Unit 1 CHAPTER 7 Geriatric Considerations

Question 1

Physiologic changes in Older Adults

Answer 1

Physiologic changes associated with aging can influence absorption, distribution, metabolism, and excretion of drugs as well as pharmacodynamic responses at receptors and target organs.

 Reduction in total body water and lean body mass(dehydration)
 Reduction in kidney mass and function(smaller kidney)
 Reduction in liver mass and blood flow(smaller liver)
 Volume depletion & electrolyte imbalance with diuretics
 Postural hypotension with antihypertensives(get up slowly to avoid dizziness and falls)
 Excess bleeding with anticoagulants or antiplatelets
 GI irritation with NSAID’s

Question 2

The Pharmcakinetics of an Older Adult

Answer 2

Pharmacokinetics
 Absorption – Slowing of the GI tract
These include a decrease in small-bowel surface area, slowed gastric emptying, reduced gastric blood flow, and a 5% to 10% decrease in gastric acid production.

 Distribution – Decreased available protein
Aging can significantly alter drug distribution. With aging, adults experience a decline in muscle mass and a 20% to 40% increase in fat. The increase in body fat means lipid-soluble drugs have a greater volume of distribution, increased drug storage, reduced elimination, and a prolonged period of action

 Metabolism – Decreased liver function
Older adults are pout at risk for drug toxicity
Hepatic blood flow in the older adult may be decreased by 40%; aging also results in a 15% to 30% decrease in liver size and a reduction in cytochrome P450 (CYP450) enzyme activity, which is responsible for the breakdown of drugs. Drug clearance by hepatic metabolism can be reduced by these age-related changes. A reduction in hepatic metabolism can decrease first-pass metabolism and can prolong drug half-life, resulting in increased drug levels and potential drug toxicity. Nurses must be aware of these metabolic changes and must monitor response to drug therapy to avoid adverse reactions.

 Excretion – Decreased kidney function
Renal excretion of drugs decreases with age. Excretion is altered by age-related changes in kidney function, such as decreased renal size and volume, which differ for each individual.
Changes in kidney function affect many drugs, leading to a prolonged half-life and elevated drug levels. Changes in kidney function require dosage adjustment, especially if the drug has a narrow therapeutic range.

Question 3

Pharcadynamics is Altered in Older Adults

Answer 3

How the drug affects the body

Pharmacodynamic responses to drugs are altered with aging as a result of changes in the number of receptor sites, which affects the affinity of certain drugs.

Age-related changes
 Loss of sensitivity in adrenergic receptors
 Blunting of compensatory reflexes
 Loss of dopaminergic and cholinergic receptors, neurons, and
neural connections in brain
 Reduced blood flow to brain

Question 4

Polypharmacy

Answer 4

Polypharmacy refers to the use of more medications than is medically necessary.

Older adults mainly are in use pf polypharmaceutical drugs due to the lack of medication reconciliation.

Question 5

Effects of Polypharmacy

Answer 5

Polypharmacy can cause an increase in geriatric syndromes (cognitive impairment, falls, decreased functional status, urinary incontinence, and poor nutrition) as well as an increased incidence of adverse drug reactions and poor adherence.

Question 6

Risk factors for the use of Polypharmacy

Answer 6

Risk factors associated with polypharmacy include advanced age,
female sex,
multiple health care providers,
use of herbal therapies and OTC drugs,
multiple chronic diseases, and
the number of hospitalizations and care transitions

Question 7

What number of drugs consistitutes Polypharmacy
B.15
C.10
D. 5

Answer 7

D. 5

There is li le agreement on the actual number of drugs that constitutes polypharmacy, but researchers use five drugs because this number has been associated with increased incidence of adverse drug reactions, geriatric syndromes, and increased mortality.

Question 8

How do you as a health care provider decrease Polypharmacy?

Answer 8

To reduce the risk for and incidence of polypharmacy, nurses must be involved in the coordination of care for older adults. Older adults should be encouraged to use only one pharmacy and should give the pharmacist a list of all the drugs taken—prescribed, herbal, and OTC.

A properly informed pharmacist will be able to conduct a clinical review of the patient’s drugs to ensure the appropriateness of therapy. A pharmacist can also confirm patient understanding of individual therapy and can monitor responses to drug therapy. All of this is done to improve the overall quality of life of patients in their care.

