A seizure is what happens when the brain has abnormal and

uncontrolled electrical activity. Not all people who experi-

ence seizures have epilepsy as a patient must have two or

more seizures in order to be diagnosed with epilepsy. Elder-

ly patients fall into two categories: early onset (having sei-

zures since childhood)

and late onset (having

seizures due to an event

that occurred during

adulthood such as a trau-

matic brain injury, brain

tumor, stroke [accounting

for 40-50% of late-onset

epilepsy], or cerebrovas-

cular event; it could alter-

natively be due to disease

progression that goes

along with dementia or

other neurodegenerative

brain processes). Seizure

therapy in the older adult

can be somewhat tricky as

they tend to have more

sensitivity to anti-epileptic medications and their symptoms

can be confounded with other disease

states such as dementia, depression,

and anxiety. With that being said, it is

important to attempt to maintain a pa-

tient on only one antiepileptic medica-

tion if at all possible. You can also

consider anti-epileptic discontinuation

if there have been no seizures for 3-5

years based on the risk/benefit for each

individual patient.

There are several types of seizures and

it can sometimes be hard to tell when a

person is having a seizure. A person

having a seizure may seem confused or

look like they are staring at something

that’s not there. Seizures can also

cause a person to fall, shake, and be-

come unaware of what’s going on around them. Seizures are

classified into two types.

The first type are called generalized seizures (meaning they

affect both sides of the brain). The first subtype of general-

ized seizures is absence

seizures (old term being a

petit mal seizure) and

these can cause rapid

blinking, movements of

the mouth, or a few sec-

onds of staring into space

while maintaining the

same posture or position

(this type of seizure is

often mis-diagnosed dur-

ing adolescence as a child

being inattentive in

school). The second sub-

type of generalized sei-

zures is tonic-clonic sei-

zures (old term being

grand mal seizure) and

these can make a person cry out, lose consciousness, or have

muscle jerks or spasms. They cause a person to have stiffen-

ing of the arms and legs on both sides of the body which

causes them to fall if standing up. The stiffening is referred

to as the tonic phase. After a period of time the stiffening is

replaced by cycles of stiffening and relaxation of the muscles

that present as shaking movements (and this is referred to as

the clonic phase). The patient will then become limp and

unconscious until the brain recovers enough to allow the per-

son to wake up. Drugs effective for generalized tonic clonic

seizures include lamotrigine, levetiracetam, oxcarbazepine,

topiramate, zonisamide, phenytoin, carbamazepine, and

valproic acid/divalproex. A less common or third subtype of

generalized seizure is what is called an atonic seizure (aka

loss of tone). These seizures present with the patient becom-

ing abruptly limp and collapsing and they often have to wear

protective helmets to prevent serious head injury. The fourth

subtype of generalized seizures is myoclonic seizures. These

are classified as extremely brief, jerking movements that can

Seizure and Epilepsy Update

A Publication of Neil Medical Group Applying Clinical Expertise to Improve Health Outcomes

July/August 2020

PHARM NOTES

Volume 23, Issue 4

Continued on page 4

Inside this issue:

Seizure & Epilep-

sy Update

1

The Mental &

Emotional As-

pects of Covid19

2-3

Seizure & Epilep-

sy Update: Con-

clusion

4-6

IV Considera-

tions in the El-

derly

7

Neil Medical

Group Contact

Information

8

Page 2

PHARM NOTES

The COVID-19 pandemic has affected many aspects of our

existence and has impacted how we live our daily lives. Con-

cerns surrounding the

virus may include fi-

nancial pressures and

long-term economic

effects, social isola-

tion, worry regarding

becoming infected

with the virus or fear

that a loved one will

become infected, un-

certainty about the the

duration of the pan-

demic, and what will

the future hold. All of

these factors may con-

tribute to stress, anxie-

ty, fear, sadness, and

loneliness. Mental

health issues may be exposed, and unhealthy behaviors may

result such as excessive substance abuse.

Resilience is seen in most people after a tragedy and new

strengths are sometimes discovered. In typical natural calami-

ties, a main concern is the development of post-traumatic stress

disorder (PTSD). On the other hand, medical disorders result-

ing from a life-threatening viral infection do not meet the exist-

ing criteria necessary for a PTSD diagnosis. What is now be-

ing seen is a rise in depression and anxiety illnesses.

