PHARMACOLOGY AND OLDER ADULTS (WEEK 4)

 Older persons body is at greater risk for adverse drug events than younger persons. FACTORS THAT CONTRIBUTE TO INCREASED RISK OF ADE

In body water (as much as 15%) 1. PHARMACOKINETIC CHANGES : WHAT THE BODY DOES TO THE DRUG???
- results to increase concentration of water-soluble drugs (e.g. alcohol)
 DRUG ABSORPTION
In body fat  Do not usually contribute to drug response and have less impact on pharmacokinetics.
- more prolonged effects of fat soluble drugs  altered distribution into the peripheral circulation and tissues
 decrease in plasma albumin levels with age may result in decreased binding of drugs
Hepatic blood flow results in increase toxicity = Increased SGPT that are mainly bound to serum albumin
= Increased PT, PTT  decrease in total body water, and intracellular water volumes may lead to an
Serum albumin level increased serum concentration of water soluble drugs such as lithium and alcohol
- altered binding capacity
- Increased serum level of the free or unbound proportion of protein-bound drugs  DRUG DISTRIBUTION
- toxic level of highly bound drugs  increase in body fat may increase in the distribution of fat- soluble medications ( e. g.
benzodiazepines) into fatty tissue, resulting in prolonged half-lives and drug
PREDICTORS OF MEDICATION RESPONSE accumulation
 GENERAL STATE OF HEALTH
 NUMBER AND TYPES OF OTHER MEDICATIONS TAKEN  HEPATIC METABOLISM
 LIVER (sgpt), RENAL FUNCTION - Creatinine  age-related metabolism is not easily measured.
 PRESENCE OF COMORBIDITIES OR OTHER DIAGNOSED DISEASES  Primarily, biotransformation occurs in liver, where enzymatic activity alters and
detoxifies the drug to prepare it for excretion.
MEDICATION ERROR  RENAL EXCRETION
 Results from human knowledge based deficiencies and a lack of sophisticated systems  the most important pharmacokinetic parameter that changes with age
to support and monitoring drug therapy.  changes is extremely variable, majority of older adults have a decline kidney function,
requiring a decrease dose or extension of interval for certain drugs
2 IMPORTANT DISTINCTIONS IN MEDICATION ERROR LANGUAGE  SERUM CREATININE may be used as indirect estimate of renal function.
 ADVERSE DRUG REACTION (ADR)  CREATINE CLEARANCE is an estimate of GFR and decreases with age.
- any unintended response to a drug that occurs when drugs are used to diagnose, treat or
prevent disease. 2. PHARMACODYNAMIC CHANGES : WHAT THE DRUG DOES TO THE BODY??
- ADR INCLUDES: - Aging may result in different responses for older adults to the same drug concentrations at
 Difficulties in the activity of daily living. the site of action compared with younger adults.
 Cognitive changes
 Falls CHANGES IN PHARMACODYNAMICS IN OLDER PERSON MAY BE CAUSED BY:
 Anorexia, nausea  Altered number of receptors or affinity.
 Weight changes  Decreases in receptor binding.
 Altered cellular response to the drug receptor- receptor interaction.
 ADVERSE DRUG EVENT (ADE)  Organ pathologic condition.
 any injury that results when medications are used, and this includes both ADR’s and  Altered homeostatic mechanism.
medication errors that lead to an ADR.
 NOTE: the use of too many or wrong types of medications increases the risk of both an
ADE and non-adherence!!!!!
3. DRUG-DRUG INTERACTION
 an interaction between one drug and another can result from altered
pharmacokinetics or pharmacodynamics.
 it is largely thought that alterations in hepatic metabolism are specifically responsible
for drug-drug interaction.
EX: Warfarin and aspirin- increased risk for bleeding.
4. DRUG-FOOD INTERACTION
 the effect of a drug or food can be influenced by their combined actions.
EX: Theophylline and caffeine- increased risk for potential toxicity.
- Levodopa and clonidine- decreased antiparkinsonian effect.
5. DRUG- DISEASE INTERACTIONS
 certain states may be exacerbated by specific drug therapies, and these drugs may be
contraindicated in patients with coexisting underlying disease.
EX: Aspirin, NSAID’s and Atrophic gastritis- GI hemorrhage
POLYPHARMACY
 Prescription, administration, or use of more medications that are clinically indicated in
given patient.
 MULTIPLE MEDICATIONS INCREASE THE CHANCE OF:
1. drug-drug interaction
