older adults: drug therapy in older adults

The nurse is assessing a client who is being admitted to the healthcare facility. When asked about allergies, the client states, "I'm allergic to penicillin." What is the nurse's best initial response?

"Do you remember what happened the last time you received penicillin?" Explanation: Any report of an allergy should be documented and communicated clearly. However, the nurse also has a responsibility to gather as much data as possible, especially since clients may classify a wide range of adverse effects as allergies. It would be premature for the nurse to state which antibiotics the client may or may not receive.

long term care: Basic requirements of OBRA 1990

-Prospective DUR (Drug Utilization Reviews) -retrospective DUR -education and intervention programs -patient counseling -documentation of DUR and educational activities.

indicators of inability to self-medicate

-cognitive impairments. -more than 5 prescription medications -inability to read auxiliary labels -difficulty opening non-childproof containers -inability to discriminate between medication color and shapes

what are the pharmacokinetic changes in older adults affecting metabolism?

-decreased hepatic blood flow -decreased hepatic mass -decreased activity of hepatic enzymes

what are the pharmacokinetic changes in older adults affect excretion?

-decreased renal blood flow -decreased glomerular filtration rate -decreased tubular secretion -decreased number of nephrons

factors that predispose to adverse drug reactions in older adults

-drug accumulation due to decreased renal function. -potentially inappropriate prescribing -polypharmacy -drugs with lower therapeutic index -inadequate supervision of long-term therapy -poor patient adherence -greater severity of illness -comorbidities.

cumulative use of strong anticholinergics and incident dementia

-higher cumulative use of anticholinergics associated with increased risk for all- cause dementia and alzheimer's disease. -most common anticholinergic classes used: antidepressants, antihistamines, bladder antimuscarinics. Examples of heaviest exposure level:•Daily use > 3 years•Oxybutynin 5mg •Chlorpheniramine 4mg•Doxepin 10mg•Olanzapine 2.5mg•Meclizine 25mg

anticholinergic drugs

-present on beers and STOPP lists -anticholinergic adverse effects: dry mouth, constipation, blurry vision, urinary retention, tachycardia, memory impairment, confusion, hallucinations, and falls with antihistamines. -several studies have shown that use of anticholinergic drugs may be associated with increased risk of dementia.

how to promote adherence

-simplify regimen -explain treatment plan -choose appropriate drug dosage form -label drug containers clearly -avoid containers that are difficult to open -suggest use of calendar and/or pill box -ensure patient has access to pharmacy and can afford meds -enlist aid of friend, relative, visiting healthcare professional. -monitor for therapeutic response, ADRs, drug levels.

how to reduce incidence of adverse reactions in older adults:

-taking thorough drug history, including OTC and herbal meds. -account for pharmacokinetic/ dynamic changes that occur -initiate therapy at low doses -monitor clinical responses and plasma drug levels -employ simplest regimen possible -monitor for drug-drug interactions -periodically review need for continued drug therapy -encourage patients to dispose of old medications -promote adherence -avoid potentially inappropriate medications (PIMs)

A client develops a cytotoxic reaction to a drug. What would the nurse expect to do?

Discontinue the drug immediately as ordered. Explanation: For a client experiencing a cytotoxic reaction, the prescriber is notified and the drug is discontinued. Subcutaneous epinephrine is used to treat an anaphylactic reaction. The client is also encouraged to wear some type of MedicAlert identification denoting the allergy. Antipyretics would be used to treat serum sickness reaction.

A client receiving drug therapy develops numbness and tingling in the extremities and muscle cramps. What assessment should the nurse perform?

Review the client's most recent potassium level. Explanation: Hypokalemia is suggested by numbness and tingling in the extremities, muscle cramps, weakness, and irregular pulse. Fatigue, drowsiness, hunger, tremulousness, and cold clammy skin would suggest hypoglycemia.

A client is on antibiotic therapy for an axillary abscess. The client has been outside working in the yard and observes a rash everywhere that is not covered by clothing. What should the client be told about this finding?

