GERONTOLOGICAL CARE ISSUES

Introduction

The rapidly growing population of the elderly has increased the need for improved geriatric care

and prevention of disability. Comprehensive geriatric assessment is effective in guiding

treatment of the frail elderly patients and leads to significantly improved outcomes under

appropriate conditions. For efficient care of the aged, certain issues relevant to this age group

must be taken into consideration. These include – pharmacological considerations, care settings,

death and dying, ethical and legal issues. The geriatric nurse functions to ensure balance in all

these aspects and promote optimal functioning until death beckons.

Objectives

This paper aims to

 Define the concept of pharmacogerontology

 Discuss alterations in pharmacokinetics and pharmacodynamics

 Outline the nursing implications for these changes

 Discuss ethical and issues affecting the care of the elderly

Pharmacogerontology

Drugs are potent therapeutic agents with potential to cause great harm in older adults as well as

alleviate symptoms and cure disease. Older people use more medication than any other age

group. In the United States, older people represent 12.6% of the population but consume 30% of
prescribed medication and 40% of over the counter drugs (Mezey, Fulmer & Abraham, 2002).

Medications improve the health and wellbeing of older people by relieving pain and discomfort,

treating chronic illnesses and curing infectious processes. However, adverse drug reaction are

common because of medication interactions, multiple medication effect, incorrect dosages and

the use of multiple medications (polypharmacy). The potential for drug-drug interaction

increases with increased drug use; such interactions are responsible for numerous costly visits to

the emergency department and physician’s office (Deflaunte, 2003; Mezey, Fulmer & Abraham,

2002).

Most common pharmacologic agents used by the elderly include:

 Prescription drugs such as analgesics, endocrine-metabolic agents, estrogens, thyroid

replacement, cardiovascular drugs, diuretics, central nervous system agents,

gastrointestinal agents

 Over-the-counter drugs such as analgesics, laxatives and nutritional supplements

 Vitamins and minerals such as multivitamin, vitamin E, vitamin C and calcium

 Herbal supplements such as gingko biloba extract, mustard, aloe vera

Certain types of medications that carry high risks for older patients are often inappropriately

prescribed. A study matching explicit criteria for appropriate prescription against a

comprehensive complete drug benefit plan for elderly patients found that significant percentages

of patients could be considered to be taken certain medications inappropriately ( 38% taking

antidepressants, 19% taking sedative-hypnotics and 13% taking NSAIDS) (Anderson, Beers &

Kerluke, 1997).
Medications are capable of altering nutritional status, they irritate the stomach, cause nausea and

vomiting, cause constipation and may alter electrolyte balance. Combining multiple medications

with alcohol as well as over the counter and herbal medications complicates the problem.

Nurses have tremendous opportunities through assessment, monitoring, teaching and evaluation

to intervene so that maximum benefit and minimal harm come to the older adult undergoing drug

therapy. Safe and effective drug therapy for older adults requires an understanding of the

psychological and social influences on drug utilization in this population, the effects of aging on

pharmacokinetics and pharmacodynamics and the potential drug - related health problems.

Psychosocial influences on drug usage and responses of older adults

The psychosocial variables include individual and system factors. They are:

 Personal values: value system influences individual pattern of drug usage. Because older

adults have witnessed the advancements in therapy, they tend to expect a pill once they

visit the physician’s office. They spend less time, yet always leave with a prescription

because the health professionals prefer to prescribe pills rather than speak with patients to

find solutions to their problems.

 Health care system: many aspects of the health care system reinforce the tendency to use

drugs as the first line of therapy for diseases which can lead to suboptimal utilization of

drugs. They do not emphasise human approaches to management of chronic diseases.

