Chapter 8: Medications and Laboratory Values

1
Chapter 8 Medications and Laboratory Values

• Bonnie M. Wivell, MS, RN, CNS

2
Demographics related to Medications

• The elderly consume about 1/3 of all prescription
  and OTC drugs
• Of those over age 65 (2002)
• 40 took 5 meds per week
• 12 took over 10 meds
• The more medications taken, the greater risk of
  side effects
• Greater risk of side effects in elderly due to
  normal aging changes

3
The Effect of Aging on Drugs

• Pharmacokinetics
• How drugs move through the body via
  absorption/excretion
• Pharmacodynamics
• Effect of drugs in the body
• Medications can stay in the body longer due to
  decreased clearance or excretion and thus
  increase risk of side effects.

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Drug-Related Problems in the Elderly

• Adverse drug reactions
• Drug-drug
• Drug-disease (pg. 263)
• Food drug interactions
• Greens Warfarin
• Grapefruit juice antihistamines
• Polypharmacy more than clinically necessary
• Adverse outcomes
• ADRs
• Increased cost
• noncompliance

• Inappropriate prescribing
• Is tx necessary?
• Is it safest drug available?
• Is it the most appropriate dose, route, and form?
• Is frequency appropriate?
• Do benefits outweigh risks?
• Compliance
• 40 do not adhere

5
Beers Criteria

• In 1997, Dr. Beers developed and published the
  Beers criteria in the Archives of Internal
  Medicine, outlining explicit criteria for use in
  prescribing medications for seniors
• Adopted by CMS in 1999 for nursing home
  regulations
• Revised in 2003
• The criteria have been widely used over the past
  10 years for
• Studying prescribing patterns within populations
• Educating clinicians
• Evaluating health outcomes, cost, and utilization
  data

6
Beers Criteria Continued

• Lists more than 40 concerns associated with
  specific drugs or drug classes when prescribed
  for older adults.
• These concerns explain the overall clinical
  rationale for inclusion on the list.
• See page 267 in your text
• Start LOW and go SLOW

7
Medication Blood Levels

• Cardiac meds, anti-epileptics, certain
  antibiotics
• Random typically to rule out overdose, not dose
  time dependent
• Peak dose time dependent time blood level is
  expected to be at its highest
• Too high reduce dose
• Too low increase dose
• Trough dose time dependent time blood level is
  expected to be at its lowest, right before dose
• Too high extend time between doses
• Too low shorten time between doses

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Laboratory Values

• Renal impairment
• NSAIDs
• ACE inhibitors
• IV contrast materials
• BUN/Creat, Creatinine Clearance (formula pg. 271)
• Hepatic impairment
• Alk Phos, AST, ALT, albumin, bili, protein, coags
• Decreased serum albumin concentration can
  possibly increase free drug concentrations

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5 Rights

• Drug
• Others meds
• Old meds
• RX for same drug from different MDs
• OTC meds
• Amount
• Lack of understanding
• Using wrong measuring device
• Confusing schedules
• Forget what was already taken
• Not getting refills
• Rationing

• Route
• Please dont chew your suppository
• Time
• Multiple drugs with different times
• Patient
• Please dont take your spouses medications

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Challenges to Successful Medication Regimens

• Function
• Physical
• Sensory
• Reading
• Memory
• Motivation
• Funding

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Medications Prescribed for the Elderly

• Medications for dementia
• Cholinesterase inhibitors Cognex, Aricept,
  Exelon, Reminyl
• Medications for osteoporosis
• Antiresorptives
• Bisphosphonates (Fosamax, Actonel, Boniva,
  Aredia, Zometa)
• HRT
• Selective estrogen-receptor modulators (Evista,
  Tamoxifen)
• Anabolic or bone-forming
• Calcitonin nasal spray
• Calcimar - injection
• Medications for anxiety
• Benzodiazepines
• Buspirone no cognitive impairment
• Selective Serotonin reuptake inhibitors (SSRIs)

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Nursing interventions

• Medication review
• Bring in all home meds
• Education
• Name
• How often
• How many
• Side effects
• Funding
• Social worker
• Accommodation
• Pill boxes are great

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Summary

• Geriatric people make up about 13 of the
  population, but consume 33 of all prescription
  medications.
• Older adults have significant physiological
  changes related to aging that may interfere with
  medications.
• Older adults are more sensitive to the effects of
  drug therapy.