Psychosocial effects may be seen in some more than others.

Specifically, people who acquire the disease, those at increased

risk for infection, including the elderly and individuals with a

weakened immune system, those living in congregate environ-

ments, and people with preexisting medical, psychiatric, or

substance use problems. Especially susceptible to emotional

difficulty during this pandemic are health care providers. This

is in relation to their risk of contact with the virus, apprehen-

sion about infection and caring for loved ones, scarcities of

personal protective equipment (PPE), longer work hours, and

participation in stressful

resource-allocation deci-

sions.

Bulk stay at home directives

are new to Americans and

are in direct contrast to our

desire to have interaction

with others and gather in

times of celebration, grief,

and everyday social events.

A recent review of psycho-

logical consequences in

samples of quarantined peo-

ple revealed stress, depres-

sion, irritability, insomnia,

fear, confusion, anger, frus-

tration, boredom, and stig-

ma associated with quarantine. Some of these issues continued

after the quarantine was removed. Main stressors included

longer period of confinement, not having enough supplies, dif-

ficulty obtaining medical care and medications, and conse-

quential financial losses. This emotional struggle has caused

some to be tempted to breach their restrictions.

Countless Americans have abruptly been taken down to the

basic level of Maslow’s hierarchy of needs. Within Maslow’s

hierarchy of needs there are three levels of needs. At the top

are the self-fulfillment needs, in the middle the psychological

needs, and at the bottom are the basic needs. The basic needs

include security, safety, food, water, warmth, and rest. The

needs lower down in the hierarchy must be satisfied before

individuals can attend to the needs higher up. To better under-

stand this, consider the fact that many Americans have been

laid off, small businesses are trying to hang on, and those who

freelance or do contract labor are severely impacted by the

cancellation of their services. Financial insecurity is unexpect-

edly being felt by people of all levels of wealth. We think that

financial security should be connected to a person’s wealth,

however, it is more complicated. To the extent that a person is

stressed financially to the point that they do not have savings

with which to pay their mortgage, they can be extremely af-

fected by a job loss or decreased number of work hours.

This pandemic may have found us in situations where our pri-

orities have come in direct conflict with each other. Typically,

we live by understood rules that we are not aware of until they

are challenged. For example, two accepted rules we follow

could be to provide for my family and to keep my family safe.

A couple earning two incomes may find themselves with one

income if one person gets laid off and the other person is an

essential healthcare worker who remains employed. This is

where the dilemma between the previous stated traditional

rules come into conflict. For the healthcare worker to provide

The Mental & Emotional Aspects of COVID 19

Page 3

Volume 23, Issue 4

financially for the family, they must go into an environment

where they may be more likely to be exposed to the virus and

may not have sufficient PPE. Therefore, working could put

those in the healthcare workers home at greater risk of becom-

ing sick. This can create large amounts of stress as it is innate

to want to protect out children at all cost.

Many people find themselves on opposites of the spectrum

during this unusual time in history in that some are busier that

ever and others find themselves with more spaciousness and

time on their hands. As humans, we like to feel we can do

something to help a situation or make things better, however

we have been asked to shelter in place. For those with more

time on their hands, this can feel like doing nothing which can

interfere with our sense of identity which is established in a

system of interdependent roles and relationships. The result

of this loss after the early disbelief can be helpless rage. This

can lead to devastating sequels if a prolonged time of social

distancing leads to damage of a valuable position in society.

This touches on two risk factors of Joiner’s Interpersonal

Model of Suicide: thwarted belongingness and feelings of bur-

densomeness.

In attempt to feel in control and less fearful when things seem

to be spinning out of control around us, many people resort to

hoarding limited provisions. This can keep us feeling like we

will be destitute, therefore, increasing our fear. Also, people

moving out of participating in the economy are trying to find a

sense of safety but are actually aiding the conditions that can

lead to the collapse of the economy that is now feared.

