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N352: Practice of Nursing I > Module 4 - Polypharmacy > Flashcards

Module 4 - Polypharmacy Flashcards

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1
Q

Polypharmacy

A

Poly = “Many”

Studies give different numbers but regardless it means use of many medications at once

It is the concurrent use of more than 1 medication either OTC, prescribed, or herbal supplement

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2
Q

Sometimes polypharmacy is about appropriateness, so what are some inappropriate polypharmacy situations?

A

Use without indication

Duplicate Therapy

Use of generic and brand at the same time

Prescribing Cascade

Excessive Duration

Excessive Dose

In presence of adverse consequences where drug should be reduced or discontinued

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3
Q

Prescribing Cascade

A

prescribing medications to solve other medications side effects and that continues and spirals from there

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4
Q

What sort of medications are included as part of the definition of polypharmacy

A

OTC - over the counter drugs

prescribed drugs

herbal supplements

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5
Q

Knowledge of polypharmacy requires awareness of …

A

increased risks of drug interactions and adverse effects

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6
Q

Why is a 78 yo male with BPH and dementia an inappropriate situation for use both ditropan and benadryl?

A

both drugs have anticholinergic effects that lead to increased urinary retention

this can lead to urosepsis and subsequent ER visits and hospitalization

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7
Q

Beers Criteria

A

A medication list for the elderly that lists meds that should be avoided in the elderly, avoided in elderly with certain conditions, and meds to use cautiously in the elderly with conditions like renal concerns

It is a guideline for what medications to be careful using when treating the elderly

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8
Q

When giving the elderly medications, it is important to be cognizant of…

A

dosages and monitoring reactions to medications

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9
Q

How big of a problem is polypharmacy?

A

In 2000: 13% of the US was under polypharm, but 33% of all Rx users and 40% of OTC users were

In 2015, This increased to 14% of the US and 33% of Rx Meds (costing 325 billion dollars)

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10
Q

As many as ___% of elderly take at least ONE med? ___% take 5+? ___% take 10+?

A

90% - 1

40% - 5+

12% - 10+

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11
Q

Why is polypharmacy not just a prescription issue?

A

There are over 100,000 OTC on the US market with elderly using as much as 40%, 50-90% take at least 1 OTC, and 50% >5 combined OTC and Rx

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12
Q

Common OTCs include…

A

sleep

analgesics

antacids

constipation

cough and cold

herbals

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13
Q

Risk factors for Polypharmacy

A

Multiple Medical Diagnoses

Multiple Medical Providers

Multiple Sources for Drugs

Lack of Patient Knowledge

Lack of Provider Knowledge

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14
Q

We do not really need a medication for every diagnosis, but…

A

we have been conditioned to think we do

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15
Q

Primum Non Nocere

A

“Do No Harm”

Before 1999, the elderly were never used in clinical drug trials, only health 20s males

So in the end we did not know the drug impacts on the elderly population leading to Iatrogenesis

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16
Q

Iatrogenesis

A

Harm coming from a therapeutic regimen

The most common form of iatrogenic illness is ADVERSE DRUG REACTIONS

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17
Q

Positive outcomes of polypharmacy?

A

Medication purposefully changes physiologic function for therapeutic effect(s) which can lead to improved quality of life

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18
Q

Potential negative outcomes of polypharmacy?

A

Adverse drug reactions (drug-drug, drug-food)

Adverse drug events (falls, ER visits, hospitalizations, death)

Medication errors

Non-adherence to medical regimen

Financial burden

Decreased quality of life from side effects or adverse reactions

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19
Q

What are two factors affecting polypharmacy related to an elders behavior?

A
  1. Accurate Diagnoses - elders may under report symptoms, attributing it to “old age”, but vague and atypical symptoms and overlap between physio/psycho symptoms can lead to bad diagnoses and wrong medications
  2. Tendency to treat with drugs - OTCH (1000s available)
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20
Q

ADR

A

Adverse Drug Reaction

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21
Q

What are the chances of an ADR with 2 meds? with 5 meds? with 8+ meds?

