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Best Nursing Practices in Care for Older Adults
ELDER Project
Fairfield University School of Nursing
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Session 5Topic:
Polypharmacy and the Older Adult
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Polypharmacy: What is it?
Use of more than one chemical agent to effect a therapeutic endpoint
Some references say, the use of 5 or more drugs for an individual patient
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Over the Counter Medications
Older adults use the greatest number of nonprescription over the counter medications
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How Many Meds Do Older Adults Use? Over 30% of all prescriptions dispensed
Community Dwelling: use 2-4 prescriptions regularly
Long-Term Care: use 2 – 10 prescriptions regularly
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Misuse of Drugs
…is the 5th leading cause of death in older adults
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Pharmacokinetics
Means: What the body does to the drug
Has 4 Components Absorption Distribution Metabolism Excretion
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Normal Physiologic Changes…
Can affect Pharmacokinetics
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Absorption of Drugs
Meaning: how the drug gets into the blood stream
Not significantly altered with age, but absorption may be slightly delayed
Can postpone onset of action, and peak effect of medication
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Changes in Absorption Due to Aging: Slowed Gastric
Emptying
Decreased Gastric Acidity
Decreased Blood Flow to intestines
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Drug Distribution
Meaning: where the medication goes in the body
Can change with aging due to:Higher percentage of fat compared to lean body
massDecrease in total body waterDecrease in serum albumin
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How does Aging Change Drug Distribution? The older adult is exposed to fat soluble
drugs for a longer time There is more blood concentration of
water soluble drugs Albumin is main site for protein binding
drugs to bind for transport prior to being distributed to body tissue
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Changes in Distribution
CAN ACCENTUATE DRUG EFFECTS AND TOXICITY!!
Example: long acting fat soluble benzodiazepine drugs such as diazepam (Valium) should be avoided
Use short acting benzodiazepines in small doses instead
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More Examples
Water Soluble Drugs should be started at lower doses and then monitored Example: Digoxin and
Lithium
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Drug Metabolism or Clearance
Meaning: how the medication is broken down
Can change with aging due to: Decreased liver massDecreased liver blood flowAltered liver metabolism
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How Does Aging Change Drug Metabolism? The metabolism will
be delayed for some drugs, so they will have greater serum concentrations
Need to monitor liver functions
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Examples of Metabolism Changes
Delayed metabolism of: Labetalol, Propanolol Verapamil Diazepam Amitriptyline
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Excretion of Drugs
Meaning: how the medication is cleared from the body
Can Change with Aging Due to: Decreased Glomerular Filtration RateDecreased Ability to Concentrate Urine and
Conserve SodiumDecrease Renal Blood FlowDecrease Renal Mass
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How Does Aging Effect Excretion?
Increases drug half lives for those drugs excreted by the kidney
This means the time it takes for 50% of the drug to be eliminated from the body
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Examples of Drugs with Increased Half-Lives for Older Adults
Examples: gentamicin lisinopril Atenolol Digoxin HCTZ Cimetidine Furosemide
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Pharmacodynamics
Means: What the drug does to the body
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Adverse Reactions for Older Adults
Many medications taken by older adults have potentially dangerous side effects
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Falls
Related to orthostatic hypotension
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Confusion and Disorientation
Can be related to inappropriate dosages
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Hepatic Toxicity
May be direct result of one medication, or due to a drug-drug interaction
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Renal Toxicity
May be direct result of one medication, or due to a drug-drug interaction
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Common Problems Associated with Medications
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Drugs with Anticholinergic Side Effects Can Cause
ConfusionOrthostatic HypotensionDry mouthBlurred visionUrinary retention
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Tricyclic Antidepressants
Use cautiously with patients who are being treated for glaucoma and cardiac conduction disturbances
Rarely used for older adults
Ex: Elavil, Doxepin, Nortriptyline
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Tricyclic Antidepressant Drugs Can cause
Sedation and Fatigue Anxiety, Insomnia and
Confusion Unstable gait Hypotension Tachycardia and
Arrhythmias Seizures
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Antiemetics
Can cause Confusion Orthostatic Hypotension Blurred vision Falls Dry Mouth Urinary Retention
Ex: Chlorpromozine (Thorazine), Prochlorperazine (Compazine)
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Anti-Arrhythmic
Example: Lanoxin (Digoxin)Can cause toxicity even with normal serum
concentrations
Therefore controversial for older adults
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Histamine-2 Receptor Blockers
Can cause Confusion
Therefore need dose reductions
Examples: Zantac, Pepcid
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Benzodiazepines
Can causeCentral nervous system toxicity
May have half-lives prolonged as much as 4 days
Ex: Valium, Xanax, Ativan, Halcion
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Narcotics Can cause: Confusion and Constipation
Older adults are more sensitive to narcotics than younger adults
“Start low, go slow” with dose
Ex: codeine, morphine, demerol,
USE WITH CAUTION!!
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Medication Compliance/Adherence
Older adults taking multiple medications, with complex regimens may require social and nursing support
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Risk Factors for Non-Adherence:
Cognitive Changes Living alone with
social supports Insufficient Funds Depression Declining Function
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Ways to Promote Adherence:
Patient Education Written Instructions Assessment of environment: funds,
transportation Discouraging pill sharing
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Support Systems
Medication Event Monitoring Systems (MEMS)
Pill boxes Pre-poured Medications Friendly Calls Pill Counts
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Cost Issues Related to Medications
Older adults may have difficulty paying for medications out of pocket
Ability to purchase medications needs to be assessed individually
Some will cut pills in half to prolong use
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Reference
The content covered in this presentation is provided by the
John A. Hartford Foundation Institute for Geriatric Nursing
(2001)
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Reference:
Some of the material in this presentation obtained from graciously shared by:
Mather’s LifeWays, 2003
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Power Point Presentation Created by:
Diana R. Mager, CRN, MSN
Fairfield University School of Nursing
ELDER Project Director