1. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School of Nursing

2. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 2 Session 5 Topic: Polypharmacy and the Older Adult

3. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 3 Polypharmacy: What is it? Use of more than one chemical agent to effect a therapeutic endpoint Some references say, the use of 5 or more drugs for an individual patient

4. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 4 Over the Counter Medications Older adults use the greatest number of nonprescription over the counter medications

5. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 5 How Many Meds Do Older Adults Use? Over 30% of all prescriptions dispensed Community Dwelling: use 2-4 prescriptions regularly Long-Term Care: use 2 – 10 prescriptions regularly

6. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 6 Misuse of Drugs …is the 5 th leading cause of death in older adults

7. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 7 Pharmacokinetics Means: What the body does to the drug Has 4 Components  Absorption  Distribution  Metabolism  Excretion

8. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 8 Normal Physiologic Changes… Can affect Pharmacokinetics

9. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 9 Absorption of Drugs Meaning: how the drug gets into the blood stream Not significantly altered with age, but absorption may be slightly delayed Can postpone onset of action, and peak effect of medication

10. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 10 Changes in Absorption Due to Aging: Slowed Gastric Emptying Decreased Gastric Acidity Decreased Blood Flow to intestines

11. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 11 Drug Distribution Meaning: where the medication goes in the body Can change with aging due to:  Higher percentage of fat compared to lean body mass  Decrease in total body water  Decrease in serum albumin

12. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 12 How does Aging Change Drug Distribution? The older adult is exposed to fat soluble drugs for a longer time There is more blood concentration of water soluble drugs Albumin is main site for protein binding drugs to bind for transport prior to being distributed to body tissue

13. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 13 Changes in Distribution CAN ACCENTUATE DRUG EFFECTS AND TOXICITY!! Example: long acting fat soluble benzodiazepine drugs such as diazepam (Valium) should be avoided Use short acting benzodiazepines in small doses instead

14. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 14 More Examples Water Soluble Drugs should be started at lower doses and then monitored  Example: Digoxin and Lithium

15. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 15 Drug Metabolism or Clearance Meaning: how the medication is broken down Can change with aging due to:  Decreased liver mass  Decreased liver blood flow  Altered liver metabolism

16. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 16 How Does Aging Change Drug Metabolism? The metabolism will be delayed for some drugs, so they will have greater serum concentrations Need to monitor liver functions

17. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 17 Examples of Metabolism Changes Delayed metabolism of:  Labetalol, Propanolol  Verapamil  Diazepam  Amitriptyline

18. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 18 Excretion of Drugs Meaning: how the medication is cleared from the body Can Change with Aging Due to:  Decreased Glomerular Filtration Rate  Decreased Ability to Concentrate Urine and Conserve Sodium  Decrease Renal Blood Flow  Decrease Renal Mass

19. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 19 How Does Aging Effect Excretion? Increases drug half lives for those drugs excreted by the kidney This means the time it takes for 50% of the drug to be eliminated from the body

20. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 20 Examples of Drugs with Increased Half-Lives for Older Adults Examples:  gentamicin  lisinopril  Atenolol  Digoxin  HCTZ  Cimetidine  Furosemide

21. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 21 Pharmacodynamics Means: What the drug does to the body

22. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 22 Adverse Reactions for Older Adults Many medications taken by older adults have potentially dangerous side effects

23. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 23 Falls Related to orthostatic hypotension

24. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 24 Confusion and Disorientation Can be related to inappropriate dosages

25. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 25 Hepatic Toxicity May be direct result of one medication, or due to a drug-drug interaction

26. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 26 Renal Toxicity May be direct result of one medication, or due to a drug-drug interaction

27. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 27 Common Problems Associated with Medications

28. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 28 Drugs with Anticholinergic Side Effects Can Cause  Confusion  Orthostatic Hypotension  Dry mouth  Blurred vision  Urinary retention

29. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 29 Tricyclic Antidepressants Use cautiously with patients who are being treated for glaucoma and cardiac conduction disturbances Rarely used for older adults Ex: Elavil, Doxepin, Nortriptyline

30. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 30 Tricyclic Antidepressant Drugs Can cause  Sedation and Fatigue  Anxiety, Insomnia and Confusion  Unstable gait  Hypotension  Tachycardia and Arrhythmias  Seizures

31. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 31 Antiemetics Can cause  Confusion  Orthostatic Hypotension  Blurred vision  Falls  Dry Mouth  Urinary Retention Ex: Chlorpromozine (Thorazine), Prochlorperazine (Compazine)

32. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 32 Anti-Arrhythmic Example: Lanoxin (Digoxin)  Can cause toxicity even with normal serum concentrations Therefore controversial for older adults

33. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 33 Histamine-2 Receptor Blockers Can cause  Confusion Therefore need dose reductions Examples: Zantac, Pepcid

34. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 34 Benzodiazepines Can cause  Central nervous system toxicity May have half-lives prolonged as much as 4 days Ex: Valium, Xanax, Ativan, Halcion

35. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 35 Narcotics Can cause: Confusion and Constipation Older adults are more sensitive to narcotics than younger adults “Start low, go slow” with dose Ex: codeine, morphine, demerol, USE WITH CAUTION!!

36. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 36 Medication Compliance/Adherence Older adults taking multiple medications, with complex regimens may require social and nursing support

37. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 37 Risk Factors for Non-Adherence: Cognitive Changes Living alone with social supports Insufficient Funds Depression Declining Function

38. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 38 Ways to Promote Adherence: Patient Education Written Instructions Assessment of environment: funds, transportation Discouraging pill sharing

39. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 39 Support Systems Medication Event Monitoring Systems (MEMS) Pill boxes Pre-poured Medications Friendly Calls Pill Counts

40. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 40 Cost Issues Related to Medications Older adults may have difficulty paying for medications out of pocket Ability to purchase medications needs to be assessed individually Some will cut pills in half to prolong use

41. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 41 Reference The content covered in this presentation is provided by the John A. Hartford Foundation Institute for Geriatric Nursing (2001)

42. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 42 Reference: Some of the material in this presentation obtained from graciously shared by: Mather’s LifeWays, 2003

43. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D62HP06858 43 Power Point Presentation Created by: Diana R. Mager, CRN, MSN Fairfield University School of Nursing ELDER Project Director