Health Literacy in Older Adults

Patient/Family Issues

A Quote from the AMA• Communication, essential for the effective

delivery of healthcare, is perhaps one of the most powerful tools in a Clinician’s arsenal. Unfortunately, there is often a mismatch between a Clinician’s level of communication and a patient’s level of comprehension. In fact, evidence shows that patients often misinterpret or do not understand medical information given to them by Clinicians. This lack of understanding can lead to medication errors, missed appointments, adverse medical outcomes, and even malpractice lawsuits.

• The need for today’s patients to be more health literate is greater than ever, because medical care has grown increasingly complex.

• We treat out patients with an ever-increasing array of medications, and we ask them to undertake more and more complicated self-care regimens.

Points to Ponder• Recent studies have shown that almost

half of the US population lacks sufficient general literacy to effectively undertake and execute medical treatments and preventive healthcare it needs.

• Inadequate health literacy affects all segments of the population, although it is more common in the elderly, poor, minorities, and recent immigrants to the United States.

• Low Health Literacy cost the United States between $50 Billion and $73 Billion a year.

Health Literacy Defined by the AMA

• Health Literacy is the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment.

Implications of Limited Literacy

• A limited ability to read and understand information translates into poor health outcomes. Most Clinicians are surprised to learn that literacy is the single best predictor of health status. In fact, all of the studies that have investigated the issue report that literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education levels, and racial or ethnic group.

Examples of Some Patient Issues and Misunderstandings

Video

You Can’t Tell by Looking• Key Risk Factors for Limited Literacy:

-Elderly

-Low Income

-Unemployed

-Did not Finish High School

-Minority Ethnic Group

-Recent Immigrant to the United States and does not speak English

-Born in the United States, but English is a second language

Red Flags• Behaviors:-Forms are Incomplete, Missed

Appointments, Noncompliance with Medications, Lack of Follow-Through with Diagnostics, and Patients state they are taking their medications, but the clinical values don’t support their claims.

Red Flags• Responses to Receiving Written

Information:- “I forgot my glasses. I’ll read this

when I get home.”- “I forgot my glasses. Can you read

this to me?”- “Let me take this home so I can

discuss it with my children.”

Red Flags

• Responses to Questions about Medication Regimens:

- Unable to Name Medication- Unable to Explain a Medication’s

Purpose- Unable to Explain timing of

Medication Administration- Unable to Explain basic Health or

Diet Concerns Related to the Medication

“Brown Bag Review”• When a patient brings in their

medication, review the medications with the patient.

• Note if the patient opens the bottle and looks at the medication or do they identify their medication by reading the label?

• Be aware that some patients memorize the label and directions so probe further by asking when did they take the medication last and before that. If they looked confused, suspect the patient memorized.

What is Your Patient Really Reading?

• Your naicisyp has dednemmocer that you need a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out you noloc.

What You Actually Gave Them

• Your physician has determined that you have a colonoscopy. Colonoscopy is a test for colon cancer. It involves inserting a flexible viewing scope into your rectum. You must drink a special liquid the night before the examination to clean out your colon.

- Are You Thinking What I’m Thinking?- Liability?

• According to research from the American Tort Reform Association, Attorneys estimate that a clinician’s communication style and attitude are major factors in nearly 75% of malpractice suits. The most frequently identified communication errors are inadequate explanations of diagnosis or treatment and communicating in such a way that the patients feel their concerns are being ignored.

Steps to Improve Communication• Slow Down: Communication is

improved by speaking slowly• Use Plain, Non-medical Language

“Layman's Term”• Show or Draw Pictures• Limit the Amount of Information and

Repeat It• Use the Teach-Back or Show-Me

Technique• Create a Shame Free Environment

Quote From a Patient• A good Nurse is not too busy to help, doesn’t

use big words, sits down and listens, asks how you are doing and what is your problem. The Nurse asks how you want to be addressed, and doesn’t read your chart in front of you. Good Nurses tell you things in plain English and breaks things down to what’s really important. If you don’t understand what the nurse says, you are comfortable asking. If you still don’t understand, then they go out of their way to make sure you do.

