Ch 9 older adult Geropharmacology

Parkinsonian Symptoms

Bilateral tremor, bradykinesia, rigidity. Inflexible facial expression. Occurs weeks to months after antipsychotic therapy.

Analysis of Assessment Findings Related to Medication Use

1 Is the drug working to improve the patient's symptoms? aWhat are the therapeutic effects of the drug? (What symptoms are targeted?) bWhat is the time frame for the therapeutic effects? cHave the appropriate drug and dose been prescribed? dHas the appropriate time been tried for therapeutic effects? 2 Is the drug harming the patient? a What physiological changes are occurring? b What laboratory values are changing? c What mental status changes are occurring? d What functional changes are occurring? e Is the patient experiencing side effects? f Is the drug interacting with any other medication? 3 Does the patient understand the following? aWhy he or she is taking the drug bHow the drug is supposed to be taken cHow to identify side effects and drug interactions dHow to reduce or manage side effects eLimitations imposed by taking the drug (e.g., sedative effects)

Medications Most Commonly Used by Older Adults

Cardiovascular agents, antihypertensives, analgesics, antiarthritic agents, sedatives, tranquilizers, laxatives, antacids

Metabolite

Chemical structure of a drug when it has been converted to be more easily used and excreted. Occurs through biotransformation.

metabolism

Chemical structure of drug is converted to metabolite more easily used and excreted. Liver is the primary site of metabolism, although other organs have metabolizing enzymes.Genetic differences in drug metabolism can affect serum drug levels and rate of excretion. the duration of a drug action is determined by the metabolic rate

Components of a Medication Assessment with Special Emphasis for Older Adults*

Ability to pay for prescription medications • Ability to obtain medications and refills • Persons involved in decision-making regarding medication use • Drugs obtained from others • Recently discontinued drugs or "leftover" prescriptions • Strategies used to remember when to take drugs • Recent drug blood levels as appropriate • Recent measurement of liver and kidney functioning • Ability to remove packaging, manipulate medication, and store supply

Which pharmacokinetic process is thought to be the least affected by the aging process?

Absorption There is no conclusive evidence that the absorptive process is changed appreciably in the older adult. However, Distribution, Metabolism and excretion are all significantly affected by the aging process

alterations of distribution, metabolism, and excretion.

Altered distribution may be caused by displacement of one drug from its receptor site by another drug, or by binding to plasma albumin or α1-acid glycoprotein. Altered distribution is a common cause of adverse drug reactions in older adults and is especially important to the older adult in the situation of lowered albumin levels, which is common among the chronically ill frail elders often residing in long-term care facilities (Beyth and Shorr, 2007). Altered metabolism can occur when one drug increases (inducts) or decreases (inhibits) the metabolism of another drug (Hartshorn and Tatro, 2003). Drugs may induce or inhibit the specific CYP450 isoenzymes responsible for metabolizing another drug. One drug may inhibit the metabolism of another drug if they are both substrates for the same metabolic pathway. Tables listing medications affected by those that have an effect on the CYP450 enzymes are available in most references on pharmacotherapeutics. Altered excretion can occur when one drug changes the urinary pH such that another drug is either reabsorbed or excreted to a greater extent (e.g., sodium bicarbonate raises urinary pH, resulting in greater reabsorption of amphetamine and thereby prolonging its half-life) (Hartshorn and Tatro, 2003). Another mechanism may involve one drug increasing or decreasing active transport in the renal tubules (e.g., probenecid decreases the active transport of penicillin, thereby prolonging its half-life) (Hartshorn and Tatro, 2003).

Drugs with Increased Biological Half-Life

Antibiotics, barbituates, cimetidine, digoxin, salicylate. Dehydration influences half-life

Psychotherapeutics in Late Life

Antidepressants, stimulants, anxiolytic agents, and antipsychotics are of concern

**Promoting Healthy Aging withSafe Medication Use: assessment

Assessment Ask person to bring in all medications being taken, including OTCs, herbals, and neutraceuticals or dietary supplements Ask person how he or she actually takes medicine rather than depending on label Best way to evaluate the meds an older adult is taking is by asking them to bring all meds. (in a brown paper bag) The nurse's analysis of the assessment data is centered on identifying unnecessary or inappropriate medications, establishing safe usage, determining the patient's self-medication management ability, monitoring the effect of current medications and other products (e.g., herbals), and evaluating effectiveness of any education provided (Box 9-7). Ideally, the nurse should know what resources are available for teaching about medications, such as the clinical pharmacist. The nurse is well situated to coordinate care, learn about the patient's goals, learn what the patient needs for understanding his or her medications, and arrange for follow-up care to determine the outcome of medication teaching.

