Chapter 8 Medication and Laboratory Values

Demographics
Today, the geriatric population makes about 13% of the general population. It is expected to increase to greater than 20% by the year 2030.

 Elderly patients however, consumes about 33% of all prescription and OTC drugs . Overall, the elderly have more disease states than the other age groups and therefore require the use of more medications.

 Thus effective and safe drug therapy is one of the greatest challenges within the elderly population.

The effects of Aging on Drugs

Normal aging is associated with certain physiological changes that can significantly influence drug response. Both pharmacokinetics and pharmacodynamics play a role in how a person will respond to drug.

Pharmacokinetics
Is the time course by which the body absorbs, distributes, metabolizes and excrete drugs. In other words, it speaks to how drugs move through the body and how quickly this occurs.

Absorption
Is defined as the movement of a drug from the site of administration, across biological barriers, into the plasma. But as the age increases, it decreases the rate of absorption.

Distribution
Is the movement of a drug from the plasma into the cells. As patient age, total body water declines and fat stores increases.

Pharmacodynamics
Is the time course and effect of drugs on cellular and organ function. In other words, it is what drugs do once theyre in the body.

Drug related problems in the Elderly About one third of drug related hospitalizations occur in persons over 65 years old. Even though medications provide benefit by preventing and treating disease, older people, are more susceptible to drug related problems including adverse drug reactions, polypharmacy, inappropriate prescribing and non compliance

Adverse Drug Reactions

The World Health Organization defines ADR as any noxious, unintended and undesired effect of a drug, which occurs at doses used in humans for prophylaxis, diagnosis or therapy.

Polypharmacy
It is defined as the prescription, administration, or use of more medications than are clinically indicated in a given patient.

Disease
Benign Prostatic hyperplasia

Drugs Anticholinergics

Adverse Reaction Urinary Retention

Bronchoconstriction, repiratory depression

COPD
Dementia Depression Diabetes Glaucoma HPN HypoKalemia Hyponatremia

B-Blockers
Opioids Corticosteroids Corticosteroids Anticholinergics NSAIDS Digoxin Diuretics,SSRI

Confusion, Delirium
Precipitation or exacerbation ofdepression

Hyperglycemia Exacerbation of glaucoma Increase BP Cardiac arrythmias

Decreased Sodium concentrations

Orthostatic
Ostopenia Parkinsons Peptic ulcer

Tricyclic anti dep

Corticosteroids Antipsychotics Anticoagulants,NSAIDS

Dizziness, falls, hip fracture

Fracture
Worsening movement disorder

Upper GI bleeding

Compliance
Although age does not affect compliance, about 40% of elder persons do not adhere to their medication regimen. The more complex the medication regimen, the less likely the patient will comply.

Reasons for not complying to medications in the elderly

Trying to avoid the side effects and therefore reducing the amount of drug consumed. Lack of money Forgetfulness (early dementia)

Compliance can be encourage by

Establishing a good relationship with the patient. Providing education about possible side effects Providing clear instructions for how the medication should be taken.

 Encouraging questions from the patient And providing home nursing support as needed.

Potentially inappropriate medications for Geriatric patients

There is a benefit/risk relationship with consumption of any medication. The benefit of medication is use to provide positive outcomes; the risk may include unwarranted side effects.

 There are several medications available on the market that provide excellent results but are not ideal for use in elderly patients.

Laboratory Values
Lab results for older adults differ from those younger adults thus reference ranges or normals may be different.

Medications to avoid in the Elderly

Medication Effect

Propoxyphene(Darvon)and combination products(Darvon with ASA etc)

Amitriptyline

Offers few advantages over acetaminophen yet has the same adverse effects as other narcotic meds
Strong cholinergic and sedation effects May cause confusion and sedation

Benadryl

All barbiturates

Highly addictive

Medications to avoid in the Elderly

Medication Effect

Demerol

May cause confusion

Catapres

Potential for orthostatic HPN and CNS adverse effects Potential for aspiration and adverse effects Lack of cardioprotective effect in older women; evidence of carcinogenic potential

Mineral Oil

Estrogens only

Medications to avoid in the Elderly

Medication

Effect

Macrodantin

Potential for renal impairement

Cimetadine (tagamet)

CNS effects including confusion

Indomethacin

CNS adverse effects; other NSAIDS available with fewer adverse effects Anticholinergic effects, sedation, weakness

Methacarbamol

Changes in Lab Values with Age

Increased with Age Alkaline phosphate ANA C-reactive protein Cholesterol, total Clotting factors VII and VIII Copper

Decreases with Age Albumin Aldosterone Serum Calcium HDL cholesterol (women) Creatinine kinase Creatinine clearance

Unchanged with Age Hepatic function test Coagulation tests Biochemical test (serum electrolytes, total protein.) Arterial blood tests Renal function tests Thyroid function tests