Questions

Memory Loss / Dementia

Dee Tucker RN, GCNS-BCClinical Nurse Specialist – GerontologyNursing Administration

DEMENTIA

• An irreversible confusional state, impairment and progressive decline of mental function– Compromise in at least three areas of following

mental activities:• Language• Memory• Visuospatial skills• Personality and emotional state• Executive Function (abstraction, judgment)

• 50% never diagnosed and treated– Most treated are treated inappropriately

• NOT A NORMAL PART OF AGING!!!!

Types of Dementia

Alzheimer’s

Frequency: 55-75%

Features: insidious onset

progressive worsening

clear consciousness

Types of Dementia

Vascular

Frequency: 13-16%

Features: Step wise

progression

Types of Dementia

Lewy Bodies

Frequency: 15-35%

Features: Fluctuating cognition

Visual hallucinations

Parkinsonism

Types of Dementia

Frontotemporal

Frequency: 1uncommon

Features: Insidious onset

Gradual progression

impaired personal conduct

emotional blunting

Treatment of Dementias

MedicationsACIs acetylcholinesterase

AriceptExcelonReminyl

Memantine

Presentation

• Poor historian• Unable to recall phone number, address,

names of children, • Word finding problems• Repeats same information or stories• Poor personal hygiene• Irritability or refusal to participate in

screening

Behaviors and Psychological Symptoms

• Depression• Agitation and aggression• Delusions• Hallucinations• Poor sleep• Wandering

Pseudo-Dementias

• Vitamin Deficiency• Endocrine• Infections• Toxins• Others

Assessment/Interventions

• Assess mental status• Identify daily routines • Involve family • Identify as high fall risk• Be proactive• Expect behavioral disturbances

Triggers

• Fatigue • Change• Overwhelming stimuli• Demands exceed capacity• Physical stressors

Teach Back Time

CONFIDENTIAL

Senior Healthcare Consultant Education

Series

PAIN MANAGEMENT

Monica N. Tennant, RN, MSN, CCNSGeriatric Clinical Nurse Specialist

CONFIDENTIAL

Learning Objectives1. Identify the incidence of pain in older

adults2. Assess pain using client self report or

validated pain instruments.3. Discuss barriers to pain relief in older

adults.4. Identify problems and strategies in

assessing pain in cognitively impaired older adults.

5. Describe adverse consequences associated with pain in older adults.

6. Identify considerations and specific strategies in treating pain in older adults.

7. Explain the dimensions of palliative care.8. Describe the nurse’s role in end of life care.

CONFIDENTIAL

Objective 1 Incidence

• Pain is an unpleasant sensory and/or emotional experience– whatever the experiencing person says it is, existing

whenever he/she says it does (McCaffrey)

• Acute pain – results from injury, surgery, or disease related tissue

damage – is usually associated with autonomic activity such as

tachycardia and diaphoresis

• Chronic pain – endures past the normal duration of tissue damage,– usually more than 3 to 6 months– autonomic activity is usually absent

CONFIDENTIAL

Objective 1• Prevalence in adults > age 60 is double

those below the age of 60

• Pain is the most common symptom at the end of life, occurring in 90% of patients

• It has been estimated that as much as 95% of pain at the end of life can be relieved.– CME Resource August 2006, Vol. 131 No.10

CONFIDENTIAL

Objective 1• Common disorders associated with

pain– cancer, AIDS, ESRD, and COPD

• Older adults are likely to suffer from– arthritis (Osteoarthritis is the most common)

– bone and joint disorders– back problems– post stroke central or neuropathic pain– post herpetic neuralgia– post amputation (phantom limb) pain

CONFIDENTIAL

Objective 1• Under-treated pain in older adults can be

correlated with advanced age, even though there is frequent overmedication of the older adult for other purposes– Why would RNs overmedicate an older adult who is not

in pain?

• healthcare professionals said that under-treated pain was their primary ethical concern

– American Pain Society

» CME Resource August 2006, Vol.131 No.10

CONFIDENTIAL

Objective 2 Assessment

• Pain is a subjective experience – most reliable indicator is patient’s self report

• Ask the patient about the pain experience – believe the patient’s assessment of his own pain

• Questions should be asked to elicit descriptions of the pain characteristics– Remember COLDSPA?

