Download Best Nursing Practices in Care for Older Adults

Best Nursing
Practices in Care for
Older Adults
ELDER Project
Fairfield University School of Nursing
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
Session 5
Topic:
Polypharmacy and the Older
Adult
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
2
Polypharmacy: What is it?

Use of more than one
chemical agent to
effect a therapeutic
endpoint

Some references say,
the use of 5 or more
drugs for an individual
patient
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
3
Over the Counter Medications

Older adults use the
greatest number of
nonprescription over
the counter
medications
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
4
How Many Meds Do Older Adults
Use?

Over 30% of all prescriptions dispensed

Community Dwelling: use 2-4 prescriptions
regularly

Long-Term Care: use 2 – 10 prescriptions
regularly
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
5
Misuse of Drugs
…is the 5th leading cause of death in older
adults
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
6
Pharmacokinetics

Means: What the
body does to the drug

Has 4 Components
 Absorption
 Distribution
 Metabolism
 Excretion
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
7
Normal Physiologic Changes…
Can affect Pharmacokinetics
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
8
Absorption of Drugs

Meaning: how the drug gets into the blood
stream

Not significantly altered with age, but
absorption may be slightly delayed

Can postpone onset of action, and peak
effect of medication
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
9
Changes in Absorption Due to
Aging:

Slowed Gastric
Emptying

Decreased Gastric
Acidity

Decreased Blood
Flow to intestines
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
10
Drug Distribution

Meaning: where the medication goes in
the body

Can change with aging due to:
 Higher
percentage of fat compared to lean
body mass
 Decrease in total body water
 Decrease in serum albumin
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
11
How does Aging Change Drug
Distribution?
The older adult is exposed to fat soluble
drugs for a longer time
 There is more blood concentration of
water soluble drugs
 Albumin is main site for protein binding
drugs to bind for transport prior to being
distributed to body tissue

Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
12
Changes in Distribution
CAN ACCENTUATE DRUG EFFECTS AND
TOXICITY!!
Example: long acting fat soluble
benzodiazepine drugs such as diazepam
(Valium) should be avoided
Use short acting benzodiazepines in small
doses instead
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
13
More Examples

Water Soluble Drugs
should be started at
lower doses and then
monitored
 Example:
Digoxin and
Lithium
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
14
Drug Metabolism or Clearance

Meaning: how the medication is broken
down

Can change with aging due to:
 Decreased
liver mass
 Decreased liver blood flow
 Altered liver metabolism
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
15
How Does Aging Change Drug
Metabolism?

The metabolism will
be delayed for some
drugs, so they will
have greater serum
concentrations

Need to monitor liver
functions
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
16
Examples of Metabolism Changes

Delayed metabolism of:

Labetalol, Propanolol
 Verapamil
 Diazepam
 Amitriptyline
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
17
Excretion of Drugs

Meaning: how the medication is cleared
from the body

Can Change with Aging Due to:
 Decreased
Glomerular Filtration Rate
 Decreased Ability to Concentrate Urine and
Conserve Sodium
 Decrease Renal Blood Flow
 Decrease Renal Mass
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
18
How Does Aging Effect Excretion?

Increases drug half lives for those drugs
excreted by the kidney

This means the time it takes for 50% of the
drug to be eliminated from the body
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
19
Examples of Drugs with Increased
Half-Lives for Older Adults

Examples:

gentamicin
 lisinopril
 Atenolol
 Digoxin
 HCTZ
 Cimetidine
 Furosemide
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
20
Pharmacodynamics

Means: What the drug
does to the body
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
21
Adverse Reactions for Older Adults

Many medications taken by older adults
have potentially dangerous side effects
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
22
Falls

Related to orthostatic hypotension
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
23
Confusion and Disorientation

Can be related to inappropriate dosages
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
24
Hepatic Toxicity

May be direct result of one medication, or
due to a drug-drug interaction
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
25
Renal Toxicity

May be direct result of one medication, or
due to a drug-drug interaction
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
26
Common Problems Associated with
Medications
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
27
Drugs with Anticholinergic Side
Effects

Can Cause
 Confusion
 Orthostatic
Hypotension
 Dry
mouth
 Blurred vision
 Urinary retention
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
28
Tricyclic Antidepressants

Use cautiously with patients who are being
treated for glaucoma and cardiac
conduction disturbances

Rarely used for older adults

Ex: Elavil, Doxepin, Nortriptyline
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
29
Tricyclic Antidepressant Drugs

Can cause
 Sedation
and Fatigue
 Anxiety, Insomnia and
Confusion
 Unstable gait
 Hypotension
 Tachycardia and
Arrhythmias
 Seizures
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
30
Antiemetics


Can cause
 Confusion
 Orthostatic Hypotension
 Blurred vision
 Falls
 Dry Mouth
 Urinary Retention
Ex: Chlorpromozine (Thorazine),
Prochlorperazine (Compazine)
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
31
Anti-Arrhythmic

Example: Lanoxin (Digoxin)
 Can
cause toxicity even with normal serum
concentrations
Therefore controversial for older adults
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
32
Histamine-2 Receptor Blockers

Can cause
 Confusion
Therefore need dose reductions
Examples: Zantac, Pepcid
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
33
Benzodiazepines

Can cause
 Central
nervous system toxicity

May have half-lives prolonged as much as
4 days

Ex: Valium, Xanax, Ativan, Halcion
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
34
Narcotics

Can cause: Confusion and Constipation

Older adults are more sensitive to narcotics
than younger adults

“Start low, go slow” with dose

Ex: codeine, morphine, demerol,
USE WITH CAUTION!!
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
35
Medication Compliance/Adherence
Older adults taking multiple
medications, with
complex regimens may
require social and nursing
support
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
36
Risk Factors for Non-Adherence:





Cognitive Changes
Living alone with
social supports
Insufficient Funds
Depression
Declining Function
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
37
Ways to Promote Adherence:
Patient Education
 Written Instructions
 Assessment of environment: funds,
transportation
 Discouraging pill sharing

Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
38
Support Systems





Medication Event Monitoring Systems
(MEMS)
Pill boxes
Pre-poured Medications
Friendly Calls
Pill Counts
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DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
39
Cost Issues Related to Medications



Older adults may
have difficulty paying
for medications out of
pocket
Ability to purchase
medications needs to
be assessed
individually
Some will cut pills in
half to prolong use Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
40
Reference
The content covered in this
presentation is provided by the
John A. Hartford Foundation Institute
for Geriatric Nursing
(2001)
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
41
Reference:

Some of the material in this presentation
obtained from graciously shared by:
Mather’s LifeWays, 2003
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
42
Power Point Presentation Created
by:
Diana R. Mager, CRN, MSN
Fairfield University School of Nursing
ELDER Project Director
Supported by
DHHS/HRSA/BHPr/Division of Nursing
Grant #D62HP06858
43