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Drug Therapy in Geriatric Patients NURS 310 Winter 2016 Drug Therapy in Geriatric Patients : Learning objectives 1. 1. Stages of adulthood; patterns of health and illness 2. Demographics of the aging population: 3. Demographics of prescription and over-the-counter drug use in people over the age of 50 is disproportionately high a.Why does polypharmacy occur? b.Why is it a problem? c. What can be done about it? 4. Physiologic changes associated with aging are coupled with pathologic changes in older adults a.Impact of physiologic changes on pharmacokinetics i. Absorption, distribution, metabolism, elimination ii. Use the Cockroft-Gault Equation to calculate an age and genderadjusted creatinine clearance b.Impact of physiologic changes on pharmacodynamics Drug Therapy in Geriatric Patients : Learning objectives 5. Older adult patients experience more adverse drug reactions and drug-drug interactions than younger patients. 6. How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions in the elderly? 7. Strategies to promote adherence in the adult population 8. Application of reliable sources of drug information: Beers list of potentially inappropriate meds for the older patient 9. References & resources for further learning Stages of adulthood Patterns of health & illness 1 stages of adulthood Young adulthood = 18 – 40 years of age Middle adulthood = 40 – 65 years of age Older adulthood = over 65 years of age The United States' older adult population can be divided into three life-stage subgroups: young-old (approximately 65 –74) middle-old (ages 75 – 84) old-old (over age 85) https://lumen.instructure.com; and Adams, Holland and Urban, 2014 patterns of health & illness Young adulthood; health status is usually good; absorption, distribution, metabolism and excretion are at their peak; relatively minimal need for px drugs (except contraception, STI); risk of drug and alcohol use, especially among younger adults Middle adulthood; increased stress; “sandwich generation”; meds are often taken when therapeutic lifestyle measures would be the optimal choice; health impairments (for example) r/t CVD, HTN, DM2, obesity, arthritis, cancer, depression, anxiety, childbirth, smoking/drug and alcohol use, begin to surface around mid to late middle-age Older adulthood; improved therapies for disease and improved living conditions have resulted in greater longevity; polypharmacy is commonplace; overall general decline in most body systems Demographics of the aging population 2 United States Overall life expectancy at birth 78.37 Male life expectancy at birth 75.92 Female life expectancy at birth 80.93 (2012 data) Drug Therapy in Geriatric Patients: Demographics of the aging population BABY BOOMERS: BORN 1946 - 1964 People born in 1946 became 65 years old in 2011; retirement began. Demographics of drug use in the aging population 3 Demographics r/t drug use in the aging population: Disproportionate drug use • Drug use among adults age 65 years or older is disproportionately high •Represent 13% of current US population •Consumers of 33% of prescription drugs •Consumers of 40% of OTC drugs • Ambulatory older adults use 2 to 4 prescription drugs regularly • Long-term care residents use an average of 7-8 medications (Tindall, Sedrak & Boltri, 2014) Demographics r/t drug use in the aging population: Adverse Drug Reactions Adverse Drug Reactions are seven times more likely in the elderly 1/3 of drug-related hospitalizations 1/2 of drug-related deaths Demographics r/t drug use in the aging population: polypharmacy & associated risks Greater prevalence in older adults due to increased prevalence and/or severity of disease Drugs to manage disease(s) Drugs to manage symptoms (of disease or aging) Drugs to treat side effects of other drugs Multiple prescribers, excessive prescribing Multiple pharmacies Drug advertising (…pills to cure all…stay young..) Older adult patients experience more adverse drug reactions and drug-drug interactions than younger patients do Demographics r/t drug use in the aging population: common drugs in community-dwelling older adults Classes most commonly used in community-dwelling older adults: Analgesics Diuretics Cardiovascular drugs Sedative hypnotics (Tindall, Sedrak & Boltri, page 419, 2014) ?Antidepressants, anxiolytics ? Bowel meds? Fiber, stool softeners Age-related physiologic changes Age and/or disease- related physiologic changes • profoundly affect pharmacokinetics • whereas pharmacodynamic effects not understood 4 Age-related physiologic changes affect organ systems, organs, and the molecular level General reduction in function occurs throughout body CNS and PNS Vision, hearing, dexterity, balance, taste, olfaction, Cardiac muscle, heart valves, blood vessels Respiratory system Gastrointestinal, liver, kidney, all vital organs Hair, Skin and Mucosa With the exception of estrogen and testosterone, the level of hormone secretion remains relatively constant Menopause (average age 51 years) Male and female reproductive systems/ sexual Musculoskeletal changes: skeletal muscle, bones And more.