Parents need to be aware that children and teens can feed off

of what they see in the adults in their lives. If parents appear

peaceful and secure, then their children are likely to portray

this demeanor. Be aware of warning signs of stress in chil-

dren which can include but are not limited to excessive crying

or frustration in younger children, irritability and “acting” out

behaviors in teens, exaggerated worry or sadness, problems

with attention and concentration, and unexplained physical

symptoms. Talk with your children regarding how they are

feeling and let them know it is okay to be upset.

It is important that we take care of ourselves so that we can be

there for those that need us most. There is a reason we are

instructed on airplanes to put our oxygen masks on before we

assist others and the same applies during the pandemic. Self-

care acts may include:

Get enough rest, get up and go to bed at the same times

every day

Engage in physical exercise; this can aide in reducing anx-

iety and enhance mood

Avoid refined sugar and restrict caffeine as it can increase

stress and anxiety

Avoid tobacco, alcohol and drugs

Limit the amount of time on electronic devices, particular-

ly 30 minutes before bedtime

Make time for relaxation and activities you enjoy

Decrease time watching or listening to news reports; this

can amplify fears pertaining to the virus

Stay busy with hobbies, projects, etc.

Center on positive thoughts

Pull strength from your spiritual belief system

Set reachable goals every day

Connect with others using methods that allow for social

distancing

Discover new ways to be productive, utilizing the

strengths that you have attained

Assist others with needs such as picking up groceries or

prescriptions and stay in touch with those who may be

quarantined

In summary, if you find yourself feeling sad, angry, irritable,

hopeless, anxious, helpless, fearful, having trouble concentrat-

ing, having body aches or pain, changes in appetite or trouble

sleeping for several days in a row in spite of your best efforts

it is time to seek help. Talk to a family member, close friend,

or spiritual leader about your feelings. Schedule an appoint-

ment with your primary physician or mental health profession-

al. Organizations such as the National Alliance on Mental

Illness (NAMI) or the Substance Abuse and Mental Health

Services Administration (SAMHSA) are available to help. If

you are having thoughts of hurting yourself get help immedi-

ately. The National Suicide Prevention Lifeline can be

reached at 1-800-273-8255. Article by Sheri Idol, RN, BSN, CRNI

Nurse Consultant, Neil Medical Group

Page 4

Seizure & Epilepsy Update…………………..continued from page 1

PHARM NOTES

occur as a single jerking movement lasting a second or less or

as a repetitive jerking movement that lasts several minutes.

Myoclonic seizures are frequently seen in patients that have

other types of generalized seizures. Drugs to avoid in myo-

clonic and/or absence seizures include oxcarbazepine, carbam-

azepine, zonisamide, pregabalin, gabapentin. Drugs to use for

myoclonic seizures include levetiracetam, lamotrigine, topir-

amate, and valproic acid/divalproex.

The second type of seizure is a focal (aka partial) seizure

(meaning located in just one area of the brain, also known as

partial seizures). The first subtype of focal seizures are simple

focal seizures (meaning they affect a small part of the brain).

Simple focal seizures can cause twitching and simple motor

dysfunctions (if happening in the frontal lobe of the brain) or a

change in sensation and simple sensory dysfunctions (if hap-

pening in the parietal lobe), such as a strange taste or smell.

The second subtype of focal seizures are complex focal sei-

zures (meaning they affect a larger part of the brain but still

only a specific portion of the brain). Complex focal seizures

happen in the temporal lobe or frontal lobe and cause abnor-

mality of awareness or consciousness. They can make a person

feel confused or dazed due to the inability to recognize faces

and the inability to speak/understand words. Some patients are

unable to respond to questions or direction for up to a few

minutes. Drugs effective for focal seizures include lamotrigi-

ne, levetiracetam, brivaracetam, oxcarbazepine, topiramate,

zonisamide, pregabalin, gabapentin, lacosamide, eslicarbaze-

pine, phenytoin, carbamazepine, phenobarbital, and valproic

acid/divalproex. Levetiracetam is most preferable when com-

pared to phenobarbital and lamotrigine if treating Alzheimer's

patients with focal epilepsy as there is no negative impact on

cognition and it actually has been shown to increase cognition

(whereas lamotrigine is cognition neutral and phenobarbital

decreases cognition).

