A. Pharmacology and the Older Adult B. Psychological and Cognitive Function 1 Age related changes affecting drug therapy Decreased GI motility and absorption surface Dry mouth Decreased liver perfusion, liver mass Increased body fat, Decreased body water Decreased renal perfusion, renal mass Visual, hearing changes Brain and brain function changes 2 Predictors of the patient’s reaction to a drug Chronological age alone is a poor indicator Better indicators include: General state of health Number and types of medications prescribed/taken Liver function Renal function Comorbidities Other diagnosed diseases 3 Predicting renal function in the elderly patient Do not rely on BUN Calculate creatinine clearance: Creatinine clearance = (140 – age) x lean weight (kg) 72 x serum creatinine x .85 for women Normal values: Male: 97 to 137 ml/min. Female: 88 to 128 ml/min. 4 Adverse drug effects in the elderly People >65 yrs 2x likely to have ADE than <65 Most are preventable Client frequently stops the suspected medication Suspect ADE if patient experiences unexplained: Cognitive changes Falls Anorexia Nausea Weight loss 5 Cognitive changes Changes in mood (anxiety, depression) from antihypertensives, antiparkinsonians, narcotics, NSAIDs, steroids Central anticholinergic effects—agitation, confusion, disorientation, hallucinations, psychosis (e.g., diphenhydramine, furosemide, digoxin, antidiarrheals) 6 Major drug-drug interactions in LTC Warfarin with NSAIDs, sulfa drugs, macrolides, quinolones, phenytoin => increased bleeding ACE inhibitors with potassium supplements or spirolactone => elevated serum potassium Digoxin and amiodarone => digoxin toxicity Theophylline and quinolones => theophylline toxicity 7 Adverse Drug Reactions in the Elderly Signs and symptoms of ADR may vary in the elderly Evidence of ADR may take longer in the elderly ADR may be apparent even after the drug has been discontinued ADR can develop suddenly even if medication has been used over a longer period of time 8 Medication reconciliation Identify an accurate list of all medications patient is taking Verify the medications are appropriate to the patient Determine if patient is taking them correctly Compare list with physician’s admission, transfer, or discharge orders 9 Drugs that should be used cautiously in the elderly New drugs on the market CNS drugs Drugs that are highly protein bound (e.g., thyroxine, warfarin, diazepam, heparin, imipramine and phenytoin) Drugs eliminated by the kidneys (e.g., digoxin, glucose, some antibiotics) Drugs with a high 1st pass effect, i.e., low bioavailability (e.g., propanolol, orphine, nitroglycerin) Drugs with a low therapeutic-to-toxicity ratio (e.g., oral chemotherapy) 10 Guiding Principles of Drug Administration Why is the drug ordered? Is this the smallest possible dose? Does the patient have any allergy to the drug? Are there potential drug-drug interactions? Are there any special administration requirements? Is this the most effective route of administration? 11 Beers Criteria “Potentially Inappropriate Medications for the Elderly” Lists medications that require provider justification if prescribed to this population Intended to limit adverse drug events Monitored in long term care and acute settings 12 Gradual dose reduction Required by Medicare in LTC facilities Stepwise tapering of the dose Determine if condition can be managed by lower dose Determine if medication can be discontinued 13 OBRA requirements Chemical restraints may be used only to ensure the safety of an older patient in an emergency situation Must correlate to an appropriate diagnosis if given long term May not be given for wandering, restlessness, insomnia, failure to cooperate, etc. 14 Evaluating appropriate prescribing Is the problem significant? What nonpharmacological interventions are available? Is the justification for the medication documented? Has informed consent been obtained? Is achieving therapeutic goals likely and reasonable? When will tapering begin? Are there any duplications is drug purposes? 15 Collaborative responsibility Know correct medication, dosage, parameters for use Assess patient for response to medication Consult with prescribing provider Provide reasonable alternative action if indicated 16 Criteria for use of anxiolytics Generalized anxiety disorder (diagnosed) Panic disorder (diagnosed) Symptomatic anxiety in patients with another diagnosed psychiatric disorder Sleep disorder (diagnosed) Acute ETOH or benzodiazepine withdrawal Significant situational anxiety (documented) Behaviors associated with persistent delirium, dementia, cognitive impairment (documented) 17 Strategies to promote adherence Smallest number of drugs, smallest number of pills per day Establish a routine Schedule at time of other normal activity Develop method to remember drug was taken Total assessment of all drugs at each visit Telephone, email reminders 18 Practices to discourage Sharing medications Using imported medications Using outdated medications 19 Psychological, cognitive problem diagnosis Problems may be overlooked due to: Missed diagnosis Denial of problem by patient Finances Poor coordination of health care team Limited geriatric mental health expertise Fear of stigma 20 Normal age related cognitive changes Decreased information processing speed Decreased ability to divide or sustain attention Long term memory requires greater