Download Medications - Delaware Association of Home and Community Care

Gems for Geriatric
Medication
Management in the
Home
Cindy Drew, MS, RN, GNP-BC
With thanks to Susan Conley, BSN, RN
DAHCC Conference
November 3, 2010
Home Health Nursing
Objectives
• Overview key geriatric concepts.
• Review normal aging changes that
affect medication use in the
elderly.
• Identify risk factors associated
with polypharmacy in the elderly.
• Identify risk factors associated
with under use of medications in
the elderly.
Pediatrics ≈ Geriatrics
• Physical differences
• High risk, vulnerable population
• Needs differ from adults
This is me….This should be us…
Heterogenicity
• The longer you live, the less like
anyone else you become.
• Body systems within one individual
can age at different rates.
• Each person increasingly becomes
“one of a kind” over time.
Definitions
• Adverse Drug Reactions (ADR)-any
unintended or toxic response to a
medication (ex. Someone w/high BP
takes pseudoephedrine, BP elevates)
• Adverse Drug Events (ADE)- an injury
resulting from the use of a drug
(ex. Arthritis-NSAID therapy=GI bleed)
Zwicker, D. & Fulmer, T. (2008) pg.258-259
Definitions
• Polypharmacy- the use of several
different medications simultaneously
• Drug-Drug Interactions-Changes in a
drug’s effects when two (or more) drugs
are taken at the same time.
levothyroxin taken with metformin =
effect of metformin = blood sugar
Patel, R.B. (2003), Zwicker & Fulmer, 2008, pg. 275
Definitions
Food-Drug Interactions • Some drugs may work less or not at all when
taken with food
• Some drugs may work better or too much
when taken with food.
Example of Food-Drug Interactions
Grapefruit juice can increase the effects of
dozens of medications
• Coumadin® - bleeding
• Statins - muscle aches and pain
Examples of Food – Drug Interactions
Food may decrease the effect of
certain medications:
• Dairy products - tetracycline
• Green leafy vegetables Coumadin®.
Some Statistics…
Elders and Medications
• 65+ yrs older - 7 times more likely to have an
Adverse Drug Reaction (ADR)
• California study noted a mean of 9 drug/day
• Study 1998-1999 (amb. Older adults)
– 71% men/81% women had taken 1 Rxs
– 19% men/23% women took 5 or more Rxs
– OTCs-12% of both sexes took 10 or more
Molony, S.L. (2009).
Elders and Medications
• Those older than 65 yrs
– 79% taking medication
– 39% are taking 5 or more
– 90% taking over the counter
• Estimated 35% exp. an ADE
– ½ could have been prevented
Zwicker, D. & Fulmer, T. (2008) pg. 258
What’s the COST?
• ADEs
– Cost more than $85 billion
– cause more than 100,000
deaths/year
– 5th leading cause of death in US
Neafsey, P.J. (2005).
The Typical Older American…
Persons > 65 years old…
• Takes 4 to 5 prescription
and 2 OTC drugs at a
time; fills 12 – 17
prescriptions/year
• Is on a fixed income—
main source of income is
Social Security
Non-Compliance
• 17,685 Medicare recipients 65 yrs >
– 52% not taking meds as ordered
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25% reported made them feel worse/not helping
26% not cost effective (skip or take sm dose)
37% non adherence due to lack of coverage
22% non adherence had coverage?
Safran et. al., 2005
Zwicker, D. & Fulmer, T. (2008) pg. 260
Why do ADRs, ADEs, & Polypharamcy
happen in the Elderly?
• Physiologic age changes
– Pharmacokinetics/dynamics
– Body changes due to aging
• Multiple meds from multiple
prescribers
• Incorrect doses (over/under
therapeutic)
• Self medication (OTCs etc.)
• Inappropriate prescribing
• Medication adherence
• Medication errors
Medications & Aging Changes
Aging Skin
• thinning dermis,  collagen & subcutaneous fat
•  interstitial fluid, muscle tone, glandular activity,
sensory receptors
•  blood supply & capacity for repair
• capillary fragility
Transdermal Patches
• Used to deliver: hormones, pain medication,
Parkinson’s meds, nicotine, heart meds,
motion sickness meds, bladder meds
• Do not use on very thin people!
