Medication Management in the Elderly An Introduction

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Medication Management in the Elderly- An
Introduction

• Rose Knapp, RN, MSN, APRN-BC
• Clinical Faculty NYU College of Nursing
• Professor of Pharmacology
• Acute Care Nurse Practitioner

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Learning Objectives

• 1. Discuss the specific medication needs of the
  elder patient
• 2. Describe the variables when choosing s
  medication for the elder adult
• 3. Discuss causes and prevention of polypharmacy
• 4. Discuss the JCAHO recommendations and the
  medication reconciliation process

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Drug Therapy in the Elder Patient

• Statistics
• Drug use in the elderly is disproportionately
  high
• Patient over 65 constitute 12 of the population
  and consume 31 of prescribed drugs secondary to
• Increased severity of chronic illness
• Presence of multiple pathologies
• Excessive prescribing

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Specific Therapeutic Challenge of Prescribing for
the Elder Patient

• Principle factors
• Altered Pharmacokinetics
• Multiple and severe illness
• Multiple drug therapy
• Poor adherence

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Physiologic changes that affect Pharmacokinetics
in the Elderly

• Absorption of Drugs
• Increased gastric pH
• Decreased absorptive surface area
• Decreased gastric motility
• Delayed gastric emptying

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Pharmacokinetic changes

• Distribution of Drugs
• Increased body fat
• Decreased lean muscle mass
• Decreased serum albumin
• Decreased cardiac output
• Decreased total body water

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Pharmacokinetic changes

• Metabolism of Drugs
• Decreased hepatic blood flow
• Decreased hepatic mass
• Decreased activity of hepatic enzymes

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Pharmacokinetic changes

• Excretion of Drugs
• Decreased renal blood flow
• Decreased glomerular filtration rate
• Decreased tubular secretion
• Decreased number of nephrons

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Pharmacodynamics

• Increased drug sensitivity
• Changes in blood-brain barrier
• Alteration in receptor properties
• Increased Adverse Drug Reactions (ADRs)

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Adverse Drug Reactions and Drug Interactions in
the Elderly Patient

• ADR are 7 times more common in the elderly
• Account for 16 of hospital admission and 50 of
  medication related deaths

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Factors that Predispose Elderly to ADRs

• Drug accumulation secondary to reduced renal
  function
• Polypharmacy
• Greater use of drugs with a low therapeutic index
  ( i.e. digoxin)
• Inadequate supervision of long-term therapy
• Poor patient adherence

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Factors Attributing to Poor Drug Adherence in the
Elderly Patient

• Multiple chronic disorders
• Multiple prescribers
• Multiple prescriptions
• Multiple doses
• Change in daily drug regime
• Cognitive or physical impairment
• Living alone
• Recent Hospital discharge
• Inability to pay for drugs
• Presence of side effects

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Polypharmacy

• Definition Taking a many of medications at
  the same time Beers 2005
• Average person over 65 takes an average of 4.5
  prescription medications at a time plus 2 OTC
  medications

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Polypharmacy

• A quote from Love in the Time of Cholera by
  Gabriel Garcia Marquez
• He rose at the crack of dawn when he began his
  secret medicine, bromides to raise the spirits,
  salicylates for the aches in his bones when it
  rained, ergosterol for vertigo, belladonna for
  sound sleep. But in his pocket he always carried
  a little pad of camphor that he inhaled deeply
  when no one was watching , to calm his fear of so
  many medication mixed together

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Medication Appropriateness

• Overuse of a Medication
• Antibiotics
• GI Medications
• Sleep medications
• Misuse
• Wrong dose and/or frequency
• Underuse
• Chronic disease
• Preventative medications- vaccines

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Beers Criteria

• Purpose To reduce medications related risks
• Increase nursing awareness of high-risk
  medications
• Monitoring of adverse effects
• Facilitates collaborative efforts of health care
  providers
• Best Tool HCFA Guidelines for Potentially
  Inappropriate Medications in the Elderly
• Identifies medications that have potential risks
  that outweigh benefits
• Universally appropriate for all patients over 65
• Provides a rating of severity for adverse
  outcomes
• Provides a descriptive summary associated with
  the education

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Beers Criteria

• Strengths-
• Developed by 6 nationally known experts in
  geriatric care and pharmacology
• Widely used to screen populations for possible
  drug-related problems
• Limitations-
• Does not identify all cases of potentially
  inappropriate prescribing
• Is not a substitute for professional judgment

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Medication Reconciliation

• - Definition The process of comparing a
  patients medication orders to all medications
  that the patient has been taking.
• Medication Reconciliation will avoid
• 1. omissions,
• 2. duplications
• 3. dosaging
• 4. errors
• 5. drug interactions

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Medication Reconciliation

• 5 Step Process
• Develop a list of medications
• Develop a list of medications to be prescribed
• Compare the 2 lists
• Make clinical decision based on the comparison
• Communicate the new list to the appropriate
  caregivers and the patient