2. ADE’s and ADR’s
3. Error of dosing
PREVENTION OF POLYPHARMACY
1. Use of the same pharmacy to fill all prescriptions.
2. Notification to all prescribing clinicians of drug used.
3. Nurse obtaining a complete history of all drugs used.
FEDERAL LEGISLATIONS
1. Omnibus Budget Reconciliation Act ( OBRA) 1987
 legislated the appropriate use of medications in institutionalized older persons.
a. use of chemical restraint
b. use of unnecessary drugs
 Antipsychotic drugs should not be used unless necessary to treat a specific condition
that is diagnosed and documented in the clinical record.
2. BEERS CRITERIA
 Commonly used consensus criteria r/t inappropriate medications.
 Developed in 1997, and adopted in 1999 by the Centers for Medicare and Medicaid
Services for the regulations of medications in nursing homes.
 Inappropriate medications administered to older person include:
 a. prescriptions for long-acting benzodiazepines, persantine, propoxyphene
b. long-term use of drugs that are to be used for short-term use only ( e.g. histamine
blockers, short-acting benzodiazepines, oral antibiotics)
c. High doses of drugs prescribed above dosage limitations ( Fe supplements, histamines
blockers, antipsychotic agents).
COMMONLY USED MEDICATIONS
 Anxiolytic and Hypnotics
 anxiety can be significant problem in older persons and is often associated with
depression & dementia
 according to the Beer’s list, benzodiazepines with long half-lives should be avoided
because of the likelihood of the accumulation of the patent drug and its active
metabolite, thus increase toxicity.
 NOTE: DAILY USE OF BOTH SHORT- AND LONG-TERM ACTING BENZODIAZEPINES
 should be limited for less than 4 continuous months
 should be limited unless an attempt at gradual dose reduction is unsuccessful
 dose reduction should be considered after 4 months
 ANTIDEPRESSANTS
 all antidepressant are generally equally effective and typically take effect in 2-4 weeks
 overall, tricyclic antidepressants should be avoided in the older patient because of
their anticholinergic and sedative side effect
 newer SSRI’s are often considered the first choice for antidepressants in older adults
because of their lack of TCA side effects
 ANTIPSYCHOTICS
 should be only when valid and clear documentation of need exist
 appropriate indications for antipsychotic prescription include schizophrenia, paranoid
states, and symptoms of psychosis such as hallucinations and delusion
 3D’s that may justify antipsychotic use:
- Danger to the resident of others
- Distress for the residents
- Dysfunction of the resident, including interference with basic nursing care
 CONDITIONS INAPPROPRIATE FOR ANTIPSYCHOTIC DRUGS
 Wandering, Poor self-care, Restlessness
 Impaired memory, Anxiety, Depression
 Insomnia, Unsociability
 Indifference to surroundings
 Nervousness, Uncooperativeness
 Agitated behavior when not a danger to other self or others
RESIDENTS WHO USE ANTIPSYCHOTIC DRUGS SHOULD RECEIVE:  Use of Isotonic liquids or sugar-free lozenges can help with dry mouth.
 GRADUAL DOSE REDUCTION
 DRUG HOLIDAYS-a patient stops taking a medication(s) for a period of time. GENERAL PRESCRIBING PRINCIPLE
 BEHAVIORAL PROGRAMMING unless contraindicated 1. Encourage the discontinuation of one drug when another is added.
2. Consider reducing dosages when:
 PRN NEUROLEPTICS  Weight is less than average.
 Are not to be used more than twice in a 7-day period without further assessment  Liver or renal function is decreased.
unless for the purpose of titrating dosage for optimal response and for management of  An individual experiences exaggerated responses to drug.
unexpected behaviors otherwise unmanageable. 3. One drug should not be used to treat the side effect of another drug.
 Better to change the offending drug.
 CARDIOVASCULAR MEDICATIONS  Decrease the dosage in order to decrease the side effects.
 * Older adults have an increased risk for orthostatic hypotension and dehydration, 4. ALTERNATIVES should be considered.
especially with volume-depleting agents and vasodilators* 5. START SLOW, go SLOW.
6. TITRATE therapy.
 ANTIMICROBIAL 7. Educate the client.
 Dosing may need to be altered in older clients because of reduced renal elimination. 8. Review regularly.