• Character• Onset• Location• Duration• Severity• Pattern• Alleviating factors

CONFIDENTIAL

Objective 2 Assessment

• Wong-Baker FACES scale developed for pediatric setting

• Facial expressions and physical indicators don’t always change when a client has chronic or persistent pain

• Pain instruments may assist in qualifying pain

CONFIDENTIAL

CONFIDENTIAL

Objective 3: Barriers to pain relief

• Patient’s fears:– addicted to opioids– side effects– Increasing pain = disease is getting worse– being a good patient

• keys to overcoming barriers– Open communication and education

• CME Resource August 2006, Vol. 10

CONFIDENTIAL

Objective 3: System barriers

• Other barriers include:– Failure to apply standardized assessment

instruments– Belief that the cognitively impaired older adult

cannot be assessed for pain.– Misinterpretation of cognitively impaired

person’s behavior as being unrelated to pain.

CONFIDENTIAL

Objective 4

Cognitively Impaired Older Adults

• May or may not be able to communicate pain

• Evaluate nonverbal pain behavior– Recent changes in function and vocalizations

• Utilize objective pain instruments:– Assess for changes in behavior after analgesics are

used• Caregiver Reports

CONFIDENTIAL

Objective 4Physical Exam Nursing Assessment• Determine underlying causes of pain

– History- subjective data– If non-verbal?

• Moaning • Grimacing• Protective movements• Vocalizations• Disruptive behaviors

• Detect evidence of trauma or skin breakdown– Examination of painful area – objective data

• Inspection, auscultation, percussion, palpation– There is no substitute for good assessment skills!

CONFIDENTIAL

Assessment- Other Causes of Pain

• Fear• Anxiety• Depression• Family concerns• Lying in bed• Loneliness

CONFIDENTIAL

Innovative Strategies• Music Therapy• Massage• Spirituality• Psychosocial Intervention• Listening

CONFIDENTIAL

Objective 5 Consequences

• Adverse effects of chronic pain– decreased quality of life– depression– decreased socialization– sleep disturbance– impaired ambulation– suicidal ideation– decreased appetite and food intake– increased health care utilization and cost

CONFIDENTIAL

Objective 5

• Assess patient for depression – Geriatric Depression Scale (GDS)

• Pain may effect mobility, sleep, bowel, bladder, and cognition– Ask if sleep and toileting patterns changed

• Uncontrolled pain may be evidenced in hopelessness and suffering

• Observe the patient – note how pain limits movement – ask the patient or family how the pain interferes

with normal activities

CONFIDENTIAL

Objective 6 Treatment

• Objectives of pharmacologic management of pain include :

– Selection of appropriate drug, dose, route, and interval

– Aggressive titration of the drug dose– Prevention of pain and relief of breakthrough

pain– Use of appropriate co-analgesic medications– Prevention and management of side effects

CONFIDENTIAL

• World Health Organization 3 step analgesic ladder – designates the type of analgesic agent based on the severity

of pain

1. Mild pain (score 1-3) • non-opioid with or without co-analgesic

2. Moderate pain (score 4-6) • calls for low dose opioid

3. Severe pain (score 7-10) • Opioids are optimum choice at doses higher than step 2.

Objective 6 Treatment

CONFIDENTIAL

Objective 6 Treatment

• Non-opioid analgesics used for mild pain, *also helpful as co-analgesics*:– Acetaminophen (Tylenol = safest)

• doses higher than 4000mg/day can cause liver dysfunction

– NSAIDS (Motrin, Naproxen, and Indocin)• most effective for pain associated with inflammation

as well as bone pain. • inhibit platelet aggregation, increasing the risk of

bleeding & can damage stomach mucosal lining, leading to GI bleeding

– ASA

CONFIDENTIAL

Objective 6 Treatment

• Morphine– most commonly used opioid – drug of choice for severe pain by the WHO

• Most potent opioids – Dilaudid – Fentanyl (the most potent) 80-100x’s more potent than

morphine• Methadone

– commonly used for treating pain– toxic accumulation can cause respiratory depression & death– average half life of Methadone is 24 to 36 hours

