Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858

Best Nursing Practices in Care for Older Adults

ELDER Project

Fairfield University School of Nursing


2

Session 5Topic:

Polypharmacy and the Older Adult


3

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


4

Over the Counter Medications

Older adults use the greatest number of nonprescription over the counter medications


5

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


6

Misuse of Drugs

…is the 5th leading cause of death in older adults


7

Pharmacokinetics

Means: What the body does to the drug

Has 4 Components Absorption Distribution Metabolism Excretion


8

Normal Physiologic Changes…

Can affect Pharmacokinetics


9

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


10

Changes in Absorption Due to Aging: Slowed Gastric

Emptying

Decreased Gastric Acidity

Decreased Blood Flow to intestines


11

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


12

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


13

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


14

More Examples

Water Soluble Drugs should be started at lower doses and then monitored Example: Digoxin and

Lithium


15

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


16

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


17

Examples of Metabolism Changes

Delayed metabolism of: Labetalol, Propanolol Verapamil Diazepam Amitriptyline


18

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


19

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


20

Examples of Drugs with Increased Half-Lives for Older Adults

Examples: gentamicin lisinopril Atenolol Digoxin HCTZ Cimetidine Furosemide


21

Pharmacodynamics

Means: What the drug does to the body


22

Adverse Reactions for Older Adults

Many medications taken by older adults have potentially dangerous side effects


23

Falls

Related to orthostatic hypotension


24

Confusion and Disorientation

Can be related to inappropriate dosages


25

Hepatic Toxicity

May be direct result of one medication, or due to a drug-drug interaction


26

Renal Toxicity

May be direct result of one medication, or due to a drug-drug interaction


27

Common Problems Associated with Medications


28

Drugs with Anticholinergic Side Effects Can Cause

ConfusionOrthostatic HypotensionDry mouthBlurred visionUrinary retention


29

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


30

Tricyclic Antidepressant Drugs Can cause

Sedation and Fatigue Anxiety, Insomnia and

Confusion Unstable gait Hypotension Tachycardia and

Arrhythmias Seizures


31

Antiemetics

Can cause Confusion Orthostatic Hypotension Blurred vision Falls Dry Mouth Urinary Retention

Ex: Chlorpromozine (Thorazine), Prochlorperazine (Compazine)


32

Anti-Arrhythmic

Example: Lanoxin (Digoxin)Can cause toxicity even with normal serum

concentrations

Therefore controversial for older adults


33

Histamine-2 Receptor Blockers

Can cause Confusion

Therefore need dose reductions

Examples: Zantac, Pepcid


34

Benzodiazepines

Can causeCentral nervous system toxicity

May have half-lives prolonged as much as 4 days

Ex: Valium, Xanax, Ativan, Halcion


35

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!!


36

Medication Compliance/Adherence

Older adults taking multiple medications, with complex regimens may require social and nursing support


37

Risk Factors for Non-Adherence:

Cognitive Changes Living alone with

social supports Insufficient Funds Depression Declining Function


38

Ways to Promote Adherence:

Patient Education Written Instructions Assessment of environment: funds,

transportation Discouraging pill sharing


39

Support Systems

Medication Event Monitoring Systems (MEMS)

Pill boxes Pre-poured Medications Friendly Calls Pill Counts


40

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


41

Reference

The content covered in this presentation is provided by the

John A. Hartford Foundation Institute for Geriatric Nursing

(2001)


42

Reference:

Some of the material in this presentation obtained from graciously shared by:

Mather’s LifeWays, 2003


43

Power Point Presentation Created by:

Diana R. Mager, CRN, MSN

Fairfield University School of Nursing

ELDER Project Director

Documents

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School