There is also the possibility of what are called focal seizures

with secondary generalization. These begin in one part of

the brain, but then spread to both sides of the brain (aka

they start as focal seizures but then become generalized

seizures). They present as initial shaking movements in

one part of the body with the patient subsequently be-

coming unconscious and exhibiting other manifestations

of a generalized seizure. Approximately 90% of the new-

onset cases in older adults present as focal epilepsy with

or without secondary generalization.

The seizure threshold can be lowered by sleep depriva-

tion, alcohol, infection, recreational drugs, menstruation,

hyperventilation, flashing lights, stress, and medications

(including sedating antihistamines and some antibiotics).

Psychiatric symptoms are also associated with poorly

controlled seizures that occur in the same timeframe as

the occurrence of a seizure. Symptoms that precede the

seizure by a few hours and for up to three days prior are

called pre-ictal symptoms. Psychiatric symptoms that

occur within a period of five days after a seizure are

called post-ictal symptoms. Psychiatric symptoms may

be the only or principle symptom of the actual seizure

and these are called ictal psychiatric symptoms. Lastly,

symptoms that occur independently of a seizure are called

inter-ictal psychiatric symptoms.

Pre-ictal and post-ictal psychiatric symptoms include a wide

range of depression symptoms including feeling sad, losing

hope, feeling helpless, crying constantly, feeling guilty without

reason, feeling restless, insomnia, and concentration problems

as well as irritability, impulsivity, aggressive behavior, and

hyperactivity. These symptoms are out of character for the

patient and they then return to “normal” after the seizure and

all of the ictal periods. Post-ictal symptoms include depres-

sion, anxiety, and irritability and patients are less likely to

make the connection between the seizure occurrence and post-

ictal symptoms as they usually occur one or two days later.

A single seizure can occur in any person under certain extreme

circumstances (such as after a traumatic brain injury, ischemic

stroke, intracerebral hemorrhage, or subarachnoid hemor-

rhage). These events are often treated with preventative thera-

py (commonly with levetiracetam). It is important to differen-

tiate between prevention/prophylaxis of early seizures (seizures

occurring within a week of the event) versus late seizures

(seizures occurring greater than one week after the event). Sei-

zures that happen within a week (the acute period) of the event

Page 5

Volume 23, Issue 4

are common occurrences and they are not an indication of

newly present epilepsy. It is always recommended to discon-

tinue prophylactic treatment after 3-7 days. The restarting of

anti-epileptic therapy is appropriate if seizures manifest after

the first week following the event.

So far there is no medication that can completely cure epilep-

sy. Anti-epileptics work via various mechanisms (inhibition of

voltage gated sodium channels, enhancement of GABA trans-

mission, decreased glutamate transmission, carbonic anhydrase

inhibition, and SV2A synaptic unit binding) that suppress sei-

zure activity. Each drug’s mechanism is associated with differ-

ent adverse effects. For example, topiramate and zonisamide

are carbonic anhydrase inhibitors. This mechanism increases

the risk of metabolic acidosis (aka increased chloride, de-

creased serum carbonate). This side effect requires the drug to

either be decreased in dose or discontinued.

The best way to avoid adverse reactions is to

start at a low dose and increase in small, slow

steps. Also, it is best to avoid drugs in the

same class/with the same mechanism of ac-

tion (for example – phenytoin + carbamaze-

pine) as their concurrent use does not usually

enhance efficacy and instead only increases

dose dependent adverse effects. On the other

hand, use of phenytoin, carbamazepine, or

oxcarbazepine (these work on fast acting so-

dium channels) + lacosamide would be ok

(works on slow inactivation of sodium chan-

nels) due to their different mechanisms.

Older first generation epileptic drugs (aka

aromatic anti-epileptics) include carbamaze-

pine, phenytoin, primidone, phenobarbital,

and valproic acid/divalproex. These drugs are

associated with lots of interactions due to

their inhibition/induction of enzyme systems

as well as due to the fact that they are heavily metabolized by

cytochrome P450 in the liver. For example, the use of

omeprazole with phenytoin will double or triple phenytoin lev-

els and lead to toxicity due to omeprazole inhibiting the break-

down of phenytoin via CYP2C19 (therefore esomeprazole is

recommended if both a proton pump inhibitor and phenytoin

therapy are required). Phenytoin is a strong cytochrome induc-

er (and will decrease serum levels/efficacy of other medica-

tions) such as methadone, galantamine, and donepezil. On the

other hand, valproic acid is a strong inhibitor (and will in-

crease serum levels/efficacy and/or toxicity of other medica-

tions) such as lamotrigine. Although Onfi (clobazam) is not a

first generation anti-epileptic (and is instead a benzodiazepine)

