Chapter 8: Medications and Laboratory Values

Chapter 8: Medications and Laboratory Values Bonnie M. Wivell, MS, RN, CNS

Demographics related to Medications • The elderly consume about 1/3 of all prescription and OTC drugs • Of those over age 65 (2002) • 40% took 5+ meds per week • 12% took over 10 meds • The more medications taken, the greater risk of side effects • Greater risk of side effects in elderly due to normal aging changes

The Effect of Aging on Drugs • Pharmacokinetics • How drugs move through the body via absorption/excretion • Pharmacodynamics • Effect of drugs in the body • Medications can stay in the body longer due to decreased clearance or excretion and thus increase risk of side effects.

Adverse drug reactions Drug-drug Drug-disease (pg. 263) Food drug interactions Greens & Warfarin Grapefruit juice & antihistamines Polypharmacy – more than clinically necessary Adverse outcomes ADRs Increased cost noncompliance Inappropriate prescribing Is tx necessary? Is it safest drug available? Is it the most appropriate dose, route, and form? Is frequency appropriate? Do benefits outweigh risks? Compliance 40% do not adhere Drug-Related Problems in the Elderly

Beers Criteria • In 1997, Dr. Beers developed and published the Beers criteria in the Archives of Internal Medicine, outlining explicit criteria for use in prescribing medications for seniors • Adopted by CMS in 1999 for nursing home regulations • Revised in 2003 • The criteria have been widely used over the past 10 years for • Studying prescribing patterns within populations • Educating clinicians • Evaluating health outcomes, cost, and utilization data

Beers Criteria Continued • Lists more than 40 concerns associated with specific drugs or drug classes when prescribed for older adults. • These concerns explain the overall clinical rationale for inclusion on the list. • See page 267 in your text • Start LOW and go SLOW

Medication Blood Levels • Cardiac meds, anti-epileptics, certain antibiotics • Random: typically to rule out overdose, not dose time dependent • Peak: dose time dependent; time blood level is expected to be at its highest • Too high = reduce dose • Too low = increase dose • Trough: dose time dependent; time blood level is expected to be at its lowest, right before dose • Too high = extend time between doses • Too low = shorten time between doses

Laboratory Values • Renal impairment • NSAIDs • ACE inhibitors • IV contrast materials • BUN/Creat, Creatinine Clearance (formula pg. 271) • Hepatic impairment • Alk Phos, AST, ALT, albumin, bili, protein, coags • Decreased serum albumin concentration can possibly increase free drug concentrations

Drug Other’s meds Old meds RX for same drug from different MDs OTC meds Amount Lack of understanding Using wrong measuring device Confusing schedules Forget what was already taken Not getting refills Rationing Route Please don’t chew your suppository Time Multiple drugs with different times Patient Please don’t take your spouse’s medications 5 Rights

Challenges to Successful Medication Regimens • Function • Physical • Sensory • Reading • Memory • Motivation • Funding

Medications Prescribed for the Elderly • Medications for dementia • Cholinesterase inhibitors: Cognex, Aricept, Exelon, Reminyl • Medications for osteoporosis • Antiresorptives • Bisphosphonates (Fosamax, Actonel, Boniva, Aredia, Zometa) • HRT • Selective estrogen-receptor modulators (Evista, Tamoxifen) • Anabolic or bone-forming • Calcitonin – nasal spray • Calcimar - injection • Medications for anxiety • Benzodiazepines • Buspirone – no cognitive impairment • Selective Serotonin reuptake inhibitors (SSRIs)

Nursing interventions • Medication review • Bring in all home meds • Education • Name • How often • How many • Side effects • Funding • Social worker • Accommodation • Pill boxes are great

Summary • Geriatric people make up about 13% of the population, but consume 33% of all prescription medications. • Older adults have significant physiological changes related to aging that may interfere with medications. • Older adults are more sensitive to the effects of drug therapy.

Summary (cont’d) • Adverse drug reactions are any noxious, unintended or undesired effect of a drug which occurs at doses in humans for prophylaxis, diagnosis or therapy. • Certain disease states may interfere with optimal drug therapy.

Summary (cont’d) • Polypharmacy is defined as the prescription, administration, or use of more medications than are clinically indicated for a patient. • Inappropriate prescribing may be very harmful to elderly persons. • Compliance to drug regimens is essential to improving medical diagnosis and outcomes.

