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Medication Management in the Elderly An Introduction

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Title: Medication Management in the Elderly An Introduction


1
Medication Management in the Elderly- An
Introduction
  • Rose Knapp, RN, MSN, APRN-BC
  • Clinical Faculty NYU College of Nursing
  • Professor of Pharmacology
  • Acute Care Nurse Practitioner

2
Learning Objectives
  • 1. Discuss the specific medication needs of the
    elder patient
  • 2. Describe the variables when choosing s
    medication for the elder adult
  • 3. Discuss causes and prevention of polypharmacy
  • 4. Discuss the JCAHO recommendations and the
    medication reconciliation process

3
Drug Therapy in the Elder Patient
  • Statistics
  • Drug use in the elderly is disproportionately
    high
  • Patient over 65 constitute 12 of the population
    and consume 31 of prescribed drugs secondary to
  • Increased severity of chronic illness
  • Presence of multiple pathologies
  • Excessive prescribing

4
Specific Therapeutic Challenge of Prescribing for
the Elder Patient
  • Principle factors
  • Altered Pharmacokinetics
  • Multiple and severe illness
  • Multiple drug therapy
  • Poor adherence

5
Physiologic changes that affect Pharmacokinetics
in the Elderly
  • Absorption of Drugs
  • Increased gastric pH
  • Decreased absorptive surface area
  • Decreased gastric motility
  • Delayed gastric emptying

6
Pharmacokinetic changes
  • Distribution of Drugs
  • Increased body fat
  • Decreased lean muscle mass
  • Decreased serum albumin
  • Decreased cardiac output
  • Decreased total body water

7
Pharmacokinetic changes
  • Metabolism of Drugs
  • Decreased hepatic blood flow
  • Decreased hepatic mass
  • Decreased activity of hepatic enzymes

8
Pharmacokinetic changes
  • Excretion of Drugs
  • Decreased renal blood flow
  • Decreased glomerular filtration rate
  • Decreased tubular secretion
  • Decreased number of nephrons

9
Pharmacodynamics
  • Increased drug sensitivity
  • Changes in blood-brain barrier
  • Alteration in receptor properties
  • Increased Adverse Drug Reactions (ADRs)

10
Adverse Drug Reactions and Drug Interactions in
the Elderly Patient
  • ADR are 7 times more common in the elderly
  • Account for 16 of hospital admission and 50 of
    medication related deaths

11
Factors that Predispose Elderly to ADRs
  • Drug accumulation secondary to reduced renal
    function
  • Polypharmacy
  • Greater use of drugs with a low therapeutic index
    ( i.e. digoxin)
  • Inadequate supervision of long-term therapy
  • Poor patient adherence

12
Factors Attributing to Poor Drug Adherence in the
Elderly Patient
  • Multiple chronic disorders
  • Multiple prescribers
  • Multiple prescriptions
  • Multiple doses
  • Change in daily drug regime
  • Cognitive or physical impairment
  • Living alone
  • Recent Hospital discharge
  • Inability to pay for drugs
  • Presence of side effects

13
Polypharmacy
  • Definition Taking a many of medications at
    the same time Beers 2005
  • Average person over 65 takes an average of 4.5
    prescription medications at a time plus 2 OTC
    medications

14
Polypharmacy
  • A quote from Love in the Time of Cholera by
    Gabriel Garcia Marquez
  • He rose at the crack of dawn when he began his
    secret medicine, bromides to raise the spirits,
    salicylates for the aches in his bones when it
    rained, ergosterol for vertigo, belladonna for
    sound sleep. But in his pocket he always carried
    a little pad of camphor that he inhaled deeply
    when no one was watching , to calm his fear of so
    many medication mixed together

15
Medication Appropriateness
  • Overuse of a Medication
  • Antibiotics
  • GI Medications
  • Sleep medications
  • Misuse
  • Wrong dose and/or frequency
  • Underuse
  • Chronic disease
  • Preventative medications- vaccines

16
(No Transcript)
17
Beers Criteria
  • Purpose To reduce medications related risks
  • Increase nursing awareness of high-risk
    medications
  • Monitoring of adverse effects
  • Facilitates collaborative efforts of health care
    providers
  • Best Tool HCFA Guidelines for Potentially
    Inappropriate Medications in the Elderly
  • Identifies medications that have potential risks
    that outweigh benefits
  • Universally appropriate for all patients over 65
  • Provides a rating of severity for adverse
    outcomes
  • Provides a descriptive summary associated with
    the education

18
Beers Criteria
  • Strengths-
  • Developed by 6 nationally known experts in
    geriatric care and pharmacology
  • Widely used to screen populations for possible
    drug-related problems
  • Limitations-
  • Does not identify all cases of potentially
    inappropriate prescribing
  • Is not a substitute for professional judgment

19
Medication Reconciliation
  • - Definition The process of comparing a
    patients medication orders to all medications
    that the patient has been taking.
  • Medication Reconciliation will avoid
  • 1. omissions,
  • 2. duplications
  • 3. dosaging
  • 4. errors
  • 5. drug interactions

