Chapter 7 Medications and Older Adults Copyright 2012

Lesson 7. 1 Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of

Objectives Identify factors that increase the risk of medication-related problems. Discuss the reasons each

Objectives (cont. ) Identify the risks related to aging and pertinent nursing observations for

Risks Related to Drug-Testing Methods Copyright © 2012, 2008 by Mosby, Inc. , an

Geropharmacology The study of how older adults respond to medication is a new but

Risks Related to the Physiologic Changes of Aging Copyright © 2012, 2008 by Mosby,

Pharmacokinetics Study of drug actions in the body: absorption, distribution, metabolism, and excretion Drug

Pharmacokinetics (cont. ) Drug distribution Water-soluble drugs tend to remain in higher concentrations in

Pharmacokinetics (cont. ) Drug metabolism Aging often results in decreased activity of liver cells

Audience Response System Question 1 The organ that is the primary site of drug

Pharmacokinetics (cont. ) Drug excretion Aging kidneys are significantly less effective at removing waste

Pharmacodynamics Polypharmacy The prescription, administration, or use of more medications than are clinically indicated,

Polypharmacy Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc.

Risks Related to Cognitive or Sensory Changes Copyright © 2012, 2008 by Mosby, Inc.

Cognitive Changes Lack of the literacy skills needed to read the labels and directions

Sensory Changes Vision changes may render an older person unable to read a medication

Risks Related to Inadequate Knowledge Copyright © 2012, 2008 by Mosby, Inc. , an

Sharing Medications With Friends or Relatives Practice is common and persists because many older

Over-the-Counter (OTC) Preparations Many do not think of OTC medications as “real” drugs, because

Alcohol The most commonly consumed nonprescription drug used by adults Most older adults do

Prescription Medications The directions provided may be very clear to a knowledgeable health care

Risks Related to Financial Factors Copyright © 2012, 2008 by Mosby, Inc. , an

Saving Money Older adults living on limited incomes may fail to take their medications

Medication Administration in the Institutional Setting Copyright © 2012, 2008 by Mosby, Inc. ,

Safe Drug Administration Before administering a medication, nurses should have the following information The

Lesson 7. 2 Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of

Objectives Discuss how medications fit into the nursing plan of care. Describe specific nursing

Nursing Assessment and Medication Copyright © 2012, 2008 by Mosby, Inc. , an affiliate

Assessment Nurses must be sure to assess older residents thoroughly before administering any medications

CARE Acronym for Medication Assessment C – Caution/compliance A – Adjust R – Review

Drug Categories with Precautions Related to Aging There are many drug categories that have

Medications and the Nursing Care Plan Copyright © 2012, 2008 by Mosby, Inc. ,

Nursing Interventions and Precautions Could include the use of safety devices, call signals, behavior

Nursing Interventions Related to Medication Administration Right resident Right medication Right amount Right dosage

Right Resident Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier

Audience Response System Question 2 The most accurate way to verify identity is to

Patient’s Rights and Medications Copyright © 2012, 2008 by Mosby, Inc. , an affiliate

Patient’s Rights Right to know what medication they are receiving and why they are

Self-Medication and Older Adults Copyright © 2012, 2008 by Mosby, Inc. , an affiliate

In an Institutional Setting Under OBRA legislation, residents of care facilities should have the

In the Home Because medications are a significant part of the medical plan of

Teaching Older Adults About Medications Copyright © 2012, 2008 by Mosby, Inc. , an

Safety Alert Identification must be checked (following agency policies) each time a medication is

Safety and Noncompliance Issues Copyright © 2012, 2008 by Mosby, Inc. , an affiliate

Risk for Noncompliance Cognitive and sensory limitations Special precautions and complicated time schedules To

Techniques That Improve Safety and Compliance Associating medication schedules with regular daily events Explain

Techniques That Improve Safety and Compliance (cont. ) Modify containers for ease of use

