Pharmacologic aspects of aging

PHARMACOLOGIC ASPECTS OF AGING

What is Pharmacology?

• from Greek pharmakon, "drug"; and logia meaning study

• study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function

• It encompasses drug composition and properties, interactions, toxicology, therapy, and medical applications and antipathogenic capabilities

How Does it Affect the Older People

• Medications have improved the health and well-being of older people by alleviating symptoms of– discomfort– treating chronic illnesses– curing infectious processes.

• Problems commonly occur, however, because of medication interactions, multiple medication effects, multiple medication use (polypharmacy), and noncompliance

Medications Given to Elders, if not Monitored Properly can

• Depress appetite• cause nausea and vomiting • irritate the stomach• Cause constipation or diarrhea• decrease absorption of nutrients• alter electrolyte balance and

carbohydrate and fat metabolism.

Examples• antacids, which produce thiamine(Vit B1)

deficiency• cathartics, which act as laxative• antibiotics and phenytoin, which reduce

utilization of folic acid• phenothiazines, estrogens, and

corticosteroids, which increase food intake and cause weight gain

Altered Pharmacokinetics

• Pharmacokinetics is the study of the actions of medications in the body, including the processes of absorption, distribution, metabolism, and excretion.

• Changeability in those processes in older people is caused, in part, by a reduced capacity of the liver and kidneys to metabolize and excrete the medications and by lowered efficiency of the circulatory and nervous systems in coping with the effect of certain medications.

Nursing Implications

• Medications removed from the body primarily by renal excretion remain in the body for a longer time in people with decreased renal function.

• Medications with a narrow safety margin (eg, digitalis glycosides) must be administered cautiously.

• A decline in cardiac output may decrease the delivery rate to the target organ or storage tissue.

• The circulatory and central nervous systems of older people are less able to cope with the effects of certain medications, even when blood levels are normal.

• Unusual responses to medications may manifest as toxic reactions and complications.• As a result of a slowing metabolism,

medication levels may increase in the tissues and plasma, leading to prolonged medication action.

• Many elderly people have multiple medical problems that require treatment with one or more medications. • The possibility of interactions between

medications is further magnified if the older person is also taking one or more over-the-counter medications.

• A high-fiber diet and the use of psyllium (Metamucil) or other laxatives may accelerate gastrointestinal transport and reduce absorption of medications taken concurrently.

• If, for any reason, a patient is not dependable about taking medication, the nurse must be sure that the pill or capsule is actually swallowed and not retained between the cheeks and the gums or teeth.

Teaching Self Administration of Medication

• Considerations:– requires asking the patient questions– requesting return demonstrations to ensure that

learning has occurred– Sensory and memory losses, as well as decreased

manual dexterity, can affect the patient’s ability to carry out instructions properly

– Need assistance from significant other/caregiver.

Steps1. Explain the action, side effects, and dosage of

each medication.2. Write out the medication schedule.3. Suggest the use of a multiple-day, multiple-

dose medication dispenser to help patients adhere to the medication schedule

4. Destroy old, unused medications.5. Review the medication schedule periodically.6. Discourage the use of over-the-counter

medications and herbal agents without consulting a health professional.

7. Encourage the patient to take all medications, including over-the-counter medications, with him or her regularly when visiting the primary health care provider.

GERIATRIC SYNDROMES:MULTIPLE PROBLEMS WITH

MULTIPLEETIOLOGIC FACTORS

What are these Syndromes?

• Impaired Mobility• Dizziness• Falls and Falling• Urinary Incontinence• AIDS

• These syndromes happen because old people are frail.

• The term “frail” is used to describe those elders who are at highest risk for adverse health outcomes or geriatric syndromes.

• Early intervention can prevent further complications and help to maximize the quality of life for many older people

• Frail people are those who are most vulnerable to significant problems because they meet one or more of the following conditions:–Being unable to perform IADLs or ADLs

independently–Suffering from multiple chronic diseases

Impaired Mobility

• Impaired Physical Mobility– subject with a physiological defect or

deficiency regardless of its cause, nature or extent that renders the person unable to move about without assistive devices that limit the person's functional ability to ambulate, climb, descend, sit or rise or to perform any related function

• Common causes –Parkinson’s disease–Diabetic neuropathy–Cardiovascular compromise–Osteoarthritis –Osteoporosis–Sensory deficits

• Elderly patients should be encouraged to stay as active as possible to avoid the downward spiral of immobility• During illness, bed rest should be kept

at minimum as it may lead to deconditioning and other complications.

• If bed rest is unavoidable, patient should perform range of motion and strengthening exercises with the unaffected extremities.• Nurse should perform passive RoM

Exercises on the affected extremities.• Frequent position changes help offset the

hazards of immobility.

Dizziness

• Painless and lightheadedness discomfort.• Older people frequently seek help

for dizziness, which presents a particular challenge because there are so many possible internal and external causes

• It is further complicated because of an inability to differentiate between:–true dizziness (a sensation of

disorientation in relation to position) –vertigo (a spinning sensation)

Causes of Dizziness• Minor build up of ear wax can result in – loss of balance – subsequent fall and injury

• Severe Dysfunction of:–Cerebral Cortex–Cerebellum–Brain stem–Proprioceptive receptors–Vestibular system

Where are Proprioceptors Found?

• Muscle spindles (stretch receptors). These are the primary proprioceptors in the muscle that are sensitive to changes in muscle length.

• The golgi tendon organ. This proprioceptor in the tendon near the end of the muscle fiber is sensitive to changes in muscle tension.

