Transcript Chapter 8: Medications and Laboratory Values

Chapter 8: Medications
and Laboratory Values
Bonnie M. Wivell, MS, RN, CNS
Demographics related to
Medications
The elderly consume about 1/3 of all
prescription and OTC drugs
 Of those over age 65 (2002)

– 40% took 5+ meds per week
– 12% took over 10 meds
– The more medications taken, the greater risk
of side effects
– Greater risk of side effects in elderly due to
normal aging changes
The Effect of Aging on Drugs
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Pharmacokinetics
– How drugs move through the body via
absorption/excretion
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Pharmacodynamics
– Effect of drugs in the body
– Medications can stay in the body longer due
to decreased clearance or excretion and thus
increase risk of side effects.
Drug-Related Problems
in the Elderly
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Adverse drug reactions
– Drug-drug
– Drug-disease (pg. 263)
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– Is tx necessary?
– Is it safest drug available?
– Is it the most appropriate
dose, route, and form?
– Is frequency appropriate?
– Do benefits outweigh risks?
Food drug interactions
– Greens & Warfarin
– Grapefruit juice &
antihistamines
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Polypharmacy – more than
clinically necessary
– Adverse outcomes
 ADRs
 Increased cost
 noncompliance
Inappropriate prescribing
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Compliance
– 40% do not adhere
Beers Criteria
In 1997, Dr. Beers developed and published the
Beers criteria in the Archives of Internal
Medicine, outlining explicit criteria for use in
prescribing medications for seniors
 Adopted by CMS in 1999 for nursing home
regulations
 Revised in 2003
 The criteria have been widely used over the past
10 years for
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– Studying prescribing patterns within populations
– Educating clinicians
– Evaluating health outcomes, cost, and utilization data
Beers Criteria Continued
Lists more than 40 concerns associated
with specific drugs or drug classes when
prescribed for older adults.
 These concerns explain the overall clinical
rationale for inclusion on the list.
 See page 267 in your text
 Start LOW and go SLOW
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Medication Blood Levels
Cardiac meds, anti-epileptics, certain antibiotics
 Random: typically to rule out overdose, not dose
time dependent
 Peak: dose time dependent; time blood level is
expected to be at its highest
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– Too high = reduce dose
– Too low = increase dose
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Trough: dose time dependent; time blood level
is expected to be at its lowest, right before dose
– Too high = extend time between doses
– Too low = shorten time between doses
Laboratory Values
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Renal impairment
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NSAIDs
ACE inhibitors
IV contrast materials
BUN/Creat, Creatinine Clearance (formula pg. 271)
Hepatic impairment
– Alk Phos, AST, ALT, albumin, bili, protein, coags
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Decreased serum albumin concentration can
possibly increase free drug concentrations
5 Rights
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Drug
– Other’s meds
– Old meds
– RX for same drug from
different MDs
– OTC meds
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Amount
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Lack of understanding
Using wrong measuring device
Confusing schedules
Forget what was already
taken
– Not getting refills
– Rationing
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Route
– Please don’t chew your
suppository
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Time
– Multiple drugs with
different times
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Patient
– Please don’t take your
spouse’s medications
Challenges to Successful
Medication Regimens
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Function
– Physical
– Sensory
– Reading
– Memory
– Motivation
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Funding
Medications Prescribed for the
Elderly
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Medications for dementia
– Cholinesterase inhibitors: Cognex, Aricept, Exelon, Reminyl
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Medications for osteoporosis
– Antiresorptives
 Bisphosphonates (Fosamax, Actonel, Boniva, Aredia, Zometa)
 HRT
 Selective estrogen-receptor modulators (Evista, Tamoxifen)
– Anabolic or bone-forming
 Calcitonin – nasal spray
 Calcimar - injection
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Medications for anxiety
– Benzodiazepines
– Buspirone – no cognitive impairment
– Selective Serotonin reuptake inhibitors (SSRIs)
Nursing interventions
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Medication review
– Bring in all home meds
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Education
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Name
How often
How many
Side effects
Funding
– Social worker
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Accommodation
– Pill boxes are great
Summary
Geriatric people make up about 13% of
the population, but consume 33% of all
prescription medications.