A

2 = 6%

5 = 50%

8+ = 100%

it grows exponentially fast!

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22
Q

Types of Meds associated with ADR occurrence

A

cardiovascular

diuretics

hypoglycemics

anticoagulants

pain meds

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23
Q

ADR incidence is ___x greater in the edlerly

A

2 to 3 x

24
Q

ADRs manifest differently and vaguely sometimes, so we must monitor

A

elder status on a day by day basis

25
Q

What are some ways ADRs can manifest differently?

A

May take prolonged time to be apparent

May manifest differently in elderly vague symptoms

May happen only after long term drug use

May be mistaken for geriatric conditions like falls and changes in cognition

26
Q

Difference between a side effect and adverse effect?

A

Side effect are known to occur and common while adverse effects are unintended and need intervention

27
Q

Ex: Side effects of Ibuprofen

A

Unintended event at normal dose

GI: Nausea

abdominal pain

headache

dizziness

28
Q

Ex: Adverse Effects of Ibuprofen

A

Intervention needed to prevent harm

GI bleeding

Cardiac issues like MI or CHF

Renal damage or failure

29
Q

Pharmacodynamics

A

What drugs do to the body

30
Q

Receptors in the brain are more sensitive to what types of drugs?

A
  1. Opioids
  2. Benzodiazepines
  3. Anticholinergics
31
Q

What are some age related changes when it comes to medications?

A

Pharmacodynamically:
1. receptors in the brain become more sensitive
2. heightened response to anticoagulants
3. decreased sensitivity to beta blockers

Pharmacokinetically:
1. Absorption, distribution, metabolism, and elimination changes effecting concentration of drug in the body

32
Q

Pharmacokinetics

A

What the body does to the drug

this determines the concentration of the drug in the body

33
Q

What 4 factors determine concentration of drug in the body?

A

Absorption

Distribution

Metabolism

Elimination

34
Q

What is the “First Pass” for a drug in the body?

A

Metabolism

35
Q

Drug Metabolism

A

drug passes through the small intestines into a network of veins that surround it (“portal system”) and drain into portal vein which enters the liver

Drugs passing this way have high “FIRST PASS”

36
Q

How does age effect drug metabolism?

A

Liver function, blood flow, and metabolism decrease so greater non-metabolized or free medication exists in plasma

So, main drugs and oral doses of the drugs will need to be adjusted downward to account for this

37
Q

What 3 Elimination factors decrease with age?

A
  1. Decreased sweat and saliva
  2. Decreased respiratory function
  3. Decreased renal function
38
Q

Glomerular Filtration Rate can be decreased as much as ___% in the elderly. Why is this important?

A

50%

Serum creatinine is not a good measure of renal function in the elderly, because decreased lean muscle mass leads to decreased creatinine production - so it is not a renal problem in this case

39
Q

Increased risk of toxicity as medications remain in the body is related to …

A

delayed excretion

40
Q

Cockcroft-Gault Calculation

A

Physician calculation to know how much a potentially toxic drug can be given

This is often referred to as “Creatinine Clearance”

Not done by the nurse

41
Q

How does Drug half life impact the elderly?

A

Half life will increase with age.

For example: Xanax 5 mg - in a healthy adult HL is 11 hours but in an older adult it is 16.3 hours

42
Q

If you give an 8 pm dose of xanax 5 mg to chemically restrain a patient with dementia exhibiting behaviors, how will that dose stay in their system?

A

2.5 mg will still be active at 12:20 pm that day

1.25 mg will still be in their system at 4:40 a.m. - that is two days later!

43
Q

S/S of Polypharmacy commonly misinterpreted as a part of aging?

A

Fatigue and tiredness, not as alert

constipation, Diarrhea, incontinence

confusion, LOC changes

depression

weakness, tremors, dizziness

anxiety

decreased sexual desire/performance

44
Q

Nurse’s Role with Polypharmacy?