Aging Eyes
• lens less elastic, denser,
yellow with  light
passage
• Persons 65+ need 30%
more light to see the
same as a 30 year old
Aging Lungs
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Enlarged, rigid chest
wall
 muscle
strength/endurance
 alveolar surface
area; airway collapse
Effects of aging on the body…
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Lean body mass
Water in the body
Hepatic mass & blood flow
Serum albumin (protein)
Metabolism
Renal mass
Body fat
Molony, S.L. (2009).
Effects of aging on the body and
Pharmacokinetics….
• Absorption
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Gastric pH
Gastric motility and absorb surface
• Distribution
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Cardiac outpt (slow transport)
Total body water (incr. conc. Hydrophilic drugs
– alcohol, morphine, digoxin)
Serum albumin (malnutr./acute illness)
(incr. unbound drugs in liver-protein bound drugs
warfarin, salicylic acid, dilantin, diazepam)
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Body fat (long acting benzos stay in body fat
longer)
Effects of aging on the body and
Pharmacokinetics….
• Metabolism - must occur within the
body before its able to removed; if
body system fails, can lead to toxicity.
– Effected by disease states (thyroid,
CHF,cancer) or drug induced
– Drugs removed in stages hepatic &
renal
Patel, R. B. (2003); Zwicker, D. & Fulmer, T. (2008) pg. 263
Effects of aging on the body and
Pharmacokinetics….
• Elimination- slowed; blood flow,
glomerular filtration rate and tubular
secretion= slow removal
– Glomerular filtration is not accompanied
by an elevated serum creatinine, because
lean muscle mass and subsequent
decline in creatinine production
associated with aging.
–  Serum Cr is not an accurate measure
of renal function in the elderly!
Patel, R. B. (2003); Zwicker, D. & Fulmer, T. (2008) pg. 263
Beers Criteria
• Mark Beers, MD
– 1997 extensive lit review
– Formed group (clin Rx, psychoRx)
• Modified Delphi effect
• Evidence based list
– List of suggested medications to be avoided
– Should not override clinical judgment
• American Medical Directors Association (AMDA) and
American Society of Consultating Pharmacist (ASCP)
– Based on consensus data (lower level of evidence)
Rather than randomized controlled studies (higher level of evidence)
Neafsey, P.J. (2005); Zwicker, D. & Fulmer, T. (2008) pg. 264
Beers Criteria
• Endorsed by CMS, Joint Commission
– Used in long term care facilities
• Can be sited
• Addresses
– Meds/classes of that should be avoided
– Meds to avoid with specific medical cond.
– Severity rating of low-high based on the potential
negative outcome
• 2003 revised (in handouts)
– 48 medications
– 20 meds to avoid w/specific medical conditions
Zwicker, D. & Fulmer, T. (2008) pg. 264
Potential Inappropriate Medications
• Darvocet
(Propoxyphene)
• Indocin (Indomethacin)
• Muscle relaxant
antispasmatics (Flexeril)
• Elavil (Amitriptyline)
• Long acting Benzos
– Valium (Diazepam)
– Librium
(Chloridiazepoxide)
• Digoxin >0.125mg/day
• GI antispasmodics
(Bentyl)
• Antihistamines
– Benadryl
(Diphenhydramine)
• Iron 3/day
• Demerol (Meperidine)
• GEODON
Anicholinergic effects
• confusion/delirium, constipation, urine
retention, orthostatic, paradoxical excitement
• "red as a beet, dry as a bone, blind as a bat,
mad as a hatter, and hot as a hare."
(flushing, dry skin and mucous membranes,
dry eye with loss of accommodation, altered
mental status (AMS), and fever)
What is delirium?