Evidence-Based Principles for Reducing Adverse Drug Events

By paying attention to the following principles for prescribing and monitoring medications for older adults, one might also reduce the risk for adverse drug events: •Give the lowest dose possible. •Discontinue unnecessary therapy. •Attempt nondrug approaches first. •Give the safest drug possible. •Assess renal function. •Always consider the risk-to-benefit ratio when adding drugs. •Assess for new interactions with any new prescription. •Avoid the prescribing cascade, i.e., new medications without consideration of those to be discontinued. •Avoid inappropriate medications.

What factors affect the amount of time between the administration of a drug and its absorption?

Route of administration, bioavailability, amount of drug that passes through the absorbing surfaces in the body. For a drug to be effective, it must be absorbed into the bloodstream.First pass metabolism is extremely variable based on the individual older adult's degree of decline in hepatic blood flow.

Akathisia

Compulsion to be in motion, a sense of restlessness. Fidgeting, pacing, common. Often mistaken for worsening psychosis

antidepressants

Selective serotonin reuptake inhibitors (SSRIs) have been found to be highly effective antidepressants. SSRIs are the drugs of choice for first-line use in older adults. Most older adults are sensitive to the SSRIs and may find significant relief from depression at low doses (Box 9-4). Most have also been found to be useful for anxiety, and in some cases obsessive-compulsive disorder and posttraumatic stress disorder as well

Issues and Trends in Medication Use: self prescription

Self-Prescribing of Medicinal Products: People of all ages frequently medicate themselves with former prescriptions, prescriptions borrowed from friends, or over-the-counter (OTC) drugs Self-treatment includes purchasing herbal and nutritional supplements, which may be recommended by acquaintances and are thought to be harmless because they are "natural"

Aging and Biokinetics

Decrease in total body water (due to decrease in muscle mass) and increase in total body fat affects volume of distribution

Conditions that Decrease Metabolism of Drugs

Dehydration, hyperthermia, immobility, liver disease

Fat Soluble Drugs

Diazepam (on Beers criteria), thipental, trazadone. Half-life increased with increase in body fat. Extends the effects of the drug.

Precautions in Drug Administration

Do not crush enteric coated tablets. Assure suppositories are not melted or expelled. Avoid cardiac overload from too rapid ID admin

Drug Interactions Herbal, food, or other drugs

Drug-Herbal Interactions: St. John's Wort decreases effectiveness of digoxin & potassium competes. Warfarin and gingo biloba and increased INR. Because of inadequate labeling requirements, drug interactions may not be listed on the product labels of these supplements. Patients, prescribers, and nurses administering medications need to be aware of the potential interactions of the herbal preparation or nutritional supplement used to the extent possible Drug-Food Interactions: Calcium binds to levothyroxine, tetracycline, and ciprofloxacin, reducing aborption. Lovastatin increases with high fat. Vitamin K in green veg decreases warfarin. Foods can bind to drugs, affecting their absorption. For example, calcium in dairy products will bind levothyroxine, tetracycline, and ciprofloxacin, greatly decreasing their absorption; lovastatin absorption is increased by a high-fat, low-fiber meal. Grapefruit juice contains substances that inhibit CYP3A4-mediated metabolism in the gut . Blood levels of amiodarone, lovastatin, simvastatin, and buspirone are greatly increased when the drugs are taken on the same day as grapefruit. Certain foods antagonize the therapeutic action of a drug. The vitamin K in leafy green vegetables antagonizes the anticoagulant effects of warfarin ( (Table 9-2). It is recommended that patients taking warfarin ingest a consistent amount of greens to avoid variations in coagulability. Spironolactone, prescribed for end-stage heart failure, increases potassium (K+) reabsorption by the renal tubule. If a patient ingests a diet high in potassium (e.g., KCl salt substitute, molasses, oranges, bananas) while taking spironolactone or other potassium-sparing agents, toxic K+ levels can quickly occur Drug-Drug Interactions: The more chronic conditions one has, the more likely that a medication for one condition will affect the body in such a way as to influence the other. When two or more medications are given at the same time or closely together, the drugs may potentiate one another (i.e., when given together the drugs have stronger effects than when given alone) or antagonize each other (i.e., when given together one or more of the drugs become ineffective).. Medications intended for oral administration must be put in soluble form for passage through the tube without clogging and yet also remain in their original form. When several medications are crushed, mixed together, and then dissolved in water for administration, a new product is created and drug-drug interactions may have already begun. Drugs may bind to another drug in small intestine to form nonsoluble compound or compete for binding sites. Antispasmodic drugs slow gastric and intestinal motility. Changes to pH.