 Drug marketing: drug advertising which is aimed at making profit induces prescription by

the physician and the purchase of over the counter drugs by the elderly. The elderly get

confused of the multiple names and take multiple drugs to relieve their symptoms.
Altered pharmacokinetics

Pharmacokinetic is defined as the study of drug movement, includes four processes: absorption,

distribution, metabolism and elimination. Alterations in these processes occur as a result of

normal aging and may result from drug and food interactions (Smeltzer, Bare, Hinkle &

Cheever, 2008). Absorptions may be affected by changes in gastric PH and a decrease in

gastrointestinal motility. Drug distribution may be altered as a result of decrease in body water

and increase in body fat. Normal age related changes and diseases that alter blood flow, liver and

renal function or cardiac output may affect distribution and metabolism (Mezey, Fulmer &

Abraham, 2002). The extent to which these changes are present in a particular person is highly

individualized, therefore drug responses are individualized.

Absorption

A number of age-related changes in the stomach such as increased gastric PH, delayed gastric

emptying and splanchnic blood flow could potentially affect drug absorption. Rate of drug

absorption is delayed with vitamins but calcium absorption is not affected (Smeltzer, Bare,

Hinkle & Cheever, 2008 ). Whereas the percentage of drug absorbed remains stable with aging,

the rate of absorption is slower.

Distribution

The distribution of medication in the body depends on blood flow, plasma protein binding and

body composition. Age-related changes that can alter drug distribution include a relative

decrease in body water and lean body weight, an increase percentage of body fat and reduced

serum albumin. Drug characteristics also influence drug distribution. For example, water soluble

drugs are more concentrated in body fluids because of reduced total body water, resulting in
more intense effects. Lipid-soluble drugs are readily stored in body fat, which reduces their

concentration in plasma thereby reducing their physiological effects.

The two major plasma proteins that medications bind to are albumin and alpha-1-acid

glycoprotein. Acidic drugs bind with the former while basic drugs the later. Deficiencies in the

protein are important because only unbound drugs are available to interact with tissue receptors

to give the pharmacologic effect. A slight decrease in albumin has been observed with older

adults but it is unclear whether this is a normal age-related change or if it is caused by chronic

disease, poor nutrition or some other factor (Sarkoz & Ramanathan, 2003). Examples of highly

protein binding drugs whose intensity of effects increase with hypoalbuminaemia are phenytoin,

warfarin, sulfonylureas, barbiturates, calcium channel blockers, lasix, NSAIDS, sulphonamides,

quinidine.

Alpha-1-acid glycoprotein remains same or increase with age. The level is increased in

inflammatory disease, burns and cancer. An increase in alpha-1-acid glycoprotein may bind a

higher proportion of drug molecules leading to a decreased free fraction of basic medication such

as lidocaine, beta blockers, quinidine and tricyclic antidepressants.

Reduced cardiac output and impaired peripheral blood flow decreases perfusion of many organs.

Increased proportion of body fat increases with age resulting in increased ability to store fat

soluble medications, this causes drug accumulation, prolonged storage and delayed excretion.

Examples of fat soluble medications include: barbiturates, diazepam, lidocaine, phenothiazines,

ethanol, morphine etc. Decreased lean body mass (body volume) allows higher peak levels of

medications ( Smeltzer, Bare, Hinkle & Cheever, 2008).

Metabolism
The liver is the major organ responsible for drug metabolism. Hepatic metabolism can be divided

into either phase I or phase II. Phase I comprises of preparative reactions that include oxidation

and reductive and hydrolytic biotransformations. Cyto-chrome P450 mono oxygenase enzymes

are the primary mediators of phase I reactions while phase II reactions comprises

conjugative/synthetic reactions including glucoronidation, sulfation and acetylation

biotransformations. Advancing age does not appear to alter phase II reactions, however, changes

in phase I reactions are more detectable. Specifically, there is a decline in drug oxidation

attributed to reduced liver volume (Crome, 2003). In older people, decreased drug metabolism

and clearance with associated increased half-life have been reported for medications such as

diazepam, piroxicam, theophylline and quinidine. Age related decrease in hepatic blood flow

also could significantly decrease the metabolism of drugs that undergo extensive first pass

metabolism such as imipramine, lidocaine and propanolol.