“a disturbance of consciousness with impaired
attention and disorganized thinking that
develops rapidly and with evidence of an
underlying physiological or medical condition”
American Psychiatric Association, 2000
– Sudden onset, fluctuating course, altered attention
– ADR most common cause in elderly
Medications Most Commonly
Causing Delirium
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Anticholinergics
Narcotics (meperidine)
Sedative hypnotics (benzodiazepines)
Histamine (H2) receptor antagonists
Corticosteroids
Centrally acting antihypertensives
Antiparkinsonian drugs
1. Visceral pain (opioid responsive)
©Shila Hayden RN, PhD
2. Bone pain (semi-responsive to opioids)
3. Nerve pain
a. compressive (semi-responsive to opioids)
b. neuropathic (opioid resistant)
4. Muscle (opioid resistant)
5. Colic (opioid resistant)
6. Pleuritic (semi-responsive to opioids)
For pain “Give this, NOT that”
• No Demerol (Meperidine)
• No Darvocet (Propoxyphene
Acetaminophen)
•Acetaminophen
•Hydrocodone
•Codeine
•Oxycodone
•Morphine
•Fentanyl
Tylenol = acetaminophen
•Alters the body’s perception of Pain, fever
•Does not reduce/change the underlying inflammation or
cause of pain
Regular
325 mg
Extra
500 mg
Arthritis
650 mg
Adult Dose = 2 tablets
650 mg
1000 mg
1300 mg
Cost of Medications
• Older adults save money on
prescription drugs by
– Cutting medications in half
– Borrowing money from friends
– Discontinuing certain medications
because they ‘feel good’
Help Your Patients
• Talk about the cost of medications with
patients.
• Find a less expensive drug that will do the
same thing.
• Encourage the use of generics.
• Encourage samples or partial Rx fills for trials
of a new medication.
• Discuss special programs from drug
companies – consult social workers.
The Tale of Two Medication Regimens
Cost for 10 days
Lipitor 10mg daily…......$27.30
Lexapro 10mg daily..…..$23.30
Nexium 20mg daily…..…$47.48
Accupril 20mg daily…....$13.69
Clarinex 5mg daily……….$27.50
Levaquin 500mg daily…$105.00
Lovastatin 20mg daily…..$12.48
Fluoxetine 20mg daily…..$ 2.52
Prilosec 20 mg daily………$14.22
Lisinopril 20mg daily……..$ 6.39
Claritin 10 mg daily……….$ 8.20
Bactrim DS Twice daily…$ 1.45
10 day Total = $244.27 10 day Total = $ 42.26
References
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Ballentine, N. H. (2008). Polypharmacy in the Elderly. Critical
Care Nursing
Quarterly, 31(1), 40-45.
Beer’s Criteria-Potentially inappropriate medications for geriatrics
retrieved 1/20/2010, Lexicomp.
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JoySingh, S. D. (2009). Polypharmacy in older adults is increasing. American
Journal of Nursing, 109 (4), 72.
Molony, S.L. (2009). Monitoring medication use in older adults. American Journal
of Nursing, 109 (1), 68-78.
Neafsey, P.J. (2005). Inappropriate drug prescriptions for older adults. Home
Healthcare Nurse, 23 (8), 495-497.
Patel, R. B. (2003). Polypharmacy and the elderly. Journal of
Infusion Nursing,
26 (3), 166-169.
Zwicker, D. & Fulmer, T. Reducing Adverse Drug Events. Evidence Based Geriatric
Nursing Protocols for Best Practice, 3rd ed. Springer, New York; 2008;pp 257-308.
