Planning, Implementation, and Evaluation: Care Coordination, Medications, Safety, and Palliative Care
From plan to outcome
Care planning should be measurable, patient-centered, and shared with the team and family. Transitions are the danger zone: medication discrepancies, missing records, and unclear follow-up cause most harm. Reconcile medications at every handoff, use teach-back with patient and caregiver, and arrange a follow-up contact.
Pharmacology: aging brings lower glomerular filtration and hepatic blood flow, higher body fat, lower total body water, and lower albumin. Lipid-soluble drugs (benzodiazepines, some opioids) have longer half-lives; protein-bound drugs have more free fraction; the brain is more sensitive to anticholinergics, sedatives, and opioids. Start low, go slow, and deprescribe when possible. Watch for the prescribing cascade - a new symptom appearing days to weeks after a new drug is drug-induced until proven otherwise. Beers criteria lists drugs to avoid in older adults.
Dementia-related behaviors: use DICE (Describe, Investigate, Create, Evaluate) and try nonpharmacologic strategies first - pain, constipation, overstimulation, and unmet needs drive most behavior. Antipsychotics carry a boxed warning for increased mortality in dementia; CMS expects gradual dose reduction.
Safety: falls prevention is multifactorial; restraints are a last resort requiring a time-limited order, monitoring, and least-restrictive alternatives tried first. Report suspected abuse per state law.
Palliative and end-of-life: palliative care fits at any stage alongside curative treatment; hospice requires a prognosis of six months or less if the disease follows its usual course. Opioids are titrated to effect with no arbitrary ceiling - treat dyspnea and pain, and prophylax for constipation.
Evaluation: reassess the outcome against the goal, revise when the plan is not working, and document. Worked example: an older adult develops new confusion three days after a sedative is added - suspect the drug first, review the list, and trial discontinuation rather than adding another medication.