Gerontological

1
Gerontological Community Based Nursing

• Safety and Security
• Issues of Aging

2
Safe Medication use in Older Adults

• Age related changed in relation to
• Pharmacokinetics- absorption, distribution,
  metabolism, excretion of drug
• Pharmacodynamics -
• Chronopharmacology

3
Effects of aging on drug absorption

• Diminished gastric pH ?
• Delayed stomach emptying ?
• ?GI motility?
• ?GI motility ?
• Note antacids iron preparations affect drug
  absorption

• ?action of acid-dependent drugs
• diminished effectiveness of short-acting drugs
• diminished effects due to short contraction time
• ? s absorption of drug possible adverse
  reactions

4
Effects of aging on distribution

• Changes in body composition i.e.
• Lean body mass ?d total H2O ?
• ?d (adipose tissue) body fat ?

• Higher serum levels of certain H20 -soluble drugs
• Lipid-soluble drugs stored in fatty tissue ?d
  effects (valium, ativan, haldol)

5
Effects of aging on metabolism

• ?in liver mass, activity, volume, and blood flow?

• ?d ability for liver to metabolize drugs?
• ?d half-life (i.e. valium- from 37 hrs.young
  adult) -83 hours-older adult)

6
Effects of aging on excretion

• ?kidney function ie. glomerular filtration rate?
• Estimation of Creatinine Clearance important
  in evaluation renal function for drug clearance
• (see formular p222 text)

• ?d half-life of drug? potential toxicity/adverse
  effects

7
Pharmacodynamics in agingdrug-body interaction

• Aging process ?
• ?response to beta adrenergic receptor stimulants
  blockers
• ?barorecptor sensitivity

• ?d sensitivity to many types of medications i.e.
• Benzodiiazapines, anticholinergics, narcotic
  analgesics, warfar, certain cardiac drugs
• Refer to tables 14-1 14-2
• Ebersole/Hess (herbal medication interactions)

8
Chronopharmacology in agingbio-rhythms bodys
response

• Time of med administration
• Consider elders bio-rhythms

• Elders may benefit from decrease in individual
  dose/frequency of administration. ??toxicity
  effects

9
Prescription drug use in the elderly
10

• Nursing home patients receive an average of 6
  drugs/day
• 45 take 7 or more/day
• 20 take more than 10/day
• 60 of all visits to a physician for pts agegt50
  include renewal, continuation, or prescription of
  at least one medication
• Prescription use increases with age
• One in 13 prescriptions received from office
  based physicians involves a potentially
  inappropriate medication

11
The Good, the Bad and the Ugly

• The- good news advances in medications ?
  improved quality of life
• The bad news- the wrong combination or the wrong
  doses of medication can cause serious problems
  i.e. permanent injuries and even death.
• Older adults are particularly vulnerable to
  adverse drug side effects.

12
Polypharmacy- The excessive use or unnecessary
medications

• Causes of problems in older adults
• Inadequate diagnosis
• Inappropriate prescribing
• Multiple prescribers w/out adequate communicating
• Failure to d/c medications that are no longer
  necessary
• Failure to agree on therapeutic endpoint
• Inadequate or ineffective family/patient education

13
Adverse Drug Reactions

• Any undesirable or unintended effect occurring
  with medication dosages
• 2-3 times more likely to occur in older than in
  younger adults
• Drug-drug interactions
• Drug-nutrient interactions
• OTCs, vitamins, and foodstuffs
• Drug-disease interactions

14
Toxic characteristics of specific drugs

• Aspirin can increase the effect of
  anticoagulants, penicillins
• Antacids can decrease the effect of aspirin
• Antidepressants can increase the effect of
  narcotics
• Meperidine can decrease the effect of glaucoma
  medication

15
Noncompliance

• Non-adherence to medication prescription
• Risk factors
• Multiple medications
• Recent prescription changes
• Inability to name prescriptions
• Multiple practitioners
• Vision defecits
• Inability to perform a simple calculation
• Inability to judge an appropriate twice-daily
  dosing schedule

16
Assessment of Medication use in older adults

• Review all medications (prescriptions, OTC,
  herbal supplements, folk remedies, etc.) at least
  Q 6 months
• What is the purpose of the drug?
• Has the aphorism start low, go slow been
  followed?
• Are there any patient allergies that have not
  been reported?
• Are there drug-drug interactions that need to be
  checked?
• Has the most effective route of administration
  been selected?

