Transcript Gerontological Nursing

A. Pharmacology and the Older Adult
B. Psychological and Cognitive Function
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Age related changes
affecting drug therapy
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 Decreased GI motility and absorption surface
 Dry mouth
 Decreased liver perfusion,
liver mass
 Increased body fat,
 Decreased body water
 Decreased renal perfusion,
renal mass
 Visual, hearing changes
 Brain and brain function changes
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Predictors of the patient’s
reaction to a drug
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 Chronological age alone is a poor indicator
Better indicators include:
 General state of health
 Number and types of medications prescribed/taken
 Liver function
 Renal function
 Comorbidities
 Other diagnosed diseases
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Predicting renal function in
the elderly patient
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 Do not rely on BUN
 Calculate creatinine clearance:
Creatinine clearance =
(140 – age) x lean weight (kg)
72 x serum creatinine
x .85 for women
 Normal values:
Male: 97 to 137 ml/min.
Female: 88 to 128 ml/min.
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Adverse drug effects in the
elderly
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 People >65 yrs 2x likely to have ADE than <65
 Most are preventable
 Client frequently stops the suspected medication
 Suspect ADE if patient experiences unexplained:
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Cognitive changes
Falls
Anorexia
Nausea
Weight loss
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Cognitive changes
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 Changes in mood (anxiety, depression) from
antihypertensives, antiparkinsonians, narcotics,
NSAIDs, steroids
 Central anticholinergic
effects—agitation,
confusion, disorientation,
hallucinations, psychosis
(e.g., diphenhydramine,
furosemide, digoxin, antidiarrheals)
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Major drug-drug
interactions in LTC
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 Warfarin with NSAIDs, sulfa drugs, macrolides,
quinolones, phenytoin => increased bleeding
 ACE inhibitors with potassium supplements or
spirolactone => elevated serum potassium
 Digoxin and amiodarone => digoxin toxicity
 Theophylline and quinolones =>
theophylline toxicity
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Adverse Drug Reactions in
the Elderly
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 Signs and symptoms of ADR may vary in the elderly
 Evidence of ADR may take longer in the elderly
 ADR may be apparent even after
the drug has been discontinued
 ADR can develop suddenly even
if medication has been used over a
longer period of time
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Medication reconciliation
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 Identify an accurate list of all medications patient is
taking
 Verify the medications are appropriate to the patient
 Determine if patient is
taking them correctly
 Compare list with
physician’s admission,
transfer, or discharge
orders
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Drugs that should be used
cautiously in the elderly
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 New drugs on the market
 CNS drugs
 Drugs that are highly protein bound (e.g., thyroxine,
warfarin, diazepam, heparin, imipramine and phenytoin)
 Drugs eliminated by the kidneys (e.g., digoxin, glucose,
some antibiotics)
 Drugs with a high 1st pass effect, i.e., low bioavailability
(e.g., propanolol, orphine, nitroglycerin)
 Drugs with a low therapeutic-to-toxicity ratio (e.g., oral
chemotherapy)
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Guiding Principles of Drug Administration
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 Why is the drug ordered?
 Is this the smallest possible dose?
 Does the patient have any allergy to the drug?
 Are there potential drug-drug interactions?
 Are there any special administration requirements?
 Is this the most effective route of administration?
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Beers Criteria
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 “Potentially Inappropriate Medications for the
Elderly”
 Lists medications that require provider justification if
prescribed to this population
 Intended to limit adverse drug events
 Monitored in long term care and acute settings
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Gradual dose reduction
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 Required by Medicare in LTC facilities
 Stepwise tapering of the dose
 Determine if condition can be
managed by lower dose
 Determine if medication can be
discontinued
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OBRA requirements
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 Chemical restraints may be used only to ensure the
safety of an older patient in an emergency situation
 Must correlate to an appropriate diagnosis if given
long term
 May not be given for wandering, restlessness,
insomnia, failure to cooperate, etc.
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Evaluating appropriate
prescribing
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 Is the problem significant?
 What nonpharmacological interventions are
available?
 Is the justification for the medication documented?
 Has informed consent been obtained?
 Is achieving therapeutic goals likely and reasonable?
 When will tapering begin?
 Are there any duplications is drug purposes?
