Drugs and Aging

Chapter 16

Drugs and Aging

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Drugs are important in the management of conditions and the maintenance of well-being in older adults.

All drugs carry some level of risk.

Important to understand how aging and conditions associated with aging can affect drug processes and actions.

Demographics of Drug Use

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Aging alters dynamic processes that drugs undergo to produce therapeutic effects.

Pharmacokinetic changes: what the body does to the drugs.

Pharmacodynamic changes: what the drug does to the body.

 

Changes in Drug Response With Aging

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Movement of a drug from site of administration to systemic circulation

Aging is accompanied by decreased secretion of gastric acid, slowed gastric emptying, and decreased gastrointestinal motility which may slow absorption of oral drugs.

The first dose of a new drug may take longer to take effect.

Reduction in subcutaneous fat alters topical drug absorption.

Pharmacokinetic Changes: Absorption

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Movement of drug from systemic circulation to site of action

Total body water decreases with aging; results in higher concentrations of water-soluble drugs.

Decreased lean body mass and increased percentage of fat storage offer increased storage capability for fat-soluble drugs.

Decreased protein available for binding may cause toxicity and difficulty maintaining stable drug levels of drugs that are highly protein bound.

 

Pharmacokinetic Changes: Distribution

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Biotransformation of drugs into metabolites that are more easily excreted

A decrease in hepatic blood flow occur that may result in a decrease in the amount of a drug inactivated before entering the systemic circulation causing a greater amount of active drug, increasing the risk that standard drug doses may have toxic effects.

 

Pharmacokinetic Changes: Metabolism

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Elimination of drugs from body primarily via kidneys

With decreased renal function, half-life increases and drugs may accumulate to toxic levels.

Renal function typically decreases with aging and the best indicator of renal function is glomerular filtration rate (GFR).

Pharmacokinetic Changes: Excretion

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Careful patient monitoring to assess adequacy of drug to achieve desired effect and to identify any adverse effects that can create problems for the patient

Become familiar with signs and symptoms of toxicity for each drug that the patient takes so that any problem is detected in the early stages

Important to understand therapeutic drug monitoring

 

Nursing Management

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Age-related changes affect all substances involved in pharmacodynamics.

Drug sensitivity may be either increased or decreased unrelated to drug levels.

Autonomic control and reflex activity become less responsive, may be less able to tolerate certain drugs.

Pharmacodynamic Changes

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Assess responses to drugs so therapy can be adjusted, if needed, to improve patient outcomes.

Nursing Management

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As result of the age-related changes in pharmacokinetics and pharmacodynamics some drugs and drug classes are less likely to be tolerated.

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is screening tool and list detailing inappropriate drugs for older adults.

Recognize that drugs considered appropriate and frequently prescribed may also carry serious drug-related risks.

Usage must be weighed in terms of benefit versus risk.

Inappropriate Drugs for Older Patients

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Important to view drugs in terms of desired versus undesired outcomes

Drugs may have detrimental effects on cognition, emotion, ambulation, continence, and other essential functions.

Negative effects on quality of life must be carefully considered as part of pharmacologic therapy.

Some patients may prefer to endure a condition rather than suffer an adverse effect so inquire why a patient refuses a drug and if substitution is available.

Drugs and Quality of Life

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Most common interaction is the result of altered metabolism via the CYP450 hepatic enzyme system.

Drugs can induce or inhibit the activity of various CYP isozymes, which causes increased or decreased biotransformation of drugs.

Drugs may interact indirectly through opposing or antagonistic actions.

Drugs may also interact chemically.

Drug–Drug Interactions

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These occur less commonly

Drug metabolism or effect of certain drugs can be altered when combined with certain foods

These dangerous interactions can cause drug levels to accumulate or reach toxic levels

Drug–Food Interactions

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These interactions may exacerbate patient conditions and hinder healing.

Drugs generally contraindicated in patients with coexisting underlying disease

 

Drug–Disease Interactions

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“Giving medications without a clear indication, giving two similar medications for the same indication, giving medications that are contraindicated, and/or giving medications where the dosage is either too high or too low”

Having one or more chronic conditions requiring several medications for management; may see more than one provider for the same health problem; may have prescriptions filled at more than one pharmacy

Additional contributors: use of over-the-counter and alternative medicines or supplements

Polypharmacy

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Assess whether a new symptom or problem could be caused by a drug the patient is taking.