 Older adults have significant physiological
changes related to aging that may
interfere with medications.
 Older adults are more sensitive to the
effects of drug therapy.
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Summary (cont’d)
Adverse drug reactions are any noxious,
unintended or undesired effect of a drug
which occurs at doses in humans for
prophylaxis, diagnosis or therapy.
 Certain disease states may interfere with
optimal drug therapy.
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Summary (cont’d)
Polypharmacy is defined as the
prescription, administration, or use of
more medications than are clinically
indicated for a patient.
 Inappropriate prescribing may be very
harmful to elderly persons.
 Compliance to drug regimens is essential
to improving medical diagnosis and
outcomes.

Chapter 12: Identifying and
Preventing Common Risk
Factors in the Elderly
Bonnie M. Wivell, MS, RN, CNS
Health Promotion and Disease Prevention
Health promotion can help prevent
functional decline in the elderly
 U.S. Preventive Services Task Force
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– Evaluate benefits of individual services and to
create age, gender, and risk-based
recommendations about services that should
routinely be incorporated into primary care
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Healthy People 2010
– Sets of objectives developed by many experts
to promote health and quality of life in
Americans
Definitions
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Primary prevention
– Activities to prevent disease from occurring
– Example: Immunizations
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Secondary prevention
– Early detection and management
– Screenings
– Example: colonoscopy to detect and remove polyps
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Tertiary prevention
– Manage existing disease, preventing progression or
complications
– Example: meds used to remodel heart with CHF
Screening Recommendations
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Level A: Strongly recommends based on good
evidence that screening = Outcomes > Risks
Level B: Recommends screening based on fair
evidence than screening = Outcomes > Risks
Level C: Makes no recommendation for or
against based on balance of benefit/risk
Level D: Recommends against screening
because screening is ineffective or harmful
Level 1: Makes no recommendation due to
insufficient evidence
Focus of Health Promotion Efforts
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Self-Management
– Chronic disease programs
– Contracting for behavior change
Physical Activity
 Nutrition
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Physical Activity Counseling
Level I recommendation
 Found insufficient evidence to determine
whether encouraging or counseling
patients to begin an exercise program
actually led to improvements in their level
of physical activity
 There is strong evidence to support the
effectiveness of physical activity in
reducing morbidity and mortality from
chronic illness
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Nutrition Counseling
Level B recommendation
 Found good evidence to support counseling
interventions among adults at risk for dietrelated chronic disease
 Interventions that have proven to stimulate
healthy dietary changes combine nutrition
education with behavioral counseling
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Tobacco Use
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5 A’s
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Ask
Advise
Assess willingness
Assist
Arrange follow-up
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5 R’s
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Relevance
Risks
Rewards
Roadblocks
Repetition
Tobacco Cessation Counseling
Level A recommendation
 Found good evidence that screening, brief
behavioral counseling, and pharmacotherapy,
are effective in helping clients to quit smoking
and remain smoke-free after one year.
 There is good data to support that smoking
cessation lowers the risk for heart disease,
stroke, and lung disease
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Safety
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Inflammation of joints or joint deformity
H ypotension (othostatic blood pressure change)
A uditory and visual abnormalities
T remor
E quilibrium problems
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F oot problems
A rrythmias, heart block, valvular disease
L eg-length discrepancy
L ack of conditioning (generalized weakness)
I llness
N utrition (poor, weight loss)
G ait distrubance
Fall Prevention Counseling
Level B recommendation
 Recommended in order to reduce fall risk
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– Balance and strengthening exercise programs
– Home safety assessment and training
– Medication monitoring and adjustment
Polypharmacy and Medications
Adults over age 65 take an average of 4.5
prescription meds and 2 OTC meds at any
given time
 Many elders are prescribed drugs that are
not recommended in the elderly
 Polypharmacy a major problem, with
increased risk of side effects the more
medications are added
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Immunizations
Influenza vaccination annually: Level
B recommendation
 Amantadine or Rimantadine
prophylaxis: Level B recommendation
 Pneumococcal vaccine: Level B
recommendation
 Tetanus vaccination: Level A
recommendation
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Mental Health Issues
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Depression
– Level B recommendation to support screening
– Found good evidence that screening effectively identifies
depressed patients and that treatment of depression
improves clinical outcomes
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Dementia Screening
– Level I recommendation.
