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

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

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

Specific Therapeutic Challenge of Prescribing for the Elder Patient

Principle factors:

Altered Pharmacokinetics Multiple and severe illness Multiple drug therapy Poor adherence

Physiologic changes that affect Pharmacokinetics in the Elderly

Absorption of Drugs

Increased gastric pH Decreased absorptive surface area Decreased gastric motility Delayed gastric emptying

Pharmacokinetic changes

Distribution of Drugs:

Increased body fat Decreased lean muscle mass Decreased serum albumin Decreased cardiac output Decreased total body water

Pharmacokinetic changes

Metabolism of Drugs

Decreased hepatic blood flow Decreased hepatic mass Decreased activity of hepatic enzymes

Pharmacokinetic changes

Excretion of Drugs:

Decreased Decreased Decreased Decreased

renal blood flow glomerular filtration rate tubular secretion number of nephrons

Pharmacodynamics

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

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

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

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

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

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

Medication Appropriateness

Overuse of a Medication

Antibiotics GI Medications Sleep medications Wrong dose and/or frequency Chronic disease Preventative medications- vaccines

Misuse

Underuse

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

Beers Criteria

Strengths

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

Limitations

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

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

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

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

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

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

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

Case Study continued

What is problematic about this patients drug management?

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

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

Acetaminophen

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

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

Case Study

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

5 steps of Clinical Decision Making

Assessment Diagnosis Planning Intervention/Education Evaluation

REMEMBER

Individualized drug therapy in the elderly is essential

70% of nonadherence is INTENTIONAL

References

Abrams, WB, Beers, MH. Clinical Pharmacology in an aging population. Clinical Pharmacology Therapeutics 1998:63:281-4. Beers, MH. Explicit criteria for determining potentially inappropriate medication use in the elderly. Archives of Internal Medicine 1997: 157: 15316. 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. 2003;163:2716-2724 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

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