Medication Use in Older Adults by Rose Knapp, MSN, RN, APRN-BC, ANP

8/14/2019 Medication Use in Older Adults by Rose Knapp, MSN, RN, APRN-BC, ANP

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Medication M anagem ent inthe Elderly An Introduction

Rose Knapp, RN, MSN, APRN-BCClinical Faculty NYU College of Nursing

Professor of Pharmacology Acute Care Nurse Practitioner


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Learning Objectives1. Discuss the specific medication needs ofthe elder patient2. Describe the variables when choosing smedication for the elder adult3. Discuss causes and prevention ofpolypharmacy

4. Discuss the JCAHO recommendationsand the medication reconciliation process


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Drug Therapy in the Elder Patient

Statistics:Drug use in the elderly isdisproportionately high

Patient over 65 constitute 12% of thepopulation and consume 31% ofprescribed drugs secondary to:

Increased severity of chronic illness

Presence of multiple pathologiesExcessive prescribing


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Specific Therapeutic Challenge ofPrescribing for the Elder Patient

Principle factors:

Altered PharmacokineticsMultiple and severe illnessMultiple drug therapyPoor adherence


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Physiologic changes that affect

Pharmacokinetics in the Elderly

Absorption of DrugsIncreased gastric pHDecreased absorptive surface areaDecreased gastric motilityDelayed gastric emptying


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Pharmacokinetic changes

Distribution of Drugs :Increased body fatDecreased lean muscle massDecreased serum albuminDecreased cardiac output

Decreased total body water


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Metabolism of DrugsDecreased hepatic blood flowDecreased hepatic massDecreased activity of hepatic enzymes


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Excretion of Drugs :Decreased renal blood flowDecreased glomerular filtration rateDecreased tubular secretionDecreased number of nephrons


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Pharmacodynamics

Increased drug sensitivityChanges in blood-brain barrier

Alteration in receptor propertiesIncreased Adverse Drug Reactions(ADRs)


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Factors that Predispose Elderly to ADRs

Drug accumulation secondary toreduced renal functionPolypharmacyGreater use of drugs with a lowtherapeutic index ( i.e. digoxin)Inadequate supervision of long-term

therapyPoor patient adherence


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Factors Attributing to Poor Drug Adherence in the Elderly Patient

Multiple chronic disordersMultiple prescribersMultiple prescriptionsMultiple dosesChange in daily drug regimeCognitive or physical impairmentLiving aloneRecent Hospital dischargeInability to pay for drugsPresence of side effects


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Polypharmacy

Definition : Taking a many ofmedications at the same time Beers2005

Average person over 65 takes an

average of 4.5 prescription medicationsat a time plus 2 OTC medications


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Polypharmacy

A quote from Love in the Time of Cholera byGabriel Garcia Marquez :

He rose at the crack of dawn when he beganhis secret medicine, bromides to raise thespirits, salicylates for the aches in his boneswhen it rained, ergosterol for vertigo,belladonna for sound sleep. But in his pockethe always carried a little pad of camphor thathe inhaled deeply when no one was watching ,to calm his fear of so many medication mixedtogether


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Medication AppropriatenessOveruse of a Medication

AntibioticsGI MedicationsSleep medications

MisuseWrong dose and/or frequency

UnderuseChronic diseasePreventative medications- vaccines


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Beers CriteriaPurpose: To reduce medications related risks

Increase nursing awareness of high-risk medicationsMonitoring of adverse effectsFacilitates collaborative efforts of health care providers

Best Tool: HCFA Guidelines for PotentiallyInappropriate Medications in the Elderly

Identifies medications that have potential risks thatoutweigh benefitsUniversally appropriate for all patients over 65Provides a rating of severity for adverse outcomesProvides a descriptive summary associated with theeducation


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Beers CriteriaStrengths-

Developed by 6 nationally known experts ingeriatric care and pharmacology

Widely used to screen populations for possibledrug-related problems

Limitations-Does not identify all cases of potentially

inappropriate prescribingIs not a substitute for professional judgment


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Medication Reconciliation- Definition : The process of comparing a patients

medication orders to all medications that thepatient has been taking.