The client is having photosensitivity and this can occur even with brief exposure to the sun or UV rays.

A newly admitting client has signs and symptoms of an infection and the nurse anticipates that the client will be prescribed antibiotics. What assessment should the nurse prioritize when determining the client's risk for an excessive drug response due to impaired excretion?

The client's blood urea nitrogen level and creatinine clearance rate.

The nurse is caring for a client receiving an aminoglycoside (antibiotic) that can be nephrotoxic. Which will alert the nurse that the client may be experiencing nephrotoxicity?

a decrease in urine output Explanation: Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can occur with nephrotoxicity.

any new symptom should be investigated as

a potential drug-related problem.

most important cause of adverse drug reaction is

drug accumulation secondary to reduced renal failure.

Many drugs can affect the functioning of the nerves in the periphery and central nervous system. Which are examples of potential neurologic effects of drugs? (Select all that apply.)

neuroleptic malignant syndrome Parkinson-like syndrome atropine-like (anticholinergic) effects Explanation: Many drugs can affect the functioning of the nerves in the periphery and central nervous system. Nerves function by using a constant source of energy to maintain the resting membrane potential and allow excitation. Neuroleptic malignant syndrome, Parkinson-like syndrome, and atropine-like (anticholinergic) effects are all examples.

definition of polypharmacy

the use of multiple medications by a patient

An older adult client has an elevated serum creatinine level. This client is at greatest risk for which medication-related effect?

toxicity Explanation: An elevated creatinine level is indicative of diminished kidney function, which will result in serum drug toxicity. The creatinine level indicates kidney function, does not affect absorption, and has no effect on gastric emptying. Idiosyncratic effects are reactions that occur rarely and unpredictably among the population.

what are the pharmacokinetic changes in older adults affecting distribution?

-increased body fat -decreased lean body mass -decreased total body water -decreased serum albumin -decreased cardiac output

factors that contribute to poor adherence in adults

-multiple chronic disorders (3 or more) -multiple prescription medicines (5 or more) -multiple doses/ day for each medication (12 or more) -change in the regimen (4 times in past 12 months) -multiple prescribers (3 or more) -cognitive or physical impairment -living alone in the community -recent discharge from hospital -low literacy -inability to pay for drugs -personal conviction that drug unnecessary/ dose to high. -presence of side effects -reliance on caregiver -demonstrated poor compliance history

what are the pharmacokinetic changes in older adults affecting absorption?

-increased gastric pH -decreased absorptive surface area -decreased splanchnic blood flow -decreased GI motility -delayed gastric emptying

american geriatric society

-introduced in 1991, last updated in 2012 -three medication categories: potentially inappropriate/ avoid in older adults. potentially inappropriate/ avoid in certain disease states. Medications to be used with caution. -limitations: Does not consider drug interactions, dosing for renal impairment, therapeutic duplication. does not provide alternatives. no evidence that improves clinical outcomes.

screening tool of older person's prescriptions (STOPP):

-introduced in 2008 -identifies 65 potentially inappropriate medications organized by physiologic system -incidence of PIMs identified by STOPP in elderly presenting to hospital is 35% -likelihood of adverse drug events increases about 85% with each STOPP identified PIM used -limitations: does not consider dosing for renal impairment and no evidence that improves clinical outcomes.

polypharmacy

-minimum number of meds varies, but generally ranges 5-10. -estimated that half of medicare beneficiaries receive 5 or more medications -increases risk of ADRs -increases potential for drug-drug interaction -increases potential for prescribing cascades -increases problems with medication adherence

The nurse is assessing a new client who states being allergic to nonsteroidal anti-inflammatories (NSAIDs. What subsequent assessment should the nurse prioritize?

asking the client what the client's response is to taking NSAIDs Explanation: The nurse should ask additional questions of clients who state that they have a drug allergy to ascertain the exact nature of the response and whether or not it is a true drug allergy. This would be a priority over exploring alternatives or determining the client's pain tolerance.