MEDICATION AND LABORATORY MONITORING

GEM Conference 2013September 17th, 2013

Clara Tsang RN (EC)

Agenda• Background• Pharmacology Issues Among the Elderly• Clinical Management & Medication Issues• Diagnostic Testing• Case Study/Quiz• Our Role as GEM Nurses• High Risk Drugs to Avoid• Take Home Message

Background4 out of 5 seniors (age 75+) take at least ONE type of medicine

Takes 1+ meds

10% adverse drug-related events lead to ED visits for patients > 65

On average, seniors take 4.5 prescription, and 3.5 over the counter drugs at any point in time

31% of elderly patients in the emergency room have at least 1 potential adverse drug interaction (PADI)

~1/3 have PADI in ED

Pharmacology Issues Among the Elderly

• Administration• Absorption• Distribution• Hepatic metabolism• Excretion• Pharmacokinetic/pharmacodynamic

Clinical Management & Medication Issues

• Many types… for today’s discussion:– Cardiovascular– Respiratory– Gastrointestinal– Hematological– Musculoskeletal– Endocrine– Neurologic– Skin– Renal/Urological

• Cardiovascular: B/P, Cr, e’– ACEI/ARB (K, Scr, coughing)– Antiarrhythmics (QTs, GI, TSH, Scr)– Anticoagulant/Antiplatelet (bleeding, plt, hb)– Beta Blocker(bradycardia, brochospasm, cold extremities/pain,

hypoglycemia), – CCB (constipation, peripheral edema)– Diuretic (e’, Scr, orthostatic, gout, hyperglycemia)– Vasodilator (headache, orthostatic)– Lipid lowering (muscle discomfort, CK, LFT)

Clinical Management & Medication Issues

• Respiratory: – OTC cough med (B/P)– Hydrocodone (CNS side effects)– Theophylline (arrhythmia, narrow therapeutic range)– Antibiotic (GI, QTs, C-Diff, ulcerative stomatitis)

• Gastrointestinal: – PPI (pneumonia, C-Diff, mal-absorption)– Antacids (Mg, Ph, absorption)– H2 blocker (arrhythmia, AV block)– Laxative (e’)

Clinical Management & Medication Issues

• Hematological: – Anti-coagulants/platelets, Iron, B12 (INR, plt, Hb, ferritin, TIBC, Scr

(for pradaxa, xarelto, LMWH)• Musculoskeletal:

– Analgesic (Tylenol/narcotics) (CNS, constipation, N/V)– Anti-inflammatory (edema, B/P, bleeding, Scr)

• Endocrine:– Antidiabetic (hypo, BUN/Scr)– Thyroid (Ca)– Corticosteroids (edema, B/P, GI bleeding, CNS, Blood sugar,

osteoporosis, glaucoma)

Clinical Management & Medication Issues

Clinical Management & Medication Issues

• Neurologic– Cholinesterase Inhibitor (GI, bladder/bowel incontinence)– Parkinson med (B/P, hallucination, sedation)– Anti-psychotic (QTs, EPS, sedation, diabetes, dyslipidemia)– Anti-depressant (CNS, hypoNa, anticholinergic side effects,

bleeding)– Anti-convulsants (toxicity, CNS, LFT, Scr)– Benzodiazepines (CNS, ataxia)

• Skin: Anti-pruritius (CNS, anticholinergic effect)• Renal/Urological:

– Anti-spasmodic & Adrenergic antagonist (B/P, CNS)

Diagnostic Testing • Risk of diagnostic tests: preparation, procedure, and tolerance• Alkaline phosphatase• BUN/Creatinine• CBC: Hb, HCT, MCV • D-dimer• Drug level (Dilantin, INR, Digoxin)• Electrolytes (Na, K, Ca, Mg)• ESR• HbA1C/serum glucose• Troponin• TSH

80 yrs male with glaucoma having angina visited ED, prescribed Diltiazem 30mg qid, ASA 81 od in addition to his Timoptic eye drop. He would have risk for…

A. Bleeding episodes

B. Fainting episodes and falls

C. Rebound supraventricular tachycardia

D. Blurred vision

CASE STUDY #1: 80-Yr-Old Male

The answer?