Audience Response System Question 3 Why do older persons sometimes fail to ask questions

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Objectives Identify factors that increase the risk of medication-related problems. Discuss the reasons each of these factors increases health risks for the aging person. Describe how pharmacokinetics changes with aging. Discuss the pharmacologic dynamic changes observed in the aging person. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 3

Objectives (cont. ) Identify the risks related to aging and pertinent nursing observations for specific drug categories. Explain specific precautions necessary when administering medications to older adults in an institutional setting. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 4

Geropharmacology The study of how older adults respond to medication is a new but growing area Drug testing and establishing of therapeutic dosages does not take into account the unique characteristics of older adults Older adults normally have some change in body function and are more likely to suffer from at least one disease process; they are not physiologically the same as younger adults Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 6

Pharmacokinetics Study of drug actions in the body: absorption, distribution, metabolism, and excretion Drug absorption Gastric acid secretion decreases as we age Ø When the concentration of acid is lower than normal, drug absorption is reduced Ø Decreased acidity also affects the breakdown of capsules and tablet coatings in the stomach, resulting in a variable absorption rate depending on the way a drug is manufactured Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 8

Pharmacokinetics (cont. ) Drug distribution Water-soluble drugs tend to remain in higher concentrations in the bloodstream because there is less total body water Ø Fat-soluble drugs become trapped in the fatty tissue because of decreased muscle mass and increased adipose tissue Ø A decrease in hemoglobin and the plasma protein albumin results in fewer available sites for proteinbound drugs Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 9

Pharmacokinetics (cont. ) Drug metabolism Aging often results in decreased activity of liver cells Ø Reduction in perfusion decreases the liver’s effectiveness in metabolizing drugs Ø When drugs are not metabolized effectively by the older adult’s liver, the risk for toxicity increases Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 10

Audience Response System Question 1 The organ that is the primary site of drug metabolism is the: A. kidney. B. pancreas. C. lungs. D. liver. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 11

Pharmacokinetics (cont. ) Drug excretion Aging kidneys are significantly less effective at removing waste products, including the byproducts of medications Ø As the kidneys become less effective in the excretion of drugs, more drug remains in the circulation, leading to elevated drug levels and symptoms of drug toxicity Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 12

Pharmacodynamics Polypharmacy The prescription, administration, or use of more medications than are clinically indicated, is a common problem in older adults Ø The more medications taken, the greater the risk for untoward reactions, drug interactions, and drug toxicities Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 13

Cognitive Changes Lack of the literacy skills needed to read the labels and directions Inability to understand comply with directions Inability to make correct judgments about medications May not recognize that they have to take medication Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 16

Sensory Changes Vision changes may render an older person unable to read a medication label or to recognize the different sizes, shapes, or colors of the various medications Adequately assessing the person’s ability to read labels accurately, proper teaching, and using special labels or magnifying devices may help reduce the risks Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 17

Sharing Medications With Friends or Relatives Practice is common and persists because many older adults are unaware of the dangers All people, particularly older adults, must be aware that it is not safe to take a medication prescribed for someone else Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 19

Over-the-Counter (OTC) Preparations Many do not think of OTC medications as “real” drugs, because no prescription is needed to purchase them OTC medications are capable of potentiating or interfering with the effects of prescription medications, possibly resulting in serious harm Can also create or mask symptoms of disease Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 20

Alcohol The most commonly consumed nonprescription drug used by adults Most older adults do not think of alcohol as a drug, so they do not think about it when taking medications Alcoholic beverages can cause adverse reactions when taken in conjunction with many prescription and OTC drugs Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 21

Prescription Medications The directions provided may be very clear to a knowledgeable health care professional, but they are often misunderstood or misinterpreted by older adults Even simple misunderstandings can lead to improper self-medication and result in serious consequences To reduce the risks, older adults often require additional instruction Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 22

