Therapeutic drug monitoring is a frequent practice in health care. How does age affect drug absorption, metabolization and excretion?

fter studying Module 3: Lecture Materials & Resources, discuss the following:

  • Therapeutic drug monitoring is a frequent practice in health care. How does age affect drug absorption, metabolization and excretion?
  • The use of salt substitutes can cause hyperkalemia in older adults when use in conjunction with what types of drugs?
  • Describe how you would prevent and evaluate risk factors for medication nonadherence in older adults?

Submission Instructions:

  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources
  • Chapter 15

    Laboratory and Diagnostic Tests

     

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    Aging does not affect the life span of an erythrocyte, but replenishment after bleeding may be delayed due to a decrease in hematopoietic tissue in the marrow of the long bones.

    Anemia may be unnoticed if it is mild.

    Anemia symptoms include fatigue, shortness of breath, and paresthesia.

    Chronic pulmonary disease or heart failure may led to overproduction of RBCs—polycythemia.

    Red Blood Cells

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    2

    Hematocrit and hemoglobin values decline slightly after the age of 90.

    Hemoglobin and Hematocrit

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    Decrease in leukocytes may be related to drugs or severe infection.

    Increase in leukocytes is generally seen with infections.

    White cell count may be only moderately elevated in older adults with infection like pneumonia.

    Other typical symptoms of infection such as fever, pain, and lymphadenopathy may be minimal or absent in older adults with infections, therefore look for sudden onset of confusion or lethargy.

    Drugs can also cause an increase in leukocytes.

     

    White Blood Cells

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    Reduced effect on the bone marrow to release and store neutrophils

    Impaired function of lymphocytes in vitro is suspected to cause a reduction in antibody response in later life.

    Possibility of decline in monocyte function leading to increased susceptibility to infections and increased incidence of malignancies

    Educating older adults about importance of participating in cancer screenings and maintaining immunizations throughout life are essential.

    Effect of Aging on White Blood Cells

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    5

    Decrease in folic acid can indicate macrocytic anemia, megaloblastic anemia, and liver and renal disease.

    Alcohol and various other drugs are known to interfere with absorption of folate.

    Anticonvulsants, antimalarials, and methotrexate decrease folic acid levels.

    Important to assess patients regarding their nutritional intake, including alcohol consumption habits

    Elevated levels of folic acid may be seen in people with pernicious anemia.

     

    Folic Acid

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    Deficiency is caused by malabsorption secondary to gastric bypass, pancreatic disease, ileal resection or inflammation, prolonged use of certain medications, and strict vegan diets.

    Malabsorption may be result from the effect of antibodies on gastric parietal cells and a decrease in intrinsic factor leading to pernicious anemia.

    Prevalence of pernicious anemia increases significantly with aging.

    Low B12 levels may cause fatigue, weakness, and memory loss.

    Vitamin B12

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    7

    Serum iron levels show progressive decreases with advancing age.

    Iron deficiency anemia is the most common form of anemia seen in older adults.

    Anemia is not a normal consequence of aging.

    Nurse should assess older adults for poor dietary intake of iron-containing foods and occult or chronic blood loss.

    Iron

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    8

    Excreted by the kidneys

    Estrogen thought to promote excretion of uric acid; elevated levels rarely seen in women before onset of menopause

    Altered levels may result from faulty excretion, overproduction of uric acid, or presence of other substances that compete for excretion sites.

    Elevated levels seen with gout

    Thiazide diuretics, caffeine, low-dose aspirin, and antiparkinsonian drugs can also increase uric acid.

     

    Uric Acid

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    9

    Increased PT seen in liver disease, vitamin K deficiency, bile duct obstruction, and salicylate intoxication

    Medications that cause increase in PT: allopurinol, cephalothin, cholestyramine, clofibrate, and sulfonamides

    Digitalis and diphenhydramine can cause decreased PT level.

     

    Prothrombin Time (PT)

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    Older adults are often prescribed the drug warfarin (Coumadin) after open-heart surgery and for chronic atrial fibrillation.

    Adequacy of warfarin therapy can be assessed by following patient’s PT level.