Despite the decrease in liver size and apparent altered metabolism of some drugs, most sources

agree that age alone has little effect on drug metabolism. Confounding factors that affect hepatic

metabolism include race, gender, frailty, smoking and drug interactions. For example,

theophylline metabolism is increased by smoking and phenytoin but decreased by cimetidine.

Decreased cardiac output and decreased perfusion of the liver delays breakdown of medication

resulting in prolonged duration of action, accumulation and drug toxicities (Smeltzer, Bare,

Hinkle & Cheever, 2008).

Elimination

Renal excretion is the primary route of elimination for many drugs or their active metabolites. It

is unclear whether declining renal function is part of normal aging or underlying pathology
(Lamb, O’Riordan & Delaney, 2003). The changes that have been attributed to age are

reductions in renal mass, size and number of nephrons, renal blood flow, glomerular filteration

and tubular secretion. These changes impair the excretion of water soluble drugs leading to

increased duration of action, accumulation and drug toxicity. Since serum creatinine is not

sufficient for measuring renal function in older adult because of the tendency to remain in the

normal range until significant function has been lost, serum cystatin C measurement is preferred.

Cystatin C is a protein that is produced at constant rate by all nucleated cells, catabolised and

excreted in the urine. Medications that may be affected include aminoglycosides, cimetidine,

chlorpropamide, digoxin, lithium, procainamide etc.

Altered pharmacodynamics

Drug pharmacodynamics is defined as the effect medication has on the body, simply the

pharmacological effect that results from drug interacting with receptors at the site of action.

There is evidence in older adults of enhanced responses or sensitivity to some drugs and

diminished responses to other drugs. This may be due to changes in the number of receptors or

affinity (Lehne, 2004). It is also possible that some effects are blunted because of age related

impairment in physiological responses or homeostatic mechanisms.

Older adults have been found to have diminished responses to beta blockers and beta agonists,

frusemide and vaccines. They demonstrate enhanced responses to benzodiazepines, H1 blockers,

neuroleptics, opioids and warfarin. Knowledge of medications that demonstrate altered

pharmacodynamic sensitivity can allow clinicians and persons to use these drugs safely by

making appropriate adjustments in dosage. Many prescribers start with the lowest possible dose

and only increase if the medication is tolerated. The rule of the thumb is “start low, go slow”.
Some drugs demonstrate both enhanced and decreased sensitivity. For example, with calcium

channel blockers, enhanced sensitivity is evident in greater reduction in blood pressure and

decreased sensitivity is evident in reduced atrioventricular node blockade.

Drug related problems

Although drug therapy offers many benefits to older adults, the potential for drug related

problems exists. These problems include adverse drug reactions (ADRs) also known as adverse

drug events and triggering or exacerbation of common geriatric syndromes such as cognitive

impairment, falls, dysmobility and incontinence. Not only does ADRs present physical threats,

they also significantly add to cost of healthcare.

An adverse drug reaction can be defined as “an undesired effect produced by a drug at standard

doses, which typically necessitates reducing or stopping the suspected agent and may require

treatment for the noxious effect produced” (Diasio, 2000). Most ADRs in older adults are dose

related (Lehne, 2004). ADRs can be classified as predictable or unpredictable. Predictable

reactions represent exaggerated pharmacological effects and are dose related. Unpredictable

reactions cannot be anticipated based on known pharmacologic effects and include toxic,

idiosyncratic and immunological reactions (Diasio, 2000).

