Lecture #3 Flashcards
Geropharm Background
65+ largest consumer of medications
12% of population
1/3 of medication consumers
1/2 of OTCs
94% take Rx meds
46% take OTCs
53% take supplements
most common Rx med in older adults:
CV
diuretics
non-opioid analgesics
anticoagulants
antiepileptics
most common OTCs meds in older adults:
GI
analgesics
cough products
eye washes
vitamins
study of the movement and actions of a drug in the body: absorption, distribution, metabolism, and excretion
pharmacokinetics
aging changes affecting: absorption
increased: gastric pH
decreased: surface for absorption, blood flow to SPLEEN, GI activity
aging changes affecting: distribution
increased: body fat
decreased: cardiac output, total body H2O, LEAN body mass, serum albumin, and protein binding
aging changes affecting: metabolism
increased: body FAT
decreased: hepatic mass, hepatic blood flow, enzyme activity, and enzyme inductability
aging changes affecting: excretion
decreased: renal blood flow, GFR, tubular secretory function, and kidney size
think = TOXICITY!!
physiological processes between drug and body
the older a person gets, the more likely they will have an alteration or unreliable response to drug
less reliable and more unpredictable
pharmacodynamics
What is decreased in normal aging?
baroreceptor response
myocardial sensitivity to catecholamines (nor-epi, epi)
response of a-adrenergic system
what are the increased sensitivity to anticholinergic effects?
can’t…
- SEE (blurry vision)
- PEE (urinary retention)
can’t…
-SPIT (dry mouth)
- SH…POOP (constipation)
also, confusion and dizziness
what are the increased sensitivity to diuretics?
reduce baroreceptor response – higher risk of orthostatic hypotension
what are the increased sensitivity to beta agonist and antagonists?
reduced effects due to alterations in adrenergic system activity
taking multiple medications at same time:
20% 65+ adults take 10+ meds
more meds take in LTC facilities
disabled have higher %
increased risk for drug interactions
increased risk of adverse events
polypharmacy
what are the drug-supplement interactions? echinacea
risk of bleeding; digoxin level altered)
what are the drug-supplement interactions? garlic
risk of bleeding; monitor glucose
what are the drug-supplement interactions? Ginkgo
risk of bleeding; several meds contraindicated; monitor glucose
what are the drug-supplement interactions? Ginseng
risk of bleeding; several meds contraindicated
what are the drug-supplement interactions? red yeast rice
risk of bleeding; monitor glucose
what are the drug-supplement interactions? St. john’s wart
several med contraindicated
What are some food-drug interactions?
Ca+ binds to some meds (reduces absorption)
grapefruit (increases or decreases bioavailability)
green leafy veggies (contain vitamin K, antidote to warfarin, keep intake consistent)
high K+ diet (K+ sparing diuretics, risk of hyperkalemia, keep intake consistent)
may affect absorption
what happens with drug-drug interactions?
increase with polypharmacy
competition for receptor sites (triangle in bioavailability)
antispasmodics slow GI motility (competition for plasma proteins to bind to)
altered metabolism
triangle in pH
alterations in renal tubules > prolonging half life of some meds
similar SEs or MOAs (simultaneous sedative effects)
what are some high risk for medication errors?
occluded tube
reduced drug effect
drug toxicity
patient harm
patient death
What do you need to know about adverse drug reactions? (ADRs)
not just a SE
one drug or from two (or more) drugs together)
reactions causing or potentially causing harm
sometimes predictable (can be proactive)
sometimes unpredictable (allergic reactions, bleeding risk)
often overlooked in older adults
prevention (lover dosages, “start low, go slow, but go”
drugs identified to have a higher than usual risk when used in older adults
overwhelming benefit vs. risk documentation when prescribing these drugs considered a standard of practice
use as guide, not absolute direction
“safety alert: do not use list”
Beer’s List
(not an absolute! can’t always be avoided. collaborate w/ provider to reduce or change to other options when possible)
what are the psychotherapeutics in late life?
1.) antidepressants
2.) anxiolytic agents
3.) mood stabilizers
4.) antipsychotics
What are some antidepressants?
SSRIs
SNRIs
SSRIs: what neurotransmitter?
Serotonin
Selective SEROTONIN reuptake inhibitor (SSRIs):
first line
work well in older
small doses effective
often have sexual side effects –> switch to SNRIs
SNRIs: what neurotransmitter?
Serotonin
Nor-epinephrine
SEROTONIN & NOR-EPI reuptake inhibitor (SNRIs)
second line
less sexual side effects
Bupropion (Wellbutrin): reduces nicotine dependency as well
Trazodone: also used as a sleep aid
What is serotonin syndrome?
excessive amounts of serotonin can cause this. It is characterized by an altered mental status, high fever, sweating, and clonus. Clonus is an involuntary, rhythmic muscle contraction.
