldosterone axis that maintains glomerular filtration pressure in the volume-depleted state, and the MRA is the principal driver of his hyperkalaemia (potassium 5.6). Holding them allows the creatinine and potassium to recover as the volume status is restored.
2. The metformin — held because of the risk of lactic acidosis in the setting of AKI, hypoperfusion, and sepsis. Metformin is renally cleared and accumulates in renal failure, and the lactate accumulation in the setting of tissue hypoperfusion from gastroenteritis is a recognised cause of fatal lactic acidosis.
3. The SGLT2 inhibitor (empagliflozin) — held because of the risk of euglycaemic diabetic ketoacidosis in the setting of acute illness, dehydration, and reduced oral intake. The SGLT2 inhibitors cause ketone production by reducing insulin secretion and increasing glucagon, and acute illness is a recognised precipitant of euglycaemic ketoacidosis. It should be restarted once the patient is clinically stable, eating and drinking normally, and the renal function has recovered. [1]

(b) Medications to continue and the rationale (2 marks): [1]

1. The bisoprolol — continue. Abrupt withdrawal risks rebound tachycardia, hypertension, myocardial ischaemia, and destabilisation of the heart failure. The beta-blocker does not require renal dose adjustment and does not cause hyperkalaemia or lactic acidosis; if the patient becomes hypotensive or bradycardic, the dose may be reduced, but it should not be abruptly stopped.
2. The atorvastatin — continue. The statin does not require renal dose adjustment, does not cause hyperkalaemia, and abrupt withdrawal has been associated with a rebound in cardiovascular events in some (controversial) studies; there is no indication to stop it. [1]

(c) Plan for restarting the held medications (3 marks): [1]

The held medications are restarted when the patient is clinically stable, eating and drinking normally, and the renal function and potassium have returned to near baseline. Specifically: [1]

1. Restart the ACE inhibitor (ramipril) and the MRA (spironolactone) once the creatinine is within 30 per cent of baseline, the potassium is below 5.0 mmol per litre, the blood pressure is stable, and the patient is euvolaemic. Restart at the previous dose unless there has been a significant change in renal function, in which case restart at a lower dose and titrate up. Check renal function and potassium at 1 to 2 weeks after restarting.
2. Restart the diuretic (frusemide) once the patient is euvolaemic and the renal function is recovering; titrate to clinical euvolaemia and weight.
3. Restart the metformin once the renal function is within 30 per cent of baseline (eGFR above 30) and the patient is eating and drinking normally; restart at the previous dose unless the renal function has declined, in which case reduce the dose.
4. Restart the SGLT2 inhibitor (empagliflozin) once the patient is clinically stable, eating and drinking normally, and the renal function is stable; the cardio-renal benefit resumes on restarting. [1]

(d) Patient education for future acute illness (2 marks): [1]

I would educate Mr Chen and his family on the sick-day rules: during any acute illness with diarrhoea, vomiting, fever, reduced oral intake, or suspected dehydration, temporarily hold the ACE inhibitor, the MRA, the diuretic, the metformin, and the SGLT2 inhibitor, continue the beta-blocker and the statin, maintain hydration with small frequent sips of oral rehydration solution, and seek medical review early. The held drugs should be restarted once the illness resolves and oral intake is normal. I would provide this in writing (a sick-day rules card), communicate it to his GP and community pharmacist, and document it in his shared care plan. This is a key part of multi-morbidity self-management — empowering the patient and family to act safely during intercurrent illness reduces the risk of AKI, hyperkalaemia, and other medication-related harm. [1]