Changes in Lab Values with Age

Increased with Age D-dimersen Ferritin Fibrinogen Gastrin 2 h pp glucose Interleukin 6

Decreases with Age Dihydroepiandrosterone 1,25-dihydroxyvitamin D Estradiol Growth hormone IGF-1 Interleukin 1

Unchanged with Age CBC ( HCT, HGB, erythrocyte indices)

Changes in Lab Values with AGE

Increased with Age PSA PTH

Decreases with Age Magnesium PaO2

Unchanged with Age

Rheumatoid factor
Sedimentation rate Triglycerides Uric Acid

Phosphorus
Platelets Free testosterone Total protein Zinc, serum

Lab values and Medication Administration

Laboratory values and medication administration go hand in hand. Lab work may be done to: Monitor compliance w/ medication administration Check for therapeutic or toxic levels of medication in blood

 Evaluate the bodys ability to metabolize medications. Evaluate the need for medications to treat a condition.

Medication blood levels (Therapeutic blood levels)

The amount of medication circulating in the blood can be monitored for some medications. This may include monitoring for blood levels of medications taken on a routine basis or in an emergency situation where drug overdosed is suspected.

 Measuring medication blood levels is important for monitoring the metabolism of the medication so that the correct dosage can be given at the correct intervals to obtain the best results without side effects or adverse effect or adverse drug reactions.

Random medication level in blood

Random levels are not dependent upon the administration time of the medication. The blood level is drawn the order is received.

Trough medication levels in the blood

Are dependent the administration times of the medication. Is drawn at the time that the blood level is expected to be at its lowest: right before a dose is due.

Peak medication level in blood

Are also dependent upon the time of administration. This varies according to the route of administration. The peak is typically drawn within a set of time after a dose is given and trough follows right before the next dose is given

Renal and Hepatic Function

Drugs are metabolized differently in older adults. The kidneys and liver may not function well as in younger persons. This can affect how medication are cleared from the body and likelihood of side effects or toxic levels of medications.

Lab test that is used to monitor the function of kidneys and liver
Blood Urea Nitrogen (BUN) it is used as a gross measure of glomerular function and the production and excretion of urea. Creatinine is a substance removed from the body by the kidneys. Measurement of the creatinin level will give a clue as to the function of the kidneys.

 Alkaline phosphatase is an indicator of liver disease. Levels in the blood will rise when excretion of this enzyme is impaired.

Normal Laboratory Values (Serum)

Test Blood Urea Nitrogen Body System Renal Normal Levels 7-23 mg/dl
Male, 13 yrs adult 0.7-1.7mg/dl Female, 13 yrs -adult 0.4-1.4mg/dl

Creatinine
Albumin Alkaline phosphate

Renal
Hepatic Hepatic

3.2-5.2 g/dl 34-122 u/l

ALT
AST Direct bilirubin Indirect bilirubin Total Protein

Hepatic
Hepatic Hepatic Hepatic Hepatic

9-51 u/l
13-38 u/l 0.0-0.3 mg/dl 0.1- 1.1 mg/dl 6.0-8.0 g/dl

Challenges to successful medication regimens for the older adult

For medication to work properly, the right drug must be taken in the right amount, by the right route at the right time by the right patient.

Failure to follow these five rights can delay or prevent the outcome intended by the health care provider.

Other issues that interfere with Medication Administration

Hearing
The ability to hear instructions given by the health care provider or pharmacist is a very important part of the ability to take medications accurately and safely.

 Vision
Another sense that is important to help ensure adherence to prescribed medication to regimens. The ability to find and read the label of medication.

 Memory/Cognition
Impaired memory can be a barrier to adherence with medication routiness. Remembering which medications to take and at what times can be difficult if memory is impaired.

 Motivation
Is important in adherence to a medication routine. There must be motivation to obtain the medication, to learn about the medication, to take the medication on time and to report inability to take the medication to the physician.

 Funding
Many older adults have difficulty purchasing medications due to costs.

Nursing Intervention
Nurses in all settings have a responsibility to help ensure that the five rights are followed for each patient. Specific interventions include:

Medication review Education - ensures that the patient understands the medication instructions etc.

 Accommodation note sensory, motor, cognitive limitations that the patient may have that could interfere in the medication Funding assess the patients ability to pay for medications

Medications for Dementia

There are several drugs on the market for dementia, although there is as yet no cure these medications help to slow the progress of the disease.

Four medications commonly used in patients with Alzheimers dementia are

 Tacrine (cognex)
Is taken 4 times a day Can potentially affect the liver, so liver enzymes must be closely monitored. Side effects: Nausea, vomiting, diarrhea, abdominal pain, rash and indigestion.