Employ nonpharmacologic interventions, whenever possible.

Nursing Management of Polypharmacy

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The injuries resulting from patient harm are commonly referred to as adverse drug events (ADEs).

Study showed a marked increase in fatal drug errors among those who take their drugs at home.

Development of new drugs has resulted in an increase in the number of prescriptions for drugs.

Many patients may keep drugs long after they have expired rather than disposing of them.

Errors may occur when rights of administration are not followed.

 

Drug Errors

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Which of the following are true statements about pharmacology and the older adult?

 

Polypharmacy in older adults occurs when they get their prescription filled at many different pharmacies.

Because of age-related changes, older adults may be more sensitive to side effects of a drug, like dry mouth.

Older adults would rather have their condition treated and will put up with side effects.

The best indicator of renal function when monitoring a drug elimination is the creatinine level.

It is importance to ask about the over-the-counter and herbal medications the older adult is using.

Quick Quiz!

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ANS: A, B, E

 

Answer to Quick Quiz

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Often prescribed for older adults despite evidence demonstrating their “limited efficacy and significant adverse effects”

Have been prescribed for hitting, yelling, and screaming; refusing care and wandering; and, inconsolable crying, agitation, and aggression

These drugs do not help persons with dementia become more involved in their care, interact better with others, or stop inappropriate behavior.

These drugs increase risk for falls, fractures and breaks, incontinence, strokes, and death.

Antipsychotics

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Drugs used to treat insomnia and anxiety have the potential for bothersome and sometimes potentially dangerous adverse effects.

Often occur secondary to medication side effects or to medical conditions such as dementia, thyroid abnormalities, or depression

Barbiturates are not recommended.

Benzodiazepines with long half-lives should be avoided.

Antihistamines are potentially inappropriate drugs for use in older adults.

Anxiolytics and Hypnotics

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For anxiety, non–central nervous system (CNS) depressants such as buspirone are effective agents.

For sleep short-term treatment with benzodiazepine receptor agonists (BZRAs)—zolpidem; pyrazolopyrimidines—zaleplon; and melatonin receptor agonists—ramelteon are appropriate, short-term, alternatives

Better Options for Insomnia and Anxiety

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Selective serotonin reuptake inhibitors (SSRIs) are generally first choice because they are better tolerated.

Side effect profile of an antidepressant may be used to identify the most appropriate drug for a patient’s depressive symptoms.

Antidepressants

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Which of the following medication orders for an older adult would the nurse question?

 

Zolpidem for sleep prn

Haldol for behavioral management of dementia

BuSpar for anxiety prn

Sertraline (Zoloft) daily for depression

Quick Quiz!

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ANS: B

Answer to Quick Quiz

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Drugs used for managing hypertension are also used to manage other cardiovascular conditions.

Chlorthalidone first-line therapy

Second drug is determined by the benefits and risks: BBs improve mortality rates for patients with history of cardiovascular disease.

CCBs decrease cardiac workload through decreasing peripheral resistance.

ACEIs and ARBs decrease chances of cardiac mortality in patients with heart failure, good for diabetes mellitus.

 

Cardiovascular Drugs (1 of 2)

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JNC 7 recommends selecting hypertensive treatment based on comorbid conditions or compelling indications.

Main concerns with use of antihypertensive medications are increased risk of orthostatic hypotension and dehydration.

Reduced kidney function

Decreased sense of thirst, and intake of fluids

Cardiovascular Drugs (2 of 2)

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Infections may cause devastating health events because of decreased physiologic reserves.

Reduced renal function leads to dosage adjustments for certain antibiotics.

Antibiotic resistance may hinder finding the right treatment mix.

Common antibiotic side effects such as diarrhea may create significant and even dangerous shifts in fluids and electrolytes.

 

Antimicrobials

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Largest consumers of nonprescription drugs

Often believe drugs available over-the-counter are safe

May not know that any drugs with nonprescription status have a potential for significant harm in older populations

May not volunteer information about the use of over-the-counter medications, increasing the potential for drug–drug interactions

 

 

Nonprescription Agents

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Includes vitamins, minerals, herbal remedies, and alternative medicines

49% take dietary supplements on a regular basis.