– Found the clinical evidence to be insufficient to
recommend screening for all elderly clients in a primary
care setting
– Most expert panels agree that clients who are suspected of
having cognitive impairment or whose families express
concern about their cognitive functioning, should be
screened
Alcohol Abuse
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More the 7 drinks per week for women and
14 drinks per week for men is considered
hazardous
Can use 5 A’s and 5 R’s also
Screening
– Level B recommendation for screening
– Found good evidence that screening is beneficial
in identifying patients whose alcohol consumption
patterns place them at risk for increased
morbidity and mortality, and good evidence that
counseling about alcohol reduction can produce
sustained benefit over a six to twelve month
period
Elder Abuse and Neglect
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Clues to abuse:
– The presence of several injuries in different stages of
repair
– Delays in seeking treatment
– Injuries which cannot be explained or that are
inconsistent with the history
– Contradictory explanations by the caregiver and the
patient
– Bruises, burns, welts, lacerations, restraint marks
Elder Abuse and Neglect
Continued
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Clues to abuse (cont’d):
– Dehydration, malnutrition, decubitus ulcers or poor
hygiene
– Depression, withdrawal, agitation
– Signs of medication misuse
– Pattern of missed or cancelled appointments
– Frequent changes in healthcare providers
– Discharge, bleeding or pain in rectum or vagina or
sexually transmitted disease
– Missing prosthetic device(s), such as dentures,
glasses, hearing aids
Lipid Screening
Level A recommendation for screening
 There is strong evidence to correlate lipid
abnormalities with cardiac risk
 A simple blood test is a valid and reliable
method of diagnosing lipid abnormalities
 Diet and drug therapies are effective
remedies
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Heart and Valvular Disease
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Each component below will be examined
individually
Risk factors:
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Age > 50 for men and 60 for women
Hypertension
Smoking
Obesity
Heart and Valvular Disease Continued
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Risk factors (cont’d)
– Family history of premature CHD
– Diabetes (Considered to be a CHD riskequivalent i.e. Carries the same risk of
coronary event as known CHD)
– Sedentary life style
– Abnormal lipid levels
Blood Pressure Screening
Level A recommendation
 There is strong evidence that blood pressure
measurement can identify adults at increased
risk for cardiovascular disease due to high blood
pressure
 Treatment of hypertension substantially
decreases the incidence of cardiovascular
disease
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Aspirin Therapy
Level A recommendation
 There is good evidence that aspirin decreases
the incidence of CHD in adults who are at
increased risk for heart disease
 Aspirin increases the incidence of
gastrointestinal bleeding and hemorrhagic
strokes
 Concluded that evidence is strongest to support
aspirin therapy in patients at high risk of CHD
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Cerebral Vascular Disease
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Risk factors
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Increased age
Smoking
Hypertension
Diabetes
Sedentary lifestyle
Alcohol use
High fat diet
Atrial fibrillation
Carotid stenosis
Thyroid Disease Screening
Level I recommendation
 There is insufficient evidence to
recommend for or against screening based
on limited evidence to establish health
risks of subclinical disease, and due to the
risks of treatment
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Osteoporosis
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Risk factors:
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Advanced age
Low BMI
Caucasian or Asian race
Family history of compression or stress fracture
Fall risk or history of fracture
Low levels of weight-bearing exercise
Smoking
Excessive alcohol or caffeine use
Low intake of calcium or vitamin D.