A
  1. Assessment
  2. Education - teach them and even write down meds so people clearly know what to take
  3. Monitoring - for change d/t drugs
  4. Coordination of Care - follow up with them and talk to physician about concerns
45
Q

Why is coordination so important for the RN to do?

A

RNs are on the “front lines” perfectly positioned to enhance/support the communication between the patient and provider and should do so!

46
Q

What are some aspects of Polypharmacy Assessment?

A
  1. Functional and cognitive ability to self manage meds
  2. Nutrition
  3. health beliefs of the individual - do they use herbals, recreational drugs, ETOH, nicotine
  4. Socioeconomic - can they pay for medications
  5. Complete medication lists - home inspection, know where all the drugs are
  6. Beers Criteria Review - the bible for elder drugs and online apps
  7. Drug-Drug Interaction Checkers - online apps
47
Q

3 Things to Monitor in regard to patients and polypharmacy?

A
  1. Therapeutic effects
  2. Side effects
  3. Adverse effects
48
Q

Central Anticholinergic Effects in the Elderly r/t polypharmacy

A

Agitation

Confusion

Disorientation

Poor Attention

Hallucinations

Psychoses

49
Q

Peripheral Anticholinergic Effects in the elderly r/t polypharmacy

A

Constipation from decreased intestinal peristalsis

Urinary retention

Inhibition of sweating

Decreased salivary and bronchial secretions

Tachycardia

Pupil dilation

50
Q

Anticholinergic Effects are dependent on what?

A

Effects are dose dependent!

We need to know the person and information about them to prevent too much effects slowing everything down

51
Q

What things educate elders about an Rx/OTC drug in order to empower them?

A

Patient/Caregiver should know these things about each drug:

  1. Name
  2. Purpose
  3. Dose
  4. Best time to take
  5. With other drugs?
  6. how long to take
  7. what to do if you miss a dose?
  8. not to share the drug
  9. keep in original container
  10. common side effects
  11. what to do if side effects occur
  12. how to store properly
  13. How many refills
  14. how to dispose of
  15. not to take >1 year old or past expiration date
52
Q

Examples of Safe Website for Online Rx

A
  1. National Association of Boards of Pharmacy
  2. VIPPS
  3. Anything in the US, where a license Rx can answer questions, requires a prescription from a provider that knows you, and has excellent customer service
53
Q

How should safe disposal of medication be done?

A
  1. Discourage pill sharing/hoarding
  2. Check med cabinets 1x/year for expired and unused meds
  3. Sharps and unwanted medications should be disposed properly, potentially at a disposal area like a collections box at the sheriffs office or by putting it in kitty litter for disposal
54
Q

The golden rule for medications in the elderly is…

A

START LOW AND GO SLOW

(Gradual Dose Reduction)

55
Q

Gradual Dose Reduction (GDR)

A

Tapering of a dose in a stepwise manner

We start at the bottom and work up and taper or get rid of things that are unneeded

we ask if symptoms, risk, and condition could be managed with a lower dose and if drugs can be discontinued

We commonly see this in LTC with psychotropic drugs but you should ask this in any setting

56
Q

It is particularly important to “Start low and go slow” when …

A
  1. drugs are new to market
  2. the drug has CNS, anticholinergic, renal elimination, strong 1st pass effects
  3. When the drug has a very narrow therapeutic window
57
Q

Example: Why is it important to “start low and go slow” particularly for acetaminophen in the elderly?

A
  1. Increased risk of toxicity is r/t age related decreases in hepatic function
  2. Must be used cautiously in those with impaired hepatic function OR ETOH use
  3. Many meds contain acetaminophen in combination and the elderly may not recognize that

MDD (maximum adult daily dose) is 3 gms/24 hours, and it can interact with warfarin to increase INR

Also, liver damage can occur if 3-4 gms is used daily for a year

N352: Practice of Nursing I (14 decks)

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