75 yrs old female with hypertension visited ED due to dizziness and falls, Ixs r/o infection, cardiac, CVA. Drug review found Niacin 1mg PO tid was prescribed 2 weeks ago for high cholesterol. What specific education should be included upon patient discharge?

A. limiting fluid intake

B. measures to minimize orthostatic hypotension

C. administration of the drug an hour after eating

D. slight modifications in diet that are required with drug therapy

CASE STUDY #2: 75-Yr-Old Female

The answer?

78 yrs old man with chronic asthma visited ED due to vomiting, stomach cramps and confusion. He is on Theophylline 400 mg od and hypertensive medications. What diagnostic study should be obtained?

A. Serum electrolytes

B. Digoxin level

C. Theophylline level

D. Arterial blood gases

CASE STUDY #3: 78-Yr-Old Male

The answer?

What anti-hypertensive drug classifications tend to reduce insulin sensitivity?

A. Diuretics & CCB

B. Diuretics & Beta-blockers

C. CCB and ACEI

D. Alpha-blockers & ACEI

The answer?

QUIZ QUESTION #1

When a patient is on Metformin, what do we need to closely monitor for?

A. Significant increase of body weight

B. Elevation of LDL cholesterol level

C. Lactic acidosis

D. Increase insulin requirement

The answer?

QUIZ QUESTION #2

An elderly man has BPH, which medication will likely aggravate this condition?

A. Glyburide

B. Oral buspirone

C. Inhaled ipratropium (Atrovent)

D. Ophthalmic timolol (Timoptic)

The answer?

QUIZ QUESTION #3

Our Role as GEM NursesHow can we help?

INFORMATIONaccurate list of meds with the contact information of providers

INSTRUCTIONOffer proactive education on indications, potential adverse efforts,

potential interaction with other meds/foods, proper medicine administration, and advise to use one pharmacy for clear records

ORGANIZATIONTeach / offer suggestions for how to manage/store/dispose of medicines,

and to avoid sharing

HEALTH LITERACY

Drugs to Avoid

• Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

• Digoxin• Certain Diabetic Drugs• Muscle Relaxants• Certain anti-anxiety/anti-

insomnia

• Certain Anti-cholinergic Drugs

• Demerol• Certain over the counter

drugs (such as cold regime)• Anti-psychotics if not for

psychosis• Estrogen replacement (HRT)

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdfAGS Beers Criteria 2012

High Risk for Drug-Drug Interactions

• Cardiac Med: Digoxin, CCB• Oral Anticoagulant• Theophyllin derivatives• Endocrine therapies:

Glyburide, Pioglitazone, Simvastatin

• Opioid analgesics

• Immunosuppresants• Psychiatric Med: Lithium,

SSRI, MAOI• Anticonvulsants• Antimicrobials: Macrolide,

Quinolone, Oral Antifungals, Antiretrovirals

• Anithistamine

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdfAGS Beers Criteria 2012

Key Take Home Messages1) Consider the possibility that a drug could exacerbate

an existing condition, or even lead to a new consider… then evaluate all alternatives

2) Recognize a change of function as an early sign of ADR

3) Avoid using drugs to correct a drug-induced problem

Reference• American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012) American

Geriatric Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012

• Durso S. C, Bowker L. K., Price J. D. & Smith S. C. (2010) Oxford American Handbook of Geriatric Medicine Oxford University Press

• Fick D. M. & Semla T. P. (2012) 2012 American Geriatrics Society Beers Criteria: New Year, New Criteria, New Perspective. JAGS 2012

• Kazer M. D. & Grossman S. (2011) Gerontologyical Nurse Practitioner: Certification Review. Springer Publishing Company

• Vega C. P. (2013) PIM: The Real Drug Problem in Seniors Retrieved on Aug 20/2013 from www.medscap.com/viewarticle/802898

• Woodfruff. K (2010) Preventing Polypharmacy in Older Adults. American Nursing Today 2010:5(10)

• Wotten J.M.(2012) Pharmacotherapy Considerations in Elderly Adults South Med. Journal 2012; 105(8);437-445.

Questions?

GEM Conference 2013September 17th, 2013

Clara Tsang RN (EC)

Thank You