Pharmacologic management

After this lecture, you should be able to:

1. Describe the unique aspects of drug
pharmacokinetics and pharmacodynamics in
older people.
2. List measures to promote safe drug use.
3. Describe alternatives to medications.
4. Identify medication issues and proper nursing
intervention

Week 10
 Terms to Know
• Biological half-life: the time necessary for half of a drug to be excreted from the body
• Pharmacokinetics: refers to the process of absorption, distribution, metabolism, and excretion of drugs
• Pharmacodynamics: refers to the biologic and therapeutic effects of drugs at the site of action or on the target
organ
• Clearance: The removal of a drug from the plasma
• Polypharmacy: use of multiple medications
Factors that interfere with safe and successful drug therapy

• Drug testing methods

Most drug testing is performed on healthy, young adult who are not physiologically the same as older adults with
numerous age-related changes
• Physiological changes of the body
1. Pharmacokinetics
Drug absorption:
• Route of administration. Drugs given intramuscularly, subcutaneously, orally, or rectally are not absorbed as efficiently
as drugs that are inhaled, applied topically, or instilled intravenously.
• ↓ GI peristalsis and motility Reduced gastric emptying Delays transport of drugs to tissues Slower
absorption of oral drugs.
• ↓ Cardiac output/ Impaired circulation ↓ 40-50% gastric blood flow Delays transport of drugs to tissues
Absorption slowed.
Factors that interfere with safe and successful drug therapy

• Physiological changes of the body

1. Pharmacokinetics
Drug distribution:
• Total body water leading to higher serum level of water-soluble drugs as digoxin
• Adipose tissue compared to lean body mass, drugs stored in adipose tissue will have increased tissue
concentrations, and a longer duration in the body (half lives).

• Cardiac output can raise the plasma levels of drugs while reducing their deposition in reservoirs.

• Serum albumin levels results in binding of drugs that are mainly bound to serum albumin
Factors that interfere with safe and successful drug therapy

• Physiological changes of the body

1. Pharmacokinetics
Drug metabolism:
• Hepatic Enzyme function and Blood flow lead to drugs are metabolized more slowly and less completely.
• Drug excretion:
• Nephron units are decreased in number, and as much as 64% of the nephron can be unfunctional in older adults.

• The glomerular filtration rate and tubular function and this can greatly affect elimination of various drugs that are
renally excreted, resulting prolongation of the half-life of the drug, resulting in more accumulation and increase the
risk of adverse drug reactions.(e.g, antibiotics, digoxin, barbiturate, and salicylates).

• Drug elimination is correlated with creatinine clearance, which is declines by 50% between 25 and 85 years.
Factors that interfere with safe and successful drug therapy
• Physiological changes of the body
2. Pharmacodynamics
• Increased myocardial sensitivity to anesthesia
• Increased central nervous system receptor sensitivity to narcotics, alcohol, and bromides
• Increasing the risk and adverse drug reaction and interactions in older people may be related to changes in
receptor binding, decrease receptor number.
3. Changes in vision: distinguishing colors - Reading small print.
4. Hearing changes: older person may be unable to hears and understand instructions.
5. Decreased taste acuity:
• The ability to differentiate medications by taste is inhibited, and the potential for unknowingly taking no
medications or caustic poisons increases.
6. Changes in touch and dexterity: difficult to open modern packages.
7. Cognitive changes:
• With increasing age and subsequent risk for diseases, older adults may have changes in their thought patterns or
forgotten to take medications.
Factors that interfere with safe and successful drug therapy

8. Atypical presentation of illness

9. Multiple illnesses
10. Impairments to adherence (cultural, physical, psychologic)
11. Increased susceptibility to adverse drug events
12. Financial concerns: Medications are expensive and sometimes older adults unable to pay the
prescribed medications.
13. Social support: Social support has increased the adherence to the prescribed medications.
Promoting Safe and Effective Administration

• Most common route to administer drugs: oral

• Oral administration: problems can interfere with process
• To ensure that oral medications achieve full benefit, encourage good oral hygiene, ample fluids, and proper
positioning to facilitate swallowing
• Suppository form: due to lower body temperature may take longer to melt
• Intramuscular and subcutaneous administration
• Immobile limb will reduce rate of absorption
• Intravenous administration
• Monitor for complications
• Older adults are at risk for circulatory overload during intravenous drug therapy; close monitoring is
essential.
Providing Patient Teaching

• Self-medication
• Assess for risk of medication errors
• Plan interventions to minimize risks
• Factors interference with safe administration
• Functional limitations
• Cognitive limitations
• Educational limitations
• Sensory limitations
• Financial limitations
• Choice
Alternatives to Drugs

• Drugs can produce serious side effects.