• Demerol is not recommended – neuro-toxic effects may cause tremor, irritability, cognitive

changes, and seizures

CONFIDENTIAL

CONFIDENTIAL

CONFIDENTIAL

Objective 6 Treatment

• Darvon is an opioid similar to Methadone– Not recommended due to long half life and toxicity of

by-products• Toradol requires increased assessment

– due to decreased clearance and increased half life in the elderly

• Precautionary Measures for Opioids:– Encourage extra fluid– Exercise– Combination stool softener + non-bulk-forming

laxative– Minimize side effects

• Gastric distress, sedation, nausea

CONFIDENTIAL

Nonpharmacologic Strategies

• Education program• Cognitive program:

– Imagery, relaxation, biofeedback, hypnosis

• Behavioral program• Exercise• Acupuncture• Physical methods: heat, cold,

massage• Chiropractic• Spiritual healing

CONFIDENTIAL

Objective 7 Palliative Care

• Cost of medication – In hospice care there is no cost to the patient

• Relief of pain symptoms and the stress of serious illness– Pain– Shortness of breath– Fatigue– Constipation– Nausea– Difficulty Sleeping

CONFIDENTIAL

Objective #8The Nurses Role in End of Life

Care• Physical, psychosocial, and spiritual problems• Accomplishment of developmental tasks of life• Family dynamics / relationship issues / opportunities• Grief / loss / bereavement issues• Functional status / environmental status• Identifies patient and family needs• Recruits health care team members• Coordinate interdisciplinary pain program and manage

chroniccoexisting problems

• Identify patient appropriateness for Hospice services• Encourage family to participate in goals, processes and

evaluation ofcare

CONFIDENTIAL

Assurance• Availability of pain relievers cannot be

exhausted– there will always be medication if pain becomes more

severe– Patients’ biggest Fear- Unrelieved pain

• Side effects can occur but they can be managed promptly

• Pain and severity of disease are not necessarily related

CONFIDENTIAL

Addiction

• Addiction is not a concern at the end of life!

• Give the dosage that is ordered

• It may relieve the shortness of breath

CONFIDENTIAL

REMEMBER

• PAIN IS WHAT THE PATIENT SAYS IT IS AND IT EXISTS WHENEVER THE PATIENT SAYS IT EXIST.

CONFIDENTIAL

References• Best practice information on care of older adults: www.ConsultGeriRN.org.• Bennett, M.I., Attal, N., Backonja, M.M., et al. (2007). Using screening tools to identify

neuropathic pain. Pain, 127, 199-203.• Bouhassira, D., Attal, N., Alchaar, H., et al. (2005). Comparison of pain syndromes

associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain, 114(1-2), 29-36.

• Gilron, I., Watson, C.P.N., Cahill, C.M., & Moulin, D.E. (2006). Neuropathic pain: A practical guide for the clinician. Canadian Medical Association Journal, 175(3), 265-275.

• Hadjistavropoulos, T., Herr, K., Turk, D.C., et al. (2007, Jan). An interdisciplinary expert consensus statement on assessment of pain in older persons. The Clinical Journal of Pain, 23(1 Suppl), S1-S43.

• Krause, S.J., & Backonja, M.M. (2003). Development of a Neuropathic Pain Questionnaire. The Clinical Journal of Pain, 19(5), 306–314.

• McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd.ed.). St. Louis, MO: Mosby.• http://consultgerirn.org/resources/media/?vid_id=4669429#player_container (retrieved

12/29/ 2009)

Incontinence

Best Practices and Foley Catheters

Dee Tucker RN, MS, GCNS-BC

Geriatric Clinical Nurse Specialist

Piedmont Nursing Administration

Incontinence

Clinical Definition (UI):

Urine loss of sufficient problem to be perceived as bothersome or it creates a prompt desire to seek care

An Estimated 16 million people in the U.S.