Factors that predispose older adults to ADRs

 Polypharmacy: concurrent use of multiple drug, about as four or five or more by a single

person. Could as be referred to as “ the administration of more medications than are

clinically indicated” (Hanlon, Lindbald, Mahet & Schmader, 2003, p. 1290). It is

modifiable risk factor and therefore important that it is recognized.

accepted medical standards. Prescribing errors involve incorrect drug selection, dose,

dosage form, quantity, route, concentration, rate of administration and instructions for use

(American hospital formulary service, 1994). The Beers criteria have been used to

classify potentially inappropriate drug use as medications that generally should be

avoided in ambulatory older adults; doses, frequencies of administration or therapy

duration of drugs that generally should not be exceeded; medications that should be

avoided in older adults with specific common conditions. This criteria serve to alert

prescribers of potential problems and are not applicable in all cases. Factors responsible

for inappropriate prescribing are prescriber knowledge deficit, multiple diseases, multiple

prescribers and pharmacies serving the same people, patients’ demands (Liu &

Christensen, 2002).

 Drug interaction: a drug interaction can be defined as the effect that the administration of

one medication has on another drug. Drug interactions cam also be considered as

involving medications that can affect and be affected by patients’ diseases, nutrition and

biochemical status. Mechanism by which one drug might affect the actions and effects of

another drug include inhibition of absorption, hepatic enzyme induction or inhibition,

inhibition of excretion, displacement from plasma protein binding sites and altered

pharmacodynamics at the tissue level (Bressler & Bahl, 2003). Polypharmacy places the

patient at high risk of drug interactions and increases with each additional medication.

 Presence of multiple diseases

 Previous history of an ADR

 Medication dispensing and administration errors

 Gastrointestinal: diarrhoea, constipation and dry mouth

 Circulatory: dizziness, cardiac dysrhythmias, orthostatic hypotension

 Central nervous system: sleep disturbance, neuropsychiatric symptoms

 Fluid and electrolyte: leg oedema

 Metabolic: hypoglycaemia

 Haematological: bleeding, bruising, haemorrhage.

Nursing implications

Prescription principles that have been identified for older patients include “start slow and go

slow” and “keep the medication regimen as simple as possible” (Mezey et.al., 2002). A

comprehensive assessment with medication history which should include use of alcohol,

recreational drugs, over the counter and herbal medications is essential. Nurses should ensure

that patients understand the purpose of the medication, when and how to use it depending on

their cognitive ability. This ensures compliance with the medications. Noncompliance leads to

significant morbidity and mortality among the elderly. The contributing factors to

noncompliance include- number of medications prescribed, complexity of the regimen, difficulty

opening containers, inadequate patient education, financial cost and disease or medication

interference. Visual and hearing impairments may make it difficult to read and hear directions.

Nurses can take the following steps to help patients manage their medications and improve

compliance:

 Explain the purpose, adverse effects and dosage of the medication

 Provide the medication schedule in writing

the house).

 Suggest the use of a multiple-day, multiple-dose medication dispenser to help the patient

adhere to medication schedule

 Destroy or remove old, unused medication

 Encourage patient to inform primary care provider about the use of over the counter

medications and herbal agents, alcohol and recreational drug.

 Encourage the patient to keep a list of all medications including over the counter drugs in

his/her wallet to share with the primary care provider at each visit or in case of

emergency

 Review the medication periodically and update as it is necessary

 Recommend using one supplier for prescriptions, pharmacies frequently track patients

and are likely to notice a prescription problem such as duplication or contraindication in

the medication regimen

 If the patient’s competence is doubtful, identify a reliable family member or friend who

might monitor the patient for compliance (Smeltzer, Bare, Hinkle & Cheever, 2008).

Ethical and legal considerations

Nurses play important role in supporting and informing patients and families when making

treatment decisions. This nursing role becomes even more important in the care of aging patients

who are facing serious, life altering and possibly end of life decisions (Smeltzer, Bare, Hinkle &

Cheever, 2008). There is the potential for loss of rights, victimization and other serious problems
if patient has made no plans for personal and property management in event of disability or

death. As advocates, nurses can encourage end-of-life decision making and encourage older

people to prepare advance care planning for future decision making in the event of incapacitation

(Plotkin & Roche, 2000).