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Summary (contd)

• Adverse drug reactions are any noxious,
  unintended or undesired effect of a drug which
  occurs at doses in humans for prophylaxis,
  diagnosis or therapy.
• Certain disease states may interfere with optimal
  drug therapy.

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Summary (contd)

• Polypharmacy is defined as the prescription,
  administration, or use of more medications than
  are clinically indicated for a patient.
• Inappropriate prescribing may be very harmful to
  elderly persons.
• Compliance to drug regimens is essential to
  improving medical diagnosis and outcomes.

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Chapter 12 Identifying and Preventing Common
Risk Factors in the Elderly

• Bonnie M. Wivell, MS, RN, CNS

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Health Promotion and Disease Prevention

• Health promotion can help prevent functional
  decline in the elderly
• U.S. Preventive Services Task Force
• Evaluate benefits of individual services and to
  create age, gender, and risk-based
  recommendations about services that should
  routinely be incorporated into primary care
• Healthy People 2010
• Sets of objectives developed by many experts to
  promote health and quality of life in Americans

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Definitions

• Primary prevention
• Activities to prevent disease from occurring
• Example Immunizations
• Secondary prevention
• Early detection and management
• Screenings
• Example colonoscopy to detect and remove polyps
• Tertiary prevention
• Manage existing disease, preventing progression
  or complications
• Example meds used to remodel heart with CHF

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Screening Recommendations

• Level A Strongly recommends based on good
  evidence that screening Outcomes gt Risks
• Level B Recommends screening based on fair
  evidence than screening Outcomes gt Risks
• Level C Makes no recommendation for or against
  based on balance of benefit/risk
• Level D Recommends against screening because
  screening is ineffective or harmful
• Level 1 Makes no recommendation due to
  insufficient evidence

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Focus of Health Promotion Efforts

• Self-Management
• Chronic disease programs
• Contracting for behavior change
• Physical Activity
• Nutrition

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Physical Activity Counseling

• Level I recommendation
• Found insufficient evidence to determine whether
  encouraging or counseling patients to begin an
  exercise program actually led to improvements in
  their level of physical activity
• There is strong evidence to support the
  effectiveness of physical activity in reducing
  morbidity and mortality from chronic illness

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Nutrition Counseling

• Level B recommendation
• Found good evidence to support counseling
  interventions among adults at risk for
  diet-related chronic disease
• Interventions that have proven to stimulate
  healthy dietary changes combine nutrition
  education with behavioral counseling

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Tobacco Use

• 5 As
• Ask
• Advise
• Assess willingness
• Assist
• Arrange follow-up

• 5 Rs
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

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Tobacco Cessation Counseling

• Level A recommendation
• Found good evidence that screening, brief
  behavioral counseling, and pharmacotherapy, are
  effective in helping clients to quit smoking and
  remain smoke-free after one year.
• There is good data to support that smoking
  cessation lowers the risk for heart disease,
  stroke, and lung disease

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Safety

• Inflammation of joints or joint deformity 
• H ypotension (othostatic blood pressure change)
• A uditory and visual abnormalities
• T remor
• E quilibrium problems
•  
• F oot problems
• A rrythmias, heart block, valvular disease
• L eg-length discrepancy
• L ack of conditioning (generalized weakness)
• I llness
• N utrition (poor, weight loss)
• G ait distrubance

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Fall Prevention Counseling

• Level B recommendation
• Recommended in order to reduce fall risk
• Balance and strengthening exercise programs
• Home safety assessment and training
• Medication monitoring and adjustment

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Polypharmacy and Medications

• Adults over age 65 take an average of 4.5
  prescription meds and 2 OTC meds at any given
  time
• Many elders are prescribed drugs that are not
  recommended in the elderly
• Polypharmacy a major problem, with increased risk
  of side effects the more medications are added

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Immunizations

• Influenza vaccination annually Level B
  recommendation
• Amantadine or Rimantadine prophylaxis Level B
  recommendation
• Pneumococcal vaccine Level B recommendation
• Tetanus vaccination Level A recommendation