• Crucial drugs should be used cautiously.
• Benefits versus risk must be weighed = more good than harm?
• Lifestyle changes may allow eliminating need for drugs.
• Alternative and complementary therapies treat various health issues.
• Insomnia…..Alternatives To Using Hypnotics
• Pain…… Alternatives To Using analgesics
• Constipation …… Alternatives To Using Laxatives
• Urinary Incontinence…… Alternatives To Urinary Incontinence Drugs
• Heart burn…… Alternatives To anti-acids
Medication issues and older adults

1. Polypharmacy
• The most commonly used drugs by the older population include the following:
Cardiovascular agents - Antihypertensives - Analgesics - Antiarthritic agents - Sedatives - Tranquilizers -
Laxatives – Antacids
• Factors leading to Polypharmacy:
• Multipathologies
• People go to multiple physicians or pharmacies for their medical/medication needs.
• The use of medications that has no apparent indications.
• Self- treatment.
• Continuing use of medications after conditions has been resolved.
• Adverse reactions treated as pathologies: Use of medications to treat the side effects of another medication.
• Use of duplicate medications, patient may not be aware of different names. The same drug has been prescribed
by more than one prescriber
 Medication issues and older adults

1. Polypharmacy
➢ The nurse should obtain a complete history of all drugs prescribed.
➢ Information about other drugs should also be collected from the patient since they may be the basis for significant
interactions with drug therapy. These included the use of vitamins, dietary supplement and herbal remedies.
➢ Encourage the patient to take all medications, including over-the-counter medications, with him or her regularly
when visiting physician or admitted to hospital.
➢ Discourage the use of OTC and herbal agents without consulting a health professional
➢ Obtain all of medications (prescription and OTC) from the same pharmacy as possible.
➢ Review medication schedule periodically.
➢ Get rid of old, unused medications.
Medication issues and older adults
2. Adverse Drug Reactions (ADRs) in the Elderly Patient
• An adverse drug reaction (ADR) is an expression that describes harm associated with the use of given medication
at a normal dosage.
• ADR are 7 times more common in the elderly.
• ADR account for 16% of hospital admission and 50% of medication related deaths.
• Mental dysfunction is often an early sign of adverse reaction to many medications.
• Any SYMPTOM in an elderly patient should be considered a Drug Side Effect until proved otherwise ”
• Numerous syndromes in old age are actually consequences of pharmacological therapies: e.g.,
▪ Delirium  use of some drugs e.g., Anticholinergic drugs, opiates)
▪ Falls and fractures  e.g., benzodiazepines, anti-hypertension drugs
▪ Urinary incontinence  e.g., diuretics
Factors that predispose elderly to ADRs
 Poly-pharmacy
 Drug accumulation secondary to reduced renal function
 Inadequate supervision of long-term therapy
 Poor patient adherence
Medication issues and older adults
2. Adverse Drug Reactions (ADRs) in the Elderly Patient
 Adverse drug reactions misinterpreted as disease related symptoms can result in treatment with other medication

rather than discontinuation of the offending medication. Medication reactions should be considered when
evaluating an older adult with new symptoms.

 The nurse should obtain a complete drug history including OTC and herbals drugs

 Initiate therapy with low doses

 Inform the patient about foods and herbals to avoid.

 Nurses should ensure that drug-induced cognitive and behavioral problems are not treated with additional drugs.

 Avoid routine treatment of adverse reactions/side effects of drug with other drugs! Examples:

– Routine analgesics for treating dizziness from anti-hypertensive drugs

– Routine diuretics for edema from a calcium-channel blocker

– Routine Potassium supplementation in patients receiving diuretics

Medication issues and older adults

3. Drug Non-Adherence
40-60% of elderly patients do not follow their prescription properly
Factors Attributing to Poor Drug Adherence in the Elderly Patient
• Change in daily drug regimen (Taking several medications with different schedules (e.g., combination of daily,

twice daily, three times daily plus medications to be taken with or without meals)

• Multiple chronic disorders

• Limitations in vision/hearing
• Multiple prescribers
• Impaired memory
• Multiple prescriptions
• Other physical impairment
• Multiple doses
• Recent Hospital discharge
• Living alone
• Inability to pay for drugs
• Illiteracy
• Presence of side effects
Medication issues and older adults

Suggestions to Improve Adherence

Simplify Process:
 Medication calendar

 Pill organizer

 Diary , Telephone reminders other reminder systems

 Easy to open containers

 Reduce number of daily doses “once or twice a day” when possible

 Tailor regimen to lifestyle

 Label containers clearly

 Diary
TIME 7 8 9 11 12 13 16 19 20 21 22 23 24

Drug
(pantoprazolo) 1 cpr

(gliclazide) 1 cpr 1 cpr 1 cpr

(furosemide) 1 cpr 1 cpr

(ramipril) 1 cpr

(metoprololo) ½ cpr ½ cpr

(amlodipina) ½ cpr

(digossina) 1 cpr

(warfarin) 1 cpr

(simvastatina) 1 cpr

(triazolam) 1 cpr
Medication issues and older adults

Suggestions to Improve Adherence…cont.

• Clearly explain treatment plan
• Assure affordability of medication “identify low-cost alternative”
• Involve a family member or friend
• Store medications in a location that will serve as a reminder system (e.g., keep mealtime medications at the
dining table or bedtime-only medications at the bedside).
• When travelling, keep medications with a cosmetic or toiletry kit, or some other item that is used on a daily basis.
• Monitor therapeutic responses, adverse reactions and plasma drug levels
Reference
Almost., all information on this lecture was directly abstracted from :
Eliopoulos C. (2018). Gerontological Nursing. Lippincott Company.
(Chapter 17: Safe Medication Use)