Osteoporosis Screening
Level B recommendation
 Osteoporosis is common in the elderly and
is correlated with fracture risk
 There are good screening tests to
diagnose osteoporosis and effective
treatments for the disease
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Vision and Hearing
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Cataracts, glaucoma, and diabetes
contribute to visual impairments in elderly
Prostate CA Screening
Level I recommendation
 Insufficient evidence to recommend
screening based on inconclusive evidence
that screening with DRE and PSA improves
health outcomes
 Men with a life expectancy of less than 10
years are unlikely to benefit from prostate
screening
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Breast CA Screening
 Mammography
(with or without
clinical breast exam): Level B
evidence
There is fair evidence to support benefit from
breast cancer screening for older women by
mammogram every one to two years
 There is no age at which screening should be
discontinued but the task force agrees that
screening would have no benefit when life
expectancy is significantly limited by dementia or
other serious, life-limiting chronic illnesses
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Colorectal Screening
Level A recommendation
 The task force strongly recommends colorectal
screening by FOBT, FOBT + sigmoidoscopy, or
sigmoidoscopy alone for clients with average risk
of developing colorectal cancer.
 The task force was unable to determine whether
the increased sensitivity of colonoscopy
compared with the other screening methods
outweighed the costs, risks and inconvenience
of the procedure.
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Chapter 18: Appreciating
Diversity and Enhancing
Intimacy
Bonnie M. Wivell, MS, RN, CNS
Definitions
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Heritage: encompasses a person’s ethnic origin,
nationality, religion and culture
Ethnicity: refers to what some have called race;
African, European, Asian, etc.
Nationality: refers to the geographic location of
birth
Religion: refers to a belief system based on a
higher power
Culture: refers to the group to which the person
belongs and which influences the person’s
values and beliefs (shared beliefs)
Appreciating Diversity
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Diversity of elders
– Elderly cohort is becoming more
heterogeneous
– At present, most elders are white females, but
this is changing with growth of minority
groups
– Differences in race, diet, leisure,
socioeconomic status, and health care beliefs
present challenges to nursing
Cultural Competence
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“A key strategy for achieving cultural
competence is to learn about different
cultural and religious preferences,
customs, and restrictions, and the use this
knowledge in planning and providing
care.” (Mauk, page 604)
Health Care Disparities
Reframe the problem of health disparities from a
racial issue to one of a phenotype/environmental
mismatch (HTN and Vit D deficiency)
 The disparities to be discussed are the most
significant health-related differences found
among ethnic groups, based on Keppel’s
research
 While not all of the disparities cited in Keppel’s
study pertain directly to older adults, these
differences among ethnic groups points to
certain foci of nursing care that, if not addressed
early, may carry into older age
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European Americans
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Constitute majority of US population
Christian denominations
– Protestant and Catholic
– Less likely to turn to religion for coping or problem
solving
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Top 5 health disparities
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Smoking by pregnant women
Drug-induced deaths
Deaths from poisoning
Deaths from melanoma
Deaths from chronic lower respiratory disease before
age 45
African Americans
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Second largest minority population
Religion plays important part in health and
wellness
– Equate good luck, good fortune, and good health with
“Being right with God.”
– Disease and illness equated with God’s wrath
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Top 5 health disparities
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1 and 2 = new cases of gonorrhea
Congenital syphilis
New cases of AIDS
Deaths due to HIV infection
Hispanic Americans
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Second largest population in the US
Place high value on family, religion, and community
Will seek homeopathic remedies and religious artifacts
before engaging a health care provider
Catholic but have been acculturated to the US
– Illness are categorized as hot or cold
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Top 5 health disparities
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Congenital syphilis
New cases of tuberculosis
New cases of AIDS
Exposure to particulate matter
Cirrhosis deaths
Increased prevalence and mortality from DM and CHD
Asian/Pacific Islanders
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Majority in US are Chinese
Naturalistic approach to health and illness
Everything composed of opposing forces – Yin and Yang
– and health depends on these forces
To maintain balance
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Acupuncture
Burning herbs on or near the body (moxibustion)
Cupping
Massage
Herbs
Movement and concentration exercises
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New cases of tuberculosis
Congenital syphilis
No Pap test among females older than 18
Exposure to particulate matter
Carbon monoxide exposure
Top 5 health disparities
Native American Indians
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There are about 500 different Native American tribes in
the U.S.