Excretion

Drugs and their metabolites are excreted in sweat, saliva, and other secretions but primarily through kidneys. Renal drug excretion occurs when drug is passed through kidney and involves glomerular filtration, active tubular secretion, and passive tubular reabsorption.Assessment of creatinine clearance rate an important consideration in older adults to prevent drug toxicity Kidney fxn declines in many older adults, so does the ability to excrete or eliminate drugs in a timely manner

**Education for Safe Medication Use

Education for Safe Medication Use Assessment of patient's readiness to learn, ability to comprehend, and functional capacity to incorporate lifestyle adaptations for medication management Pamphlets and booklets written in lay terms and in appropriate language and reading level should be available Nurses have the greatest opportunity to impact medication use and improve treatment outcomes through patient education

interventions to Maximize Drug Absorption

Exercise, stimulate circulation and increase blood flow, prevent fluid volume deficit, hypothermia, and hypertension; avoid preparations that neutralize gastric secretions if a low gastric pH is required, monitor for interactions, use most effective route of administration

**Safe Administration of Medications via Enteral Feeding Tubes

High risk for medication errors: Occluded tube Reduced drug effect Drug toxicity Patient Harm Patient Death Most often this preparation occurs at the bedside, further increasing the risk for errors.

***What is the Beer's list?

IT is the Safety AlertThe "Do Not Use" List Drugs identified to have a higher than usual risk when used in older adults Overwhelming benefit vs. risk documentation when prescribing these drugs considered a standard of practice extra info: The appropriate use of medications in the older adult means that such products are used only as needed, at the dose necessary to achieve the desired effects, and in a manner in which the risks and benefits have been considered within the greater context of the person's life, health, lifestyle, and values. identified 20 drugs that were frequently prescribed to older adults but had questionable risk-to-benefit ratios, especially controversial cardiovascular agents such as propranolol, methyldopa, and reserpine. Since that time, Beers (1997) and others have continued to identify drugs that have higher than usual risk when used in older adults. These have now been transferred to a "do not use" list for residents in nursing facilities, otherwise known as the "Beers list." When one is prescribed without documentation of the overwhelming benefit of its use, it can be considered a form of drug misuse by the prescribing practitioner.2012 List is 14 pages

Responses to Drugs in Elderly

Increased myocardial sensitivity to anesthesias. Increased CNS sensitivity to narcotics, alcohol, and bromides

**Pearls for gerontological nurses:

Key persons Environment Timing Communication Reinforce teaching Provides both oral explanations and important to send the client home with a copy of written info as well relating to care or med administration Key persons: Find out who, if anyone, manages the person's medications, helps the person, or assists with decision-making; and with the elder's permission, make sure that the helper is present when any teaching is done (Box 9-8). Environment: Minimize distraction, and avoid competing with television or others demanding the patient's time; make sure the person is comfortable and is not hungry, thirsty, tired, too warm or too cold, in pain, or in need of the toilet. Timing: Provide the teaching during the best time of the day for the person, when he or she is most engaged and energetic. Keep the education sessions short and succinct. Communication: Ensure that you will be understood. Make sure the elders have their glasses or hearing aids on if they are used. Use simple and direct language, and avoid medical or nursing jargon (e.g., "intake"). Speak clearly, facing the person and with light on your face, at head level. Use formal language (e.g., Mr. Jones) unless you have permission to do otherwise. Do not touch the patient unless he or she gives you indications that it is acceptable to do so (e.g., patient lays his or her hand on yours). If the person is blind, Braille instructions may be available from the pharmacy. If the person has limited language proficiency in the country in which care is delivered, a trained medical interpreter is needed. Reinforce teaching: Although there is a wide array of teaching tools and medication reminders available on the market today, many older adults continue to use the strategies they have developed over the years to remember to take their medications. These may be as simple as a commercially available storage box or turning a bottle upside down once it has been taken for the day, or as intense as having a family member or friend call the person at designated times. Encourage the person to use techniques which have worked in the past or develop new strategies to ensure correct and timely medication use when needed.