• The pacinian corpuscle. This proprioceptor is responsible for detecting changes in pain and pressure within the body

Falls and Falling

• Major cause of trauma in the elderly, falls are not often fatal but do threaten health and the quality of life

• Falling is a common and preventable source of mortality and morbidity in older adults

Risk Factors that contribute to Falling

• Visual changes or impairment– loss of depth perception– loss of visual acuity– difficulty in light accommodation

• Neurologic changes – loss of balance– Dizziness– loss of position sense– delayed reaction time

Cont.• Cognitive changes– include confusion– loss of judgment – Impulsive behavior

• Musculoskeletal changes –altered posture stability like osteoporosis,

stroke and Parkinson’s disease–decreased muscle strength or muscle weakness

• Some studies showed that elderly people who fall experience a greater decline in their ability to perform ADLs or Activities of Daily Living.

• The most common fracture occurring from a fall is hip fracture resulting from the combined osteoporosis and the condition or situation that provoked the fall.

Forms of Restraints Used in Institutionalized Elderly People

• Physical Modalities–Geriatric Chairs– Lap Belts–Vest, Waist, Jacket Restraints

• Chemical Modalities–Medication

NOTE: May precipitate injuries than they were meant to prevent.

• Documented injuries and deaths resulting from these restraints include – Strangulation–Vascular and neurologic damage–Pressure ulcers– Skin tears– Fractures– increased confusion– Significant emotional trauma

Rehabilitative strategies to prevent

Fall• therapeutic exercise• wearing proper footwear • utilizing appropriate ambulation devices

Environmental Strategies to Prevent Falling

• Maintain an appropriate bed height. • Equip the individual's bed with a transfer

bar to support safe transfers. • Install toilet grab bars to support toilet

transfers.• Provide a bedside commode to support

safe toileting activities

Urinary Incontinence

• The unplanned loss of urine.• Affects up to 50% of community-residing older

adults and approximately 75% to 85% of nursing home residents.

• Normal urination requires intact neural control, intact anatomic structures, mobility, and awareness of need to urinate.

• Other measures that help prevent episodes of incontinence include having quick access to toilet facilities and wearing clothing that can be unfastened easily.

Types of UI

• Transient Incontinence• Urge incontinence• Stress incontinence• Overflow incontinence• Functional incontinence• Mixed incontinence

Transient

• Transient incontinence is characterized by the sudden onset of potentially reversible symptoms or medical conditions.

• The patients may be suffering from delirium, urinary tract infection, atrophic vaginitis, psychological problem (such as depression), endocrine disorder, impaired immobility and/or stool impaction. It may be due to drugs such as diuretics and sedatives.

Attributed Transient UI Causes

According to Brunner and Suddhart’s Med. And Surg. Textbook• Delirium and dehydration; • Restricted mobility and restraints; • Inflammation, infection, and

impaction; • Polyuria

Attributed Transient CausesAccording to Agency for Health Care Research

and Quality (AHRQ)– Delirium– Infection– Atrophy– Pharmaceuticals– Psychological– Endocrine or excess urine output– Restricted mobility– Stool impaction

Urge Incontinence• Associated with a strong urge to void.• Caused by overactive detrusor muscle that contracts

prematurely, referred to as detrusor instability• Involuntary bladder contraction caused by

inflammation or irritation within the bladder.• Uncontrollable contractions can also occur when the

brain centre that inhibits bladder contractions is impaired by neurologic conditions such as stroke, Parkinson’s disease or dementia

Stress Urinary Incontinence (SUI)

• Also known as effort incontinence• Essentially due to insufficient strength of the

pelvic floor muscles. It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder

Overflow Incontinence

• involuntary loss of urine resulting from an over-distended bladder.

• may be caused by an inactive or acontractile detrusor, or bladder outlet or urethral obstruction.

• In men, it is often related to enlarged prostate and impacted feces.

Functional Incontinence

• is the involuntary urine loss caused by factors outside the lower urinary tract such as impairment of physical or cognitive functioning, or both.

• It is important to note that immobile and cognitively impaired individuals may also have other types and causes of UI

Mixed Incontinence

• is a combination of both stress and urge incontinence. It is most common in older women.

Strategies for Continence Promotion and

Management of UI• Factors to be considered– Communication– odor control– skin care– regulation of fluid balance– Physical environment like poor lighting– review of the person’s medication as there are

drugs that may contribute to UI

Common Drug Causes of Incontinence

• Anticholinergics• Alpha antagonists• Diuretics (including caffeine)• Calcium channel blockers• Sedative hypnotics and any CNS

depressants, including ETOH

Behavioral Intervention

• Toileting assistance– Timed voiding/ scheduled toileting–Habit training–Prompt/Timely voiding

• Pelvic floor muscle exercise or Kegel’s exercise.

Other Measures & Support

• Intermittent urinary catheterization• Indwelling urinary catheterization• External collection system• Absorbent products• Dietary and fluid management

AIDS in Older Adults

• Acquired Immunodeficiency Syndrome or AIDS is a disease of the human immune system caused by the human immunodeficiency virus (HIV)

• This condition progressively reduces the effectiveness of the immune system and leaves individuals susceptible to opportunistic infections and tumors.

Mode of Transmission

• HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, pre-seminal fluid, and breast milk.

• This transmission can involve – anal vaginal or oral sex–blood transfusion– contaminated hypodermic needles–exchange between mother and baby during

pregnancy and childbirth, breastfeeding –other exposure to one of the above bodily

fluids.

• According to a report of the Centers for Disease Control and Prevention, between 1981 to 1989, more than 10% of all AIDS patients in US were 50 years of age or older at the time of diagnosis, and about 3% were age 60 years or older.

Common AIDS-indicator diseases in older people are

• Pneumocystis carinii pneumonia.

• Malignancies such Kaposis Sarcoma

• Wasting syndrome

• HIV encephalopathy

Pneumocystis carinii pneumonia

Wasting Syndrome

END

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