the one major drug interaction to look out for regarding cyto-

chrome P450 would be when it is used concomitantly with

cannabidiol (aka marijuana products). Cannabidiol inhibits the

metabolization of the active metabolite desmethylclobazam by

3-fold and thus greatly increases the levels of Onfi which can

lead to toxicity.

Another concern with some of the first generation antiepileptic

drugs (phenytoin and valproic acid/divalproex) is their charac-

teristic of being highly protein bound. This effects distribu-

tion/other medications that are highly protein bound. Phenyto-

in also has a narrow therapeutic index so close monitoring is

needed as metabolism can become saturated which leads to

small dose changes causing huge changes in serum concentra-

tion (especially in patients with CKD, decreased albumin, ure-

mia, hypoalbuminemia, or that are on other medications that

will displace phenytoin from albumin).

Second and third generation anti-epileptics have more predict-

able absorption as they follow 1st order kinetics (aka the

amount of drug given is linearly related to its effect in the

body). They do have a variety of protein binding but it is not

clinically significant. They are also metabolized more so by

glucuronidation versus cytochrome P450 which leads to less

drug interactions.

Carbamazepine has the most evidence for effectiveness from

randomized controlled trials for use in management of aggres-

sion in Alzheimer disease dementia. However, it should be

only used when the benefits for the patient outweigh the risks

associated with its use as it carries significant risk for interac-

tions and adverse effects. Divalproex sodium has been shown

to have low to no efficacy and carries high risk for adverse

effects and interactions. There are also reports of brain atrophy

and worsened cognition when using divalproex in individuals

with mild-moderate Alzheimer disease dementia.

A drug interaction that requires additional drug monitoring is

Seizure & Epilepsy Update…………………..continued from page 5

Page 6

PHARM NOTES

the interaction between valproic acid and carbamazepine. Car-

bamazepine is metabolized to carbamazepine epoxide. Car-

bamazepine epoxide is eliminated by epoxide hydrolase.

Valproic acid inhibits epoxide hydrolase. When epoxide hy-

drolase is inhibited, it causes accumulation of carbamazepine

epoxide which leads to subsequent carbamazepine toxicity. If

you must be on both valproic acid/divalproex and carbamaze-

pine. then carbamazepine epoxide levels must be monitored as

well as normal carbamazepine levels.

Adverse drug reactions are classified as dose dependent (aka

higher doses increase risk) and idiosyncratic (aka any dose at

any time can cause the adverse reaction). The most common

dose dependent adverse drug reactions are neurologic symp-

toms including dizziness, drowsiness, ataxia, incoordination,

blurred vision, nausea, and nystagmus. Specific dose depend-

ent adverse effects can further be classified by disease states in

which specific drugs should be avoided. One example is car-

bamazepine as it is fairly anticholinergic at higher doses and is

even on the BEERS list. Also, Vimpat is associated with AV

block/PR interval prolongation so EKG monitoring is recom-

mended at baseline as well as after dosage changes. This

makes Vimpat a non-ideal option in heart failure and in pa-

tients who must also be on verapamil or beta blockers. Le-

vetiracetam, brivaracetam, phenytoin, topiramate, and zonis-

amide are bad options in the presence of depression/anxiety

due to negative mood effect risk as they can worsen irritabil-

ity. Phenytoin, phenobarbital, primidone, valproic acid/

divalproex, and topiramate should ideally be avoided in Alz-

heimer's disease/dementia due to their worsening effects

on cognition. Lastly, valproic acid/divalproex and

lamotrigine should be avoid if a tremor is already pre-

sent as they can exacerbate tremor.

Side effects to look out for regardless of dose (aka idio-

syncratic reactions) include hyperammonemia and car-

nitine deficiency with valproic acid, thrombocytopenia/

bleeding risk/hematologic abnormalities with phenytoin/

carbamazepine/phenobarbital/primidone/valproic acid,

and hyponatremia with carbamazepine/oxcarbazepine/

eslicarbazepine.