Naturalistic approach to health and illness
Religion is centered on legends of sacred spirits that
take many forms
Health beliefs and practices blend with religion and carry
a magic facet
Top 5 health disparities
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Fetal alcohol syndrome
Smoking by pregnant women
Alcohol-related motor vehicle deaths
Cirrhosis deaths
New cases of gonorrhea
Alcoholism and diabetes are two major health problems
among Native Americans
Implications for Nursing
Continue to help minorities have a strong
voice in their care
 Use well elders as volunteers and staff
 Focus efforts and resources on those who
are not being served and who lack
resources; target those who really need
the care
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Diversity in the Health Care Team
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Promote diversity
Avoid stereotyping
Learn about other cultures (become culturally
competent)
Overcome racism
Decrease language barriers
Learn effective health promotion strategies for
those with varying lifestyles
Educate self and others
Draw on each individuals strengths
Providing Culturally
Competent Care
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Racist comments from Patients
– Reporting
– Educating
– Redirecting
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Invisible groups/unheard voices
– Those with dementia
– Those living in group homes
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Providing culturally competent care
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Educate self about the culture that is unfamiliar
Provide interpreters
Involve family
Honor religious or cultural requests when possible
Providing Spiritually
Competent Care
Spirituality related to a sense of well being
in the elderly
 Many use prayer and faith as successful
coping strategies
 Provide opportunity to practice religion
 Incorporate spiritual leader into the team
if needed
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Lifestyles and Health Promotion
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Taking lifestyle into account when promoting
health
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Changes related to disease or illness
Activity level
Preferences
Past practices
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Individualize care plan
Periodically check to be sure plan is working
Make adjustments as needed
Continue to support
Patient adherence
Enhancing Sexual Intimacy
A basic human need of people of all ages
is intimacy
 Sex is not seen as a priority for either
patient or provider
 Most sexual concerns that result from
aging or chronic health problems are
within the realm of nursing practice
 Most health promotion strategies have the
potential to make a positive impact on sex
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Sexual Revolutions
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Roaring 20s – women gain the right to vote and
gain sexual freedom
1948 – Sexuality in the Human Male
1952 – Sexuality in the Human Female
1960-1970 – BCP available and abortion legal
Discovery of HIV and promotion of safe sex
? Another one occurring with advent of better
treatments for ED and vaginal dryness
Elders and HIV
HIV/AIDs is on the rise among older
adults partially because they often do not
see themselves as being at high risk and
thus take fewer precautions to prevent
HIV infection
 See page 617 of text
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Triphasic Model of Human
Sexual Response
Desire: the sensations that move one to
seek sexual pleasure; may or may not
change with aging
 Excitement: increased muscle tone and
vasodilitation of the genital blood vessels;
usually changes with age
 Orgasm: climactic release of the genital
vasodilation and muscle tone; usually
changes with age
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Vaginal Dryness and Erectile
Dysfunction
Lubrication decreased in female
 Female changes can lead to dyspareunia
(painful intercourse)
 Lengthened arousal and refractory period
in men
 May not have orgasm with each
experience
 ED a common problem for men
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Obstacles to Intimacy
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Overcoming fatigue
– Plan for sex when rested
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Overcoming pain
– Plan for sex when pain is at its lowest level
– Hot bath, massage
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Adopting new sexual positions
– Consider the problem/condition
– Suggestions on page 621 of text
Romantic and Sexual
Relationships in LTC
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Romantic and sexual relationships in longterm care
– Barriers
– Need to provide privacy
– Rooms for couples
– Stigma
– http://www.terranova.org
– Freedom of Sexual Expression: Dementia and
Resident Rights in Long-Term Care Facilities
Sexually Inappropriate Behavior
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Extinguish behavior while maintaining the
dignity of the patient
Confront calmly and firmly
Redirect
Do not tolerate
Educate
Consider disease processes such as dementia
Provide privacy as needed