20
Medication Reconciliation
  • 5 Step Process
  • Develop a list of medications
  • Develop a list of medications to be prescribed
  • Compare the 2 lists
  • Make clinical decision based on the comparison
  • Communicate the new list to the appropriate
    caregivers and the patient

21
JCAHO Requirements
  • 2005 National Patient Safety Goal 8
  • to accurately and completely reconcile
    medication across a continuum of care
  • Goal for 2006
  • 8a) implement a process for obtaining and
    documenting a complete of patient medications on
    admission
  • 8b) a complete list of patient medications is
    communicated to the next care provider
  • Addendum- that a patient who is unable to
    participate in medication reconciliation has an
    authorized person involved in the process in all
    interfaces of care and on admission and discharge
    from the facility
  • JCAHO 2/06

22
JCAHO Recommendations
  • Place medications list in a highly visible
    location in patient chart
  • Create a process for reconciling medications at
    all interfaces of care
  • On discharge from a facility, provide patient
    with the complete list of medications

23
Measures to Prevent ADRs
  • Complete drug history including OTC and herbals
  • Account for pharmacokinetic and pharmacodynamic
    changes that occur with aging
  • Initiate therapy with low doses
  • Monitor clinical response and plasma drug levels
  • Employ simplest regime possible
  • Monitor drug-drug interactions
  • Periodically review drug regime
  • Encourage patient to dispose of old medications
  • Promote adherence to drug regime

24
Factors that Promote Drug Adherence
  • Simplify regime
  • Clearly explain treatment plan
  • Choosing appropriate dosage form
  • Label containers clearly
  • Suggest a calendar, diary or pill counter
  • Assure patients access to a pharmacy
  • Assure affordability of medication
  • Involve a family member or friend
  • Monitor therapeutic responses, adverse reactions
    and plasma drug levels

25
Case Study
  • Mrs. A. is a 71 year old widow with CHF and
    osteoarthritis who has recently been exhibiting
    quite unusual behavior. Her daughter is concerned
    about her mother's ability to remain independent
    and wishes to pursue nursing home admission
    arrangements. She fears the development of a
    dementing illness. Over the last two to three
    months, Mrs. A. has become confused, easily
    fatigued and very irritable. She has developed
    disturbing obsessive/compulsive behavior
    constantly complaining that her lace curtains
    were dirty and required frequent washing.
    Detailed questioning revealed that she thought
    they were yellow-green and possibly 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

26
Case Study continued
  • What is problematic about this patients drug
    management?

27
Furosemide
  • Dosage
  • Indication
  • Adverse Effects- hypokalemia
  • Considerations monitor serum K, observe for
    signs of hypokalemia- fatigue, muscle weakness
    and cramping
  • Effect on Digoxin
  • Potassium Supplements
  • Best time to administer medication
  • Teach patient and family about foods high in K

28
Digoxin
  • Dosage
  • Indication
  • Early signs of toxicity- weakness, anorexia, GI
    distress
  • Late signs of toxicity- confusion,
  • visual color disturbances, arrhythmias, headache
  • Relationship of K and Digoxin
  • Obtain baseline vital signs
  • Check digoxin and K levels
  • Mylantas effect on digoxin

29
Acetaminophen
  • Dosage
  • Indication
  • Adverse reactions severe liver damage, rash
  • Observe for hepatic damage

30
Mylanta
  • Dosage
  • Indications
  • Adverse reactions diarrhea/constipation
  • Aluminum-constipation, Magnesium-diarrhea
  • Magnesium based- caution with renal disease
  • May alter absorption of many drugs
  • Potential for adverse reaction with Digoxin

31
Case Study
  • Mrs. A is a victim of polypharmacy
  • Digoxin dosage with digoxin toxicity
  • Mylanta interacts with digoxin
  • Lasix and digoxin interation

32
5 steps of Clinical Decision Making
  • Assessment
  • Diagnosis
  • Planning
  • Intervention/Education
  • Evaluation

33
REMEMBER
  • Individualized drug therapy in the elderly is
    essential
  • 70 of nonadherence is INTENTIONAL

34
References
  • Abrams, WB, Beers, MH. Clinical Pharmacology in
    an aging population. Clinical Pharmacology
    Therapeutics 199863281-4.
  • Beers, MH. Explicit criteria for determining
    potentially inappropriate medication 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 the Beers criteria for
    potentially inappropriate medication use in older
    adults results of a US consensus panel of
    experts. Arch Intern Med. 20031632716-2724
  • ISMP Medication Safety Alert, April 21, 2005,
    http//www.ismp.org/MSAarticles/20050421.htm
    Institute for Healthcare Improvement website
    includes a section on Medication Reconciliation
    Review, including samples of a reconciliation
    tracking tool and a medication reconciliation
    flowsheet, http//www.ihi.org/
  • (Lehne, Richard A.. Pharmacology for Nursing
    Care, 6th Edition. W.B. Saunders Company, 062006.
    11).
  • 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 and Safety, Volume 30, Number 1, January
    2004, pages 5-14
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