The most dangerous idiosyncratic adverse reactions are

cutaneous reactions. These occur with the use of aro-

matic antiepileptic drugs (phenytoin, carbamazepine,

oxcarbazepine, lamotrigine, primidone, phenobarbital,

zonisamide, eslicarbazepine) as well as sulfonamides

and tricyclic antidepressants (as they are structurally

similar). They are usually just a benign rash but can turn

into Stevens Johnsons Syndrome (SJS – 9% mortality),

Toxic Epidermal Necrolysis (TEN – up to 50% mortali-

ty), or Drug Reaction with Eosinophilia and Systemic

Symptoms (DRESS – 10% mortality). They occur 1-12

weeks after drug initiation or dose adjustment and are

more likely to occur in the elderly. This is another reason to

avoid multi-drug therapy with more than one aromatic antiepi-

leptic. Genetic monitoring exists for patients of Asian/Korean/

Japanese/Northern European decent as they are more likely to

experience cutaneous reactions. The alleles HLA-B*15:02

and HLA-A*31:01 can be checked.

Lastly, long term side effects to look out for include vitamin

B12, folic acid/folate, and vitamin D deficiency in carbamaze-

pine/phenobarbital/phenytoin/primidone use. There are also

long term negative effects on bone health that can lead to oste-

oporosis/osteopenia due to the increased metabolism of vita-

min D (so these are a bad option in multiple sclerosis as they

need high levels of vitamin D to prevent relapses) and this is

seen with valproic acid [although this specific medication ac-

tually inhibits vitamin D absorption] /carbamazepine/

phenobarbital/ phenytoin/primidone/oxcarbazepine use. It is

recommended to monitor the 25-hydroxyvitamin D level annu-

ally as well as to complete a DEXA scan every 2 years in post-

menopausal women/elderly men and every 5 years in everyone

else. Also, vitamin D/calcium supplementation is recommend-

ed even if vitamin D level is normal when treating patients

with these medications.

Many anti-epileptics are used off label to treat other disease

states. It is highly recommended to monitor each patient’s

specific diagnosis profile so that one medication can be used

to treat multiple diseases. Following is a table listing exam-

ples:

Off Label Diagnosis Antiepileptic Drug(s)

Neuropathic pain (including post-

herpetic neuralgia, diabetic neurop-

athy, and trigeminal neuralgia)

Divalproex/valproic acid, carbam-

azepine, oxcarbazepine, gabapen-

tin, pregabalin

Fibromyalgia AND/OR anxiety Gabapentin, pregabalin

Migraine prophylaxis Topiramate, divalproex/valproic

acid

Restless legs syndrome Gabapentin

Essential tremor (aka tremor of unknown origin)

Primidone, gabapentin, topiramate

Bipolar disorder

Carbamazepine, oxcarbazepine,

lamotrigine, divalproex/valproic

acid

Bipolar disorder with > 4 mood

swing episodes per year (aka rapid

cycler)

Divalproex/valproic acid

Article by Rachel Benton, PharmD, BCGP

Consultant Pharmacist, NMG

Page 7

Volume 23, Issue 4

Developing

the skills

needed to

successfully

start IV’s

takes time

and practice.

Starting IV’s

in the older

adult can be

extra chal-

lenging. Loss of sub-cutaneous tissue, decreased skin

tone and elasticity, and small fragile veins, increases the

degree of difficulty in this population. Here are some tips

and strategies to improve your chances of success.

Thorough assessment of the resident’s peripheral access

for potential IV sites is especially important in the older

adult. Here are some key strategies recommended by the

Infusion Nursing Society.

Environment Start with adequate lighting Provide privacy for resident and explain all procedures

to patient and/or family Position patient in comfortable position that allows you

to easily access the sites being evaluated for IV place-ment

Gather all the necessary supplies based on the or-dered therapy

Use the smallest catheter possible to reduce insertion related trauma (a 24g or 22g catheter is appropriate)

Choose appropriate securement device and tape for sensitive, fragile older skin.