 NONPRESCRIPTION AGENTS MEASURES TO MANAGE MEDICATION CORRECTLY

 FDA’s 3 MAIN CRITERIAS FOR SWITCHING PRESCRIBED MEDICATION TO OTC STATUS:  Decreasing the number of pills to be taken in a day.
1. A record of established safety data for the prescription product is necessary.  Establishing a routine for taking medications.
2. The drug’s expected use should be appropriate for OTC treatment.  Preparing medications for the day in different containers.
3. The drug should lack undesirable property and not require special precautions when  Developing memory methods.
used without physician oversight.  Scheduling in conjunction with other daily activities.
 Using reminders such as telephone or e-mail.
NONADHERENCE(non-compliance)  Conduct a brown bag assessment.
 RISK FACTORS  Bring all medications including OTCs.
 Living alone without social support.  Check:
 Visual or auditory impairments.  Outdated preparations
 Increasing use of alcohol.  Unused or unfinished prescriptions
 Socioeconomic factors.  Overlap or duplication of medications
 Unpalatable bulk powders or large tablets.
SLEEP AND AGING (WEEK 5)
NURSING MANAGEMENT FOR IMPROVING CLIENTS ADHERENCE
 If knowledge deficits are a problem, provide verbal education, reinforced with written Sleep
instructions and allow time for clients feedback.  is a natural, periodically recurring, physiologic state of rest for the body and mind;
 Encourage a client who “pharmacy shops” to have prescriptions filled at the same sleep is a state of inactivity or response that is required to remain active.
pharmacy each time.
 Provide cues to assist remembering to take medications. Importance of Sleep
 Reduce the impact of drug side effects.  Proper sleep architecture and adequate total sleep time are necessary for proper
 Give adequate intake of fiber and fluid to reduce constipation. functioning.
 Diuretics can be scheduled in the morning to reduce interruptions of activities and
sleep.
Biologic Brain Functions Responsible for Sleep
Regulation of sleep and wakefulness occurs primarily in the hypothalamus, which
contains both a sleep center and a wakefulness center. The thalamus, limbic system,
reticular activating system are controlled by the hypo thalamus and also influence sleep and
wakefulness.
 Age-related changes in the nervous system can affect sleep
 May be at the chemical, structural, and functional levels
 May result in a disorganization of sleep and disruption of circadian rhythms
 Declines in the cerebral metabolic rate and cerebral blood flow
 Reductions of neuronal cell counts
 Structural changes, such as neuronal degeneration and atrophy

Sleep Requirements
 A common myth is that you require less sleep as you age
 Most older adults require 6 to 10 hours of sleep per night
 Less than 4 hours or greater than 9 hours of sleep is associated with higher mortality
Potential causes of sleep disruption in older persons

Sleep Problems in Older Persons

 Sleep problems in older persons may result from
 Personal characteristics
- Advanced age
- Female gender
- Depression
 Environmental characteristics
 A combination of these factors
 Older women are more likely than older men to
- Take longer to fall asleep
- Wake more frequently after the onset of sleep
- Stay awake longer during these nighttime awakenings
Age-Related Chages in Sleep  Older persons may take more daytime naps that disrupt normal sleep patterns.

 Increased Sleep Latency Factors that Affecting Sleep

- a delay in the onset of sleep.
 Reduced Sleep efficiency  Environment
- is the relative percentage of time in bed spent asleep. Can positively or negatively influence the quality and amount of sleep persons receive. For
 Increased Nocturnal Awakenings older adults, environment conducive to relaxation are likely to be soporific.
- Contribute to an overall decrease in the average number of hrs of sleep  Home Environment
 Increased Daytime Sleepiness Supports a good night’s sleep by its very familiarity. The bed and bedding, the people, and
- May be due to nocturnal awakening or other sleep disturbances. It may also due to the noises are all familiar.
medication side effects.  Hospitals and Long-Term Care Facilities
 Greater difficulty falling asleep - The environment of a health care institution can distract from the quality of sleep not only
 More frequent awakenings because of reduced slow wave sleep unfamiliar, but the typical: bright lights, noisy people and machines, limited privacy and
 Decreased amounts of nighttime sleep, especially deep sleep space and uncomfortable mattress. There may be physical discomfort or pain from
 More frequent daytime napping invasive procedure.
 Increased time spent trying to sleep as sleep becomes less efficient  Noise
Environmental noise potentially interferences with sleep in all health care settings.
 Temperature
Nocturnal Awakening Diuretics
Falling and staying asleep are difficult when a person is cold. Being too warm will also
disrupt sleep, but some older adults sleep better if simple measures are used to keep them
warm.
 Lifestyle Changes
Lose of spouse. Widowhood is a common life event in the older adult population. Loss of Nightmares, vivid dreams Atenolol, nifedipine, carbidopa-
bed partner can make sleep psychologically less comforting. levodopa, propranolol, amitriptyline
Retirement. Brings about changes in schedule and activities
Relocation. As a change of residence from house or apartment to the home of children or
siblings, a retirement community, assisted living facility or nursing facility
Having a roomate. May interfere with sleep Antipsychotic, long acting
 Dietary influences. benzodiazepines, cold remedies,
Sleep is influenced by what we eat and drink. Popular caffeine-containing beverages make Daytime sleepiness atenolol, ranitidine
falling asleep more difficult for some older adults. Drugs Influencing Sleep. Both
prescription and over the counter drugs can contribute to sleep and to sleep disturbance.