(BOLD font indicates most vulnerable tissues, which cannot regenerate effectively) Age-related physiologic changes Individuals do not “age” uniformly at the same rate Rate of aging and effects on physiology vary “Biologic age” may not match “chronologic age” Rate of change dependent on “lifelong health” Genetic makeup Lifestyle Health status − presence or absence of disease, injury) Cardiovascular fitness Age-related physiologic changes pose unique considerations to geriatrics Age-related changes COMBINE with disease-related changes to impact pharmacokinetics and pharmacodynamics Most commonly, effects of drugs are increased in older adults Older adults are “more sensitive” to drugs than younger adults However, effects of some drugs may be decreased (eg beta blockers) Older adults show wider individual variation in responses 18 Which pharmacokinetic change is responsible for most ADRs in older adults? → Reduced renal excretion Age-related Physiologic changes: gastrointestinal changes affect pharmacokinetics r/t absorption Age-related changes to GI tract Reduced GI blood flow Reduced motility Atrophy of mucosa and glands Reduces digestive secretions Decrease in number of absorptive cells; decreased absorptive surface area gastric acid production may be unchanged or reduced (ie increased pH) delayed gastric emptying Effect on pharmacokinetics The rate of absorption may slow with age, but overall percentage (amount) absorbed from an oral med does not change with age peak onset is delayed Age-related Physiologic changes: body composition changes affect pharmacokinetics r/t distribution Body composition/ other changes & volume of distribution Decreased percentage of lean body mass Increased percentage of body fat Storage depot for lipid-soluble drugs Increased half-life of fat-soluble drugs Decreased total body water Increases serum concentration of water soluble drugs; effects more intense Reduced concentration of plasma proteins (especially serum albumin) Reduced protein binding of drugs and increased levels of free drug In some people, albumin levels and “physiologic reserve” may be significantly reduced and depleted 21 Age-related Physiologic changes: hepatic changes affect pharmacokinetics r/t hepatic metabolism Age-related changes to liver —reduced hepatic blood flow —reduced liver mass —decreased activity of some hepatic enzymes occurs Hepatic metabolism declines with age Age – related changes combine with effects of concomitant disease or social impacts such as decreased nutritional status Half-lives of some drugs may increase, responses may be prolonged Responses to some oral drugs may be enhanced (eg drugs that undergo extensive first-pass effect) Age-related Physiologic changes: renal changes affect pharmacokinetics r/t renal excretion Age-related changes to kidney: Renal function undergoes progressive decline beginning in early adulthood: Reduction in number of functional nephrons, Decreased glomerular filtration rate, Decreased active tubular secretion; Diminished ability to adapt to changes in electrolyte, acid levels Reduction in renal blood flow All the above lead to decreased renal excretion Drug accumulation as a result of reduced renal excretion is the most important cause of adverse drug reactions, drug-drug interactions, and may lead to toxicity in older adults 23 Age-related Physiologic changes: Assessment of Renal Function Age-related Physiologic changes: Assessment of Renal Function Renal function should be assessed for all pts taking drugs that are eliminated primarily by the kidneys In older adults: Use creatinine clearance to assess renal function (rather than serum creatinine), because lean muscle mass (source of creatinine) declines in parallel with kidney function Creatinine levels may be normal even though kidney function is greatly reduced 25 Age-related Physiologic changes: Assessment of Renal Function, cont’d • Serum creatinine is not reliable but still important to assess • Older adults have decreased muscle mass, and decreased muscle metabolism, therefore less creatinine production • Cockcroft – Gault Equation is adequate for most adult patients with normal muscle mass and serum creatinine (Scr) < 4.5 mg/dL Creatinine clearance (ml/min) = _140 - age in yrs x weight in kg _ 72 x serum creatinine (% mg/100mL (for women, multiply result by .85) Age-related Physiologic changes: Assessment of Renal Function: example of Cockcroft– Gault Equation 40 year old male weighs 72 kg 80 year old male weighs 72 kg Years kg cr cl = (140 - 40) 72 72 (1.0) cr cl = (140 - 80) 72 72 (1.0) Serum Creatinine cr cl = 100 ml/min cr cl = 60 ml/min * To estimate cr cl in women, multiply result by .85 Question 1 The nurse is assessing an 82-year-old patient before the administration of medications. Which laboratory result would provide the best index of renal this patient’s function? A. Serum creatinine B. Blood urea nitrogen C.Urinalysis D. Creatinine clearance 28 Question 2 An older adult patient is taking a new prescription medication. After reviewing the patient’s medical record, the nurse is most concerned about an adverse drug reaction if what is documented? A. The patient is currently taking eight prescription medications. B. The patient’s urinary creatinine clearance is 70 mL/min/1.73 m2. C. The patient regularly takes herbal and dietary supplements. D. The patient takes a medication with a high therapeutic index. 