lecture 4: chapter 6 Pharmacology and Older Adults 2

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Transcript lecture 4: chapter 6 Pharmacology and Older Adults 2

CHAPTER
6
Lecture Note PowerPoint Presentation
Pharmacology and
Older Adults
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 1
Explain the interaction between normal
aging and responses to drug therapy in
older people.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Age-Related Changes that Increase Risk for
Adverse Drug Events
• Chronic disease
• Polypharmacy
• Physiological and adaptive responses
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Determinants of Physiological
Response to Medications
• Race
• Ethnic
• Genetic background
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute and Chronic Conditions May
Alter
• Pharmacokinetics (what the body does to
the drug)
• Pharmacodynamics (what the drug does
to the body)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Age-Related Changes
• Decrease in body water (as much as 15%)
and increase in body fat
– Increased concentration of water-soluble
drugs
– More prolonged effects of fat-soluble drugs
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Age-Related Changes
• Hepatic blood flow may be decreased by
as much as 50% in individuals over 65
years
– Increased toxicity with normal doses of “firstpass effect” drugs
 Less drug would be detoxified immediately by the
liver
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Age-Related Changes
• Decreases in serum albumin
– Leads to altered binding capacity
– May cause increased serum levels of the
“free” or unbound proportion of protein-bound
drugs
– May result in toxic levels of highly proteinbound drugs because more unbound drug is
available to produce its effects
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Kidneys Excrete Most Drugs
• Considerable individual variation in the
degree of decline of renal function
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes of Changes in Pharmacodynamics
in the Older Person
• Decreased number of receptors
• Decreased receptor binding
• Altered cellular response to the drugreceptor interaction
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 2
Identify principles of safe medication
management with older persons in a variety
of patient care settings.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pivotal Role of Nurse
• Ensure drug therapy is effective for the
person’s condition
• Prevent, detect, or intervene as early as
possible if the person develops adverse
drug effects
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Common Inappropriate Drugs
Administered to Older Adults
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Psychotropic agents
Anti-inflammatory drugs
Amitriptyline
Iron supplements
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inappropriate Conditions for Use of
Antipsychotic Drugs
• Wandering (To move about without a definite destination or
purpose)
• Poor self-care
• Restlessness
• Impaired memory
• Anxiety
• Depression (without psychotic features)
• Insomnia
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inappropriate Conditions for Use of
Antipsychotic Drugs
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Unsociability
Indifference to surroundings
Fidgeting (the act of moving about restlessly)
Nervousness
Uncooperativeness
Agitated behaviors that do not represent
danger to the resident or others
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Residents Administered Antipsychotic,
Anxiolytic, and Sedative-Hypnotic Drugs
• Should receive gradual dose reductions at
scheduled intervals
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Regimen Review (MRR)
• Required by Medicare
• Involves a thorough evaluation of the
medication regimen by a pharmacist, in
collaboration with other members of the
interdisciplinary team
• Includes preventing, identifying, reporting,
and resolving medication-related
problems, medication errors, and other
irregularities
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse’s Role in Promoting Safe and
Effective Medication Management
• Assure the correct storage, preparation,
and administration (including the five
rights) in the institutional setting
• Educate the patient and family concerning
storage, preparation, and administration
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse’s Role in Promoting Safe and
Effective Medication Management
• In the institutional setting, be aware of the
legal aspects of medication delegation for
the state in which he or she practices as
well as the policies of the employing
agency
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 3
Discuss measures to prevent and reduce
polypharmacy in older patients.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Older persons More Likely to Have Adverse
Drug Reactions (ADRs) Related to
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•
Inappropriate drug or dosing
Drug-drug interactions
Polypharmacy
Nonadherence
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Interventions
• Can prevent the need for some
medications
• Can reduce the dose or length of drug
therapy
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Polypharmacy
• Definition: The prescription, administration,
or use of more medications than are
clinically indicated in a given patient
• Examples
• Medication that has no apparent indication
• Continuing use of a medication after a
condition has been resolved
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Polypharmacy
• Use of a medication to treat the side
effects of another medication
• Use of an inappropriate dose
• Use of duplicate medications because the
same drug has been prescribed by more
than one prescriber
• Self-medicating with OTC medications or
herbal remedies to treat the same
condition
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Include in a Complete Drug History
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Vitamins
OTC medications
Dietary supplements
Herbal remedies
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Indications for Reduced Dosages
• Weight is less than average
• Decreased liver or renal function