Over 50% Prevalence in the Institutionalized Elderly

Bladder Differences by Gender

Female Longitudinal Section

Male Male Longitudinal Section Lateral View

Most Prevalent Types – Urinary Incontinence

Stress UI: urine loss due to sphincter dysfunction-Prolonged use of a Urinary catheter

Urge / Over-active Bladder (OAB)

Total UI: complete loss of sphincter function or fistula formation

Most Prevalent Types – Urinary Incontinence

Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder filling causes bladder contraction)

Retention w/ Overflow UI

Mixed Incontinence: Stress UI + OAB

An Estimated 90% of UI = Stress, OAB, & Mixed Incontinence

Another type of Urinary Incontinence

Functional UI: normal voiding patterns & normal bladder function; usually related to cognitive status, motivation, and/or mobility issues, environment

ManagementPrompted / Scheduled voiding

Reversible Factors of Urinary Incontinence - “DIAPPERS”

D – Delirium I – Infection / Irritants A – Atrophic urethritis / vaginitis P – Pharmaceuticals P – Psychological causes E – Endocrine causes (Excess urine) R – Restricted Mobility S – Stool impaction

Effects of Aging R/T Continence

Increased nocturia (1-2x/night >60)Bladder fills full at lower volumesReduced strength of bladder contractions Increased irritability of bladderDelayed recognition of bladder fillingAdequate fluid intake?

Indwelling Foley Catheters

30-40% of HAI

Risk for UTI 1-2% for a single insertion

Increases to 5-8% per day with indwelling catheter

CAUTIs- one of CMS Never Events

Foley Catheters

CAUTIs- one of CMS Never Events

Most effective method to prevent CAUTIs is to avoid indwelling catheters

If MUST have- then aseptic technique, closed system, secured to leg

Indications for a Urinary CatheterCDC Recommendations

Critically Ill: Alteration in BP or volume status requiring continuous, accurate urine volume measurement

Infection Prevention: to prevent urine from soiling a Stage III or IV pressure ulcer or nearby operative site

Comfort care: for terminally ill patients

Indications for a Urinary CatheterCDC Recommendations

Comfort care: for terminally ill patients

Surgery: patients going directly to the operating room

Procedures or Tests requiring an indwelling urinary catheter, removed at the conclusion of the procedure/test

Indications for a Urinary CatheterCDC Recommendations

GU Indications Continuous bladder irrigation Instillation of medication into the bladder Obstruction to the urinary tract distal to bladder Drainage in patient with neurogenic bladder

dysfunction, hydronephrosis, and urinary retention not manageable by other means (e.g., with clean intermittent catheterization)

Aid in urologic surgery or other surgery in contiguous structures

Ordered by a urologist for a special purpose or difficult insertion

Indications for a Urinary CatheterCDC Recommendations

Prolonged immobilization due to unstable or multiple traumatic injuries

An indwelling urinary catheter is not appropriate for nursing convenience or for urinary incontinence in the absence of skin breakdown.

When NOT to use a Catheter?

Use CAUTION = Prevent C.A.U.T.I.

C – Closed systemA – Aseptic mgmt of indwelling catheterU – Use standard precautionsT – Tubing secured to leg & clipped to sheetI – Indications (do I still need it?)O – Obstruction freeN – No dependent loops

ED

• Gateway for most of our older patients• Ability to initiate change in practice that will

carry through the admission• Eliminate a risk that prolongs LOS and

had financial impact

Functional Assessment

Falls in Older Adults

Monica Tennant RN, MSN, CCNS

Geriatric Clinical Nurse Specialist

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height="300"></embed></object><p><a href="http://vimeo.com/4610636">Katz Index of Independence in Activities of Daily Living</a> from

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Objectives• Define functional assessment.

• Describe characteristics of functional decline

in older persons.

• Identify comorbid conditions that might

impact negatively on the functional status of

an older adult

• Assess function using validated tools

• Plan strategies to promote and maintain

optimal function in older adults.

Assessment• Baseline vs current status

• Observation• Katz ADL index=independent, requires

assistance, or dependent (note the degree of difficulty)

• SPICES• Sleep disorders

• Problems with eating

• Confusion

• Evidence of falls

• Skin breakdown

• Obtain services needed

Baseline

Reported abilities prior to illness

Current, on admission abilities

• co-morbid conditions (not being addressed?)

