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MEDICATIONS
pH Sensitive Medications are more likely to be affected by altered gastric acid levels or prolonged exposure to these acids b/c of delayed emptying Name 2 medications like this:
- Penicillin
- Ferrous sulfate Identify age-related changes that affect the action of medications in the body and skills involved with taking medications. GLOMERULAR FILTRATION RATE: Age-related decline in glomerular filtration rate begins in early adulthood and progresses at an annual rate of 1% to 2% which can decrease renal clearance and increase serum levels of medications. Problematic for medications that are highly water soluble and those that have a narrow therapeutic range.
HEPATIC BLOOD FLOW: Hepatic blood flow declines progressively, beginning around the age of 40 years, and this age-related change can increase serum levels of substances that are metabolized more extensively by the liver. In addition, factors such as diet, caffeine, smoking, alcohol, genetic variations, and pathologic conditions can affect liver metabolism of substances. In recent years, there has been increasing attention to the role of liver enzyme systems that are responsible for the metabolism of orally administered bioactive substances, including medications, herbs, nutrients, and dietary supplements. The combination of two or more bioactive substances competing at the same enzyme site can cause serious, and even fatal, adverse effects BODY COMPOSITION: Age-related changes in body composition (i.e., decreased body water and lean tissue and increased body fat) can affect substances according to their degree of fat or water solubility. Consequently, medications that are distributed primarily in body water or lean body mass may reach higher serum concentrations in older adults and their effects may be more intense. Similarly, the serum concentration of highly fat-soluble substances can increase, so the immediate therapeutic effects are diminished, but the overall effects are prolonged or erratic. PROTEIN-BINDING: Protein-binding capacity of a medication (i.e., the extent to which their molecules are bound to serum albumin and other proteins) is an important determinant of both therapeutic and adverse effects. Low serum albumin levels, which are common in older adults, lead to an increased amount of the active portion of protein-bound substances. In addition, when two or more protein-bound substances compete for the same binding sites, adverse effects are more likely to occur. List some medications that are more likely to have adverse effects when albumin levels are LOW: Medications that are likely to have adverse effects when they are taken together or when serum albumin levels are low include:
- Aspirin
- Digoxin
- Furosemide
- Pathologic conditions not only influence the action of substances in the body but also contribute to nonadherence, especially in combination with functional limitations. For example, dementia can significantly affect the older adult’s ability to understand directions, remember instructions, and self-manage medication regimens. Dysphagia is an example of a physical limitation that can interfere with the ability to take substances orally. Describe the Prescribing Cascade: prescribing cascade has been applied to the following commonly occurring scenario: an adverse drug reaction is viewed as a new medical condition, a drug is prescribed for this condition, another adverse drug effect occurs, the patient is again treated for the perceived additional medical condition, and the sequence perpetuates new adverse effects. Prescribing cascades are an important target for improving medication safety and reducing problematic polypharmacy in high-risk populations, such as people with dementia Medication-Medication Interactions are typically caused by competitive action at binding sites, but they can also be caused by any mechanism that influences the absorption, distribution, metabolism, or elimination of any of the medications Choose a Type of Interaction and describe it here:
Warfarin (Coumadin) requires close monitoring because serum levels are easily altered by interactions with other medications foods and herbs. Recognize the Functional Consequences of Inappropriate Prescribing in older adults. What medications are more likely to cause emergency hospitalizations in older adults? (p.129)
- Anticoagulants
- Antibiotics
- Diabetes Agents
Adverse effects may not be recognized as such b/c they are similar to the manifestations of pathologic conditions or they are mistakenly attributed to aging. Three concerns of particular importance are anticholinergic adverse effects, changes in mental status, and drug-induces movement disorders. List some adverse effects on older adults from ANTICHOLINERGIC medications (YouTube video) : You can’t see it, can’t pee it, can’t spit it, can’t shit it.