29 Age-related physiologic changes impact pharmacodynamics Alterations in receptor properties may underlie altered sensitivity to some drugs. Examples: Some drugs have more intense effects in older adults Warfarin and certain central nervous system depressants → possibly due to increases in number of receptors, affinity or both Beta blockers are less effective in older adults, even in the same concentrations → possible reduction in number of beta receptors , affinity of beta receptors for beta-receptor blocking agents, or both 30 Adverse drug reactions and drug-drug interactions are HIGH in the older adult patient population Why? What do ADE/ ADR look like in the elderly? 5 Drug Therapy in Geriatric Patients: Predisposing Factors that increase rate of ADR Drug accumulation secondary to reduced renal function is the most important cause of adverse drug reactions and drug-drug interactions in older adults Polypharmacy Greater severity of illness Multiple pathologies Greater use of drugs that have a low therapeutic index (for example, digoxin) Increased individual variations secondary to altered pharmacokinetics Inadequate supervision of long-term therapy Poor patient adherence 32 Drug Therapy in Geriatric Patients: Examples of ADE/ ADR May be undetected in older adults because they can mimic characteristics of problems, disease, or symptoms commonly present in the elderly Symptoms of ADR in older adults are often nonspecific Examples: −Oversedation −Cognitive changes such as confusion −Dizziness −Hallucinations −Accidents/ Falls −Bleeding What measures can the nurse use to decrease incidence of adverse drug events/ reactions and drug-drug interactions? 6 Drug Therapy in Geriatric Patients: Measures to Reduce ADE/ ADRs Consider pharmacokinetic and pharmacodynamic changes due to age Use the simplest regimen possible: − Consider illnesses and multiple-drug therapy Periodically review the need for continued drug therapy Take steps to promote adherence and to avoid drugs on the Beers list Monitor the patient’s clinical response, adverse effects, Monitor plasma drug levels when appropriate Monitor for drug-drug interactions Provide effective teaching to pt and family/ caregiver Encourage the patient to dispose of old medications 35 How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions based on altered pharmacokinetics? How can the nurse decrease incidence of adverse drug reactions and drug-drug interactions based on altered pharmacoKINETICS? Identify the organs involved Monitor organ functioning Liver- PT/INR good indicators of hepatic function AST, ALT are markers for hepatic inflammation Ammonia albumin Kidneys – creatinine clearance Assess for symptoms that suggest a decline in organ function Assess for desired and adverse responses to the drug How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions based on altered pharmacodynamics? How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions based on altered pharmacodynamics? Differences in receptor number and binding = UNPREDICTABLE Assess for desired and adverse responses to the drug Use caution with drugs that can have serious adverse effects, especially with low therapeutic index drugs Use less toxic analgesics first (e.g., acetaminophen versus NSAID) Watch for delayed signs of drug-related toxicity Start with low doses of meds… titrate up as needed at appropriately spaced time intervals, carefully monitoring for effect Remember: it takes between 4 – 5 doses of meds administered at properly spaced/timed intervals (r/t half-life) to achieve plateau Start low . . . . Go slow! How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions based on multiple severe illnesses & multi-drug therapy? How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions based on multiple severe illnesses & multi-drug therapy Assess polypharmacy Obtain a thorough drug history that includes: prescription, OTC, herbals, & supplements doses, timing, routes, reason, and prescriber Create a complete list Share list with all prescribers and pharmacist Teach patient when to contact the prescriber Teach to get meds from ONE pharmacy and work with pharmacist Identify risks for difficulty and develop individualized interventions that address these problems. Teach pt to dispose of old medications How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Prevalence of non-adherence ranges 40-70% 7 Nonadherence issues may be intentional or unintentional First step: identify contributing factors