Question 9

Should NSAID’S be taken with food for older adults?
A.Yes
B. No

Answer 9

A.Yes

These include a decrease in small-bowel surface area, slowed gastric emptying, reduced gastric blood flow, and a 5% to 10% decrease in gastric acid production.

 Older adults have GI irritation with NSAID’s

Question 10

Beers criteria for potential inappropriate drug use

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is a document developed by a consensus panel of 12 experts in geriatric care to aid health care providers in the safe prescription and administration of drugs to older adults

Answer 10

Although the document provides information on drugs to avoid in older adults and drugs to use with caution, it is not designed for use in isolation. All drug therapy decisions should be made taking into consideration an individual’s preferences, values, and needs. It is very important that the nurse advocate for the patient in these areas to ensure safety and promote adherence.

Question 11

Adverse Drug Effects - Older Adults

Answer 11

Older adults have multiple risk factors for ADEs, including frailty, multiple comorbidities, polypharmacy, and cognitive issues.

Older adults are twice as likely as younger adults to visit the ED with ADEs and are seven times as likely to be hospitalized. Most visits and hospitalizations occur due to reactions to blood thinners, drugs used to treat diabetes and seizures, cardiac drugs, and drugs used for pain control.

According to the World Health Organization, ADEs are “unintended and undesired effects of a [drug] at the normal dose.”

Question 12

The 5 types of Adverse Drug Effects

Answer 12

There are five types of ADEs:
(1) adverse drug reactions,
(2) medication errors,
(3) therapeutic failures,
(4) adverse drug withdrawal events, and
(5) overdoses.

Question 13

Adherence - Older Adults

Def. \

In medicine, patient compliance describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance,

Answer 13

Adherence to a drug regimen is a problem for all patient age groups, but it is especially troublesome in older adult patients.

Older adults may fail to ask questions during interactions with health care providers, which leads to the drug regimen not being fully understood or precisely followed

Failure to adhere to a drug regimen can cause underdosing or overdosing that could be harmful to the patient’s health. Table 7.2 lists barriers to effective drug use by older adults.

Failure to adhere to a drug regimen can lead to ADEs, resulting in hospital admission, readmission to health care institutions, and even death. Complex drug regimens may be difficult for older adults to follow. Education is the cornerstone of adherence, and this includes education of the patient, family, and formal and informal caregivers.

Question 14

What can cause lack of drug adherence or non adherence in Older Adults

Answer 14

Adherence
 Patient may not fully understand drug regimen.
 Nonadherence may cause underdosing or overdosing.
 Medication education extremely important
 Lack of prescription drug coverage
-

Question 15

Health teaching in Older Adults , Nursing Interventions

Answer 15

Have patient’s senses as sharp as possible.
Wearing clean eyeglasses.
Make sure that functional hearing aids are in place.
Speak in tones such that patient can hear.
Face patient when speaking.
Limit distractions.
Treat patient with respect.
 Expect that the patient can learn.
Use large print and bright colors in teaching aids.

Question 16

If an older patient is confused or disoriented, change in mental status and level of consciousness after taking a medication , What should you suspect?

Answer 16

the patient recently has been prescribed a new medication, drug toxicity, adverse effects

Question 17

When medicating an older adult, should you the nurse start off with a high dose or low dose and increase as you go on?

Answer 17

low and slow , when medicating an older adult

Question 18

What can an older patient do to avoid orthostatic hypotension when taking antihypertensive medications?
A. rise slowly from sitting or laying down for an extended period of time
B. rise quickly from laying down
C. never get up stay in bed for 24hours to a time to contract contractures
D. jump up immediately

Answer 18

A. rise slowly from sitting or laying down for an extended period of time

Question 19

Health Teaching in Older Adults

Answer 19

Encourage the patient to report if the new drug is not
improving the condition for which it was prescribed.

*Review all medications at each visit.
*Advise patient to complete vial of life (medical information
and keep on refrigerator for emergency)
*Instruct patient to take the list of all drugs taken to all
health appointments.
*Encourage a simple dosing schedule. For example:
 Dosing times do not have to match hospital times
 If patient is alert, may use a medication log or pill box cassette
 If patient has occasional confusion use pill box cassette
.

Question 20

When administering medications to the older
adult population, the nurse is aware that the
physiologic changes of aging that can affect drug
activity include all of the following except
A. increased fat-to-water ratio.
B. decreased liver enzyme production.
C. loss of nephrons.
D. increased gastrointestinal blood flow.

