Transcript Chapter 18 Safe Medication Use

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Beer’s criteria: originally developed by a group headed
by Dr. Mark H. Beers, listing of drugs that carry high risks
for older adults and criteria for potentially inappropriate
medication use in older adults
Biological half-life: the time necessary for half of a drug
to be excreted from the body
Pharmacokinetics: refers to the absorption, distribution,
metabolism, and excretion of drugs
Pharmacodynamics: refers to the biologic and
therapeutic effects of drugs at the site of action or on the
target organ
Polypharmacy: use of multiple medications
 Nursing
knowledge is essential for special
considerations for medication use in older
population
 Medications act differently in older adults;
require careful dosage adjustment and
monitoring
• Increased risk of interactions and
adverse reactions
 Sound principles of drug use are essential
 Special
challenges due to number of
drugs commonly used
 Age-related changes affect
• Pharmacokinetics
• Pharmacodynamics
 Increased risk for adverse reactions
 Due
to high prevalence of health conditions,
large use of medications
 Most older adults use at least one medication
regularly; many use several medications daily
 Most common: cardiovascular agents,
antihypertensive, analgesics, antiarthritic
agents, sedatives, tranquilizers, laxatives, and
antacids
 Taking more than one drug increases the risk
of drug‒food interactions
 Absorption
 Distribution
 Metabolism
 Excretion
 Fewer
problems with absorption
 Factors altering absorption
• Route of administration: IM, SQ, PO, Rectallynot absorbed as efficiently as inhaled,
topically applied, or IV
• Concentration and solubility of drug: highly
soluble, higher concentration absorbed with
greater speed than lesser soluble or
concentration
• Diseases and symptoms: slow absorption
Is the following statement True or False?
Decreased intracellular fluid, increased gastric pH,
decreased gastric blood flow and motility, reduced
cardiac output and circulation, and slower metabolism
can slow drug absorption.
True
Age-related changes that include a decrease in
intracellular fluid, increased gastric pH, decreased
gastric blood flow and motility, reduced cardiac
output and circulation, and slower metabolism can
slow drug absorption in the older adult population.
 Difficult to predict drug distribution
 Considerations with the older adult
Changes in circulation
Membrane permeability
Body temperature
Tissue structure: adipose tissue increases
(lipid-soluble drugs) this will increase tissue
concentration
 Dehydration and hypoalbuminemia decrease
drug distribution
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 Conditions
decreasing metabolism of drugs
• Dehydration, hyperthermia, immobility, and
liver disease
 Extended biological half-life: close evaluation
of drug clearance
 Detoxification and conjugation of drugs
reduced
 Renal system excretes drugs; implications of
reduced kidney efficiency important
 Liver influences drug detoxification and
excretion
 Refers
to biologic and therapeutic effects of
drugs at the site of action or targeted organs
 Limited information in older population
 Differences known to date
• Increased myocardial sensitivity to anesthesia
• Increased central nervous system receptor
sensitivity to narcotics, alcohol, and bromides
 Risk
of adverse drug reactions higher in older
adults related to altered pharmacokinetics and
pharmacodynamics
 Mental dysfunction is often an early sign of
adverse reaction to many medications
Is the following statement True or False?
Varying degrees of mental dysfunction are
often the early signs of adverse reactions to
commonly prescribed medications for older
adults.
True
Even the most subtle changes in mental status could
be linked to a medication and should be reviewed
with a member of the health care team.
 Avoiding
potentially inappropriate drugs
• Beers’ criteria
• Identification of drugs that carry high risks for
older adults
 Reviewing necessity and effectiveness of
prescribed drugs
• Specific questions for nursing assessment
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Scope of drug use and significant adverse reactions
• Ensure drugs are selectively and cautiously used
• Review:
 Why is drug ordered?
 Is the smallest possible dosage ordered?
 Is the patient allergic to the drug?
 Can this drug interact with other drugs, herbs, or
nutritional supplements that are being used?
 Are there any special instructions accompanying the
drug’s administration?
 Is the most effective route of administration being
used?
 Most
common route to administer drugs: oral
• Oral administration: problems can interfere
with process
 Suppository form: due to lower body
temperature may take longer to melt
 Intramuscular and subcutaneous administration
• Immobile limb will reduce rate of absorption
 Intravenous administration
• Monitor for complications
 Self-medication
• Assess for risk of medication errors
• Plan interventions to minimize risks
 Factors
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interference with safe administration
Functional limitations
Cognitive limitations
Educational limitations
Sensory limitations
Financial limitations
Choice
 Blood
test often done to determine blood levels
 Specific medications
• Type and frequency of blood work
 Assess for limitations of older adult being able to
have laboratory testing
Drugs can produce serious side effects
 Crucial drugs should be used cautiously
 Benefits versus risk must be weighed = more good
than harm?