Benzodiazepines:
ends in “am”
highly effective
fast onset but long half life
side effects: drowsiness, confusion, dizziness, impaired coordination (increasing risk for falls and accidents), depression, and increased anxiety
Buspirone (BuSpar)
taken daily
no effect until about one wk
used to treat psychosis (sometimes as mood stabilizer)
blocks dopamine
antipsychotics
what are some side effects of antipsychotics?
sedation
hypotension
anticholinergic effects
extrapyramidal syndrome (ESP) =
dystonia
akathisia
Parkinsonian symptoms
tardive dyskinesia
what is malignant syndrome?
meds affect hypothalamus and thermoregulation
increased temp: intolerant to warm temps
assess temp regularly, keep hydrated, cool baths, fans
potential for liver damage and heat stroke
what are some movement disorders?
pseudoparkinsonism
acute dystonia
akathisia
tardive dyskinesia
what does pseudoparkinsonism look like?
stooped posture
shuffling gait
rigidity
bradykinesia
tremors at rest
pill-rolling motion of the hand
what does acute dystonia look like?
facial grimacing
involuntary upward eye movement
muscle spasms of the tongue, face, neck, and back (back muscle spasms cause trunk to arch forward)
laryngeal spasms
what does akathisia look like?
restless
trouble standing still
paces the floor
feet in constant motion, rocking back and forth
what does tardive dyskinesia look like?
protrusion and rolling of the tongue
sucking and smacking movements of the lips
chewing motion
facial dyskinesia
involuntary movements of the body and extremities
promoting health aging implications for gerontological practice
monitor for potential drug reactions, s/s of ADR
prompt recognition of changes in pt status
pt and family education on purpose and side effects of all meds
How do you assess medication use?
Ask person to bring in all medications being taken, including OTCs, herbals, and dietary supplements
Ask person how he or she actually takes medicine rather than depending on label
Assess: readiness to learn, ability to comprehend, functional ability to make lifestyle changes for med management
Educate & Promote adherence
50-60% of older adults use these (vitamins, non-herb, herb)
often believe that they are natural and safe
higher use when unsatisfied with medical care
grossly under reported
herbs and supplements
what are the standards in manufacturing herbs and supplements?
overall considered dietary supplement: much less scrutiny the meds
manufactures may not say that herbs and supplements: prevent disease, treat, or cure disease
differences in manufacturing: Small business making H&S in small labs with no regulation. Some conduct scientific research to evaluate efficacy. Often with lots of fillers- soybeans, rice, yeast
FDA approves only a few: Aloe, psyllium, capsicum, witch hazel, cascara, senna, and slippery elm. Those non-FDA approved may still have positive benefits
cold and flu therapy
taken in tea from, but can be used as tincture
Contraindications: allergy to daisy plant, HIV, autoimmune disease
Echinacea
to prevent stoke and arteriosclerosis
mixed results from the research (reduced blood clots, reduce LDL & 2 meta-analysis show it lowers BP)
contrindications: use with anticoagulants (remember many cardiac pts are anti-coagulated
should be approved by healthcare provider
garlic
what are side effects for garlic?
flatulence
bleeding risk
nausea
heart burn
hypotension
hypoglycemia
what are side effects for echinacea?
fever
sore throat
N/V/D
abd pain
used to improve memory
there is NO evidence showing it improves memory
contraindications: use with anticoagulants, antihypertensives, antidepressants, pts w/ seizure disorder
should be approved by healthcare provider (most will say avoid)
Ginkgo Biloba
what are side effects of ginkgo biloba?
bleeding risk
GI upset
headache
heart palpitations
dizziness
weakness
constipation.
hypotension
reduces stress, lowers LDL, lowers glucose, immune stimulant, erectile dysfunction
research is weak, overall
contraindications: use with anti-diabetics, anti-coagulants, anti-hypertensives, immunosuppressants, stimulants, MAOIs
should be approved by healthcare provider
Ginseng (root of plant)
what are the side effects for ginseng?
HTN (possible hypo)
risk of bleeding
edema
diarrhea
mania (in those w/ bipolar)
reduce joint pain
improve function of knees with OA
often used in conjunction with chondroitin
evidence leans toward supporting efficacy
overall, well tolerated
contraindications: shellfish allergy and glaucoma (increases IOP)
use w/ caution with anti-diabetics and HTN
glucosamine sulfate
what are side effects of glucosamine sulfate?
GI upset
headache
insomnia
rash
hypoglycemia
used to lower LDL
evidence leans toward supporting efficacy
contraindications: liver dysfunction or elevated LFTs
use with other hepatotoxic meds
red yeast rice
what are side effects of red yeast rice?
muscle pain
liver damage
heartburn
bloating
flatulence
dizziness
mostly used to treat depression
evidence is mixed
contraindications: use with triptans, MAOIs, digoxin, and anti-depressants (overall, avoid in OLDER adults)
should be approved by healthcare provider
St. John’s wort
What are side effects and severe reactions with St. John’s Wart?