Needs to return to living situation

Observation

Transfers: bed-chair, sit-stand

Balance: standing, walking, turning

Gait: even, steady, speed

Unsafe behaviors

What can be done during admission? Avg LOS 4-5 days: can they progress to be safely discharged home?

Obtain Services Rehab requires MD order for reimbursement

Timing

Subacute rehab vs HHPT/OT

Falls = Geriatric Syndrome

• Aging changes• Chronic issues• Acute illness• Medications

Falls=Geriatric Syndrome

Aging Changes

• Sensory deficits

• Posture

• Flexibility

Falls=Geriatric Syndrome

Chronic Issues

• Declining nutrition

• Bowel and bladder issues

• Cognition

• Postural hypotension

Falls=Geriatric Syndrome

Acute Illnesses

• Postural hypotension

• Weakness, deconditioning

• Arrhythmia

• Stroke

Falls = Geriatric Syndrome

Medications

• Sedatives

• Antihypertensives

• Diuretics

• Narcotics

Preventing Falls

Identify

Communicate

Intervene

Preventing Falls

Identify

• Toileting

• Alone

• Restraints

Preventing Falls

Communication

• Patient

• Staff

• Family

Preventing Falls

Interventions

• Patient

• Environment

• Alarms

• Prehabilitation

Call

Don’t Fall

Your Nursing Area

Goals

Clinically relevant

Annual Program

Key Points to Take Away

• Falls have multiple causes

• Assess function-mobility by observing specific components

• Prevent falls in older patients by: identifying patient, communicate risk, intervene with specifics

• Use critical thinking to change your unit

ReferencesAssessment of the Older Adult. (1996). [Video, Two-part series]. Philadelphia: Lippincott,

Williams, & Wilkins.

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

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

Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility, and

instrumental activities of daily living. Journal of the American Geriatrics Society, 3(12).

Katz, S. (1989). Functional assessment in geriatrics: A review of progress and directions.

Journal of the American Geriatrics Society, 37.

Kresevic, D. M., & Mezey, M. (2003). Assessment of function. In M. Mezey, T. Fulmer, I.

Abraham, & D. S. Zwicker (Eds.), Geriatric nursing protocols for best practice. (2nd ed.,

pp. 31-46). New York: Springer.

Podsiadlo, D., Richardson, S. (1991). The timed “Up and Go”: A test of basic functional

mobility for frail elderly persons. Journal of the American Geriatrics Society, 29(2), 142-

148.

Wallace, M., Fulmer, T. (2000). Fulmer SPICES: An overall assessment tool of older adults.

Geriatric Nursing, 21(3), 147.

Medications and Older Adults Critical Thinking

NaaDede Badger, Pharm.D, BCPS

Objectives

Discuss polypharmacy and its risk in the elderly

Discuss pharmacokinetic and pharmacodynamic changes in the elderly

Review medication related issues to keep in mind when taking care of the elderly

A look at the geriatric patient ..

Complicated drug therapy Increase in risk of adverse drug

reactions (ADRs)– Signifcant ADRs especially with drugs

with narrow therapeutic windows, ex. Phenytoin, warfarin and theophylline.

Increased risk of drug-drug interactions

Pharmacokinetic and pharmacodynamic changes

Social Issues Depression and poor medication

adherence Economic situations may lead to

medication non-adherence Cultural differences- 10% of older

adults were born outside the US, 13% don’t speak English

>34% do not have high school diplomas

Use of alcoholGistYJ, Hetzel LI. We the People: Aging in the United States. Census 2000 Special Reports. December 2004

Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood)2003;22:220-29

Case

A 71 yof is admitted with c/o abdominal pain, n&v. Her PMH includes: ischemic colitis, HTN, CAD, chronic pruritis, PVD, and depression. Her meds at admission include: amiloride 5mg BID, ASA 81mg daily, Claritin 10mg daily, Coreg 6.25mg BID, DN-100 prn, Diovan 80mg BID, Hydroxyzine 30mg BID, Lantus 14units hs, magnesium oxide 400mg BID, Remeron 45mg qhs, K-Dur 30meq daily, Prevacid 40mg daily, Aldactone 12.5mg daily, Vitamin C 500mg daily, wellbutrin 300mg daily, Actonel 35mg weekly, demadex 40mg BID, Fibercon prn.