    The PT value is traditionally reported in seconds and includes a value called the international normalized ratio (INR).

    INR should be between 2 and 3 for most thrombosis and between 3 and 4 for patients with history of recurrent thromboembolism or mechanical heart valves.

    PT and Warfarin Therapy

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    11

    Heparin can inactivate prothrombin, so PTT is a good indicator of whether an older adult is receiving adequate anticoagulation therapy.

    Nursing considerations include monitoring for bleeding and correct administration of the heparin dosage.

     

    Partial Thromboplastin Time (PTT)

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    12

    Ordered when a person has symptoms of thrombus, embolus, or disseminated intravascular coagulation

    Age, vascular disease, and kidney or hepatic disease may affect test results.

    D-Dimer Test

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    13

    Indicates the presence of inflammation, so it is useful for monitoring the course of inflammatory activity in autoimmune diseases, infection, and cancers

    Mild elevations may be associated with advancing age.

    Due to the nonspecific nature of ESR values, interpret results in older adults in conjunction with subjective and objective findings on examination

    Erythrocyte Sedimentation Rate

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    14

    Marker present in acute phase of an inflammatory response

    CRP is useful in assessing patients with tissue injury (MI), autoimmune disease, or infection.

    C-Reactive Protein

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    15

    Which of the following statements about laboratory results are true for the older adult patient?

     

    Leukocytes may be only slightly elevated when infection is present.

    Patients with rheumatoid arthritis who are taking methotrexate need folic acid supplements.

    The most common type of anemia is pernicious anemia.

    The patient with gout who is taking thiazide diuretics may have more attacks.

    The therapeutic level of warfarin is assessed with the PTT.

    Quick Quiz!

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    16

    ANS: A, B, D

     

    Answer to Quick Quiz

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    17

    Decreases in platelet counts (to fewer than 100,000/mm3) require investigation.

    Half of patient’s over age 60 diagnosed with low platelets have Myelodysplastic syndrome (MDS) which can progress to leukemia.

    Spontaneous bleeding can occur when platelets are below 20,000/mm3.

    When 40,000/mm3 or below, prolonged bleeding after procedures can occur.

     

    Platelets

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    Older adults may have serious problems with electrolyte imbalance.

    Dehydration is the most common form of electrolyte disorder occurring in older adults.

    Usually attributed to excess loss of water or altered fluid intake

    Electrolytes

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    Index of body water deficit or excess

    Regulation maintains blood pressure, transmission of nerve impulses, and regulates body fluid levels in and out of cells.

    Movement of sodium affects blood volume, which is tied to thirst mechanism and total body fluids.

    Sodium

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    Increases with age, related to the kidneys’ inability to excrete free water because of decreased basal levels of renin and aldosterone

    Vague symptoms like malaise, confusion, headache, and nausea may progress to coma and seizures.

    Determine whether an older adult has low sodium level but normal osmolarity; this is known as hypertonic hyponatremia

    Excessive glucose, triglycerides, or plasma proteins in the blood cause normal or high osmolarity.

     

    Hyponatremia

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    Hypernatremia can occur from infusion of high-sodium solute fluids, excess water loss, and excessive diarrhea and decreased oral intake.

    Symptoms are like those of hyponatremia, and the most common neurologic signs are lethargy, weakness, progressing to altered consciousness, and coma.

    Hypernatremia

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    22

    Imbalances in older adults are caused by the same changes in the renal system as those affecting sodium.

    Salt substitutes are high in potassium and should be used with caution especially with potassium sparing drugs which can lead to hyperkalemia.

    Hypokalemia may be caused by gastrointestinal loss and the use of diuretics.

    Potassium imbalance may predispose older adults to tachyarrhythmias and potentiate digitalis toxicity.

     

    Potassium

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    23

    Hyperkalemia may cause muscle twitching, arrhythmias, and gastrointestinal symptoms.

    Hypokalemia muscle weakness, confusion, and absence of bowel sounds

    Signs and Symptoms of Hyperkalemia and Hypokalemia

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    24

    Closely tied to sodium

    Losses and excesses in sodium affect chloride levels.