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Assessment -- contd

• Assess elder client and/or family knowledge of
  medications and the ability to
• Follow instructions
• Monitor for adverse effects
• Make decisions about contacting the physician
• Assess environment -- proper storage, delivery
  systems, and memory enhancing devices

18
Nursing Diagnoses

• Noncompliance with medication regimen
• r/t to visual deficit
• Self-care deficit, medication r/t diminished
  cognitive functioning
• Injury, risk for r/t adverse drug reaction
• (e.g. hypotension, dehydration, dizziness)

19
Nursing Interventions

• Medication administration
• Help elder to locate/ create memory devices, i.e.
  pill dispensers, calendars, check-off systems
• Medication management
• Understand the therapeutic goal pathophysiology
  of disease being treated
• Continually monitor/evaluate the efficacy of the
  drug

20
Nursing Interventions contd

• Medication prescribing
• Recognize principles of pharmaco-economics that
  may affect the drug selection behaviors of the
  primary care provider (Medicare D, HMOs PPOs)
• Unit cost of the drug
• Cost of administering the drug (special skills or
  assistance needed)
• Costs associated with managing side effects
• Costs associated with monitoring the patient (lab
  work, home/physician visits)

21
Nursing Interventions contd

• Elder client/family teaching
• Drug names (generic vs. brand)
• Drug indications why is drug being prescribed
• Dosage importance of taking as prescribed
• Teach -when how to administer the medication
• Contraindications- when not to use
• Teach adverse effects and drug interactions
• Teach where/how to store med
• Provide demonstration/ return demonstration
  opportunities
• Provide guidance regarding OTCs drug use
• Instruct client to create a portable record of
  meds to share with all providers

22
Musculoskeletal Problems in older adults

• Mobility Problems, Falls, and Fractures
• Functional elements needed for mobility
• Cognition and motivation
• Skeletal system
• Muscular system
• Neurological system

23
Mobility changes with aging

• Loss of bone mass
• After age 40-50 there is incremental process of
  bone absorption without new bone formation gt
  gradual bone loss
• Loss of muscle strength
• Increase of reaction time
• Decreased speed of movement

24
Common health problems affecting mobility in
older adults

• Osteoporosis
• Osteomalacia (thinning of the bone)
• Arthritis
• Polymyalgia rheumatica
• Fibromyalgia
• Foot disorders

25
Common Bone Joint Problems in the older adult

• Osteoporosis porous bone
• Body produces fewer hormones, testerone,
  estrogen, growth hormone- not yet sure which of
  these play
• an important role in strong bones

26
Reducing Osteoporosis related risk and injury

• Exercise i.e.
• Weight bearing, walking,
• Muscle building exercise
• Tai chi
• Nutrition
• - Ca Vit D intake
• - 1200 mg calcium daily
• -400-800 iu Vit D daily
• Life-style changes
• (smoking cessation)

• Patient teaching
• fall prevention
• home safety changes
• - lighting,
• - safety rails
• - clutter free home
• Clothing -shoes
• Body mechanics
• Medication use (Fosamax, Boniva,Actonel)

27
Osteroarthritis

• DJD Degenerative Join Disease (most common cause
  of pain disability)
• Knee is the most frequently involved joint

28
Osteoarthritis vs Rheumatoid arthritis

• Chronic systemic condition c/b pain swelling in
  multiple joints

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Rheumatoid Arthritis and Gout