BONUS MATERIAL, courtesy of
Margaret McEvilly, PharmD, CDE
Bayhealth Clinical Pharmacist
Interactions between herbal
medications and prescribed
medications
Glucosamine
• Used for treatment of Arthritis
• Warfarin – Increased bleeding could be due to
chondroitin
• Insulin or oral hypoglycemic agents – could increase
blood sugar by increasing insulin resistance or
decreasing insulin production
Echinacea
• Stimulates immune system, used for treatment of colds and flu (shortens the
time to get over symptoms)
• Could produce liver disease especially when combined with:
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Corticosteroids and anabolic steroids
Cyclosporine
Amiodarone
Methotrexate
Ketoconazole
Acetaminophen
• Could decrease clearance of
– Midazolam
– caffeine
Garlic/Fish Oils/Omega fatty acids
• Lowers cholesterol
• Interacts with:
– Warfarin – decreases blood concentrations –
increases clot formation
– Garlic interacts with Chlorpropamide to decrease
blood sugar
Ginkgo
• Improves cognitive function (Alzheimer’s) and intermittent
claudication
• Interacts with:
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Warfarin – increases bleeding
Aspirin/NSAIDs/Acetaminophen – increases bleeding
Thiazide diuretics (HCTZ) – increases blood pressure
Trazodone – possible coma
Ginseng
• Improved physical and mental effects
• Interacts with:
– Warfarin – decreases blood concentrations – increases
clot formation
– Estrogens
– Corticosteroids
– Opioids – decreases pain control by opioids
Ginger
• Treatment of dyspepsia, antiemetic (nausea/vomiting)
• Contraindicated in patients with Gallstones, pregnancy and
bleeding disorders
• Interacts with:
– Warfarin/heparin/plavix – increases bleeding
– Aspirin/NSAIDs/Acetaminophen – increases bleeding
Saw Palmetto
• Treatment of benign prostatic hyperplasia
(BPH)
• Interacts with warfarin to increase bleeding
Soy supplements
• Treatment of menopause, cholesterol, prevention of
coronary heart disease, prevent hot flashes and
osteoporosis, increase cognitive function, treatment
of diabetes, hypertension, rheumatoid arthritis, and
renal disease
• Interacts with:
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Iron
Levothyroxine
Tamoxifen
Warfarin – increase bleeding
Peppermint
• Treatment of dyspepsia, irritable bowel syndrome,
headache, gall bladder disease
• Increase absorption of 5-Fluorouracil, a treatment
agent for cancer
St John’s Wort
• Treatment for depression
• Lowers blood concentrations of:
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Cyclosporine – increases chance of organ rejection
Amitriptyline
Digoxin
Indinavir
Warfarin – increases chance of clot formation
Theophylline
Simvastatin
Losartan
• Interacts with:
– Oral contraceptives – nausea, vomiting, anxiety, headaches
– Loperamide
– SSRI’s – Paxil, Zoloft, Prozac, Serzone, Celexa, Luvox, Effexor, Wellbutrin,
Lexapro, Remeron
Chamomile
• Help combat stress, nervousness, and sleep
disturbances. Decrease stomach cramps
• Warfarin – increases bleeding
• NSAIDs/Aspirin/Acetaminophen – increases bleeding
• Interacts with barbiturates/Opioids – could cause
excessive sedation
Kava
• Short term treatment of anxiety
• Acetaminophen – increases chance of liver disease
• Interacts with:
– Levodopa – decreases efficacy
– Alprazolam – induces semicomatose state
– Opioids – increases sleepiness (CNS depression)
Herbal Medications
and
Disease State Interactions
Insomnia
(Interaction)
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American ginseng
Bitter orange
Black tea
Citicoline
Cola nut
Siberian ginseng
St. John's wort (Hypericum
perforatum) – can cause
insomnia and can treat insomnia
related to depression
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Green tea
Guarana
Mate
Panax ginseng
Panax pseudoginseng
Phosphatidylserine
SAMe
Asthma
(Contraindicated)
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Chamomile
Fir Needle oil
Larch Turpentine
Belladonna
Henbane leaf
Pine Needle oil
Hypertension
(Interaction)
• Fish Oils – decrease blood pressure
• Ginseng – increase blood pressure, and decrease
concentrations of many antihypertensive agents
• Eleuthero root
• Ephedra
• Licorice root
Heart Conditions
(Interaction)
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Aloe
Belladonna
Buckthorn bark
Cascara Sagrada bark
Couch Grass
Ephedra
Henbane leaf
Licorice root
Lily of the valley
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Oak bark
Oleander leaf extract
Peppermint
Pheasant’s eye
Rhubarb
Senna leaf or pod
Scopolia root
Squill powder extract
Uzara root
Gastrointestinal Ulcer
(Interaction)
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Angelica root
Bitter Orange peel
Cola nut
Devil’s Claw root
Eucalyptus oil or leaf
Fennel seed
Peppermint – can worsen
symptoms by relaxing the
sphincter between the
stomach and the esophagus
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Gentian root
Horseradish
Indian snakeroot
Licorice root
Nasturtium
Primrose root
Rhubarb root
Thyme
Watercress
Wormwood
Diabetes
(Contraindicated)
• Glucosamine – inhibits the effects of insulin
and oral hypoglycemic agents due to an
increase in insulin resistance and/or decrease
in insulin production
• Blackthorn flower
• Echinacea Purpurea herb
• Psllium seed husk, blonde
• Senna leaf