Alternatives to Medication

Lifestyle changes, diet modifications, regular exercise, effective stress management techniques, regular schedules for sleep, rest, elimination, alternative therapies

Water Soluble Drugs

Lithium, aminoglycosides, alcohol, digoxin. Serum levels may go up due to decreased volume of distribution. Leads to relative decrease of drug

Issues and Trends in Medication Use

Misuse of Drugs Overuse, underuse, erratic use, and contraindicated use May occur due to inadequate skills of the nurse or the prescriber, misunderstanding of instructions, or inadequate funds to purchase prescribed medications

Promoting Health Aging Implications for Gerontological Practice

Monitor for potential drug reactions Monitor for signs and symptoms of adverse drug reactions Prompt recognition of changes in patient status that can affect drug regimen Patient and family education on purpose and side effects of all medications to enhance safe compliance with drug therapy

Issues and Trends in Medication Use: adverse drug events

Most common categories associated with ADR's: Cardiovascular agents Psychotropics Anticoagulants Diuretics Hypoglycemics Non-opioid analgesics Drug allergy: Can occur after prior or continuous exposure to drug ADR's need to be reported via an Incident or variance report Important to ask client to describe the type of allergy they have, sometimes allergies are not true allergies

Acute Dystonia

Movement disorder. Abnormal involuntary muscular contraction of mouth, jaw, fact, and neck.

Risk Factors for Medication Errors

Multiple meds, cognitive impairment, visual/hearing deficit, arthritic/weak hands, lack of knowledge about meds, limited finances, illiteracy, lack of support system, history of inappropriate self-medication, expired or borrowed meds in home

Transdermal Delivery Systems

Nurses working with older adults are usually familiar with the transdermal drug delivery system (TDDS) because of its long use for the topical application of nitroglycerin; the drug was dispersed in an oil-based cream, placed on a piece of paper (measured by the centimeter), and taped to the skin. This route overcomes any first-pass problems, is more convenient, acceptable, and reliable than other routes, especially in the outpatient setting and for some persons with cognitive disorders. Ideally the TDDS provides for a more constant rate of drug administration and eliminates concern about gastrointestinal absorption variation, gastrointestinal intolerance, and drug interaction. It is indicated when a slow, timed-release delivery into the tissue and ultimately the bloodstream is desired. Risk for allergic reactions but provides a more constant rate of drug admin and eliminates concerns regarding GI.The characteristic thinning, dryness, and roughness of older skin also may affect absorption of the intended dose

Distribution

Once drug is absorbed, it must be distributed or transported to receptor site on target organ to have therapeutic effect. Some drugs exert therapeutic effect in absorbed form, others must be metabolized. Circulatory disease affects distribution. Fat soluble drugs pass more easily that water soluble drugs - fat soluble drugs to be stored in the body longer. Circulatory disease, such as PVD can affect drug distribution.

Issues in Medication Use

Polypharmacy, drug-drug interactions

***simplify process of safe med administration

Simplify Process: Memory aids Calendars Day, week, month pill containers Voice-mail reminders Convenient medication refills Easy-to-open medication containers Reduce number of doses daily when possible Reduce number of medications when possible Reduce frequency per day by grouping compatible medications together Tailor medication regimen to lifestyle Pill boxes will provide safe management of multiple meds

Forms of Liquid Medications

Solutions, suspensions, tinctures, elixiris Solutions Drug: is dissolved in water Suspensions Drug: (usually water insoluble) is suspended in some liquid medium Tinctures: Drug is dissolved in alcohol-based solution Elixirs:Semi water soluble solutions of drugs are held in solution by alcohol

**What is pharmacokinetics?

Study of the movement and actions of a drug in the body. Determines the concentration of the drug in the body and effect. It consists of: Absorption (how taken in) Distribution (where dispersed) Metabolism (how broken down) Excretion (how body rids)

Risk of Adverse Reactions in the Aged

Symptoms can appear differently in older persons. A prolonged time may be required for an adverse reaction to become apparent. Adverse reactions can be demonstrated after a drug has been discontinued. Adverse reactions can develop to drugs that have been used for a long period w/o problems

Psychoactive Medications

Take 10-14 days to determine how the pt will react.