Chapter 12: Identifying and Preventing Common Risk Factors in the Elderly Bonnie M. Wivell, MS, RN, CNS

Health Promotion and Disease Prevention Health promotion can help prevent functional decline in the elderly U.S. Preventive Services Task Force Evaluate benefits of individual services and to create age, gender, and risk-based recommendations about services that should routinely be incorporated into primary care Healthy People 2010 Sets of objectives developed by many experts to promote health and quality of life in Americans

Definitions Primary prevention Activities to prevent disease from occurring Example: Immunizations Secondary prevention Early detection and management Screenings Example: colonoscopy to detect and remove polyps Tertiary prevention Manage existing disease, preventing progression or complications Example: meds used to remodel heart with CHF

Screening Recommendations • Level A: Strongly recommends based on good evidence that screening = Outcomes > Risks • Level B: Recommends screening based on fair evidence than screening = Outcomes > Risks • Level C: Makes no recommendation for or against based on balance of benefit/risk • Level D: Recommends against screening because screening is ineffective or harmful • Level 1: Makes no recommendation due to insufficient evidence

Focus of Health Promotion Efforts Self-Management Chronic disease programs Contracting for behavior change Physical Activity Nutrition

Physical Activity Counseling Level I recommendation Found insufficient evidence to determine whether encouraging or counseling patients to begin an exercise program actually led to improvements in their level of physical activity There is strong evidence to support the effectiveness of physical activity in reducing morbidity and mortality from chronic illness

Nutrition Counseling Level B recommendation Found good evidence to support counseling interventions among adults at risk for diet-related chronic disease Interventions that have proven to stimulate healthy dietary changes combine nutrition education with behavioral counseling

5 A’s Ask Advise Assess willingness Assist Arrange follow-up 5 R’s Relevance Risks Rewards Roadblocks Repetition Tobacco Use

Tobacco Cessation Counseling Level A recommendation Found good evidence that screening, brief behavioral counseling, and pharmacotherapy, are effective in helping clients to quit smoking and remain smoke-free after one year. There is good data to support that smoking cessation lowers the risk for heart disease, stroke, and lung disease

Safety Inflammation of joints or joint deformity H ypotension (othostatic blood pressure change) A uditory and visual abnormalities T remor E quilibrium problems F oot problems A rrythmias, heart block, valvular disease L eg-length discrepancy L ack of conditioning (generalized weakness) I llness N utrition (poor, weight loss) G ait distrubance

Fall Prevention Counseling Level B recommendation Recommended in order to reduce fall risk Balance and strengthening exercise programs Home safety assessment and training Medication monitoring and adjustment

Polypharmacy and Medications Adults over age 65 take an average of 4.5 prescription meds and 2 OTC meds at any given time Many elders are prescribed drugs that are not recommended in the elderly Polypharmacy a major problem, with increased risk of side effects the more medications are added

Immunizations Influenza vaccination annually: Level B recommendation Amantadine or Rimantadine prophylaxis: Level B recommendation Pneumococcal vaccine: Level B recommendation Tetanus vaccination: Level A recommendation

Mental Health Issues • Depression • Level B recommendation to support screening • Found good evidence that screening effectively identifies depressed patients and that treatment of depression improves clinical outcomes • Dementia Screening • Level I recommendation. • Found the clinical evidence to be insufficient to recommend screening for all elderly clients in a primary care setting • Most expert panels agree that clients who are suspected of having cognitive impairment or whose families express concern about their cognitive functioning, should be screened

Alcohol Abuse More the 7 drinks per week for women and 14 drinks per week for men is considered hazardous Can use 5 A’s and 5 R’s also Screening Level B recommendation for screening Found good evidence that screening is beneficial in identifying patients whose alcohol consumption patterns place them at risk for increased morbidity and mortality, and good evidence that counseling about alcohol reduction can produce sustained benefit over a six to twelve month period

Elder Abuse and Neglect Clues to abuse: The presence of several injuries in different stages of repair Delays in seeking treatment Injuries which cannot be explained or that are inconsistent with the history Contradictory explanations by the caregiver and the patient Bruises, burns, welts, lacerations, restraint marks

Elder Abuse and Neglect Continued Clues to abuse (cont’d): Dehydration, malnutrition, decubitus ulcers or poor hygiene Depression, withdrawal, agitation Signs of medication misuse Pattern of missed or cancelled appointments Frequent changes in healthcare providers Discharge, bleeding or pain in rectum or vagina or sexually transmitted disease Missing prosthetic device(s), such as dentures, glasses, hearing aids