What are the issues with her med list??

Use of multiple anticholinergic agents can increase risk of falls, sedation.

Use of multiple antidepressants – need to assess and make sure she is supposed to be on both

Use of multiple diuretics including two potassium sparing diuretics

Use of multiple medications that can increase the risk of falls

? Need for Darvocet Need for magnesium oxide – do we have a

Mg level? Need for Vitamin C??

Polypharmacy

Polypharmacy means “many drugs” Definition: The use of more

medications than is clinically warranted or indicated

Why is polypharmacy common?

The elderly have more disease states More drugs available Readily available drugs over the

counter Inappropriate prescribing Lack of medication review The “prescribing cascade”

The Prescribing Cascade

NSAIDs->HTN->antihypertensive therapy

Reglan->Parkinsonism->Sinemet Calcium channel blocker->edema->

lasix->potassium supplement NSAIDs->H2 blocker->delirium-

>Haldol Sudafed->Urinary retention->alpha

blocker

Polypharmacy: Show me the #s!!

Elderly make up 13% of population but consume ~ 30% of prescriptions1

Average elderly patient consumes– 2-6 prescription drugs and…– 1-3.4 over-the-counter drugs

Average American senior spends~ $700 / yr on pharmaceuticals alone

1. Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-241. Williams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24

Polypharmacy: What’s the big deal???

More adverse drug events– Corresponds to the # of medications

being taken More drug-drug interactions

– 50% risk in pts taking 5 meds vs. 6% in pts taking 2 meds

Decreased compliance – increased hospital visits

Poor quality of life Unnecessary drug expense

Gurwitz JH, Field TS. Et al. Incidence and preventability of adverse drug events among older persons in the ambulatory care setting. JAMA 2003;289:1107-1116

Pharmacokinetics

What the body does to the drugs– Absorption

– Distribution

– Metabolism

– Excretion

Pharmacokinetics

Absorption– Reduced gastric emptying– Reduced gastric acid production– Reduced GI motility– Reduced GI blood flow

Distribution– Decreased plasma protein– Increased body fat and decreased total body

water– Increased in volume of distribution of lipophilic

drugs like sedatives ex. Diazepam (Valium®)

Pharmacokinetics contd… Metabolism

– Reduced liver blood flow– Reduced liver metabolism– Reduced enzyme activities

Excretion – reduced by as much as 50% by age 75– Reduced renal blood flow– Reduced glomerular filtration rate– Reduced renal tubular secretory function

Common medications with decreased hepatic

metabolism Meperidine (Demerol®) Theophylline (Theo-Dur®, etc) Chlordiazepoxide (Librium®) Diazepam (Valium®) Desipramine (Norpramin®) Quinidine

Medications with decreased renal clearance

Aminoglycosides e.x. tobramycin, gentamicin, amikacin

Meperidine (Demerol®) Digoxin (Lanoxin®) Diuretics specifically HCTZ,

furosemide, triamterene Lithium H2RA ( ex Tagamet, Zantac)

Pharmacodynamic changes

What the drug does to the body:– Insulin sensitivity (↓)– Benzodiazepine (↑)– Warfarin (↑)– Anti-hypertensive agents (↑)– Phenothiazine (ex. Phenergan®) (↑)– GI side effects of NSAIDs like Naproxen,

Ibuprofen (↑)– Central effects of anticholinergics like

Benadryl® (↑)

Practice Question 1

Mrs. Brown was asked to start taking calcium replacement by her physician. Which of the following factors can affect absorption of her calcium?