 Lifestyle changes may allow eliminating need for
drugs
 Alternative and complementary therapies treat
various health issues
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Aspirin: gastrointestinal bleeding
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Acetaminophen: lacks anti-inflammatory
properties; potential for hepatic necrosis
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Short-acting opioids: mild to moderate pain
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Long-acting opioids: severe pain
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Common side effects of opioids
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Nursing guidelines for older adults taking
analgesics
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Assess the symptom of pain carefully for its underlying cause
Explore nonpharmacologic means to manage pain
If nonpharmacologic means of pain control are unsuccessful, begin with the
weakest type and dose of analgesic and gradually increase so that the
patient’s response can be evaluated
Administer analgesics regularly to maintain a constant blood level
Observe for signs of infection other than fever in patients who are taking
aspirin or acetaminophen
Because bleeding and delayed clotting times can result from long-term
aspirin use, observe for signs of anemia, bleeding, and altered hemoglobin
and prothrombin time
Note signs of salicylate toxicity, which include dizziness, vomiting, tinnitus,
hearing loss, sweating, fever, confusion, burning in the mouth and throat,
convulsions, and coma
Observe for hypoglycemic reactions in persons with diabetes who
combine aspirin with sulfonylureas.
Use narcotics very carefully
If there has been a known or suspected overdosage of any drug from this
group, refer the patient for emergency help at once, even if no symptoms
are present. Signs of poisoning may not appear for several days, although
liver damage may be occurring
Be alert to interactions
Which of the following statements is TRUE
related to acetaminophen (Tylenol)?
Used for moderate to severe pain
b. Lacks anti-inflammatory activity
c. Daily dose not to exceed 2,000 mg
d. Safe use in people with liver disease
a.
b.
Lacks anti-inflammatory activity
Although acetaminophen does not have antiinflammatory activity it is commonly used in the
treatment of osteoarthritis. Acetaminophen is used for
mild to moderate pain and the daily dose should not
exceed 4,000 mg. It should not be used for people
who have liver disease.
 Assess
reasons for antacid use
• Chronic use warrants a diagnostic evaluation
 Drug interactions
 Use only when needed
 Nursing guidelines for older adults taking
antacids
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During assessments, ask specifically about the use of antacids
Ensure that patients who have used antacids frequently or over a long
period of time have been evaluated for the underlying cause of their
problem
Avoid administering other medications within 2 hours of
administration of an antacid, unless otherwise ordered, to prevent the
antacid from interfering with drug absorption
Monitor bowel elimination. Constipation can result from the use of
aluminum hydroxide and calcium antacids; diarrhea can occur when
magnesium hydroxide combinations are used
Advise patients who are on sodium-restricted diets to avoid using
sodium bicarbonate as an antacid
Be alert to interactions
 Excessive
use leads to antibiotic-resistant bacteria
 Secondary infections may result from antibiotic use
 Side effects of antibiotic use
 Nursing guidelines for older adults taking
antibiotics
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Ensure that cultures are obtained when an infection is
suspected or present; different antibiotics are effective
for different infections
Administer antibiotics on a regular schedule to maintain
a constant blood level. Reinforce to patients that they
should not skip doses. Consider developing a medication
chart or calendar to assist the older patient in
remembering to administer the drugs
Observe for signs of superinfections, which can develop
with long-term use of antibiotics
Be alert to interactions
Which of the following classifications of
antibiotics requires close monitoring for
hearing loss and renal failure?
a. Aminoglycosides
b. Penicillins
c. Fluoroquinolones
d. Cephalosporins
a.
Aminoglycosides
Aminoglycosides (amikacin, gentamicin, and
tobramycin) require close monitoring due to the risk
of hearing loss and renal failure.