**Polypharmacy

Taking multiple medications at the same time. Inadequate communication among medical care providers is an important contribution to polypharmacy. When communication between patients, nurses, and other health care providers and caregivers becomes fragmented the risk for duplicative medications, inappropriate medications, potentially unsafe dosages, and potentially preventable interactions is accentuated. The two major concerns with polypharmacy are the increased risk for drug interactions and the increased risk for adverse events. Increased risk for drug interactions : Drug-Supplement interactions Drug-Food Interactions Drug-Drug Interactions Increased risk for adverse events

psychoactive drugs

The gerontological nurse, especially one working in a long-term care setting, is likely to care for older adults who are receiving psychoactive drugs, especially for the treatment of depression, anxiety, and bipolar disorder. A small group of elders in the community and a growing number of those residing in long-term care facilities are also being treated for a psychosis. As noted previously, drugs with psychoactive properties have a higher than usual risk for adverse events and must be prescribed, administered, and monitored with care. The nurse works with the individual to ensure that appropriate biomarkers are measured and to identify the behavioral marker against which the medication's effectiveness is measured (e.g. days of sadness, quality of sleep, ability to enjoy social activities).

most commonly used drugs:

The most commonly prescribed and used drugs in the ambulatory older population are cardiovascular drugs, diuretics, nonopioid analgesics, anticoagulants, and antiepileptics. Gastrointestinal preparations and analgesics are the most-used OTC medications, followed by cough products, eye washes, and vitamins.

**Pharmacodynamics

The physiological processes that occur between the drug and the body. The older a person gets, the more likely he or she will have an alteration or unreliable response to a drug. "Start low, go slow" and monitor first dose of medications. The older a person is, the more likely s/he is to have altered/unreliable reactions to the drugs. Age-related changes affect the way drugs are metabolized by Older Adults Potential Anticholinergic Effects • Constipation • Dry mouth • Blurred vision • Dizziness • Urinary retention • Confusion

Tardive Dyskinesia

When antipsychotics have been used 3-6 months. Wormlike movements of tongue, facial movements, twisting of limbs. No treatment to reverse.

Questions Nurses Should Ask About Meds

Why is the drug ordered? Is the smallest possible dose ordered? Is the pt allergic? Can this drug interact with other things that are being used? Is the most effective route of administration being used?

Anxiolytic Drugs

drugs to treat anxiety. provide sedating effects for acute anxiety. Have long half-lives. Should be used for the shortest time possible. Cause drowsiness, dizziness, memory impairment people often self-medicate with antihistamines, especially diphenhydramine (Benadryl), for anxiety and sleep; this is not recommended because of their significant anticholinergic effects that increase the risk for falls or confusion. The decision to treat anxiety pharmacologically is based on the degree to which the anxiety interferes with the person's ability to function and subjective feelings of discomfort. Benzodiazepines are highly effective anxiolytic and hypnotic agents. They are popular because of their quick sedating effects for the person who is experiencing acute anxiety, such as a new resident in a long-term care facility. However, their side effects include drowsiness, dizziness, ataxia, mild cognitive deficits, and memory impairment (Box 9-5). Signs of toxicity include excessive sedation, unsteady gait, confusion, disorientation, cognitive impairment, memory impairment, agitation, and wandering. Because these symptoms resemble dementia, persons can easily be misdiagnosed once the benzodiazepines have been taken.

older adults are at greater risk for?

for polypharmacy, adverse drug events, and inappropriate drug use than are younger adults. The reasons for this are many and include increases in chronic disease and varying levels of geriatric skills of health care providers. When used with caution and care, pharmacological interventions can be used alongside nonpharmacological approaches to maximize healthy aging.

The three most common errors of med administration are_______, ___________________, and ____________.

incompatible route, improper preparation, and improper administration. Incompatible route: Medications must be appropriate for the oral route for immediate action and crushable. All products intended for slow or extended release are not crushable as they are intended for only partial dissolution in the stomach; administration may lead to an excessive dose. Watch for extensions such as: CD, CR, ER, LA, SA, SE, TD, TR, XL, and XR as warnings for noncrushable drugs (this list is not inclusive). See the "do-not-crush" lists available from the pharmacy 2 Improper preparation: Medications administered via an enteral feeding tube must be in a liquid or semiliquid form in order to pass through the tube and not adhere to the lining of the tube. Each medication should be dissolved individually in a product that will not change the product* and will not clog the tube. Watch for oral suspensions and tincture; drug remaining on tubing means reduced dose administered. 3 Improper administration: Be sure to know where the distal end of the tube is resting. A drug that requires partial absorption in the stomach cannot be used when it will be administered directly into the duodenum or jejunum. Do not combine with feeding unless directions are to "administer with food." When more than one tablet is crushed or capsule opened and mixed together before administration, a new "product" has been prepared and may not have the same effect as the two products taken separately. Find "compatibility information" from pharmacists to determine which medications may be mixed in this way.

