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Gerontological Nursing

A. Pharmacology and the Older AdultB. Psychological and Cognitive Function

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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

Age related changes affecting drug therapy

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Chronological age alone is a poor indicatorBetter indicators include: General state of health Number and types of medications

prescribed/taken Liver function Renal function Comorbidities Other diagnosed diseases

Predictors of the patient’s reaction to a drug

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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.

Predicting renal function in the elderly patient

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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

Adverse drug effects in the elderly

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Changes in mood (anxiety, depression) from

antihypertensives, antiparkinsonians, narcotics, NSAIDs, steroids

Central anticholinergic effects—agitation, confusion, disorientation, hallucinations, psychosis (e.g., diphenhydramine, furosemide, digoxin, anti- diarrheals)

Cognitive changes

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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

Major drug-drug interactions in LTC

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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

Adverse Drug Reactions in the Elderly

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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

Medication reconciliation

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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)

Drugs that should be used cautiously in the

elderly

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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?

Guiding Principles of Drug Administration

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“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

Beers Criteria

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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

Gradual dose reduction

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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.

OBRA requirements

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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?

Evaluating appropriate prescribing

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Know correct medication, dosage, parameters

for use Assess patient for response to medication Consult with prescribing provider Provide reasonable alternative action if

indicated

Collaborative responsibility

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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)

Criteria for use of anxiolytics

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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

Strategies to promote adherence

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Sharing medications Using imported medications Using outdated medications

Practices to discourage

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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

Psychological, cognitive problem diagnosis

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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

Normal age related cognitive changes

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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

Stable cognitive function

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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

Coping with changes in cognition

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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

Adjusting to changes

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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

Rigidity and excess cautiousness

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Sleep problems Chronic high anxiety Substance use/abuse Irritability New onset HTN Depression Chronic fatigue Chronic pain, discomfort

Maladaptation to stress in the elderly

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Memory and intellectual difficulties Changes in sleep patterns Changes in sexual interest, capacity Fear of death Delusions Hallucinations Disordered thinking Changes in emotional expression

Changes requiring evaluation

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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

Principles for psychological assessment of the elderly

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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

Personality disorders and psychoses

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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

Adjustment to loss or life events

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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)

Depression in the elderly

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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

Geriatric depression scale

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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

Suicide

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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

Consider major depression with 4 or morepersisting for at least 2 weeks….

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Selective serotonin reuptake inhibitors (SSRIs)

Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Sertaline (Zoloft) Paroxetine (Paxil)

Tricyclic antidepressants (TCAs) Desipramine (Norpramin) Nortriptyline (Pamelor)

Antidepressants commonly used in the care of the elderly depressed

patient

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Previous suicide attempt Alcohol or substance abuse Psychiatric illness Auditory hallucinations Living alone Guns at home Exposure to suicide

Risk factors for suicide

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Memory problems Frequent falls Changes in sleep patterns Irritability, sadness, depression Trouble concentrating Chronic pain Smell of alcohol Isolation

Consider alcohol problems if:

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1. When talking to others, do you ever underestimate how much you

drink?2. After a few drinks, have you sometimes not eaten because you

don’t feel hungry?3. Does having a few drinks help decrease your shakiness or tremors?4. Does alcohol sometimes make it hard for you to remember parts of

the day or night?5. Do you usually take a drink to relax or calm your nerves?6. Do you drink to take your mind off your problems?7. Have you ever increased your drinking after experiencing a loss in

your life?8. Has a doctor or nurse ever said they were worried or concerned

about your drinking?9. Have you ever made rules to manage your drinking?10. When you feel lonely, does having a drink help?

Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)

(2+ Yes responses indicative of an alcohol problem)

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Ineffective coping Risk for suicide Disturbed thought processes Acute/chronic confusion

(also, “Risk for”) Decisional conflict

Potential Nursing Diagnoses

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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!

To begin the process….