- Blurred vision
- Urinary retention
- Dry mouth
- Constipation Cholinergic Crisis: SLUDGE o S- Salvation. o L- Lacrimation (excessive tear) o U- Urination. o D- Defecation o G- Gastric upset. o E- Emesis(vomiting). Define TOTAL ANTICHOLINERGIC BURDEN (online lecture) : Total anticholinergic burden- taken a lot of meds with the same side effects blurred vision, dry mouth and it builds up in the system poison them with this How long might it take for delirium to subside if caused from an adverse drug event? (p.130) It is important to keep in mind that medication-induced mental changes may not subside immediately after the offending medication is discontinued. In some cases it may take several weeks or even months after the medication is decreased or discontinued for mental function to return to the premedication level. Medications that are likely to cause mental changes in older adults as well as the mechanism underlying these adverse actions. (p131+ and online lecture): Tardive dyskinesia drug induced movement disorder, early sign lip smacking tongue and faces and blame it on dementia but it causes this permanent immobility Define TARDIVE DYSKINESIA: (and parkinsonism) are movement disorders that can develop as adverse effects of medication in older adults. Refers to a constellation of rhythmic and involuntary movement of the trunk, extremities jaw, lips, mouth or tongue. Manifestations can begin as early as 3 to 6 months after initiation of antipsychotic
medications, and they usually persist even after the causative agent is discontinued. Advanced age correlates w/ both an earlier onset and increased severity of tardive dyskinesia. Moreover, when combined w/ age-related changed and risk factors, tardive dyskinesia can seriously impair the older adults ability to perform activities of daily living. Define DRUG-INDUCED PARKINSONISM: is the occurrence of Parkinson-like manifestations as and adverse medication effect. Manifestations can be reversed of the offending drug is stopped, but many times the condition is misdiagnosed as Parkinson disease and treated inappropriately w/ anti-parkinsonism medication. This condition is often not diagnosed correctly and is treated inappropriately with medications rather than with the more effective approach of discontinuing the causative drug. What medication classifications can cause DRUG-INDUCED movement disorders in older adults?
- First generation antipsychotic (haloperidol, phenothiazines)
- Second-gen. antipsychotics (amoxapine, olanzapine, quetiapine)
- And some antidepressants (mirtazapine, amoxapine, duloxetine) What key role do nurses play with drug-induced movement disorders? Drug-induced movement disorders are potentially reversible conditions if the adverse effect is recognized as such and the causative medication is discontinued, nurses have key roles in observing for indicators for these conditions and facilitating referrals for further evaluation before the condition progresses. What is the Nurse’s role in MEDICATION RECONCILIATION? (pp.136-137) Medication reconciliation- MANDATORY intervention Identifying: A patients medication discrepancies such as omissions, duplications, dosing errors, or drug interactions- during transition in care. Requires collaboration with who? Requires interprofessional collaborations and is an effective intervention for addressing medication errors, which are one of the leading avoidable sources of harm to hospital patients During transitions of care, it offers an opportunity to compare information in electronic medical records and verbally reviewing the medications with professional involved in the transition. During hospital admissions and discharges medication reconciliation involves
7- Functional capacity tools for evaluating ADL, IADL, cognitive status related to ability to self-administer. Define Deprescribing (p.141) : Deprescribing is an interprofessional process of identifying and discontinuing medications that are prescribed inappropriately, meaning that the actual or potential harms outweigh the benefits. Deprescribing and the use of STOPP criteria are widely cited in geriatric literature as effective interventions for reducing polypharmacy and potentially inappropriate medications Moreover, deprescribing can reduce adverse drug effects, increase medication adherence, improve the patient’s quality of life, and reduce costs of care is particularly important for older adults with several chronic conditions and for those who are frail or with life-limiting conditions Who must the nurse collaborate with to make this happen?
- Nurses also have important roles in assessing medication regimens and advocating for a medication review by pharmacists or prescribing practitioners through interprofessional collaboration
- In addition, nurses can teach older adults and their caregivers about the need to ask their prescribing practitioners to review their medications
- Nurses accomplish this by coordinating the efforts of the prescriber(s) to discontinue duplicate medications or medications that are no longer appropriate and by educating the older person about the judicious use of medications that are not medically necessary.
- In home and community settings, nurses can teach older adults to review their medications with their health care practitioners at every visit. In long-term care settings, nurses can facilitate interprofessional collaboration for periodic consideration of medications appropriate for deprescribing