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Mental Health Issues

• Depression
• Level B recommendation to support screening
• Found good evidence that screening effectively
  identifies depressed patients and that treatment
  of depression improves clinical outcomes
• Dementia Screening
• Level I recommendation.
• Found the clinical evidence to be insufficient
  to recommend screening for all elderly clients in
  a primary care setting
• Most expert panels agree that clients who are
  suspected of having cognitive impairment or whose
  families express concern about their cognitive
  functioning, should be screened

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Alcohol Abuse

• More the 7 drinks per week for women and 14
  drinks per week for men is considered hazardous
• Can use 5 As and 5 Rs also
• Screening
• Level B recommendation for screening
• Found good evidence that screening is beneficial
  in identifying patients whose alcohol consumption
  patterns place them at risk for increased
  morbidity and mortality, and good evidence that
  counseling about alcohol reduction can produce
  sustained benefit over a six to twelve month
  period

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Elder Abuse and Neglect

• Clues to abuse
• The presence of several injuries in different
  stages of repair
• Delays in seeking treatment
• Injuries which cannot be explained or that are
  inconsistent with the history
• Contradictory explanations by the caregiver and
  the patient
• Bruises, burns, welts, lacerations, restraint
  marks

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Elder Abuse and Neglect Continued

• Clues to abuse (contd)
• Dehydration, malnutrition, decubitus ulcers or
  poor hygiene
• Depression, withdrawal, agitation
• Signs of medication misuse
• Pattern of missed or cancelled appointments
• Frequent changes in healthcare providers
• Discharge, bleeding or pain in rectum or vagina
  or sexually transmitted disease
• Missing prosthetic device(s), such as dentures,
  glasses, hearing aids

33
Lipid Screening

• Level A recommendation for screening
• There is strong evidence to correlate lipid
  abnormalities with cardiac risk
• A simple blood test is a valid and reliable
  method of diagnosing lipid abnormalities
• Diet and drug therapies are effective remedies

34
Heart and Valvular Disease

• Each component below will be examined
  individually
• Risk factors
• Age gt 50 for men and 60 for women
• Hypertension
• Smoking
• Obesity

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Heart and Valvular Disease Continued

• Risk factors (contd)
• Family history of premature CHD
• Diabetes (Considered to be a CHD risk-equivalent
  i.e. Carries the same risk of coronary event as
  known CHD)
• Sedentary life style
• Abnormal lipid levels

36
Blood Pressure Screening

• Level A recommendation
• There is strong evidence that blood pressure
  measurement can identify adults at increased risk
  for cardiovascular disease due to high blood
  pressure
• Treatment of hypertension substantially decreases
  the incidence of cardiovascular disease

37
Aspirin Therapy

• Level A recommendation
• There is good evidence that aspirin decreases
  the incidence of CHD in adults who are at
  increased risk for heart disease
• Aspirin increases the incidence of
  gastrointestinal bleeding and hemorrhagic strokes
• Concluded that evidence is strongest to support
  aspirin therapy in patients at high risk of CHD

38
Cerebral Vascular Disease

• Risk factors
• Increased age
• Smoking
• Hypertension
• Diabetes
• Sedentary lifestyle
• Alcohol use
• High fat diet
• Atrial fibrillation
• Carotid stenosis

39
Thyroid Disease Screening

• Level I recommendation
• There is insufficient evidence to recommend for
  or against screening based on limited evidence to
  establish health risks of subclinical disease,
  and due to the risks of treatment

40
Osteoporosis

• Risk factors
• Advanced age
• Low BMI
• Caucasian or Asian race
• Family history of compression or stress fracture
• Fall risk or history of fracture
• Low levels of weight-bearing exercise
• Smoking
• Excessive alcohol or caffeine use
• Low intake of calcium or vitamin D.

