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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Session 5 Topic: Polypharmacy and the Older Adult

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Over the Counter Medications Older adults use the greatest number of nonprescription over the counter medications

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Misuse of Drugs …is the 5 th leading cause of death in older adults

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Pharmacokinetics Means: What the body does to the drug Has 4 Components  Absorption  Distribution  Metabolism  Excretion

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Normal Physiologic Changes… Can affect Pharmacokinetics

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Changes in Absorption Due to Aging: Slowed Gastric Emptying Decreased Gastric Acidity Decreased Blood Flow to intestines

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Drug Distribution Meaning: where the medication goes in the body Can change with aging due to:  Higher percentage of fat compared to lean body mass  Decrease in total body water  Decrease in serum albumin

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP More Examples Water Soluble Drugs should be started at lower doses and then monitored  Example: Digoxin and Lithium

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Drug Metabolism or Clearance Meaning: how the medication is broken down Can change with aging due to:  Decreased liver mass  Decreased liver blood flow  Altered liver metabolism

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Examples of Metabolism Changes Delayed metabolism of:  Labetalol, Propanolol  Verapamil  Diazepam  Amitriptyline

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Excretion of Drugs Meaning: how the medication is cleared from the body Can Change with Aging Due to:  Decreased Glomerular Filtration Rate  Decreased Ability to Concentrate Urine and Conserve Sodium  Decrease Renal Blood Flow  Decrease Renal Mass

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Examples of Drugs with Increased Half-Lives for Older Adults Examples:  gentamicin  lisinopril  Atenolol  Digoxin  HCTZ  Cimetidine  Furosemide

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Pharmacodynamics Means: What the drug does to the body

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Adverse Reactions for Older Adults Many medications taken by older adults have potentially dangerous side effects

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Falls Related to orthostatic hypotension

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Confusion and Disorientation Can be related to inappropriate dosages

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Hepatic Toxicity May be direct result of one medication, or due to a drug-drug interaction

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Renal Toxicity May be direct result of one medication, or due to a drug-drug interaction

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Common Problems Associated with Medications

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Drugs with Anticholinergic Side Effects Can Cause  Confusion  Orthostatic Hypotension  Dry mouth  Blurred vision  Urinary retention

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Tricyclic Antidepressant Drugs Can cause  Sedation and Fatigue  Anxiety, Insomnia and Confusion  Unstable gait  Hypotension  Tachycardia and Arrhythmias  Seizures

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Antiemetics Can cause  Confusion  Orthostatic Hypotension  Blurred vision  Falls  Dry Mouth  Urinary Retention Ex: Chlorpromozine (Thorazine), Prochlorperazine (Compazine)

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Anti-Arrhythmic Example: Lanoxin (Digoxin)  Can cause toxicity even with normal serum concentrations Therefore controversial for older adults

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Histamine-2 Receptor Blockers Can cause  Confusion Therefore need dose reductions Examples: Zantac, Pepcid

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Benzodiazepines Can cause  Central nervous system toxicity May have half-lives prolonged as much as 4 days Ex: Valium, Xanax, Ativan, Halcion

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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!!

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Medication Compliance/Adherence Older adults taking multiple medications, with complex regimens may require social and nursing support

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Risk Factors for Non-Adherence: Cognitive Changes Living alone with social supports Insufficient Funds Depression Declining Function

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Ways to Promote Adherence: Patient Education Written Instructions Assessment of environment: funds, transportation Discouraging pill sharing

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Support Systems Medication Event Monitoring Systems (MEMS) Pill boxes Pre-poured Medications Friendly Calls Pill Counts

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP 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

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Reference The content covered in this presentation is provided by the John A. Hartford Foundation Institute for Geriatric Nursing (2001)

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Reference: Some of the material in this presentation obtained from graciously shared by: Mather’s LifeWays, 2003

Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP Power Point Presentation Created by: Diana R. Mager, CRN, MSN Fairfield University School of Nursing ELDER Project Director