Lipid Screening Level A recommendation for screening There is strong evidence to correlate lipid abnormalities with cardiac risk A simple blood test is a valid and reliable method of diagnosing lipid abnormalities Diet and drug therapies are effective remedies

Heart and Valvular Disease Each component below will be examined individually Risk factors: Age > 50 for men and 60 for women Hypertension Smoking Obesity

Heart and Valvular Disease Continued Risk factors (cont’d) Family history of premature CHD Diabetes (Considered to be a CHD risk-equivalent i.e. Carries the same risk of coronary event as known CHD) Sedentary life style Abnormal lipid levels

Blood Pressure Screening Level A recommendation There is strong evidence that blood pressure measurement can identify adults at increased risk for cardiovascular disease due to high blood pressure Treatment of hypertension substantially decreases the incidence of cardiovascular disease

Aspirin Therapy Level A recommendation There is good evidence that aspirin decreases the incidence of CHD in adults who are at increased risk for heart disease Aspirin increases the incidence of gastrointestinal bleeding and hemorrhagic strokes Concluded that evidence is strongest to support aspirin therapy in patients at high risk of CHD

Cerebral Vascular Disease Risk factors Increased age Smoking Hypertension Diabetes Sedentary lifestyle Alcohol use High fat diet Atrial fibrillation Carotid stenosis

Thyroid Disease Screening Level I recommendation There is insufficient evidence to recommend for or against screening based on limited evidence to establish health risks of subclinical disease, and due to the risks of treatment

Osteoporosis Risk factors: Advanced age Low BMI Caucasian or Asian race Family history of compression or stress fracture Fall risk or history of fracture Low levels of weight-bearing exercise Smoking Excessive alcohol or caffeine use Low intake of calcium or vitamin D.

Osteoporosis Screening Level B recommendation Osteoporosis is common in the elderly and is correlated with fracture risk There are good screening tests to diagnose osteoporosis and effective treatments for the disease

Vision and Hearing Cataracts, glaucoma, and diabetes contribute to visual impairments in elderly

Prostate CA Screening Level I recommendation Insufficient evidence to recommend screening based on inconclusive evidence that screening with DRE and PSA improves health outcomes Men with a life expectancy of less than 10 years are unlikely to benefit from prostate screening

Breast CA Screening Mammography (with or without clinical breast exam): Level B evidence There is fair evidence to support benefit from breast cancer screening for older women by mammogram every one to two years There is no age at which screening should be discontinued but the task force agrees that screening would have no benefit when life expectancy is significantly limited by dementia or other serious, life-limiting chronic illnesses

Colorectal Screening Level A recommendation The task force strongly recommends colorectal screening by FOBT, FOBT + sigmoidoscopy, or sigmoidoscopy alone for clients with average risk of developing colorectal cancer. The task force was unable to determine whether the increased sensitivity of colonoscopy compared with the other screening methods outweighed the costs, risks and inconvenience of the procedure.

Chapter 18: Appreciating Diversity and Enhancing Intimacy Bonnie M. Wivell, MS, RN, CNS

Definitions • Heritage: encompasses a person’s ethnic origin, nationality, religion and culture • Ethnicity: refers to what some have called race; African, European, Asian, etc. • Nationality: refers to the geographic location of birth • Religion: refers to a belief system based on a higher power • Culture: refers to the group to which the person belongs and which influences the person’s values and beliefs (shared beliefs)

Appreciating Diversity Diversity of elders Elderly cohort is becoming more heterogeneous At present, most elders are white females, but this is changing with growth of minority groups Differences in race, diet, leisure, socioeconomic status, and health care beliefs present challenges to nursing

Cultural Competence • “A key strategy for achieving cultural competence is to learn about different cultural and religious preferences, customs, and restrictions, and the use this knowledge in planning and providing care.” (Mauk, page 604)

Health Care Disparities Reframe the problem of health disparities from a racial issue to one of a phenotype/environmental mismatch (HTN and Vit D deficiency) The disparities to be discussed are the most significant health-related differences found among ethnic groups, based on Keppel’s research While not all of the disparities cited in Keppel’s study pertain directly to older adults, these differences among ethnic groups points to certain foci of nursing care that, if not addressed early, may carry into older age

Chapter 8: Medications and Laboratory Values