Don’t rush! Give yourself plenty of time to thoroughly assess for the best possible site. Staying calm and not rushing, will help you stay focused and steady and decrease anxiety in your patient. Don’t apply the tourniquet too tightly. Apply 4- 6 inches above intended venipuncture site,

snugly enough to distend veins, but not so tight to cause bruising or skin tears

Note: In some instances where the vein is visible and already somewhat distended, you may be able to elim-inate the use of the tourniquet completely. This may decrease the risk of over-distending the vein which could result in damage when the vein is punctured, and formation of a hematoma

Site selection. When determining IV site selection, start with the most

distal sites first to preserve future access sites. Choose soft, bouncy veins and avoid veins that feel

ribbed or rippled. Look for small “bumps” along the vein path. These are

valves and will inhibit your ability to thread the cathe-ter.

Evaluate for any contraindications to the extremity you are choosing, such as history of mastectomy, stroke, dialysis catheter, etc.

Care and consideration of fragile skin. Use appropriate skin cleansing agent to prepare IV

site. Adequate friction is necessary to cleanse the site, but too vigorous scrub could damage skin.

Choose appropriate securement device to stabilize the IV catheter once inserted. The decrease in sub-cutaneous fat and tissue in the older adult can make the catheter unstable and increase the risks of me-chanical irritation.

To reduce potential damage to the skin from the adhe-sive used to secure the IV catheter, it is recommended to use a skin prep solution prior to applying catheter dressing and tape to skin.

Catheter insertion considerations. Note the depth of the vein you have selected prior to

inserting your catheter. You may need to decrease the catheter insertion angle to 10-20 de-grees for shal-low, superficial veins.

Stabilize the vein to prevent vein “rolling” during inser-tion, by placing your thumb di-rectly along the vein axis approximately 2-3 inches below the insertion site. Maintain this traction until the catheter has been advanced into proper position and catheter is stabi-lized.

Only attempt a catheter placement two times; if you are unsuccessful, allow another nurse to evaluate the patient for potential IV access sites, or contact the pro-vider to discuss alternate IV access options.

Once you have successfully inserted you catheter, monitor

site for potential complications at established intervals,

and rotate insertion site every 72 hours as recommended.

For more IV insertion tips, or to schedule an IV therapy in-

service at your facility, contact your Neil Medical Nurse

Consultant.

IV Therapy Considerations in the Elderly

Article by Kimberly Gardner, RN, BSN

Clinical Nurse Consultant, Neil Medical Group

PHARM NOTES

Kinston Pharmacy

2545 Jetport Road

Kinston, NC 28504

Phone 800 735-9111

Louisville Pharmacy

13040 East Gate Parkway

Suite 105

Louisville, KY 40223

Phone 866 601-3041

Mooresville Pharmacy

947 N. Main Street

Mooresville, NC 28115

Phone 800 578-6506

To all the Pharm Notes Family,

SIX LITTLE STORIES WITH LOTS OF MEANING

1. Once all the villagers decided to pray for rain. On the day of prayer, all the people gathered,

but only one boy came with an umbrella. That is faith.

2. When you throw babies in the air, they laugh because they know you will catch them. That is

trust.

3. Every night we go to bed without any assurance of being alive the next morning, but we still

set an alarm to wake us up. That is hope.

4. We all makes big plans for tomorrow in spite of zero knowledge of the future. That is

confidence.

5. We see the world suffering, but still, we get married and have children. That is love.

6. On an old man’s shirt was written a sentence: “I

am not 80 years old; I am sweet 16 with 64 years

of experience. That is attitude.

Have a great day and try to live your life like these six

stories.

Till Next Time,

Be safe my friends…..

Cathy Fuquay

PharmNotes Editor

Pharm Notes is a bimonthly publication by Neil

Medical Group Pharmacy Services Division.

Articles from all health care disciplines pertinent

to long-term care are welcome. References for

articles in Pharm Notes are available upon request.

Your comments and suggestions are appreciated.

Contact: Cathy Fuquay (cathyf@neilmedical.com)

1-800-735-9111 Ext 23489

...a note from the Editor

Thank you for allowing Neil Medical Group to partner with

you in the care of your residents!

Burlington Pharmacy

509 S. Lexington Ave

Burlington, NC 27215

Phone 866 937-3857