Answer 20

ANS: D
Older adults have decreased gastric acidity, reduced
peristalsis, decreased body water, increased fat-to-water
ratio, decreased numbers of functioning nephrons, and
decreased liver enzyme production and function.

Question 21

Adverse reactions and drug interactions occur
frequently in older adults due to all of the
following except
A. consumption of numerous drugs owing to multiple
chronic illnesses.
B. drugs ordered by several health care providers.
C. increased incidence of allergic responses.
D. self-medication with OTC preparations

Answer 21

ANS: C
The immune system of the older adult decreases rather
than increases in allergic responses. It is common for
older adults to take many drugs together. Polypharmacy
is due to multiple health care providers ordering many
medications for older adults. Older adults are prone to
self-medicate with OTC preparations

Question 22

Older adults are at risk for taking many
medications together. This is known as
A. tachyphylaxis.
B. drug interaction.
C. polypharmacy.
D. tolerance

Answer 22

C. polypharmacy.

Polypharmacy is taking many medications together.

Question 23

Which is a physiologic change seen in the older
adult that has an effect on drug administration?
A. Lower (acidic) gastric secretions
B. Increased first-pass effect through the liver
C. Increased glomerular filtration rate
D. Lower cardiac output

Answer 23

D. Lower cardiac output

Lower cardiac output is a physiologic change associated
with the older adult. The pH increases, not decreases,
causing alkaline gastric secretions. The first-pass effect
through the liver is decreased. The glomerular filtration
rate is decreased.

Question 24

When assessing older adults’ renal function,
which laboratory value will the nurse monitor?
A. Liver enzymes
B. Serum electrolytes
C. Complete blood count
D. Blood urea nitrogen and creatinine

Answer 24

D. Blood urea nitrogen and creatinine

Blood urea nitrogen and creatinine results best reflect
kidney function.

Question 25

1. A patient has nine drugs prescribed to take daily. Which are common reasons for nonadherence to the drug regimen in an older adult? (Select all that apply.)
   a. Taking multiple drugs at one time b. Impaired memory
   c. Decreased dexterity
   d. Increased mobility
   e. Increased visual acuity

Answer 25

A,B,C

Question 26

2. The nurse is reviewing a patient’s list of drugs. The nurse understands that the older adult’s slower absorption of oral drugs is primarily because of which phenomenon?
   a. Decreased cardiac output
   b. Increased gastric emptying time c. Decreased gastric blood flow
   d. Increased gastric acid secretion

Answer 26

C

Question 27

3. The older adult patient has questions about oral drug metabolism. Information on what subject is most important to include in this patient’s teaching plan?
   a. First-pass effect
   b. Enzyme function
   c. Glomerular filtration rate
   d. Motility

Answer 27

A

Question 28

4. An older patient has just started on hydrochlorothiazide and is advised by the health care provider to eat foods rich in potassium. What is the nurse’s best recommendation of foods to consume?
   a. Cabbage and corn
   b. Bread and cheese
   c. Avocados and mushrooms
   d. Brown rice and fish

Answer 28

C

Question 29

5. The nurse is developing teaching materials for an 82-year-old African American man with macular degeneration, who is being discharged on two new drugs. Which strategies would be best to use to impart the information? (Select all that apply.)
   a. Limit distractions in the room when teaching.
   b. Wait until discharge to teach so information is fresh in the memory.
   c. Augment teaching with audio material.
   d. Use “Honey” and other terms of familiarity when addressing him to promote trust.
   e. Use large, dark print on a light background for wri en material.

Answer 29

A

Question 30

6. What changes with aging alter drug distribution? (Select all that apply.)
   a. An increase in muscle mass and a decrease in fat
   b. A decrease in muscle mass and an increase in fat
   c. A decrease in serum albumin levels
   d. An increase in total body water
   e. A decrease in kidney mass

Answer 30

B,C,E

Question 31

7. What factors contribute to polypharmacy in older adults? (Select all that apply.)
   a. Multiple health care providers
   b. Multiple chronic diseases
   c. Use of a single pharmacy
   d. Care coordination by a nurse
   e. Few hospitalizations

Answer 31

A,B

Question 32

8. What is the best measure for the nurse to use to determine a patient’s kidney function?
   a. Creatinine clearance
   b. Estimated glomerular filtration rate
   c. Serum creatinine level
   d. Blood urea nitrogen level

Answer 32

B