 Indications
for anticoagulants
 Narrow treatment range
 High risk for bleeding
 Common anticoagulants: heparin and coumadin
 Nursing guidelines for older adults taking
anticoagulants
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Ensure that patients using anticoagulants have their prothrombin time (PT)/international
normalization ratio (INR) monitored; discuss the recommended frequency with the
physician
Age-adjusted dosages may be prescribed; consult with the physician
Administer anticoagulants at the same time each day to maintain a constant blood level
Observe for signs of bleeding; teach patients to observe for these signs
Educate patients about the need to be careful about diet. A large intake of vitamin K–rich
foods (asparagus, bacon, beef liver, cabbage, fish, cauliflower, and green leafy
vegetables) can reduce the effectiveness of anticoagulants. Mango and papaya can
increase INR. High doses of vitamin E can increase bleeding risk
Advise patients to refrain from taking herbal products until they have reviewed them with
their health care provider. Many herbs interact with anticoagulants
Keep vitamin K readily available as an antidote when patients are receiving
anticoagulants
Advise patients to avoid using aspirin as it can interfere with platelet aggregation and
cause bleeding. Three grams or more of salicylatesa level that could be reached by
persons who use aspirin for arthritic painare sufficient to cause hemorrhage in older
adults
Be alert to interactions
 Treatment
of the cause of seizures may eliminate
the need for anticonvulsants
 Monitor blood levels
 Cautious use in older adults related to potential
toxicities
 Other medical uses for anticonvulsants
 Nursing guidelines for older adults taking
anticonvulsants
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Observe for and inquire about possible side effects from these drugs, including
change in bowel habits, abnormal bruising, bleedings, pallor, weakness, jaundice,
muscle and joint pain, nausea, vomiting, anorexia, dizziness (increasing the risk of
falls), blurred vision, diplopia, confusion, agitation, slurred speech, hallucinations,
arrhythmias, hypotension, sleep disturbances, tinnitus, urinary retention, and
glycosuria
As these drugs can depress psychomotor activity, ensure patients have adequate
physical activity
Ensure periodic evaluations of blood levels are done for drugs for which this is
required and/or available (e.g., carbamazepine, phenytoin, phenobarbital, primidone,
and valproic acid)
Be aware that these drugs can worsen any existing liver or kidney disease
Anticonvulsants should not be discontinued abruptly
Advise patients to avoid grapefruit and grapefruit juice when taking these drugs as
grapefruit increases the risk of toxicity
Monitor closely patients with existing glaucoma, coronary artery disease, or prostate
disease. Anticonvulsants can aggravate these conditions
Note that some anticonvulsants can cause photosensitivity
Be alert to interactions
 Diureticsmost
 Beta
commonly used
blockers
 Angiotensin-converting enzyme inhibitors
 Calcium channel blockers
 Alpha-blockers
 Nursing guidelines for older adults taking
antihypertensive drugs
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Assess blood pressure carefully. Obtain readings with the patient in
lying, sitting, and standing positions
Help patients in learning and using nonpharmacologic measures to
reduce blood pressure
Monitor patients closely when therapy is initiated. Some
antihypertensives can cause significant hypotension initially. Advise
patients to change positions slowly to prevent falls. If diuretics are
prescribed, monitor for diuretic-induced dehydration
Ensure that patients obtain lab work as ordered. Monitoring of serum
potassium is especially important when patients are receiving ACE
inhibitors with potassium or potassium-sparing diuretics
Monitor patients for side effects
Reinforce to patients the importance of adhering to treatment even
when symptoms are absent
Some antihypertensives should not be abruptly discontinued
Be alert to interactions
 Need
for careful dosage adjustment
 Insulin and sulfonylureas
 Potential for hypogylcemia
 Nursing guidelines for older adults taking
antidiabetic drugs
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Teach individuals with diabetes and their caregivers about the proper use
and storage of medications, and recognition of hypo- and hyperglycemia.
Reinforce that all insulins or oral antidiabetic drugs are not interchangeable
(i.e., different drugs have different potency, onset, and duration)
Ensure that people with diabetes wear or carry identification to alert others of
their diagnosis in the event they are found unconscious or confused
For patients using insulin, examine injection sites regularly. Local redness,
swelling, pain, and nodule development at the injection site can indicate
insulin allergy. A sunken area at the infection site can be caused by atrophy
and hypertrophy associated with insulin lipodystrophy—a harmless although
unattractive condition
Report conditions that could alter antidiabetic drug requirements, such as
fever, severe trauma, prolonged diarrhea or vomiting, altered thyroid function,
or heart, kidney, or liver disease
Advise patients to avoid drinking alcohol as this can lead to a significant drop
in blood sugar
Be alert to interactions
 Effective in relieving mild to moderate pain
 Narrow therapeutic window
 Cyclooxygenase-II inhibitors: Celebrex
 Nursing guidelines for older adults taking NSAIDs
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NSAIDs have a narrowed therapeutic window, and toxic levels accumulate
much easier and at lower doses in older adults. Closely observe for and ask
about side effects, such as GI symptoms, impaired hearing, and indications of
CNS disturbances. Be aware that older adults are at higher risk for
developing delirium as a side effect to these drugs
Ensure blood evaluations are done regularly
Administer these drugs with food or a glass of milk, unless contraindicated, to
reduce GI irritation
If patients are using aspirin for cardioprotective effects and are started on an
NSAID, review this with the physician or pharmacist as some NSAIDs (e.g.,
ibuprofen) can reduce the cardiac benefit of aspirin
Prolonged use of indomethacin, meclofenamate, piroxicam, and tolmetin can
cause CNS effects (e.g., headache, dizziness, drowsiness, and confusion).