How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Promoting adherence with Unintentional Nonadherence Simplify drug regimen Clear and concise verbal and written instructions Appropriate dosage form Containers should be clearly labeled and easy-to-open Daily reminders, timers, pill dispensers Support system Frequent monitoring 43 How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Promoting Adherence with Intentional Nonadherence Most cases (75%) of nonadherence are intentional Reasons include the following: High cost of drugs, side effects, and the patient’s belief that the drug is unnecessary or that the dosage is too high 44 How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Is non-adherence due to Health Status? Vision Hearing Dexterity Cognition Depression Finances How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Is non-adherence due to Behavioral/ Attitudinal Factors? Social isolation Health beliefs (perceptions! Self and societal) severity of illness susceptibility to illness side effects and efficacy of treatment Financial status How can the nurse decrease the incidence of adverse drug reactions and drug-drug interactions by addressing poor adherence? Is non-adherence due to Treatment Factors? Dosing frequency Complexity Duration of treatment Number of medications Types of medications (dosing forms) Drug Therapy in Geriatric Patients: Assessment of Adherence Ask client to bring all medications to clinic Open-ended questions regarding each medication what drugs are they taking? how are they taking? Direct questions: • “do you ever forget to take your medicines?” • “how many times in the last week have you missed a dose?” • “when you feel better do you stop taking your medicines” • “sometimes if you feel worse do you stop taking your medicines?” Pharmacy refill patterns Observation of home environment Question 3 An older adult patient frequently forgets to take an oral medication that has been prescribed to be taken three times per day. Which action by the nurse is best? A. Assess the patient’s ability to swallow the medication. B. Arrange for a neighbor to call the patient three times a day. C. Call the prescriber for a sustained-release form of the drug. D. Give the patient verbal and written instructions about the drug. 49 Certified Geriatric Pharmacists Application of reliable sources of drug information 8 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults updated 2015, American Geriatric Society 53 classes of drugs in 3 categories Potentially Inappropriate Medication Use in Older Adults Drugs that should be Used with Caution due to drugdisease or drug-syndrome interactions Drugs that may exacerbate condition Is a safer drug available? “Potentially Inappropriate” http://geriatricscareonline.org/ProductAbstract/american-geriatrics-societyupdated-beers-criteria-for-potentially-inappropriate-medication-use-in-olderadults/CL001 Drug Therapy in Geriatric Patients: Examples of medications from the “Beers list” First-gen antihistamines – anticholinergic effects Non-selective COX inhibitors – risk of renal damage and GI bleed Clonidine as first-line antihypertensive – risk of CNS effects and orthostatic hypotension TCAs – sedating, anticholinergic, can cause orthostatic hypotension Benzodiazepined (BZDs) – increased sensitivity to effects, risk of oversedation, cognitive impairment, falls Drug Therapy in Geriatric Patients: TAKE-AWAY MESSAGES ►Nursing action tips: * Collaborate with patient, family, & prescriber on treatment goals Teach the role of drug therapy in reaching goals Identify and address contributing factors, barriers to adherence Problem-solve on an individualized basis Individualized medical management is essential Each patient must be monitored for desired and adverse responses Regimen must be adhered to (ie agreement between what the provider thinks the pt is taking vs. meds the pt actually takes) Goals of treatment: Reduce symptoms and improve quality of life 54 Drug Therapy in Geriatric Patients: References & resources for further learning 9 American Geriatric Society Centers for Disease Control and Prevention The State of Aging and Health in America (2013) http://www.cdc.gov/aging/pdf/state-aging-health-in-america2013.pdf http://www.cdc.gov/aging/index.html Older Americans (2012): Key Indicators of Well-being http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2012_Doc uments/Docs/EntireChartbook.pdf American Association of Retired Persons (advocacy) http://depts.washington.edu/geront/ Geriatric Case Ms. Giordano - 67 YO F How would you approach your analysis of this med list? PMH: osteoarthritis both knees and the right What resources would you hip, breast cancer, spondylolisthesis with use? chronic lumber pain, depression Medications Sertraline 75 mg, daily Amitriptyline 25 mg PRN for sleep Acetaminophen 500 mg, q8h, for OA and back pain as needed Naproxen, 500 mg, bid for OA pain as needed Multivitamin Vitamin D 2000 IU/day What problems do you see? What are potential solutions?