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JCAHO Requirements

• 2005 National Patient Safety Goal 8
• to accurately and completely reconcile
  medication across a continuum of care
• Goal for 2006
• 8a) implement a process for obtaining and
  documenting a complete of patient medications on
  admission
• 8b) a complete list of patient medications is
  communicated to the next care provider
• Addendum- that a patient who is unable to
  participate in medication reconciliation has an
  authorized person involved in the process in all
  interfaces of care and on admission and discharge
  from the facility
• JCAHO 2/06

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JCAHO Recommendations

• Place medications list in a highly visible
  location in patient chart
• Create a process for reconciling medications at
  all interfaces of care
• On discharge from a facility, provide patient
  with the complete list of medications

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Measures to Prevent ADRs

• Complete drug history including OTC and herbals
• Account for pharmacokinetic and pharmacodynamic
  changes that occur with aging
• Initiate therapy with low doses
• Monitor clinical response and plasma drug levels
• Employ simplest regime possible
• Monitor drug-drug interactions
• Periodically review drug regime
• Encourage patient to dispose of old medications
• Promote adherence to drug regime

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Factors that Promote Drug Adherence

• Simplify regime
• Clearly explain treatment plan
• Choosing appropriate dosage form
• Label containers clearly
• Suggest a calendar, diary or pill counter
• Assure patients access to a pharmacy
• Assure affordability of medication
• Involve a family member or friend
• Monitor therapeutic responses, adverse reactions
  and plasma drug levels

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Case Study

• Mrs. A. is a 71 year old widow with CHF and
  osteoarthritis who has recently been exhibiting
  quite unusual behavior. Her daughter is concerned
  about her mother's ability to remain independent
  and wishes to pursue nursing home admission
  arrangements. She fears the development of a
  dementing illness. Over the last two to three
  months, Mrs. A. has become confused, easily
  fatigued and very irritable. She has developed
  disturbing obsessive/compulsive behavior
  constantly complaining that her lace curtains
  were dirty and required frequent washing.
  Detailed questioning revealed that she thought
  they were yellow-green and possibly moldy. Her
  prescribed medications are Furosemide 40 mg
  daily in the morning Digoxin 250 micrograms
  daily Acetamenophen 500 mg, 1-2 tablets
  4-hourly PRN joint pain
• Mylanta suspension, 20 ml prn

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Case Study continued

• What is problematic about this patients drug
  management?

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Furosemide

• Dosage
• Indication
• Adverse Effects- hypokalemia
• Considerations monitor serum K, observe for
  signs of hypokalemia- fatigue, muscle weakness
  and cramping
• Effect on Digoxin
• Potassium Supplements
• Best time to administer medication
• Teach patient and family about foods high in K

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Digoxin

• Dosage
• Indication
• Early signs of toxicity- weakness, anorexia, GI
  distress
• Late signs of toxicity- confusion,
• visual color disturbances, arrhythmias, headache
• Relationship of K and Digoxin
• Obtain baseline vital signs
• Check digoxin and K levels
• Mylantas effect on digoxin

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Acetaminophen

• Dosage
• Indication
• Adverse reactions severe liver damage, rash
• Observe for hepatic damage

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Mylanta

• Dosage
• Indications
• Adverse reactions diarrhea/constipation
• Aluminum-constipation, Magnesium-diarrhea
• Magnesium based- caution with renal disease
• May alter absorption of many drugs
• Potential for adverse reaction with Digoxin

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Case Study

• Mrs. A is a victim of polypharmacy
• Digoxin dosage with digoxin toxicity
• Mylanta interacts with digoxin
• Lasix and digoxin interation

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5 steps of Clinical Decision Making

• Assessment
• Diagnosis
• Planning
• Intervention/Education
• Evaluation

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REMEMBER

• Individualized drug therapy in the elderly is
  essential
• 70 of nonadherence is INTENTIONAL

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References

• Abrams, WB, Beers, MH. Clinical Pharmacology in
  an aging population. Clinical Pharmacology
  Therapeutics 199863281-4.
• Beers, MH. Explicit criteria for determining
  potentially inappropriate medication use in the
  elderly. Archives of Internal Medicine 1997 157
  1531-6.
• Fick DM, Cooper JW, Wade WE, Waller JL, Maclean
  JR, Beers MH. Updating the Beers criteria for
  potentially inappropriate medication use in older
  adults results of a US consensus panel of
  experts. Arch Intern Med. 20031632716-2724
• ISMP Medication Safety Alert, April 21, 2005,
  http//www.ismp.org/MSAarticles/20050421.htm
  Institute for Healthcare Improvement website
  includes a section on Medication Reconciliation
  Review, including samples of a reconciliation
  tracking tool and a medication reconciliation
  flowsheet, http//www.ihi.org/
• (Lehne, Richard A.. Pharmacology for Nursing
  Care, 6th Edition. W.B. Saunders Company, 062006.
  11).
• J.D. Rozich, M.D., Ph.D., M.B.A.,
  "Standardization as a Mechanism to Improve Safety
  in Health Care," Joint Commission Journal on
  Quality and Safety, Volume 30, Number 1, January
  2004, pages 5-14