Saving Money Older adults living on limited incomes may fail to take their medications or may make changes in the amount or frequency to conserve their supply Many frugal older adults save medications that were prescribed in the past, even if the drugs are no longer part of their therapy Often reluctant to discard costly medications, holding on to them “just in case. ” Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 24

Safe Drug Administration Before administering a medication, nurses should have the following information The therapeutic effects of the medication Ø The reasons this individual is receiving the medication Ø The normal therapeutic dosage of the medication Ø The normal route or routes of administration Ø Any special precautions related to administration Ø The common side effects or adverse effects of the medication Ø Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 26

Objectives Discuss how medications fit into the nursing plan of care. Describe specific nursing interventions and modifications in technique related to medication administration in older adults. Describe the older person’s rights as they relate to medication administration. Discuss the impact of age-related changes on self-administration of medications. Identify information that should be provided to older adults regarding medications. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 28

Assessment Nurses must be sure to assess older residents thoroughly before administering any medications After administration, nurses should monitor older adults continually to determine whether the medication is having the desired effect Residents should also be observed for any untoward effects or significant changes in medical condition or behavior Nurses should be particularly watchful for any signs of overdose or toxicity Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 30

CARE Acronym for Medication Assessment C – Caution/compliance A – Adjust R – Review regimen regularly E – Educate Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 31

Drug Categories with Precautions Related to Aging There are many drug categories that have precautions related to their use among the elderly. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 32

Nursing Interventions and Precautions Could include the use of safety devices, call signals, behavior monitoring, or any other specific precaution related to medications The care plan should indicate when it is necessary to check vital signs, monitor laboratory values, or make any other special observations All parameters specified by the physician should be readily identified in the care plan Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 34

Nursing Interventions Related to Medication Administration Right resident Right medication Right amount Right dosage form Right route Right time Right documentation Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 35

Audience Response System Question 2 The most accurate way to verify identity is to compare the medication record with the identification bracelet. A. True B. False Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 37

Patient’s Rights Right to know what medication they are receiving and why they are receiving it Right to refuse to take medication Right to privacy during injections or any other such procedures Use of psychotropic drugs as chemical restraints presents a risk to the rights of older adults Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 39

In an Institutional Setting Under OBRA legislation, residents of care facilities should have the option of selfmedication if they are capable of doing so safely A physician’s order stating that selfmedication is permitted is usually required The nurse remains responsible for monitoring the resident’s compliance and response to the medications Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 41

In the Home Because medications are a significant part of the medical plan of care, older adults who live independently must learn to take them properly The responsibility of assessing medicationtaking behaviors and teaching safe selfadministration often falls to the home health care nurse Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 42

Safety Alert Identification must be checked (following agency policies) each time a medication is administered Failure to do this can result in serious errors and harm to older adults Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 44

Risk for Noncompliance Cognitive and sensory limitations Special precautions and complicated time schedules To reduce the risk for noncompliance, nurses should encourage older adults to talk to the physician and/or the pharmacist to see whethere is any safe way to reduce the number of medications or simplify the medication schedule Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 46

Techniques That Improve Safety and Compliance Associating medication schedules with regular daily events Explain the importance of preparing medication in a well-lit area Ensure that containers are properly labeled Apply color codes, tape strips, pictures, or textures to containers to help older adults recognize them Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 47

Techniques That Improve Safety and Compliance (cont. ) Modify containers for ease of use Establish measures to distinguish and separate similar containers Teach older adults to store medications properly Obtain or devise a system to promote compliance Stress the importance of being alert when taking medications Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 48

Audience Response System Question 3 Why do older persons sometimes fail to ask questions about their medications? A. They are illiterate. B. They are afraid of being judged as ignorant or bothersome. C. They already know everything they need to know. D. They know the nurse is not the person to ask about their medications. Copyright © 2012, 2008 by Mosby, Inc. , an affiliate of Elsevier Inc. All rights reserved. 49