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Collaborative responsibility
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 Know correct medication, dosage, parameters for use
 Assess patient for response to medication
 Consult with prescribing provider
 Provide reasonable alternative action if indicated
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Criteria for use of anxiolytics
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 Generalized anxiety disorder (diagnosed)
 Panic disorder (diagnosed)
 Symptomatic anxiety in patients with another
diagnosed psychiatric disorder
 Sleep disorder (diagnosed)
 Acute ETOH or benzodiazepine withdrawal
 Significant situational anxiety (documented)
 Behaviors associated with persistent delirium,
dementia, cognitive impairment (documented)
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Strategies to promote
adherence
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 Smallest number of drugs, smallest number of pills
per day
 Establish a routine
 Schedule at time of other normal activity
 Develop method to remember
drug was taken
 Total assessment of all drugs
at each visit
 Telephone, email reminders
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Practices to discourage
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 Sharing medications
 Using imported medications
 Using outdated medications
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Psychological, cognitive problem diagnosis
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Problems may be overlooked due to:
 Missed diagnosis
 Denial of problem by patient
 Finances
 Poor coordination of health care team
 Limited geriatric mental health expertise
 Fear of stigma
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Normal age related
cognitive changes
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 Decreased information processing speed
 Decreased ability to divide or sustain attention
 Long term memory requires greater cuing
 Word finding, naming ability decline
 Abstraction ability shows some decline
 Decreased ability to filter out
irrelevant information
 Mental flexibility declines
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Stable cognitive function
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 Short-term, primary memory remains stable
 Language skills remain intact
 Vocabulary skills improve
 Accumulation of practical
experience continues
 Influenced by:
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Education
Pulmonary health
General health
Activity level
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Coping with changes in cognition
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 Make lists
 Memory training and techniques
 Playing computer games with
hand/eye coordination
 Challenge mind
 Use assistive devices, habit
 Find support from others
 Keep sense of humor
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Adjusting to changes
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 Most adults adjust successfully
 A life of continuous adjustment makes it easier in the
future
 Inability to adjust can be
frustrating
and/or depressing
 Assess for signs of
depression with
every life challenge
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Rigidity and excess
cautiousness
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 Not a normal age related change
 Experiences, values, and expectations no longer
congruent with current ideas
 Out of their “comfort zone”
 Method of adjustment influenced
by underlying personality
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Maladaptation to stress in the
elderly
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 Sleep problems
 Chronic high anxiety
 Substance use/abuse
 Irritability
 New onset HTN
 Depression
 Chronic fatigue
 Chronic pain, discomfort
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Changes requiring
evaluation
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 Memory and intellectual difficulties
 Changes in sleep patterns
 Changes in sexual interest, capacity
 Fear of death
 Delusions
 Hallucinations
 Disordered thinking
 Changes in emotional expression
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Principles for psychological
assessment of the elderly
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 Minimize the patient’s preoccupations: pain,
comfort, elimination, adequate hearing and seeing
 Explain what you’re doing…
and why
 Minimize distractions: quiet
room, adequate lighting
 Speak slowly and clearly
 Takes breaks if necessary
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Personality disorders and psychoses
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 Incidence of most personality disorders decline with
age
 Schizophrenia rarely occurs initially in old age
 Most common form of psychosis in the elderly is
paranoia
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Hearing loss
Social isolation
Cognitive impairment
Delirium
Underlying personality
disorder
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Adjustment to loss or
life events
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 Grief lasting up to 2 years is “normal”
 Duration of grief affected by
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Meaning associated with the person who has died
Health of the survivor
Survivor’s belief system
Existence of substance abuse
Cause, suddenness of death
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Depression in the elderly
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 Symptoms may be emotional and/or physical
 Multiple somatic complaints
 Chronic pain
 Older women 2x as susceptible
 Older men less likely to admit to
depression
 Can be associated with medications
(Box 7-2)
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Geriatric depression
scale
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 Long version—30 items
 Short version—15 items
 Can be used on healthy,
ill, or those with cognitive
impairment
 Patients who score >10
should be referred
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Suicide
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 65 years+ have highest suicide rate of all ages
 Major risk is depression
 Older Caucasian males have highest death rates from
suicide
 70% of successful suicide attempts in older adults
had seen primary physician within the previous
month
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Consider major depression with 4 or more
persisting for at least 2 weeks….
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 Significant weight loss or gain, change in appetite
 Sleep disturbances
 Agitation, slowness
 Fatigue
 Feelings of worthlessness, guilt
 Inability to concentrate, make decisions
 Recurrent thoughts of suicide, death
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Antidepressants commonly used in the
care of the elderly depressed patient
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 Selective serotonin reuptake inhibitors (SSRIs)
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Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Sertaline (Zoloft)
Paroxetine (Paxil)
 Tricyclic antidepressants (TCAs)
 Desipramine (Norpramin)
 Nortriptyline (Pamelor)
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Risk factors for suicide
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 Previous suicide attempt
 Alcohol or substance abuse
 Psychiatric illness
 Auditory hallucinations
 Living alone
 Guns at home
 Exposure to suicide
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Consider alcohol problems if:
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 Memory problems
 Frequent falls
 Changes in sleep patterns
 Irritability, sadness, depression
 Trouble concentrating
 Chronic pain
 Smell of alcohol
 Isolation
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Short Michigan Alcoholism Screening
Test—Geriatric Version (SMAST-G)
(2+ Yes responses indicative of an alcohol problem)
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When talking to others, do you ever underestimate how much
you drink?
After a few drinks, have you sometimes not eaten because you
don’t feel hungry?
Does having a few drinks help decrease your shakiness or
tremors?
Does alcohol sometimes make it hard for you to remember parts
of the day or night?
Do you usually take a drink to relax or calm your nerves?
Do you drink to take your mind off your problems?
Have you ever increased your drinking after experiencing a loss
in your life?
Has a doctor or nurse ever said they were worried or concerned
about your drinking?
Have you ever made rules to manage your drinking?
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When you feel lonely, does having a drink help?
Potential Nursing Diagnoses
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 Ineffective coping
 Risk for suicide
 Disturbed thought processes
 Acute/chronic confusion
(also, “Risk for”)
 Decisional conflict
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To begin the process….
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 Chose your nursing case study for use throughout
the semester
 Selected case studies are on the website
 Identify 2 different diagnoses within the case:
 1 diagnosis must concern the patient’s physiological
status
 1 diagnosis must addressing an identified learning
need
 Identify pertinent subjective and objective triggers
 Determine appropriate functional health pattern
 Use the standard nursing care plan format you have
been provided…first installment due per syllabus!
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