41
Osteoporosis Screening

• Level B recommendation
• Osteoporosis is common in the elderly and is
  correlated with fracture risk
• There are good screening tests to diagnose
  osteoporosis and effective treatments for the
  disease

42
Vision and Hearing

• Cataracts, glaucoma, and diabetes contribute to
  visual impairments in elderly

43
Prostate CA Screening

• Level I recommendation
• Insufficient evidence to recommend screening
  based on inconclusive evidence that screening
  with DRE and PSA improves health outcomes
• Men with a life expectancy of less than 10 years
  are unlikely to benefit from prostate screening

44
Breast CA Screening

• Mammography (with or without clinical breast
  exam) Level B evidence
• There is fair evidence to support benefit from
  breast cancer screening for older women by
  mammogram every one to two years
• There is no age at which screening should be
  discontinued but the task force agrees that
  screening would have no benefit when life
  expectancy is significantly limited by dementia
  or other serious, life-limiting chronic illnesses

45
Colorectal Screening

• Level A recommendation
• The task force strongly recommends colorectal
  screening by FOBT, FOBT sigmoidoscopy, or
  sigmoidoscopy alone for clients with average risk
  of developing colorectal cancer.
• The task force was unable to determine whether
  the increased sensitivity of colonoscopy compared
  with the other screening methods outweighed the
  costs, risks and inconvenience of the procedure.

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Chapter 18 Appreciating Diversity and Enhancing
Intimacy

• Bonnie M. Wivell, MS, RN, CNS

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Definitions

• Heritage encompasses a persons ethnic origin,
  nationality, religion and culture
• Ethnicity refers to what some have called race
  African, European, Asian, etc.
• Nationality refers to the geographic location of
  birth
• Religion refers to a belief system based on a
  higher power
• Culture refers to the group to which the person
  belongs and which influences the persons values
  and beliefs (shared beliefs)

48
Appreciating Diversity

• Diversity of elders
• Elderly cohort is becoming more heterogeneous
• At present, most elders are white females, but
  this is changing with growth of minority groups
• Differences in race, diet, leisure, socioeconomic
  status, and health care beliefs present
  challenges to nursing

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Cultural Competence

• A key strategy for achieving cultural competence
  is to learn about different cultural and
  religious preferences, customs, and restrictions,
  and the use this knowledge in planning and
  providing care. (Mauk, page 604)

50
Health Care Disparities

• Reframe the problem of health disparities from a
  racial issue to one of a phenotype/environmental
  mismatch (HTN and Vit D deficiency)
• The disparities to be discussed are the most
  significant health-related differences found
  among ethnic groups, based on Keppels research
• While not all of the disparities cited in
  Keppels study pertain directly to older adults,
  these differences among ethnic groups points to
  certain foci of nursing care that, if not
  addressed early, may carry into older age

51
European Americans

• Constitute majority of US population
• Christian denominations
• Protestant and Catholic
• Less likely to turn to religion for coping or
  problem solving
• Top 5 health disparities
• Smoking by pregnant women
• Drug-induced deaths
• Deaths from poisoning
• Deaths from melanoma
• Deaths from chronic lower respiratory disease
  before age 45

52
African Americans

• Second largest minority population
• Religion plays important part in health and
  wellness
• Equate good luck, good fortune, and good health
  with Being right with God.
• Disease and illness equated with Gods wrath
• Top 5 health disparities
• 1 and 2 new cases of gonorrhea
• Congenital syphilis
• New cases of AIDS
• Deaths due to HIV infection

53
Hispanic Americans

• Second largest population in the US
• Place high value on family, religion, and
  community
• Will seek homeopathic remedies and religious
  artifacts before engaging a health care provider
• Catholic but have been acculturated to the US
• Illness are categorized as hot or cold
• Top 5 health disparities
• Congenital syphilis
• New cases of tuberculosis
• New cases of AIDS
• Exposure to particulate matter
• Cirrhosis deaths
• Increased prevalence and mortality from DM and CHD

54
Asian/Pacific Islanders

• Majority in US are Chinese
• Naturalistic approach to health and illness
• Everything composed of opposing forces Yin and
  Yang and health depends on these forces
• To maintain balance
• Acupuncture
• Burning herbs on or near the body (moxibustion)
• Cupping
• Massage
• Herbs
• Movement and concentration exercises
• Top 5 health disparities
• New cases of tuberculosis
• Congenital syphilis
• No Pap test among females older than 18
• Exposure to particulate matter
• Carbon monoxide exposure