Are not regulated for safety and efficacy by Food and Drug Administration (FDA)

Have inherent adverse effects, particularly when taken in large doses

Dietary Supplements

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Nonadherence is failure to stick to the agreed-on drug regimen.

Most common reasons for nonadherence include cost of medications, side effects or fear of side effects, complex scheduling, age-related changes, and belief that drugs are either ineffective or unnecessary.

In one-third of older adults prescription-related costs contribute to nonadherence causing some patients decrease or skip doses.

Drug Adherence

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Are the prescribed medications costly or do they present a substantial burden to the patient?

Do the prescribed drugs have the potential for or does the patient have side effects?

Are medication schedules interfering with the patient’s daily activities or sleep?

Does the patient have any conditions that would make opening bottles, manipulating individual tablets, or swallowing medications difficult?

Medication Adherence: Checklist (1 of 2)

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Does the patient have difficulty reading and comprehending instructions?

Does the patient believe that any of the prescribed drugs are ineffective or unnecessary?

Does the patient have any cultural beliefs that would cause him or her to disdain reliance on drugs or regard certain medications as inappropriate?

 

 

Medication Adherence: Checklist (2 of 2)

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Have patient bring all prescription and over-the-counter medications and any dietary supplements

Patient teaching is essential and is rarely sufficient to evoke change.

Need to understand factors contributing to patient’s failure to take medications as directed

Develop risk-specific assessments and interventions individualized to the patient

Strategies for Improving Adherence (1 of 2)

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Encourage all patients to have prescriptions filled at the same pharmacy each time to provide an extra way to discover problems.

Nurses should tailor medication regimen to patient’s home schedule to cause the least disruption in daily life and give the patient a sense of control over medications.

Review the medication list for problems.

 

Strategies for Improving Adherence (2 of 2)

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You are the home care nurse visiting an older adult in his home. You notice that he has not been taking his medications as prescribed. What are some of the reasons for noncompliance? Discuss strategies you would use to increase his compliance.

 

Quick Quiz!

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Answers will vary.

Answers to Quick Quiz

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Illicit drugs: cocaine, opiates, and marijuana are more prevalent as Baby Boomers retire.

Misused substances include alcohol, prescription and nonprescription drugs (marijuana and cocaine), and tobacco.

Misuse of alcohol is related to bereavement, retirement, loneliness, or physical and emotional illnesses.

Abused prescription medications are opioids, benzodiazepines, sedatives, tranquilizers, and stimulants.

 

Substance Use Disorders (SUD)

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The physiologic, psychological, and sociological changes associated with aging make the identification and treatment of SUD and related disorders difficult.

Changes and symptoms can be subtle or atypical and can mimic symptoms of SUD.

Difficulty in Identification of SUD

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Patients with early-onset alcohol use disorder (AUD) appear to have a more severe course of illness than late onset AUD.

Nurses should be aware of age-related physiologic changes of absorption, distribution, plasma protein-binding, hepatic metabolism, and elimination or clearance of a drug and assess for these changes.

Physiologic Changes

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Result primarily from the numerous losses this age group experiences in a relatively short period.

Heavy drinking is often in response to bereavement, retirement, loneliness, relationship stress, and physical illness.

May become dependent on prescribed benzodiazepines

Assess for suicidal ideation

Psychologic Changes

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Decreases in finances, transportation, and social support tend to place older adults at risk for SUD.

Mail-order pharmacies tend to increase the potential for drug abuse and misuse as a result of prescription errors, late arrivals, and large quantities of drugs.

There is a lower incidence of SUD in cultures whose religious and moral values prohibit or limit their use.

Sociologic Changes

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Assess medical and psychological histories

Two commonly used tools are the CAGE (Cutdown, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) and the Michigan Alcoholism Screening Test (MAST)

Patients undergoing detoxification from AUD should be assessed with the Clinical Institute Withdrawal Assessment tool on an ongoing basis.

Can you name at least seven Nursing Diagnoses for SUD?

SUD Assessment and Nursing Diagnosis

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Inadequate family therapeutic management

Anxiety

Inadequate thermoregulation

Confusion

Inadequate coping

Disrupted family routines

Inadequate nutrition

Reduced self-care ability (bathing, dressing, feeding, or toileting)

Reduced body image

Reduced sleep pattern

Reduced social interaction

Potential for self-directed violence

Potential for outward-directed violence

 

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Effective interventions attend to the multiple needs of individuals, not just their drug or substance use.