cuing Word finding, naming ability decline Abstraction ability shows some decline Decreased ability to filter out irrelevant information Mental flexibility declines 21 Stable cognitive function Short-term, primary memory remains stable Language skills remain intact Vocabulary skills improve Accumulation of practical experience continues Influenced by: Education Pulmonary health General health Activity level 22 Coping with changes in cognition Make lists Memory training and techniques Playing computer games with hand/eye coordination Challenge mind Use assistive devices, habit Find support from others Keep sense of humor 23 Adjusting to changes Most adults adjust successfully A life of continuous adjustment makes it easier in the future Inability to adjust can be frustrating and/or depressing Assess for signs of depression with every life challenge 24 Rigidity and excess cautiousness Not a normal age related change Experiences, values, and expectations no longer congruent with current ideas Out of their “comfort zone” Method of adjustment influenced by underlying personality 25 Maladaptation to stress in the elderly Sleep problems Chronic high anxiety Substance use/abuse Irritability New onset HTN Depression Chronic fatigue Chronic pain, discomfort 26 Changes requiring evaluation Memory and intellectual difficulties Changes in sleep patterns Changes in sexual interest, capacity Fear of death Delusions Hallucinations Disordered thinking Changes in emotional expression 27 Principles for psychological assessment of the elderly Minimize the patient’s preoccupations: pain, comfort, elimination, adequate hearing and seeing Explain what you’re doing… and why Minimize distractions: quiet room, adequate lighting Speak slowly and clearly Takes breaks if necessary 28 Personality disorders and psychoses Incidence of most personality disorders decline with age Schizophrenia rarely occurs initially in old age Most common form of psychosis in the elderly is paranoia Hearing loss Social isolation Cognitive impairment Delirium Underlying personality disorder 29 Adjustment to loss or life events Grief lasting up to 2 years is “normal” Duration of grief affected by Meaning associated with the person who has died Health of the survivor Survivor’s belief system Existence of substance abuse Cause, suddenness of death 30 Depression in the elderly Symptoms may be emotional and/or physical Multiple somatic complaints Chronic pain Older women 2x as susceptible Older men less likely to admit to depression Can be associated with medications (Box 7-2) 31 Geriatric depression scale Long version—30 items Short version—15 items Can be used on healthy, ill, or those with cognitive impairment Patients who score >10 should be referred 32 Suicide 65 years+ have highest suicide rate of all ages Major risk is depression Older Caucasian males have highest death rates from suicide 70% of successful suicide attempts in older adults had seen primary physician within the previous month 33 Consider major depression with 4 or more persisting for at least 2 weeks…. Significant weight loss or gain, change in appetite Sleep disturbances Agitation, slowness Fatigue Feelings of worthlessness, guilt Inability to concentrate, make decisions Recurrent thoughts of suicide, death 34 Antidepressants commonly used in the care of the elderly depressed patient Selective serotonin reuptake inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Sertaline (Zoloft) Paroxetine (Paxil) Tricyclic antidepressants (TCAs) Desipramine (Norpramin) Nortriptyline (Pamelor) 35 Risk factors for suicide Previous suicide attempt Alcohol or substance abuse Psychiatric illness Auditory hallucinations Living alone Guns at home Exposure to suicide 36 Consider alcohol problems if: Memory problems Frequent falls Changes in sleep patterns Irritability, sadness, depression Trouble concentrating Chronic pain Smell of alcohol Isolation 37 Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) (2+ Yes responses indicative of an alcohol problem) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. When talking to others, do you ever underestimate how much you drink? After a few drinks, have you sometimes not eaten because you don’t feel hungry? Does having a few drinks help decrease your shakiness or tremors? Does alcohol sometimes make it hard for you to remember parts of the day or night? Do you usually take a drink to relax or calm your nerves? Do you drink to take your mind off your problems? Have you ever increased your drinking after experiencing a loss in your life? Has a doctor or nurse ever said they were worried or concerned about your drinking? Have you ever made rules to manage your drinking? 38 When you feel lonely, does having a drink help? Potential Nursing Diagnoses Ineffective coping Risk for suicide Disturbed thought processes Acute/chronic confusion (also, “Risk for”) Decisional conflict 39 To begin the process…. Chose your nursing case study for use throughout the semester Selected case studies are on the website Identify 2 different diagnoses within the case: 1 diagnosis must concern the patient’s physiological status 1 diagnosis must addressing an identified learning need Identify pertinent subjective and objective triggers Determine appropriate functional health pattern Use the standard nursing care plan format you have been provided…first installment due per syllabus! 40