55
Native American Indians

• There are about 500 different Native American
  tribes in the U.S.
• Naturalistic approach to health and illness
• Religion is centered on legends of sacred spirits
  that take many forms
• Health beliefs and practices blend with religion
  and carry a magic facet
• Top 5 health disparities
• Fetal alcohol syndrome
• Smoking by pregnant women
• Alcohol-related motor vehicle deaths
• Cirrhosis deaths
• New cases of gonorrhea
• Alcoholism and diabetes are two major health
  problems among Native Americans

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Implications for Nursing

• Continue to help minorities have a strong voice
  in their care
• Use well elders as volunteers and staff
• Focus efforts and resources on those who are not
  being served and who lack resources target those
  who really need the care

57
Diversity in the Health Care Team

• Promote diversity
• Avoid stereotyping
• Learn about other cultures (become culturally
  competent)
• Overcome racism
• Decrease language barriers
• Learn effective health promotion strategies for
  those with varying lifestyles
• Educate self and others
• Draw on each individuals strengths

58
Providing Culturally Competent Care

• Racist comments from Patients
• Reporting
• Educating
• Redirecting
• Invisible groups/unheard voices
• Those with dementia
• Those living in group homes
• Providing culturally competent care
• Educate self about the culture that is unfamiliar
• Provide interpreters
• Involve family
• Honor religious or cultural requests when possible

59
Providing Spiritually Competent Care

• Spirituality related to a sense of well being in
  the elderly
• Many use prayer and faith as successful coping
  strategies
• Provide opportunity to practice religion
• Incorporate spiritual leader into the team if
  needed

60
Lifestyles and Health Promotion

• Taking lifestyle into account when promoting
  health
• Changes related to disease or illness
• Activity level
• Preferences
• Past practices
• Patient adherence
• Individualize care plan
• Periodically check to be sure plan is working
• Make adjustments as needed
• Continue to support

61
Enhancing Sexual Intimacy

• A basic human need of people of all ages is
  intimacy
• Sex is not seen as a priority for either patient
  or provider
• Most sexual concerns that result from aging or
  chronic health problems are within the realm of
  nursing practice
• Most health promotion strategies have the
  potential to make a positive impact on sex

62
Sexual Revolutions

• Roaring 20s women gain the right to vote and
  gain sexual freedom
• 1948 Sexuality in the Human Male
• 1952 Sexuality in the Human Female
• 1960-1970 BCP available and abortion legal
• Discovery of HIV and promotion of safe sex
• ? Another one occurring with advent of better
  treatments for ED and vaginal dryness

63
Elders and HIV

• HIV/AIDs is on the rise among older adults
  partially because they often do not see
  themselves as being at high risk and thus take
  fewer precautions to prevent HIV infection
• See page 617 of text

64
Triphasic Model of Human Sexual Response

• Desire the sensations that move one to seek
  sexual pleasure may or may not change with aging
• Excitement increased muscle tone and
  vasodilitation of the genital blood vessels
  usually changes with age
• Orgasm climactic release of the genital
  vasodilation and muscle tone usually changes
  with age

65
Vaginal Dryness and Erectile Dysfunction

• Lubrication decreased in female
• Female changes can lead to dyspareunia (painful
  intercourse)
• Lengthened arousal and refractory period in men
• May not have orgasm with each experience
• ED a common problem for men

66
Obstacles to Intimacy

• Overcoming fatigue
• Plan for sex when rested
• Overcoming pain
• Plan for sex when pain is at its lowest level
• Hot bath, massage
• Adopting new sexual positions
• Consider the problem/condition
• Suggestions on page 621 of text

67
Romantic and Sexual Relationships in LTC

• Romantic and sexual relationships in long-term
  care
• Barriers
• Need to provide privacy
• Rooms for couples
• Stigma
• http//www.terranova.org
• Freedom of Sexual Expression Dementia and
  Resident Rights in Long-Term Care Facilities

68
Sexually Inappropriate Behavior

• Extinguish behavior while maintaining the dignity
  of the patient
• Confront calmly and firmly
• Redirect
• Do not tolerate
• Educate
• Consider disease processes such as dementia
• Provide privacy as needed