Moral principles applicable to care of older adults

Some moral principles that undergird standards of care include the following:

1. The right to quality health care: the right to quality health care for older adults means that

they have adequate access to quality care. Practically speaking, this means that older

citizens have the right to the same standards of health care as those in any other age

group. For example, older individuals have the right to complete evaluation of a problem,

information on treatment options and participation in the decision making about the best

course of treatment.

2. Respect for the individual person: older adults deserve respect for their personhood.

Inherently, they are worthy and valuable, especially in ways that make them unique

individuals. Older people are often treated stereotypically and thus are depersonalized.

One example of depersonalization and ageism is the proclamation that older people are

not open to change and this indicates disrespect for older adults as persons. Respect for

older adults will involve appreciation of the special characteristics and needs that are

more common in older persons and respecting them as persons who needs to be informed

to make decisions about their living or dying.

3. Autonomy or self- determination: this principle is critical in caring for older people.

Respecting the principle of autonomy means that older persons will be respected as
 decision makers about their own care. All competent older persons have a perspective on

their own best interest, shaped by their values and beliefs developed over a lifetime,

which defines each individual as a unique person. Based on this unique set of values and

beliefs, individuals assess alternatives, arrive at preferences, either individually or with

the assistance of others. Clinicians’ responsibilities to an older person in order to respect

autonomy include -: recognizing the validity of values and beliefs of older persons;

assisting the older person to identify these values and beliefs; assisting an older person to

express value based preference and refraining from interfering with that preference as

individuals are considered best judges of what is in their interest.

4. Confidentiality: this also applies in older adults as in other persons. Adult children of

older adults may persuade clinicians to reveal diagnosis and prognosis of the older

persons in an attempt to override their decision making capacity. This should be avoided

except in cases where the elderly want to bring harm to themselves or decision making

capacity is impaired.

5. Beneficence: this means that the highest good will be done for older people in particular

situation. An interpretation of good in medicine is alleviation of suffering and the

preservation of life, however, they are subject to interpretation and weighing of benefits

to define the highest values (Keenan, 2004).

6. Distributive justice: deals with problem of equitable distribution of scarce resources. The

implication for distributive justice is that all health care needs of older persons will

receive attention not just the acute needs that are amenable at certain times to inpatient

medical manipulation. Distributive justice would not allow curtailment of services using

chronological age alone as criterion.

As the society ages, healthcare of the older people present the nurse with challenging problems.

The result of many poorly resolved dilemmas is frustration about the quality of care given and

quality of life left to the older person. Gerontological nurses must identify issues that may come

up and prepare to intervene effectively.

Decisional capacity: decisional capacity consists of four elements: comprehension of the

information presented or available, understanding the options and their possible consequences,

deliberating among the choices consistent with one’s life values and beliefs and communicating

a choice (Mezey et al, 2002). Decision making capacity may vary from time to time and its

determination is difficult. When the older adults are unable to make decisions for themselves,

surrogate decision makers, usually family members can respect the patient’s wishes by making

decisions in accordance with patient’s general values and past choices. The practice is based on

principle of substituted judgement. The principle of best interest can also be used to decide what

seems optimal for patient’s good when specific wishes of the patient are not known.

End of life issues: issues surrounding end-of-life care in older patients are becoming

increasingly complex with advancements in technology and genetic enhancements. For example

withholding or withdrawing treatment, assisted suicide and euthanasia.

Withholding or withdrawing treatment: standards of care require that a competent patient’s right

to choose or refuse treatment is reason enough to withdraw or withhold treatment. A decision to

forgo or withdraw treatment that may prolong dying process was made by weighing the benefits

against the harm and assessment to confirm if the therapy is physiologically or medically futile.

Artificial means are not considered part of medical interventions when patient was terminally or
irreversibly ill. Rather, the goal of care became the relief of pain and suffering and provision of

comfort.