A. Reduced gastric acid productionB. Increased gastric acid productionC. The formulation of calcium she buysD. Two of the aboveE. None of the above

Practice Question 2

All of the following drugs are considered inappropriate in the elderly except:

A. Meperidine (Demerol®)B. Indomethacin (Indocin®)C. Chlordiazepoxide (Librium®)D. Metoclopramide (Reglan®)

Inappropriate medications in the elderly

Sedatives & Hypnotic agents

Chlordiazepoxide (Librium®)

Antidepressants

Amitriptyline (Elavil®)

Antihypertensive agents

MethyldopaPropranolol (Inderal®)Reserpine

Analgesic agents

Indomethacin (Indocin®)Propoxyphene (Darvon®) **also in Darvocet®

Pentazocine (Talwin®)Meperidine (Demerol®)

Potentially inappropriate medsPotentially

InappropriateSafer alternatives

Promethazine (Phenergan®) Prochlorperazine (Compazine®)

Trimethobenzamide (Tigan®) Metoclopramide (Reglan®)

Methyldopa (Aldomet®) Diuretics

Diphenhydramine (Benadryl®)

Loratidine (Claritin®), Fexofenadine (Allegra®)

Indomethacin (Indocin®) Celecoxib (Celebrex)

Chlordiazepoxide (Librium®) and Diazepam (Valium®)

Lorazepam (Ativan)

Amitriptyline (Elavil) – for depression

SSRIs

Fluoxetine (Prozac®) Sertraline (Zoloft®), Citalopram (Celexa®), Mirtazepine (Remeron®)

Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24

Potentially inappropriate meds

Potentially Inappropriate

Safer alternatives

Meperidine (Demerol®) Morphine

Propoxyphene (Darvocet®)

Percocet®

Diphenhydramine –for sleep

Zolpidem (Ambien®)

Diphenhydramine (Benadryl®)

Loratidine (Claritin®), Fexofenadine (Allegra®)

NSAIDs for arthritis Acetaminophen (Tylenol®)

NSAIDs for gout Celecoxib (Celebrex®)Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24

Question

Which of the following is / are considered drug-disease states interaction(s)?

a. NSAIDs and CHFb. Benadryl and Urinary Retentionc. Narcotics and Constipationd. A and Be. All of the above

Drug-Disease State Interaction

Patient with PD have increased risk of drug induced confusion

NSAIDs (and Cox -2 Inhibitors) can exacerbate CHF

Urinary retention in BPH patients on decongestants and anticholinergics

Constipation worsened by calcium channel blockers, anticholinergics and narcotics

Quinolones, ultram can lower seizure thresh-hold

Quinolones can affect blood sugar

Some “take home” points Acetaminophen: keep dose < 4000mg /

day. Be mindful of combination products like Lortab & Percocet®, Darvocet®

Buproprion (Wellbutrin®) – few side effects but can cause insomnia so avoid giving it in the evening

Mirtazepine (Remeron®) – Good in patients with anorexia. Stimulates appetite

Antipsychotics – atypicals are best choice since older once have higher anticholinergic side effects. Atypical antipsychotics include: Quetiapine (Seroquel®), Risperidone (Risperdal®)

More “take home”

Diphenhydramine (Benadryl®) – its use should be reserved for allergic reaction and itching only. Avoid for sedation

Zolpidem (Ambien®) – Best choice for sleep. Always start at 5mg dose (or lower)

For anxiety – low dose Lorazepam (Ativan®) – 0.5mg – 2mg

Minimizing interactions between liquid phenytoin and

enteral feeds Give phenytoin as a single daily dose Stop feeds 2 hrs before and 2 hours after

dose OR suspend feeds between 10 p.m. and 6 a.m. and give phenytoin as a single dose at midnight.

Dilute phenytoin suspension with at least equal parts (up to 1:3) of water

Flush enteral tube with plenty of water before and after administration

** different dosage forms have different bioavailability so appropriate dosage adjustment must be made when switching from liquid to capsules

Formulations that shouldn’t be crushed

CR (controlled release)CRT (controlled-release tablet)LA (long acting)SR (sustained release)TR (time release)SA (sustained action)XL or XR (extended release)ER (extended release)EC (Enteric Coated)

Pneumovax®

Why is it important?Who needs to be vaccinated?When do you re-administerWhere can I find prior pneumovax

administration in the hospital?Documentation in SCM

Conclusion

Drug therapy in the elderly can be complicated due to several reasons.

Being vigilant and paying closer attention to the medication therapy can help reduce possible ADRs and drug-drug interactions.

Be diligent with medication reconciliation especially at discharge to make sure patient is not sent home on duplicate therapy.

Utilize your zone pharmacists for drug information.

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