Medication Reconciliation will avoid :1. omissions,

2. duplications3. dosaging

4. errors5. drug interactions


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Medication Reconciliation 5 Step Process:

Develop a list of medicationsDevelop a list of medications to beprescribedCompare the 2 listsMake clinical decision based on thecomparisonCommunicate the new list to theappropriate caregivers and the patient


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JCAHO Requirements2005 National Patient Safety Goal #8

to accurately and completely reconcile medication across acontinuum of care

Goal for 2006 :

8a) implement a process for obtaining and documenting acomplete of patient medications on admission

8b) a complete list of patient medications is communicated tothe next care provider

Addendum- that a patient who is unable to participate inmedication reconciliation has an authorized person involved inthe process in all interfaces of care and on admission anddischarge from the facility

JCAHO 2/06


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JCAHO Recommendations

Place medications list in a highly visiblelocation in patient chart

Create a process for reconcilingmedications at all interfaces of careOn discharge from a facility, providepatient with the complete list ofmedications


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Measures to Prevent ADRsComplete drug history including OTC and herbals

Account for pharmacokinetic and pharmacodynamicchanges that occur with agingInitiate therapy with low dosesMonitor clinical response and plasma drug levelsEmploy simplest regime possibleMonitor drug-drug interactionsPeriodically review drug regimeEncourage patient to dispose of old medicationsPromote adherence to drug regime


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Factors that PromoteDrug Adherence

Simplify regimeClearly explain treatment planChoosing appropriate dosage form

Label containers clearlySuggest a calendar, diary or pill counter Assure patients access to a pharmacy Assure affordability of medication

Involve a family member or friendMonitor therapeutic responses, adversereactions and plasma drug levels


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Case Study Mrs. A. is a 71 year old widow with CHF and osteoarthritis who hasrecently been exhibiting quite unusual behavior. Her daughter isconcerned about her mother's ability to remain independent and wishes topursue nursing home admission arrangements. She fears the developmentof a dementing illness. Over the last two to three months, Mrs. A. hasbecome confused, easily fatigued and very irritable. She has developeddisturbing obsessive/compulsive behavior constantly complaining that herlace curtains were dirty and required frequent washing. Detailedquestioning revealed that she thought they were yellow-green andpossibly moldy. Her prescribed medications are:* Furosemide 40 mg daily in the morning* Digoxin 250 micrograms daily

* Acetamenophen 500 mg, 1-2 tablets 4-hourly PRN joint pain * * Mylanta suspension, 20 ml prn


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FurosemideDosageIndication

Adverse Effects- hypokalemia

Considerations: monitor serum K, observe forsigns of hypokalemia- fatigue, muscleweakness and crampingEffect on Digoxin

Potassium SupplementsBest time to administer medicationTeach patient and family about foods high in K


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DigoxinDosageIndicationEarly signs of toxicity- weakness,anorexia, GI distressLate signs of toxicity- confusion,visual color disturbances, arrhythmias,headacheRelationship of K and DigoxinObtain baseline vital signsCheck digoxin and K levelsMylantas effect on digoxin


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Acetaminophen

DosageIndication

Adverse reactions: severe liver damage,rashObserve for hepatic damage


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Mylanta

DosageIndications

Adverse reactions: diarrhea/constipation Aluminum-constipation, Magnesium-diarrheaMagnesium based- caution with renal disease

May alter absorption of many drugsPotential for adverse reaction with Digoxin


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Case Study

Mrs. A is a victim of polypharmacyDigoxin dosage with digoxin toxicity Mylanta interacts with digoxinLasix and digoxin interation


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5 steps of Clinical Decision

Making AssessmentDiagnosisPlanningIntervention/EducationEvaluation


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REMEMBER

Individualized drug therapy in theelderly is essential

70% of nonadherence isINTENTIONAL


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References Abrams, WB, Beers, MH. Clinical Pharmacology in an aging population.Clinical Pharmacology Therapeutics 1998:63:281-4.Beers, MH. Explicit criteria for determining potentially inappropriatemedication use in the elderly . Archives of Internal Medicine 1997: 157: 1531-6.Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating theBeers criteria for potentially inappropriate medication use in olderadults: results of a US consensus panel of experts. Arch Intern Med.2003;163:2716-2724

ISMP Medication Safety Alert, April 21, 2005,http://www.ismp.org/MSAarticles/20050421.htm Institute for HealthcareImprovement website includes a section on Medication Reconciliation Review,including s amples of a reconcil iation tracking tool and a medication reconciliationflowsheet, http://www.ihi.org/

(Lehne, Richard A.. Pharmacology for Nursing Care, 6th Edition . W.B.Saunders Company, 062006. 11).1. J.D. Rozich, M.D., Ph.D., M.B.A., "Standardization as a Mechanism to

Improve Safety in Health Care," Joint Commission Journal on Quality andSafety, Volume 30, Number 1, January 2004, pages 5-14
http://www.ismp.org/MSAarticles/20050421.htmhttp://www.ismp.org/MSAarticles/20050421.htmhttp://www.ihi.org/http://www.ihi.org/http://www.ihi.org/http://www.ismp.org/MSAarticles/20050421.htm

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Medication Use in Older Adults by Rose Knapp, MSN, RN, APRN-BC, ANP