side effects:
photosensitivity
rash
GI upset
restlessness
anxiety
headache
severe reactions:
mania
hypomania
suicidal/homicidal ideations
powerful antioxidant
to reduce risk of MI, improve HF and BP
mixed evidence
most common use: along with statins and statins reduce natural levels of this
side effects: some GI upset (overall, tolerated well)
increase effectiveness of anti-hypertensives (monitor BP)
reduce effectiveness of anti-coagulants
Coenzyme Q 10 (CoQ10)
Herb and supplement interactions w/ standardized drugs
Many herb and supplement products interact with prescription or over-the-counter medications, foods, and/or other herbs and supplements
The more herbs and other drugs that the client is taking, the more likely it is that an interaction will occur
misuse of herbal and dietary supplements:
Patients often do not reveal use of herbs and supplements to provider
Failure to share important health information can severely jeopardize client
Many products may have serious consequences of misuse based on actions or interactions with individual’s current health status
You must ask the right questions!
Nursing implications with herbs and supplements:
Proper assessment of herbs and supplements
Inform clients of benefits and harms
Manufacturing
No standardization
Where to obtain quality agents
Assess for SEs, interactions, urge to stop if any issues, and talk to HCP
Recommending H&S is a prescriptive action
Stay within your scope, even when making informal recommendations
perioperative implications with herbs/supplements?
Garlic – stop 2 wks before surgery
Ginkgo – 2 wks
Ginseng – 2 wks
St Johns wort – 5 days
pain and comfort in older adults:
Pain management is a patient right
“5th vital sign”
A key nursing quality indicator in acute care and LTC setting
Undertreated in older adults, especially in elders of color and cognitively impaired adults.
pain at the end of life:
Most common and most feared symptom of people at end of life
Comprehensive and multifactorial assessment by interdisciplinary team is key to management
Temporary
Postoperative, procedural, and traumatic pain
Easily controlled by analgesic
acute pain
No time frame
Persistent at varying levels of intensity
More difficult to control
persistent pain
most common cause of non-cancer pain in older adults are…
Musculoskeletal: arthritis and degenerative spinal conditions
Neuropathic: diabetes, peripheral vascular disease (PVD), herpes zoster, and stroke
What are consequences of untreated pain?
falls and other accidents
functional impairment
slowed rehabilitation
mood changes
increased health care cost
caregiver strain
sleep disturbances
changes in nutritional status
impaired cognition
increased dependency and helplessness
depression, anxiety, fear
decline in social and recreational activities
increased health care utilization and costs
Pain in cognitively impaired elders:
Consistently untreated or under-treated for pain
Careful observation and caregiver reports need to be used if person cannot reliably communicate pain
Non-verbal expressions of pain:
Behavioral changes
Changes in ADL’s
Vocalizations
Physical changes
pain scales and assessment:
Standard of care in pain assessment
Multiple scales available for cognitively intact older adults
Cognitively impaired non-verbal adults require close assessment of cues and behaviors to evaluate presence of pain
PAINAD
PACSLAC
what are non-opioid analgesics pharmacological interventions to promote comfort?
Acetaminophen
Maximum dose 4000mg(4gm) in 24 hours from all sources
Monitor renal and hepatic function
NSAIDS
Safety alert—Aspirin and NSAID use
–> When taken together decrease cardio-protective affect of aspirin
Associated with significant number of adverse drug events in older adults
Cox-2 inhibitors also have serious side effects
what are opioid analgesics pharmacological interventions?
Demerol (meperidine) contraindicated in older adults
Begin with short acting low dose medications and titrate to response and side effects
Age-related changes may produce a greater analgesic effect, a higher peak, and longer duration of effect
Sedation, respiratory depression, and impaired cognition often occur
Increased risk for falls and injury
Bowel regimen necessary to prevent constipation
Pain management consult for unrelieved pain
Use of adjuvant meds in pain management:
Tricyclics for neuropathic pain
Avoid drugs that precipitate or potentiate extrapyramidal symptoms
Avoid tranquilizers that produce sedation and have long half-life
–> Drugs with short half-life are more suitable
Corticosteroids
Topical agents
Muscle relaxants
What is the three-step analgesic ladder? World health organization (WHO)
1 = non-opioid + adjuvant
–> pain persisting or increasing
–> pain persisting or increasing
–> freedom from pain
Non-Pharm measures to promote comfort?
energy/touch therapies
transcutaneous electrical nerve stimulation (TENS)
acupuncture and acupressure
relaxation, meditation, and guided imagery
music
hypnosis
activity
cognitive-behavioral therapy
Promoting healthy aging: implications for gero nursing
Pain clinics
Provide specialized, comprehensive, and multidisciplinary approach to pain management that has not responded to standard approaches
promoting healthy aging: implications (pt.2)
Experience of pain is multifactorial with physical, psychological, and spiritual components
Pain is subjective; unique to each person
Careful assessment of presence or absence of pain is possible regardless of cognitive status of person
It is never acceptable to fail to treat pain to the extent possible
Western and complementary therapies both work together to manage pain
Frequent qualitative and quantitative reevaluation of perceived pain is necessary to provide adequate pain relief and promote patient comfort
