1. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. CHAPTER Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacology and Older Adults 6 Lecture Note PowerPoint Presentation

2. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 1 Explain the interaction between normal aging and responses to drug therapy in older people.

3. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Age-Related Changes that Increase Risk for Adverse Drug Events Chronic disease Polypharmacy Physiological and adaptive responses

4. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Determinants of Physiological Response to Medications Race Ethnic Genetic background

5. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Acute and Chronic Conditions May Alter Pharmacokinetics (what the body does to the drug) Pharmacodynamics (what the drug does to the body)

6. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Age-Related Changes Decrease in body water (as much as 15%) and increase in body fat –Increased concentration of water-soluble drugs –More prolonged effects of fat-soluble drugs

7. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Age-Related Changes Hepatic blood flow may be decreased by as much as 50% in individuals over 65 years –Increased toxicity with normal doses of “first- pass effect” drugs  Less drug would be detoxified immediately by the liver

8. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Age-Related Changes Decreases in serum albumin –Leads to altered binding capacity –May cause increased serum levels of the “free” or unbound proportion of protein-bound drugs –May result in toxic levels of highly protein- bound drugs because more unbound drug is available to produce its effects

9. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Kidneys Excrete Most Drugs Considerable individual variation in the degree of decline of renal function

10. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Causes of Changes in Pharmacodynamics in the Older Person Decreased number of receptors Decreased receptor binding Altered cellular response to the drug- receptor interaction

11. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 2 Identify principles of safe medication management with older persons in a variety of patient care settings.

12. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pivotal Role of Nurse Ensure drug therapy is effective for the person’s condition Prevent, detect, or intervene as early as possible if the person develops adverse drug effects

13. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Common Inappropriate Drugs Administered to Older Adults Psychotropic agents Anti-inflammatory drugs Amitriptyline Iron supplements

14. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Inappropriate Conditions for Use of Antipsychotic Drugs Wandering ( To move about without a definite destination or purpose ) Poor self-care Restlessness Impaired memory Anxiety Depression (without psychotic features) Insomnia

15. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Inappropriate Conditions for Use of Antipsychotic Drugs Unsociability Indifference to surroundings Fidgeting ( the act of moving about restlessly ) Nervousness Uncooperativeness Agitated behaviors that do not represent danger to the resident or others

16. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Residents Administered Antipsychotic, Anxiolytic, and Sedative-Hypnotic Drugs Should receive gradual dose reductions at scheduled intervals

17. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Regimen Review (MRR) Required by Medicare Involves a thorough evaluation of the medication regimen by a pharmacist, in collaboration with other members of the interdisciplinary team Includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, and other irregularities

18. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nurse’s Role in Promoting Safe and Effective Medication Management Assure the correct storage, preparation, and administration (including the five rights) in the institutional setting Educate the patient and family concerning storage, preparation, and administration

19. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nurse’s Role in Promoting Safe and Effective Medication Management In the institutional setting, be aware of the legal aspects of medication delegation for the state in which he or she practices as well as the policies of the employing agency

20. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 3 Discuss measures to prevent and reduce polypharmacy in older patients.

21. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Older persons More Likely to Have Adverse Drug Reactions (ADRs) Related to Inappropriate drug or dosing Drug-drug interactions Polypharmacy Nonadherence

22. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nursing Interventions Can prevent the need for some medications Can reduce the dose or length of drug therapy

23. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Polypharmacy Definition: The prescription, administration, or use of more medications than are clinically indicated in a given patient Examples Medication that has no apparent indication Continuing use of a medication after a condition has been resolved

24. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Polypharmacy Use of a medication to treat the side effects of another medication Use of an inappropriate dose Use of duplicate medications because the same drug has been prescribed by more than one prescriber Self-medicating with OTC medications or herbal remedies to treat the same condition

25. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Include in a Complete Drug History Vitamins OTC medications Dietary supplements Herbal remedies

26. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Indications for Reduced Dosages Weight is less than average Decreased liver or renal function Experiencing exaggerated responses to drugs that may reflect toxic levels

27. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Indications for Drug Therapy A specific diagnosis Clearly documented symptom or condition to be treated Avoid use of a drug to treat the side effects of another drug

28. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Unnecessary Drug Administration Excessive dose (including duplicate therapy) Excessive duration Inadequate monitoring Inadequate indications Presence of adverse consequences that indicate the dose should be reduced or discontinued

29. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 4 Describe assessments to monitor older patients for adverse drug effects and polypharmacy.

30. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Assessment Parameters Physiological and psychosocial status Need for the drug Risk of an adverse drug reaction

31. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski ADR Clues Cognitive impairment (e.g., delirium, dementia, depression) Loss of appetite, nausea Weight loss Falls

32. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Drugs that Can Cause Changes in Mood Antihypertensives (e.g., beta-blockers) Antiparkinsonian agents Steroids NSAID Narcotic agents Antineoplastic agents Central nervous system (CNS) depressants Psychotropics

33. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Causes of Falls in the Older Adult Alterations in vision Balance Decreases in reaction time Orthostatic hypotension Decreased muscle strength

34. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Herbal Interactions with Medications Elicit from patients any herbs, home remedies or dietary supplements that they take

35. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Reconciliation Indicated whenever an individual moves from one care setting to another Verification (collection of the medication history) Clarification (ensuring that the medications and doses are appropriate) Reconciliation (documentation of changes in the orders)

36. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Review Each Drug for Interactions with other drugs Interactions with herbal medicines Interactions with vitamins or foods Patient allergies Duplicate therapy –From more than one prescriber or from use of OTC medications containing the same or similar ingredients as prescribed medications

37. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Observe for Known adverse effects of medication General symptoms that might be drug related Monitor laboratory results as appropriate

38. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 5 Use teaching and nursing interventions to promote compliance and adherence to the medication regimen.

39. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Noncompliance Results in Considerable Costs to Patients Employer Health insurers Healthcare system

40. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Enhance Medication Compliance by Reducing the impact of side effects through –Adequate intake of fiber and fluid intake can help to offset drug-induced constipation –Scheduling diuretic so that it does not interrupt sleep or activities important to the patient –Frequent intake of liquids or the use of lozenges to help with dry mouth caused by medications

41. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Drug Regimen Unassisted Grading Scale (DRUGS) Used to assess an elderly person’s ability to take medications correctly Employs four medication management tasks –Identification or showing the appropriate medications –Access, or opening the appropriate containers –Dosage, or taking out the correct number per dose –Timing, or demonstrating the timing of the doses

42. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Measures to Manage Medications Correctly Simplifying the regimen if possible Establishing a routine for taking medications Scheduling medications at mealtime or in conjunction with other specific daily activities Developing a method with the patient for remembering if he or she actually took the medication

43. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Measures to Manage Medications Correctly Conducting a total assessment of all medication, including OTC and herbal preparations Telephone reminders, computer-based reminders, or pill boxes

44. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Measures to Manage Medications Correctly Obtain all of medications (prescription and OTC) from the same pharmacy; request no childproof packaging or caps Determine any financial restraints; identify low-cost alternatives

45. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 6 Identify nonpharmacological therapies that may be useful as alternatives to medications.

46. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Alternatives Constipation –Increase bulk in diet –Avoid cheese –Encourage exercise –Ensure adequate fluid intake Insomnia –Suggest warm milk –Adapt the environment to promote sleep –Avoid caffeinated drinks in the afternoon

47. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Alternatives “Heartburn” –Eat small, frequent meals –Stay in upright position for at least 30 minutes after taking medications Pain –Use of distraction –Guided imagery –Positioning –Ice or heat

48. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 7 Discuss issues related to ensuring the safe use of drug therapy by the older person.

49. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Drug Therapy Issues Healthcare fraud ( is a crime. It's committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits payable. ) Medication costs Internet pharmacies’ legitimacy Sharing others’ medications Use of imported medications Use of outdated medications