Assisted suicide: the role of health care professionals in assisting a person to take his or her life

is increasingly controversial. The major debate over assisted suicide is whether individuals have

the right to when and how they die, and whether health care professionals should play a role in

individual’s choice to end life prematurely. Participation in assisted suicide is viewed contrary to

the first precept of the Hippocratic oath: “to do no harm”. Many people consider assisted suicide

because of fear of inadequate pain relief and unbearable suffering at the end of their lives. The

American Nurses Association in 1994 released a position statement recommending that nurses

not participate in assisted suicide (ANA, 1994). Both the nursing and medical organizations have

major educational and practice initiatives to improve end-of-life care. Discussion of end-of-life

values, goals and preferences needs to include older people, their families and their health care

providers while they possess decisional capacity.

Euthanasia: this refers to an action taken to terminate people’s life is considered legally and

ethically unacceptable. What makes the issue controversial is the desire for a comfortable death

and evidence that patient’s wishes are often not followed at the end-of-life. The two major

objections to euthanasia base their argument on the fact that euthanasia is equal to homicide and

is considered immoral and illegal. Second is the fear that people will start deciding for others

when their life is no longer of value. Older adults and people with significant disabilities and

those with impaired cognitive functioning could be primary targets.

Rationing of services: older people are often not offered the standard level of care because of an

inherent bias that they have lived their lives and resources could be better used in a younger
population. As the population ages, costs for older people consume a disproportionate amount of

health care spending.

Special techniques to promote ethical decision making

 Value history: a value history form has been developed so that individuals could record a

summary of ideas and wishes for care. Individuals identify their values and beliefs and

then determine preferences about whether they will want certain health care procedures.

The history is obtained when the individual is competent and is preserved for use when

dilemmas occur in impaired competence. A sophisticated history would allow the patient

to rank values between length of life and quality of life. An example of items might be:-

1. I want to maintain my capacity to think clearly, 2. I want to avoid unnecessary pain

and suffering, 3. I want to be treated in accord with my religious beliefs and traditions.

Value history can also be constructed with relatives if patient is not competent

 Patient self-determination legislation: the purpose of the self-determination act is to

ensure that a patient’s right to self -determination in health care decisions be

communicated and protected. The traditional right to accept or reject medical or surgical

treatment should be available while competent so that in the event that such adult

becomes unconscious or otherwise incompetent to make decisions, such adults would

more easily continue to control decisions affecting their health care. The act requires that

any health care institution accepting medicare or Medicaid should inform patients of their

right to make decisions concerning their care, including the right to accept or reject

medical or surgical treatment.

 Advance directives: individuals are encouraged to designate their wishes in writing so

that they are available in case they become unable to express themselves or develop
 diminished decision making capacity. The two forms of advance directives are living

wills and durable power of attorney. A living will stipulates what an individual would

want in the event of terminal illness and generally identifies when the person does not

desire any life prolonging treatment. The living will may not have to be written by a

lawyer but must have two disinterested witnesses. The durable power of attorney allows

individuals to appoint a legal surrogate for health care decision. The surrogate serves as a

spokesperson for the individual in case he or she becomes incapable of making the

necessary choices about treatment and therefore should know the person well and their

values and philosophies about the end-of-life.

 Ethics committee: made up of persons from different disciplines. They come together to

offer education, develop policies and offer consultations and case reviews in situations of

ethical dilemma. It is important that members have experiences in different areas of

medicine in order to take informed decisions on how to tackle issues.

Legal issues

In organized settings, some options are legally available to help the elderly with impaired

decision making ability or dementia make decisions. They are:

 Guardianship: legal guardianship is a mechanism that allows a surrogate to exercise

individual rights for an older person who is no longer mentally competent (Mezey,

Fulmer & Abraham, 2002). When incompetence is established through court

proceedings, a guardian is appointed by the court to be responsible for the care of the

incompetent person and his or her estate. Other terms used are conservator, committee

and curator. Conservator manages an individual’s property or finances. Guardian may be

plenary guardianship makes all types of decisions while in limited guardianship, the court

specifies certain types of decision the individual is incapable of making that the guardian

should take up.