Drugs affect sleep in 3 ways:

Sleep Disorder and Conditions
a. Causing sleep by intent,
 Sleep Apnea.
b. Causing drowsiness by side effects,
May experience recurrent episodes of cessation of respiration that may last from 10 secs to
c. Causing insomnia or other sleep disturbances by side effect
2mins.
 Periodic Limb Movement.
Ex: Medications that Disturbed Sleep
There are repetitive kicking leg movements throughout the night it may occur every 20-40
Type of Sleep Disturbance Examples of Medications secs that causes a brief disruptions of sleep

Therapies to Promote Sleep

Alteration of REM sleep
Insomia
Delayed onset of sleep
 Relaxation therapies reduce either somatic and arousal or cognitive arousal.
Alcohol,arbiturates,benzodiazepines  Progressive muscle relaxation is one example of the therapy to reduce somatic
arousal.
 Cognitive arousal is reduces by attention focusing therapies such as guided imagery or
medication.
 Stimulus control therapy attempts to reestablish the bedroom environment as the
stimulus for sleep by banning activities not related to a good night sleep from the
Haloperidol, risperidone, phenytoin, bedroom.
sertraline, theophylline,
amitriptyline  Sleep Deprivation
Sleep deprivation can result in
 Harmful physical and psychological changes
 Daytime fatigue
Caffaine, amphetamines,  Irritability
theophylline, nasal decongestants  Impaired learning ability
containing stimulants  Delayed healing
 Visual and auditory hallucinations
  Daytime sleepiness
 Sleep Disturbances  Dizziness
Sleep disturbances can exacerbate:  Blurred vision
 Behavioral problems
 Traffic accidents  Benzodiazepines
 Memory lapses  Benzodiazepines can
 Emotional instability  Exacerbate sleep apnea
 Decreased daytime functioning  Suppress deep sleep
 Increase the likelihood of falling
The Risk and Benefits of Pharmacological and Non-pharmacological interventions for  Cause increased confusion
sleep disturbance.
 Sleep Restriction Therapy
 Hypnotic Drugs  Using the bed for sleep and sex only
Typical side effects of hypnotic drugs include  Getting out of bed if unable to fall asleep
 Falls  Keeping regular sleep time routines
 Swallowing difficulties  Avoiding daytime naps
 Constipation
 Dizziness  Other Nonpharmacological Sleep Interventions
 Daytime sleepiness  Cognitive therapy
 Progressive relaxation exercises
 Psychotropic Medications
Most psychotropic medications alter sleep architecture  Sleep Medications
 Decreased REM sleep  Sedating antidepressants can cause
 Decreased levels of arousal  Postural hypotension
 Increased slow wave sleep  Anticholinergic side effects

Treatment for Sleep Apnea  Barbiturates, sedatives, hypnotics, opiates, and antipsychotics have potential for
 Weight reduction  Abuse
 Sleeping on the side rather than the back  Overdose
- Wear a tennis ball in a pocket sown on the back of a nightshirt  Severe withdrawal symptoms
 Avoiding sleeping pills and alcohol before sleeping  Tardive dyskinesia
 Avoiding smoking
 Surgery  Chloral hydrate can result in
 Fewer hangover effects than some benzodiazepines
 Hypnotic Medications  Quick tolerance
 Recommended for 2 weeks or less  Gastric irritation
 Long-term use blunts the effects and can cause excessive daytime sleepiness  Renal, hepatic, and cardiac toxicity

 Newer drugs, such as zolpidem (Ambien), do not adversely affect sleep architecture
 No association with harmful side effects
 OTC Sleep Aids  Daytime sedation and decreased cognitive performance are possible
 OTC sleep aids contain antihistamines (diphenhydramine, Benadryl), which can cause
 Herbal or natural remedies include
 Melatonin
 Chamomile tea
 Valerian root
 A small evening snack (natural tryptophan)

Appropriate nursing interventions to improve or restore sleep

Nursing Interventions

 Individualize nighttime care

 If sleep disturbances are caused by underlying medical problems
 Investigate and treat nighttime pain
 Treat depression and anxiety disorders
 Encourage sleep hygiene
 Correct environmental problems
 Recommend dietary and lifestyle changes
 Encourage daytime activities
 Discourage long naps

 In Long-Term Care Facilities

Establish consistent nighttime routines
 Reduce noise and light disruption
 Turn down televisions and radios and ringers on phones.
 Avoid using intercoms and beepers during sleep hours.
 Turn night lights on at the hour of sleep and turn off overhead lights
 Keep residents busy and occupied during the daytime with exercise
 Do not put residents to bed immediately after supper
 Provide restful evening activities
 If residents are awake and noisy during the night, assist them from bed to a lounge or
recreation area