    Chloride levels have not been shown to change with aging.

    Chloride

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    Changes in calcium regulation occur with aging but there is no alteration in serum calcium levels due to homeostasis.

    Loss of calcium from bone maintains the normal level of calcium in the blood, but the resulting bone loss secondary to calcium leaching can lead to osteoporosis.

    Calcium is protein bound with albumin so any change in albumin level also affects calcium.

    Calcium has an inverse relationship with phosphorous.

    Calcium

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    Mineral found mostly in bone, in combination with calcium.

    Phosphorus plays an important role in the maintenance of homeostasis.

    Phosphorus levels are slightly decreased in comparison with younger adults.

    Phosphorus

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    27

    Mineral important to enzyme action for production of energy

    Most important sites of function are muscles (especially the heart) and nerves.

    With aging, gastrointestinal absorption of magnesium decreases and excretion of magnesium by the kidneys increases, coupled with lower dietary intake can lead to hypomagnesemia.

    Magnesium

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    28

    Four methods of diagnosing diabetes are: Fasting plasma glucose, oral glucose tolerance test, glycohemoglobin (hemoglobin A1c HbA1c), random blood sugar

    Glucose metabolism alters with aging; reduced insulin effectiveness and islet cell dysfunction.

    Higher incidence of diabetes in older adults

    Hypoglycemia is harder to recognize, dizziness and visual disturbances are more common than palpitations and sweating.

    Glucose

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    29

    Measures amount of albumin and globulin within the body

    Identifies nutritional problems, kidney, and liver disease

     

    Total Protein

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    Monitors nutritional status, liver and kidney disease

    Albumin levels decrease with age

    Levels <3.5 g/dL have been associated with increased mortality in hospitalized patients.

    Low albumin levels are also associated chronic disease including diabetes, hyperthyroidism, and HF.

    High albumin levels are associated with blood loss and dehydration.

     

    Albumin

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    Prealbumin is used to assess nutritional status.

    Measures protein status over the short term and is a more accurate measurement of malnutrition because of its short half-life of 1.9 days

    Plasma prealbumin level is useful in monitoring therapy with total parenteral nutrition.

    Prealbumin

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    Urea is major waste product of protein catabolism and a result of ammonia conversion in the liver, excreted by kidneys.

    Levels indicate both liver and kidney function.

    Values for older men are slightly higher than the adult normal levels of 7–22 mg/dL.

    In older women, BUN levels are also increased but at lower levels than for older men.

     

    Blood Urea Nitrogen (BUN)

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    End product of protein metabolism

    Rise in a patient’s BUN and creatinine levels indicates kidney disease.

    Physiologic decline in GFR does not cause a rise in creatinine level secondary to a decrease in muscle mass with aging.

    A creatinine level should not be considered an independent indicator of renal function, better to calculate creatinine clearance for a more realistic indication of renal function.

    Creatinine

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    Measure of GFR, estimated from serum creatinine and urine creatinine levels

    24-hour urine test is required along with a serum level within the same 24-hour period.

    Creatinine clearance is a reflection of an older adult’s overall health status.

    It decreases an average of 6.5 mL/min each decade of life after age 20.

    Used to monitor medication response

    Creatinine Clearance

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    35

    An optimal triglyceride level is 100 mg/dL or lower.

    Total cholesterol levels are a combination of LDL and HDL levels in the bloodstream.

    Total cholesterol levels be kept at less than 200 mg/dL.

    HDL, “good cholesterol” level >60 mg/dL is considered healthy, protects against heart disease.

    LDL, “bad cholesterol” levels <70 mg/dL for risk of heart disease; <100 mg/dL for those at high risk but without established disease; <130 mg/dL for those at moderate risk for heart disease; <160 mg/dL for those at low risk for heart disease.

     

    Triglycerides and Cholesterol

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    36

    Neurohormone secreted from cardiac ventricles in response to ventricular stretching and pressure overloading

    Help in diagnosis and treatment of patients with congestive heart failure (CHF)

    Values cannot be used to differentiate between systolic and diastolic heart failure.