ADR

occur when there is a noxious response to a drug. ADRs range from a minor annoyance to death and are a common cause of hospitalization, especially for persons more than 80 years of age. Those most serious side effects are associated with cardiovascular and psychotropic agents and others with narrow therapeutic windows or are renally excreted We now know that in many cases an older adult should be prescribed lower dosages of several of the drugs commonly needed, especially when starting a drug regimen. To minimize the likelihood of an ADR, the dose can be slowly increased until it safely reaches a therapeutic level. A common adage related to drug dosing in older adults is, "Start low, go slow, but go." There has also been a recognition that the risk of ADEs is so high with some drugs that they are simply not recommended for use in persons with any risk factors at all.

Who consumes the most drugs?

persons 65 years of age and older are the largest users of prescription and over-the-counter (OTC) medications. Although making up only about 12% of the population, they consume about one third of all prescriptions drugs and one half of those available OTC The majority (94%) regularly takes prescription medications, 46% take OTCs, and 53% take dietary supplements such as herbs

The most common routes of administration are

sublingual, rectal, topical, transdermal, intramuscular, inhalation, and opthalmic. The drug is delivered immediately to the bloodstream with intravenous administration and quickly via the parenteral, transdermal, and rectal routes. Orally and enterally administered drugs are absorbed the most slowly and primarily in the small intestine. Drugs given orally pass through the mouth and esophagus and enter the stomach. Most solid oral drug dosage forms (e.g., tablets, capsules, powders, pills) are designed to dissolve in the stomach. Drugs given enterally (via tube) are intended for an oral administration route but mechanically bypass the mouth and potentially the stomach and duodenum. Many factors affect the rate at which a medication is dissolved. These factors include the amount of liquid in the stomach, the type of coating the tablet has, the extent of tablet compression used in making the tablet, the presence of expanders in the tablet, the solubility of the drug in the acid environment of the stomach, and the rate of peristalsis.

There does not seem to be conclusive evidence that absorption in older adults is changed appreciably. However, we do know that diminished salivary secretion and esophageal motility may interfere with what?

swallowing some medications, which could in turn lead to erosions if adequate fluids are not taken with the medications. extra info: Decreased gastric acid, common in the elderly, will retard the action of acid-dependent drugs. Delayed stomach emptying may diminish or negate the effectiveness of short-lived drugs that could become inactivated before reaching the small intestine. Some enteric-coated medications, such as enteric-coated aspirin, which are specifically meant to bypass stomach acidity, may be delayed so long in older adults that their action begins in the stomach and may produce undesirable effects, such as gastric irritation or nausea.

Once a drug has been administered orally (or enterally), it may be absorbed directly into the ______________ from _____________________

the bloodstream from the stomach (e.g., alcohol), but usually passes dissolved into the duodenum or small intestine. The small intestine has a large surface area and is efficient at absorption. Slowed intestinal motility, frequently seen with aging, can increase the contact time and increase drug effect because of prolonged absorption, significantly increasing the risk for adverse reactions or unpredictable effects. The drug passes from the small intestine into the network of veins surrounding it, known as the portal system, and into the liver, where it may undergo metabolism (see below). Drugs that are extensively metabolized as they pass through the liver are said to have a large first-pass effect. Drugs with a significant first-pass effect usually require much larger oral doses than the same drug given by injection. In normal aging, both liver mass and blood flow are significantly decreased, resulting in reductions in the metabolism rate with potential but unknown implications for the older adult.

With sublingual and rectal administration, the drug is absorbed through the ____________ directly into the _________________________

the mucous membrane directly into the systemic circulation. Drying of the mouth, a common side effect of many of the medications taken by older adults, may reduce or delay buccal absorption. Rectal administration may be useful when the patient cannot tolerate oral medications.