Must address medical, nursing, psychologic, social, vocational, and legal problems

Interventions and treatment options include brief therapy, intensive outpatient or inpatient treatment, and residential treatment.

SUD Nursing Interventions

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Assessment of safe detoxification: weaned from the misused substance without seizures, delirium tremens (DTs), changes in vital signs, or other complications of withdrawal

Assessment of adherence to the sobriety treatment plan, and outpatient support by noting if the patient is abstaining from substance use and attending meetings AA or NA and individual or family group sessions

SUD Evaluation

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Symptoms of anxiety, nervousness, memory impairment, depression, blackouts, confusion, weight loss, and falls

Assess for impaired sensations in extremities, poor coordination, confusion, facial edema, alcohol on the breath, liver enlargement, jaundice, ascites, trembling or fidgeting, personal hygiene, and eating habits

Liver function and levels of electrolytes, glucose, and magnesium, as well as ECG

Alcohol Use Disorder (AUD) Assessment

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Signs associated with alcohol intoxication: Scent of alcohol on the breath, slurred speech, lack of coordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma

Signs of alcohol withdrawal: elevated blood pressure and pulse, autonomic hyperactivity, fever, increased hand tremors, insomnia, nausea and vomiting, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, anxiety, and grand mal seizures may occur.

Alcohol Intoxication vs. Alcohol Withdrawal

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Observe and document withdrawal, provide an environment of low stimulation, and initiate seizure precautions.

Administer drugs used to reduce symptoms of withdrawal and prevent complications.

Support patient with (1) education on the harmful effects of alcohol, (2) various methods to overcome potential triggers for future substance abuse, and (3) various plans to maintain sobriety in the community setting.

AUD Interventions

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Safe detoxification: Patient has been weaned from the abused substance without seizures, delirium tremens (DTs), or other withdrawal complications

Adherence is measured by noting if the patient is abstaining from substance use and attending meetings.

Outpatient support is assessed to determine whether the patient is maintaining relationship with a sponsor.

 

 

AUD Evaluation

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Number of medications prescribed is directly correlated to risk of inadvertent misuse.

Polypharmacy

Drugs commonly used: cardiovascular medications, benzodiazepines, diuretics, cathartics, antacids, thyroidal medications, and anticoagulants

 

Prescription Drug Misuse: Prevalence

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Take a careful history, using the CAGE, MAST, BMAST, or MAST-G screening tools

Assess for a tendency to repeatedly lose prescriptions or pills, prescriptions from multiple physicians, frequent emergency department visits, strong preferences for particular medications

Assess for signs associated with withdrawal

Prescription Drug Misuse: Assessment

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Ask patient or family member to bring in all medications currently in use and inform physician.

Document signs of withdrawal, provide an environment of low stimulation, and implement seizure precautions.

Administer, on a planned reduction schedule, any medications prescribed to minimize withdrawal symptoms.

Offer nutritional support interventions for patients with compromised nutritional status.

Prescription Drug Misuse: Interventions

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Assessment of safe detoxification, participation in a rehabilitation treatment plan, and decreased drug-seeking behaviors

Observe and document patient’s response to teaching

Prescription Drug Misuse: Evaluation

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Tobacco use is the single greatest cause of preventable disease and disability.

Tobacco use is a risk factor in 6 of 13 leading causes of death in older adults.

Many tobacco users 50 years or older express a desire to quit; however, only those with chronic illnesses tend to have the motivation to do so.

Tobacco Use Disorder (TUD): Prevalence

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Assess tobacco use pattern and signs of nicotine withdrawal: Depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, and increased appetite

The CAGE questionnaire can be modified, substituting the word smoking for alcohol.

TUD: Assessment

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Include monitoring for signs of withdrawal, administration of nicotine replacement, behavior modification, and education.

Type of nicotine replacement used is determined by the physician.

If nicotine replacement is not tolerated may respond to bupropion or varenicline.

Evaluation includes assessment for decreased use of tobacco, adherence to a plan to reduce tobacco use, and understanding of the effects on the body.

 

TUD: Interventions and Evaluation

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As many as 7.2% of older adults use illicit drugs; prevalence is expected to increase as more Baby Boomers reach retirement age.

Older adults should be screened for drug misuse.

Future Trends

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