• Experiencing exaggerated responses to
drugs that may reflect toxic levels
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Indications for Drug Therapy
• A specific diagnosis
• Clearly documented symptom or condition
to be treated
• Avoid use of a drug to treat the side
effects of another drug
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Unnecessary Drug Administration
• Excessive dose (including duplicate
therapy)
• Excessive duration
• Inadequate monitoring
• Inadequate indications
• Presence of adverse consequences that
indicate the dose should be reduced or
discontinued
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 4
Describe assessments to monitor older
patients for adverse drug effects and
polypharmacy.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assessment Parameters
• Physiological and psychosocial status
• Need for the drug
• Risk of an adverse drug reaction
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
ADR Clues
• Cognitive impairment (e.g., delirium,
dementia, depression)
• Loss of appetite, nausea
• Weight loss
• Falls
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Drugs that Can Cause Changes in
Mood
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Antihypertensives (e.g., beta-blockers)
Antiparkinsonian agents
Steroids
NSAID
Narcotic agents
Antineoplastic agents
Central nervous system (CNS)
depressants
• Psychotropics
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes of Falls in the Older Adult
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Alterations in vision
Balance
Decreases in reaction time
Orthostatic hypotension
Decreased muscle strength
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Herbal Interactions with
Medications
• Elicit from patients any herbs, home
remedies or dietary supplements that they
take
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Reconciliation
• Indicated whenever an individual moves
from one care setting to another
• Verification (collection of the medication
history)
• Clarification (ensuring that the medications
and doses are appropriate)
• Reconciliation (documentation of changes
in the orders)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Review Each Drug for
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Interactions with other drugs
Interactions with herbal medicines
Interactions with vitamins or foods
Patient allergies
Duplicate therapy
– From more than one prescriber or from use of
OTC medications containing the same or
similar ingredients as prescribed medications
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Observe for
• Known adverse effects of medication
• General symptoms that might be drug
related
• Monitor laboratory results as appropriate
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 5
Use teaching and nursing interventions to
promote compliance and adherence to the
medication regimen.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Noncompliance Results
in Considerable Costs to
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Patients
Employer
Health insurers
Healthcare system
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Enhance Medication Compliance by
• Reducing the impact of side effects
through
– Adequate intake of fiber and fluid intake can
help to offset drug-induced constipation
– Scheduling diuretic so that it does not
interrupt sleep or activities important to the
patient
– Frequent intake of liquids or the use of
lozenges to help with dry mouth caused by
medications
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Drug Regimen Unassisted Grading
Scale (DRUGS)
• Used to assess an elderly person’s ability
to take medications correctly
• Employs four medication management
tasks
– Identification or showing the appropriate
medications
– Access, or opening the appropriate containers
– Dosage, or taking out the correct number per
dose
– Timing, or demonstrating the timing of the
doses
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Measures to Manage Medications
Correctly
• Simplifying the regimen if possible
• Establishing a routine for taking
medications
• Scheduling medications at mealtime or in
conjunction with other specific daily
activities
• Developing a method with the patient for
remembering if he or she actually took the
medication
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Measures to Manage Medications
Correctly
• Conducting a total assessment of all
medication, including OTC and herbal
preparations
• Telephone reminders, computer-based
reminders, or pill boxes
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Measures to Manage Medications
Correctly
• Obtain all of medications (prescription and
OTC) from the same pharmacy; request
no childproof packaging or caps
• Determine any financial restraints; identify
low-cost alternatives
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 6
Identify nonpharmacological therapies that
may be useful as alternatives to
medications.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Alternatives
• Constipation
– Increase bulk in diet
– Avoid cheese
– Encourage exercise
– Ensure adequate fluid intake
• Insomnia
– Suggest warm milk
– Adapt the environment to promote sleep
– Avoid caffeinated drinks in the afternoon
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medication Alternatives
• “Heartburn”
– Eat small, frequent meals
– Stay in upright position for at least 30 minutes
after taking medications
• Pain
– Use of distraction
– Guided imagery
– Positioning
– Ice or heat
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 7
Discuss issues related to ensuring the safe
use of drug therapy by the older person.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Drug Therapy Issues
• Healthcare fraud ( is a crime. It's committed when a
dishonest provider or consumer intentionally submits, or causes someone
else to submit, false or misleading information for use in determining the
amount of health care benefits payable.
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)
Medication costs
Internet pharmacies’ legitimacy
Sharing others’ medications
Use of imported medications
Use of outdated medications
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.