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Gerontological Nursing. Pharmacology and the Older Adult Psychological and Cognitive Function. Age related changes affecting drug therapy. Decreased GI motility and absorption surface Dry mouth Decreased liver perfusion, liver mass Increased body fat, Decreased body water

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Gerontological Nursing

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Gerontological nursing

Gerontological Nursing

Pharmacology and the Older Adult

Psychological and Cognitive Function

Age related changes affecting drug therapy

Age related changes affecting drug therapy

  • Decreased GI motility and absorption surface

  • Dry mouth

  • Decreased liver perfusion,

    liver mass

  • Increased body fat,

  • Decreased body water

  • Decreased renal perfusion,

    renal mass

  • Visual, hearing changes

  • Brain and brain function changes

Predictors of the patient s reaction to a drug

Predictors of the patient’s reaction to a drug

  • Chronological age alone is a poor indicator

    Better indicators include:

  • General state of health

  • Number and types of medications prescribed/taken

  • Liver function

  • Renal function

  • Comorbidities

  • Other diagnosed diseases

Predicting renal function in the elderly patient

Predicting renal function in the elderly patient

  • Do not rely on BUN

  • Calculate creatinine clearance:

    Creatinine clearance = (140 – age) x lean weight (kg)

    72 x serum creatinine

    x .85 for women

  • Normal values:

    Male: 97 to 137 ml/min.

    Female: 88 to 128 ml/min.

Adverse drug effects in the elderly

Adverse drug effects in the elderly

  • People >65 yrs 2x likely to have ADE than <65

  • Most are preventable

  • Client frequently stops the suspected medication

  • Suspect ADE if patient experiences unexplained:

    • Cognitive changes

    • Falls

    • Anorexia

    • Nausea

    • Weight loss

Cognitive changes

Cognitive changes

  • Changes in mood (anxiety, depression) from antihypertensives, antiparkinsonians, narcotics, NSAIDs, steroids

  • Central anticholinergic


    confusion, disorientation,

    hallucinations, psychosis

    (e.g., diphenhydramine,

    furosemide, digoxin, anti-


Major drug drug interactions in ltc

Major drug-drug interactions in LTC

  • Warfarin with NSAIDs, sulfa drugs, macrolides, quinolones, phenytoin => increased bleeding

  • ACE inhibitors with potassium supplements or spirolactone => elevated serum potassium

  • Digoxin and amiodarone => digoxin toxicity

  • Theophylline and quinolones =>

    theophylline toxicity

Adverse drug reactions in the elderly

Adverse Drug Reactions in the Elderly

  • Signs and symptoms of ADR may vary in the elderly

  • Evidence of ADR may take longer in the elderly

  • ADR may be apparent even after

    the drug has been discontinued

  • ADR can develop suddenly even

    if medication has been used over a

    longer period of time

Medication reconciliation

Medication reconciliation

  • Identify an accurate list of all medications patient is taking

  • Verify the medications are appropriate to the patient

  • Determine if patient is

    taking them correctly

  • Compare list with

    physician’s admission,

    transfer, or discharge


Drugs that should be used cautiously in the elderly

Drugs that should be used cautiously in the elderly

  • New drugs on the market

  • CNS drugs

  • Drugs that are highly protein bound (e.g., thyroxine, warfarin, diazepam, heparin, imipramine and phenytoin)

  • Drugs eliminated by the kidneys (e.g., digoxin, glucose, some antibiotics)

  • Drugs with a high 1st pass effect, i.e., low bioavailability (e.g., propanolol, orphine, nitroglycerin)

  • Drugs with a low therapeutic-to-toxicity ratio (e.g., oral chemotherapy)

Guiding principles of drug administration

Guiding Principles of Drug Administration

  • Why is the drug ordered?

  • Is this the smallest possible dose?

  • Does the patient have any allergy to the drug?

  • Are there potential drug-drug interactions?

  • Are there any special administration requirements?

  • Is this the most effective route of administration?

Beers criteria

Beers Criteria

  • “Potentially Inappropriate Medications for the Elderly”

  • Lists medications that require provider justification if prescribed to this population

  • Intended to limit adverse drug events

  • Monitored in long term care and acute settings

Gradual dose reduction

Gradual dose reduction

  • Required by Medicare in LTC facilities

  • Stepwise tapering of the dose

  • Determine if condition can be

    managed by lower dose

  • Determine if medication can be


Obra requirements

OBRA requirements

  • Chemical restraints may be used only to ensure the safety of an older patient in an emergency situation

  • Must correlate to an appropriate diagnosis if given long term

  • May not be given for wandering, restlessness, insomnia, failure to cooperate, etc.

Evaluating appropriate prescribing

Evaluating appropriate prescribing

  • Is the problem significant?

  • What nonpharmacological interventions are available?

  • Is the justification for the medication documented?

  • Has informed consent been obtained?

  • Is achieving therapeutic goals likely and reasonable?

  • When will tapering begin?

  • Are there any duplications is drug purposes?