    Brain Natriuretic Peptide

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    37

    Testing for alkaline phosphatase (ALP) identifies liver and bone disorders, in older adults it’s used in the biochemical assessment of Paget disease and other bone diseases.

    Aspartate transaminase (AST) primarily used to diagnose liver disease

     

    Liver Enzymes

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    38

    Troponin T and troponin I are the preferred tests for suspected heart attack.

    Appear 2–8 hours after cardiac injury and can remain elevated up to 2 weeks after a myocardial infarction

    Troponin

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    39

    Includes assessment of two hormones secreted by the thyroid gland: thyroxine (T4) and triiodothyronine (T3)

    They are a screening tool for hypothyroidism or hyperthyroidism.

    T4 and T3 are generally elevated in hyperthyroidism and decreased in hypothyroidism.

    TSH is elevated in hypothyroidism and decreased in hyperthyroidism.

    Thyroid Function Tests

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    High levels of PSA may indicate the presence of prostate cancer, but an enlarged or inflamed prostate can also increase PSA levels.

    Patients need to understand the risks of testing for prostate cancer.

     

    Prostate-Specific Antigen (PSA)

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    41

    Which of the following statements about laboratory results are true for the older adult patient?

     

    Hyperkalemia can cause digitalis toxicity.

    Hypernatremia may be related to laxative abuse.

    Albumin levels decrease with aging.

    The BUN level stays the same, but the creatinine level rises in renal failure.

    ALP is used to assess Paget’s disease.

    T3 and T4 are decreased in hypothyroidism.

    Quick Quiz!

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    42

    ANS: B, C, E

     

    Answer to Quick Quiz

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    43

    Protein in the urine (proteinuria) is an abnormal finding, means damage to the kidneys’ glomeruli.

    Glucose spills into the urine when blood glucose exceeds 180 mg/dL and with kidney damage or disease.

    Bacteriuria >100,000 colony-forming units (CFU) per milliliter of urine indicates infection.

    Confusion, new onset of incontinence, lethargy, nocturia, and anorexia may be the first indication of underlying UTI.

    Leukocytes in urine (pyuria) are more indicative of UTI.

     

    Urinalysis (1 of 2)

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    Positive leukocyte esterase indicates the need for microscopic examination and urine culture and sensitivity testing.

    Nitrite test is used with leukocyte esterase to diagnose UTI.

    Presence of ketones in urine occurs with diabetic ketoacidosis, a low-carbohydrate diet, starvation or fasting, and severe vomiting.

    Urine pH reflects the body’s homeostatic state.

    Hematuria is always an abnormal finding.

     

    Urinalysis (2 of 2)

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    45

    Components of ABG testing are pH, oxygen, and carbon dioxide content, oxygen saturation, and bicarbonate level.

    Be aware of supplemental oxygenation at the time of blood draw

    Pulse oximetry is a reliable alternative to ABG testing and less invasive.

    Decrease in chest wall recoil and in alveolar surface area, and less effective oxygen-to-carbon dioxide (CO2) exchange contribute to potential changes in oxygenation with aging.

     

    Arterial Blood Gas (ABG) Testing

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    Therapeutic drug monitoring is performed in older adults receiving drugs such as digoxin, theophylline, valproic acid, and phenytoin.

    Therapeutic Drug Monitoring

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    47

    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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    2

    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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    3

    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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    4

    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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    5

    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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    6

    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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    7

    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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    8

    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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    10

    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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    11

    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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    12

    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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    13

    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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    14

    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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    15

    “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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    16

    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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    17

    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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    18

    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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    20

    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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    21

    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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    22

    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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    24

    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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    25

    ANS: B

    Answer to Quick Quiz

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    26

    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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    28

    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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    29

    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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    30

    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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    31

    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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    33

    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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    34

    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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    35

    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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    36

    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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    37

    Answers will vary.

    Answers to Quick Quiz

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    38

    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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    39

    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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    44

    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

     

    44

    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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    48

    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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    51

    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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    53

    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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    54

    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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    55

    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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    56

    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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    57

    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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