 Donepezil (Aricept)
Probably the most widely used drug although it does not cure Alzheimer or keep it from getting worse. It does help relieve some of the memory loss. Most effective in early stages of the disease. 5mg-10mg per day OD Side effects diarrhea, vomiting, nausea, fatigue, insomnia and weight loss.

 Galantamine (Reminyl)
Prevents breakdown of acetylcholine and stimulates nicotinic receptors to release more acetylcholine in the brain. Taken twice a day Side effects diarrhea, vomiting, nausea, fatigue, insomnia and weight loss.

 Rivastigmine tartrate (Exelon)

It prevents breakdown of acetylcholine and butyrycholine in the brain Taken twice a day Side effects diarrhea, vomiting, nausea, fatigue, insomnia and weight loss, upset stomach and muscle weakness.

Medications for Osteoporosis

Osteoporosis makes the older person more susceptible to fractures and changes the posture, thus placing strain and stress on muscles and joints and it can even affect height. There are two main types of drugs that are used to prevent and treat osteoporosis: antiresorptives and anabolic or bone forming agents

 Antiresorptives
Slows the rate of bone remodeling but cannot rebuild bone. Medications in this category include biphosphonates, hormone replacement therapy and SERMs

 Anabolic or bone formation agents

Medication include: parathyroid hormone and flouride

Medications for Anxiety

Benzodiazepine Antidepressants Buspirone

Chapter 9
Teaching Older Adults

Adult Learning theory

Develop by Malcom Knowles

Which is commonly used in teaching adults, has motivation and relevance as two key concepts.
Using andragogy as common principle.

Theory of self efficacy

Sheds some light on the behavior of older adults. Suggest that persons self efficacy is related to their belief that their actions influence outcomes in their life.

 This theory states that self efficacy and outcome expectations affect behavior, motivational level, thought patterns and emotional reactions in response to any situation.

Social Cognitive theory

Also called as social learning theory. It suggests that outcome expectations are beliefs that when a person engages in a certain behavior, certain outcomes will result.

Older adults and lifelong learning

Recently, attitudes about aging have changed for the positive, related to the fact that there is an increasing number of baby boomers who see aging as a time in which quality of life issues are priority. This is guiding many groups to conduct retirement education to assist in the transition to retirement.

 Although older adults still expect the traditional retirement, 69% plan to work post retirement in positions related to teaching, office support, crafts, retail sales or health care. Despite the trends that support postretirement employment, 67% have concerns that age discrimination will be a major barrier in the workplace.

 Older learners prefer teaching methods that are easy to access and require small investments of time and money. They expect learning to begin immediately through direct hands on experiences. Reading materials such as newspaper magazines and books are used by 64% of older adults for learning.

Barriers to Older Adults Learning

Older adults may experience some unique barriers to learning. These include chronic illnesses, normal aging changes occurring with advancing age, health disparities and other factors that may accompany cultural diversity.

Physical changes in the Older Adults that can affect Learning

Reduced vision Reduced hearing Impaired cognitive function Depressions Stress Chronic illnesses Dementia

Technology for Older Adults Lifelong Learning

According to a 2008 PEW Internet Survey on older adults and use of the internet, 70% of those age 50-64 and 38% of adults 65 or older reported using the internet.

Problems that can be overcome by older adults using computers

Age Change Hearing Vision Motor control, tremors Effect on Computer Use Sound from computer may not be heard Vision declines, need for glasses. May affect the use of keyboard and mouse, consistently click. Possible Solutions Use of earphones to enhance hearing Adjust monitors screen resolution and fonts. Highlight area and press enter to avoid double clicking

Arthritis

May not be able to hold the Highlight area and press mouse and consistently enter to avoid double clicking. clicking Problems with inability to focus. Priming- introduce concepts early on

Attention span

Cultural diversity and health disparities among older adults

The issues of cultural diversity and health disparities cannot be ignored when considering educational issues for older adults. Diversity in terms of age, race, ethnicity, gender and socioeconomic status is an important factor to consider.

Implications for Gerontological Educators

Education must meet the needs of the older adult and these needs may change over the next several decades. The older adult cohort is not a homogenous group, but is composed of persons of different cultures, races education levels and socioeconomic statuses, all that factors can impact learning

Strategies for teaching Older Adults Individually

Education of older adults must be flexible. Nurses may teach in a variety of settings including one on one instruction at bedside in acute care or in the home or in group settings. Older Adults need to have motivation to learn.

Chapter 10
Promoting Independence in Later Life

 This adage, commonly heard, rings true when considering the factors that influence independence in later life. Health, personality, state of mind, and emotional, physical and spiritual support all have a place in the adjustments one makes to aging process.

 Although self care and health promotion are indeed important in maintaining independence, aging and accompanying health factors often make this a very difficult period of life. As a person moves from the earlier adjustments of aging (65-75) to the later ones (75-85), circumstances may become even more complex.