• Disfigurement of hands
• due to rheumatoid arthritis

• Common form of inflammatory arthritis
• r/t ?uric acid crystals
• Most common site great toe

31
Assessment

• Examine joints for tenderness, swelling redness
• Crepitus crackling sound in joint
• Passive/active ROM

32
Nursing Interventions

• Pain management
• Diet/nutrition education-weight reduction
• Realistic exercise plan
• Non-pharmacological treatments (heat/cold,
  ultrasound))

33
Mobility Environmental Safety issues in the
Elderly

• Environment
• Older adults want to stay in their own homes
  independently as long as possible
• Mobility, transportation and safety factors often
  affect the living patterns of older adults

34
Safety and Security Issues

• Crime
• Safety
• Driving
• Involved in more motor vehicle accidents than
  younger people
• Sensory and cognitive changes have adverse
  effects on driving ability

• Fall Risk

35
Falls in the elderly

• 2nd leading cause of all accidental deaths
• Important health issue in those gt75
  y.oespecially women
• Causes
• Physical frailty, visual impairment
• Environmental hazards
• Most occur during the day
• Previous falls, predictor of future falls

t
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Why teaching is important!
37
Benefits of exercise
38
Assessment of Fallsin the elderly clients

• 30 of community based older adults fall each
  year
• Most falls occur in the home
• Key areas to assess
• Adequate lighting and access to switches
• Safe flooringlook for cords
• Safe stairways
• Adequate toilet height
• Kitchen-access to items
• Smoke alarms
• Clutter
• Medications--?labeled
• Safety of neighborhood
• Distance to bathroom
• Ease of getting in/out of chair

39
Nursing Diagnoses

• Injury, risk for related to falls
• Mobility, impaired physical
• Goals prevent injury, promote optimum mobility,
  prevent deformity
• Interventions assistive devices, maintain
  adequate nutrition fluid intake maintain
  normal elimination

40
Consequences of Falls in older adults - Fractures

• Hip fractures have high morbidity and mortality
• 50 of patients with a hip fx are unable to
  return home or live independently again
• 15-20 of patients die as a result of
  complications
• Immobility
• Pneumonia
• Sepsis/UTI
• Pressure ulcers

41
Transportation issues

• Transportation assessed as part of IADL
• 0independent, drives a car
• 1arranges own transport, depends on others
  except for walking
• 3assists in own transport but needs special
  accommodation e.g. wheelchair
• 5completely homebound even for medical care

42
Alternatives to Driving

• Reduced-fare taxis
• Volunteer drivers
• Public transportation
• Chartered buses
• Dial-a-ride programs

43
Pain

• Definition
• Unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
• Whatever the patient says it is.
• Incidence
• 25-50 of community-based elders have pain
• Up to 85 for long-term care residents report
  pain
• 73 of hospitalized medical patients say pain was
  excruciating

44
Pain AssessmentPain Tool descriptions -
observations
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Pharmacological pain management

• Medications to be avoided in older adults
• Demerol
• Causes confusion
• Talwin
• Confusion, disorientation
• Methadone
• Long half-life accumulates over time
• Darvon
• confusion

46
Rule of Thumb

• Start Low
• Go Slow

47
Nurses and pain

• Nurses fear addicting patients, fear giving
  narcotics, give less than prescribed dose or
  minimal doses
• Result Patients suffer!!
• Nurses underestimate patients pain
• Result Patients suffer!!
• Nurses make incorrect assumptions about pts pain
  because pts do not behave according to nurses
  expectations
• Result Patients suffer!!
• Nurses and patients believe that pain is a
  natural part of aging
• Result Patients suffer!!

48
Nonpharmacologic Management of Pain

• Touch
• Natural method of comforting, promotes
  relaxation, said to promote healing
• Relaxation
• Meditation
• Imagery
• Massage
• Heat/cold
• Accupuncture/Accupressure
• TENStranscutaneous electrical nerve stimulation
• Distraction