When reviewing patients’ drugs, note if these drugs have been used for an
extended time and review this with the physician and pharmacist
Be alert to interactions
 Increased
use of cholesterol-lowering drugs
 Treatment goals
 Examples and types of cholesterol-lowering
drugs and their specific actions
 Nursing guidelines for older adults taking
cholesterol-lowering drugs
 Assist
patients in implementing dietary and
lifestyle modifications to help reduce
cholesterol levels
 Ensure that patients receive liver functions and
other necessary tests as ordered
 Monitor for interactions and follow precautions
for each category of cholesterol-lowering drugs
 Cholinesterase
inhibitors
• Aricept, Exelon, Razadyne
 NMDA receptor antagonists
• Namenda
 Nursing guidelines: evaluate, recommend,
avoid abrupt discontinuation of these drugs,
and educate
 Use
in older adults
 Use with caution in patients with impaired renal
function
 Nursing guidelines for older adults taking
digoxin
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Check and/or instruct patients and their caregivers to check pulse for
rate, rhythm, and regularity prior to administering digoxin
The usual biological half-life of these drugs can be extended in older
adults, increasing their risk of digitalis toxicity. Signs of toxicity
include bradycardia, diarrhea, anorexia, nausea, vomiting, abdominal
pain, delirium, agitation, hallucinations, headache, restlessness,
insomnia, nightmares, aphasia, ataxia, muscle weakness and pain,
cardiac arrhythmias, and high serum drug levels (although toxicity
can occur in the presence of normal serum levels). Promptly report any
signs of possible toxicity
Hypokalemia makes patients more susceptible to toxicity. Ensure that
patients consume potassium-rich foods and that serum potassium is
evaluated regularly
Older adults can present signs of toxicity with normal plasma levels of
the drug. Be certain to monitor for signs
Be alert to interactions
 Major
types and actions:
• Thiazides
• Loop diuretics
• Potassium-sparing diuretics
 Potential
for fluid and electrolyte imbalance
 Nursing guidelines for older adults taking
diuretics
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Plan an administration schedule that interferes least with the patient’s schedule.
Morning administration is usually preferable
Monitor intake and output, and assure adequate fluids are consumed
Teach patients and their caregivers to recognize and promptly report signs of
fluid and electrolyte imbalance: dry oral cavity, confusion, thirst, weakness,
lethargy, drowsiness, restlessness, muscle cramps, muscular fatigue,
hypotension, reduced urinary output, slow pulse, and GI disturbances
Observe for signs of latent diabetes, which sometimes can be manifested
during thiazide diuretic therapy
Monitor hearing in patients receiving loop diuretics as these drugs can cause
transient ototoxicity
Diuretics can worsen existing liver disease, renal disease, gout, and pancreatitis
and raise blood glucose in diabetics. Monitor patients with these conditions
carefully
Ensure serum electrolytes, glucose, and blood urea nitrogen (BUN) are
evaluated periodically
Be alert to interactions
 Nonpharmacological
measures should be utilized
before resorting to laxatives for constipation
 Types and action of laxatives:
• Bulk formers, stool softeners, hyperosmolars,
stimulants, and lubricants
 Nursing guidelines for older adults taking
laxatives
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Recognizing that it is a common geriatric risk, assist
older adults in preventing constipation
When patients complain of constipation, assess carefully
before suggesting or administering a laxative
Reinforce to older adults and their caregivers that
laxatives, although popular, are drugs and can cause side
effects and interact with other drugs
Teach patients that good fluid intake must accompany the
use of bulk-forming laxatives and stool softeners to
prevent the accumulation of stool leading to bowel
obstruction
Be alert to interactions
 Antianxiety
drugs (anxiolytics)
 Antidepressants
 Antipsychotics
 Sedatives/hypnotics
 Used
for disorders found in the Diagnostic and
Statistical Manual of Mental Disorders
 Short-acting benzodiazepines
 Long-acting benzodiazepines
 Side effects of benzodiazepine use
 Nursing guidelines for older adults taking
anxiolytics
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Ensure that approaches other than medications have been attempted prior to
having an antianxiety drug prescribed. Even if these measures were tried
and ineffective previously, they should be tried again
Advise patients to change positions slowly and to avoid operating a car or
machinery that requires mental alertness and fast responses
Instruct patients to incorporate foods in the diet that can promote bowel
elimination as these drugs can be constipating. Monitor bowel elimination
Monitor nutritional status and weight to assure food intake is not jeopardized