 Payee status: the social security administration recognizes a payee status for relatives of

elderly individuals who are unable to manage their financial affairsit helps the individual

to manage the elderly person’s source of income without court proceedings (Gallo,

Fulmer, Paveza & Reichel, 2000).

 Elder abuse: acts that may constitute abuse and liability for the nurse in practice include –

false imprisonment applicable as restraint use (physical or chemical), assault, battery,

invasion of privacy, Larcency, negligence. The nurse in practice should be observant and

careful to in order to avoid court actions.

Decision making approach to ethical problems arising in clinical practice

 Determine the problem (health/ethical)

 Identify the appropriate decision maker (s)

 Determine the context (what is known)

 Frame the issue – determine the ethical perspective that will help informed decision

making based on patient’s values and goals. What clinical/ethical information is

necessary?

 Determine the possible options and implications

 Select a course of action

 Evaluate the decision and outcome

This paper discussed pharmacological, ethical and legal issues in the care of the elderly. It

further proffered solution to problems that may arise. With the rise in the population of the

elderly, nurses as direct care givers are expected to be prepared to handle issues that may arise in

their care and avoid possible litigations. They should be aware of ethical frameworks in their

institutions and collaborate with other members of the health care team to give quality care

aimed at improving quality of life of older persons.

References

Mezey, M., Fulmer, T. & Abraham, I. (2002). Geriartric nursing protocols for best practice. (2 nd

ed.). New York: Springer.

Deflaunte, J.C. (2003). Understanding and preventing drug interactions in the elderly patients.

Critical reviews in oncology/haematology, 2(48), 133.

Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2008). Brunner & Suddarths textbook

of medical surgical Nursing. (11th ed.). New Delhi: Wolters Kluwer.

Anderson, Beers & Kerluke, 1997

Sarkozi, L. & Ramanathan, L. (2003). Biochemical tests. In R.C. Tallis & H.M. Fillit (Eds.),

Brocklehurst’s textbook of geriatric medicine and gerontology (6th ed.). London: Churchill-

Livingstone.
Crome, 2003

Lamb, E.J., O’Riordan, S.E. & Delaney, M.P. (2003). Kidney function in older people:

pathology, assessment and management. Clinica Chimica Acta, 334(1-2), 25 – 40.

Lehne, R.A. (2004). Pharmacology for nursing care(5th ed.). Philadelphia:W.B. Saunders.

Diasio, 2000

Hanlon, J.T., Lindbald, C., Mahet, R.L. & Schmader, K. (2003). In R.C. Tallis & H.M. Fillit

(Eds.), Brocklehurst’s textbook of geriatric medicine and gerontology (6th ed.). London:

Churchill-Livingstone.

American hospital formulary service (1994). Drug information. Bethsda, MD: American society

of hospital pharmacists.

Liu, G.G. & Christensen, D.B. (2002). The continuing challenge of inappropriate prescribing in

the elderly. An update of the evidence. Journal of American pharmaceutical association, 42(6),

847-857.

Bressler, R. & Bahl, J.J. (2003). Principles of drug therapy for the elderly patient (symposium on

geriartrics). The Mayo foundation for medical education and research, 78(12), 1564-1577.

Plotkin & Roche, 2000

Gallo, J.J., Fulmer, T., Paveza, G.J. & Reichel, W. (2000). Handbook of Geriatric assessment

(3rd ed.). Gaithersburg MD: Aspen.

suicide. Silver springs, MD: Author.

Keenan, S.P. (2004). Improving end-of-life care: targeting what we can. Critical care medicine,

32(5), 1230-1231.