Advise caution in grapefruit consumption; this fruit can increase the
concentration of these drugs
Advise patients that several days of administration may be necessary before
clinical effects from the medication are noted and that the effects could
continue several days after the drug is discontinued
Avoid alcohol when these drugs are used and limit caffeine
Be alert to interactions
 Classes
of antidepressants
 SSRIs tend to be well tolerated and effective for
older adults
 Side effects of tricyclic antidepressants
 Nursing guidelines for older adults taking
antidepressants
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Assess factors contributing to depression
Explore the use of other therapies in addition to antidepressants to improve mood
Ensure that the lowest effective dosage of the drug is used
Advise patients that several weeks of therapy commonly is required before
improvement is noted
Monitor the plasma level of the drug. Be aware that dosage adjustment may be needed
Observe for, ask about, and report side effects, including diaphoresis, urinary retention,
indigestion, constipation, hypotension, blurred vision, difficulty voiding, increased
appetite, weight gain, photosensitivity, and fluctuating blood glucose levels
The dizziness, drowsiness, and confusion that can occur in older adults can increase the
risk of falls
Dryness of the mouth can be an uncomfortable side effect of these drugs. Advise
patients to use sugarless mints, ice chips, or a saliva substitute to improve this symptom
Some antidepressants need to be discontinued gradually. Advise patients not to
abruptly stop taking the drugs
Observe patients for a worsening of depression symptoms or suicidal thinking or
behavior; bring these findings to the physician’s attention immediately
Be alert to interactions
Which of the following classifications of
antidepressant medications have the most side
effects in the older adult population?
a.
b.
c.
d.
Monoamine oxidase inhibitors
Selective serotonin reuptake inhibitors
Serotonin antagonists
Tricyclic antidepressants
d.
Tricyclic antidepressants
Although popular, tricyclic antidepressants have
side effects that can pose risks to older adults, such
as anti-cholinergic effects, orthostatic hypotension,
and arrhythmias, especially in patients with
cardiovascular disease.
Used to treat delirium, agitation, and psychosis due to
Alzheimer’s disease, schizophrenia
 May improve quality of life and function
 Profound adverse effects
 Two major classifications: first generation and second
generation
 Nursing guidelines for older adults taking
antipsychotics
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Ensure that patients receive a thorough physical and mental health evaluation
before any antipsychotic drug is prescribed
Whenever possible, attempt to use other interventions to address symptoms
Antipsychotics should be used for the treatment of specific disorders and not as a
means of managing behavior
Drugs have a longer biological half-life in older adults; assure the lowest possible
dosage is initially used
Older adults are more sensitive to the anticholinergic effects of these medications:
dry mouth, constipation, urinary retention, blurred vision, insomnia, restlessness,
fever, confusion, disorientation, hallucinations, agitation, and picking behavior.
They also are at greater risk for developing extrapyramidal symptoms: tardive
dyskinesia, parkinsonism, akinesia, and dystonia. Observe and report these
symptoms promptly.
Patients taking antipsychotics are at high risk for falls due to the hypotensive and
sedative effects
Constipation is a common side effect
Men with prostatic hypertrophy may develop urinary hesitance and retention
when using antipsychotics
Gradual weaning rather than abrupt withdrawal from these drugs is
recommended
Response to these drugs can vary in older adults, necessitating close monitoring
Be alert to interactions
Is the following statement True or False?
Older adults are more sensitive to the extrapyramidal
effects of antipsychotic drugs that include tardive
dyskinesia, parkinsonism, akinesia, and dystonia.
True
Older adults who are receiving antipsychotic
medications are at a higher risk for the
anticholinergic and extrapyramidal effects of this
classification of medications.
 Used
for insomnia, nocturnal restlessness, anxiety,
confusion, and related disorders
 Tolerance after prolonged use
 Nursing guidelines for older adults taking
sedatives/hypnotics
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Before these drugs are used, evaluate factors contributing
to insomnia. Adjusting environmental lighting or
temperature, controlling noise, eliminating caffeine,
increasing physical activity, relieving pain, giving a back
rub, and controlling symptoms of diseases can improve
sleep and eliminate the need for a sedative
Carefully monitor patients who are using sedatives as they
are at higher risk for falls and fractures
Be alert to interactions