Collaborative responsibility

Collaborative responsibility

  • Know correct medication, dosage, parameters for use

  • Assess patient for response to medication

  • Consult with prescribing provider

  • Provide reasonable alternative action if indicated

Criteria for use of anxiolytics

Criteria for use of anxiolytics

  • Generalized anxiety disorder (diagnosed)

  • Panic disorder (diagnosed)

  • Symptomatic anxiety in patients with another diagnosed psychiatric disorder

  • Sleep disorder (diagnosed)

  • Acute ETOH or benzodiazepine withdrawal

  • Significant situational anxiety (documented)

  • Behaviors associated with persistent delirium, dementia, cognitive impairment (documented)

Strategies to promote adherence

Strategies to promote adherence

  • Smallest number of drugs, smallest number of pills per day

  • Establish a routine

  • Schedule at time of other normal activity

  • Develop method to remember

    drug was taken

  • Total assessment of all drugs

    at each visit

  • Telephone, email reminders

Practices to discourage

Practices to discourage

  • Sharing medications

  • Using imported medications

  • Using outdated medications

Psychological cognitive problem diagnosis

Psychological, cognitive problem diagnosis

Problems may be overlooked due to:

  • Missed diagnosis

  • Denial of problem by patient

  • Finances

  • Poor coordination of health care team

  • Limited geriatric mental health expertise

  • Fear of stigma

Normal age related cognitive changes

Normal age related cognitive changes

  • Decreased information processing speed

  • Decreased ability to divide or sustain attention

  • Long term memory requires greater cuing

  • Word finding, naming ability decline

  • Abstraction ability shows some decline

  • Decreased ability to filter out

    irrelevant information

  • Mental flexibility declines

Stable cognitive function

Stable cognitive function

  • Short-term, primary memory remains stable

  • Language skills remain intact

  • Vocabulary skills improve

  • Accumulation of practical

    experience continues

  • Influenced by:

    • Education

    • Pulmonary health

    • General health

    • Activity level

Coping with changes in cognition

Coping with changes in cognition

  • Make lists

  • Memory training and techniques

  • Playing computer games with

    hand/eye coordination

  • Challenge mind

  • Use assistive devices, habit

  • Find support from others

  • Keep sense of humor

Adjusting to changes

Adjusting to changes

  • Most adults adjust successfully

  • A life of continuous adjustment makes it easier in the future

  • Inability to adjust can be


    and/or depressing

  • Assess for signs of

    depression with

    every life challenge

Rigidity and excess cautiousness

Rigidity and excess cautiousness

  • Not a normal age related change

  • Experiences, values, and expectations no longer congruent with current ideas

  • Out of their “comfort zone”

  • Method of adjustment influenced

    by underlying personality

Maladaptation to stress in the elderly

Maladaptation to stress in the elderly

  • Sleep problems

  • Chronic high anxiety

  • Substance use/abuse

  • Irritability

  • New onset HTN

  • Depression

  • Chronic fatigue

  • Chronic pain, discomfort

Changes requiring evaluation

Changes requiring evaluation

  • Memory and intellectual difficulties

  • Changes in sleep patterns

  • Changes in sexual interest, capacity

  • Fear of death

  • Delusions

  • Hallucinations

  • Disordered thinking

  • Changes in emotional expression

Principles for psychological assessment of the elderly

Principles for psychological assessment of the elderly

  • Minimize the patient’s preoccupations: pain, comfort, elimination, adequate hearing and seeing

  • Explain what you’re doing…

    and why

  • Minimize distractions: quiet

    room, adequate lighting

  • Speak slowly and clearly

  • Takes breaks if necessary

Personality disorders and psychoses

Personality disorders and psychoses

  • Incidence of most personality disorders decline with age

  • Schizophrenia rarely occurs initially in old age

  • Most common form of psychosis in the elderly is paranoia

    • Hearing loss

    • Social isolation

    • Cognitive impairment

    • Delirium

    • Underlying personality


Adjustment to loss or life events

Adjustment to loss or life events

  • Grief lasting up to 2 years is “normal”

  • Duration of grief affected by

    • Meaning associated with the person who has died

    • Health of the survivor

    • Survivor’s belief system

    • Existence of substance abuse

    • Cause, suddenness of death

Depression in the elderly

Depression in the elderly

  • Symptoms may be emotional and/or physical

  • Multiple somatic complaints

  • Chronic pain

  • Older women 2x as susceptible

  • Older men less likely to admit to


  • Can be associated with medications

    (Box 7-2)

Geriatric depression scale

Geriatric depression scale

  • Long version—30 items

  • Short version—15 items

  • Can be used on healthy,

    ill, or those with cognitive


  • Patients who score >10

    should be referred

S uicide


  • 65 years+ have highest suicide rate of all ages

  • Major risk is depression

  • Older Caucasian males have highest death rates from suicide

  • 70% of successful suicide attempts in older adults had seen primary physician within the previous month

Consider m ajor depression with 4 or m ore persisting for at least 2 weeks

Consider major depression with 4 or morepersisting for at least 2 weeks….

  • Significant weight loss or gain, change in appetite

  • Sleep disturbances

  • Agitation, slowness

  • Fatigue

  • Feelings of worthlessness, guilt

  • Inability to concentrate, make decisions

  • Recurrent thoughts of suicide, death

Antidepressants commonly used in the care of the elderly depressed patient

Antidepressants commonly used in the care of the elderly depressed patient

  • Selective serotonin reuptake inhibitors (SSRIs)

    • Citalopram (Celexa)

    • Escitalopram (Lexapro)

    • Fluoxetine (Prozac)

    • Sertaline (Zoloft)

    • Paroxetine (Paxil)

  • Tricyclic antidepressants (TCAs)

    • Desipramine (Norpramin)

    • Nortriptyline (Pamelor)

Risk factors for suicide

Risk factors for suicide

  • Previous suicide attempt

  • Alcohol or substance abuse

  • Psychiatric illness

  • Auditory hallucinations

  • Living alone

  • Guns at home

  • Exposure to suicide

Consider a lcohol p roblems i f

Consider alcohol problems if:

  • Memory problems

  • Frequent falls

  • Changes in sleep patterns

  • Irritability, sadness, depression

  • Trouble concentrating

  • Chronic pain

  • Smell of alcohol

  • Isolation

Gerontological nursing

Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) (2+ Yes responses indicative of an alcohol problem)

  • When talking to others, do you ever underestimate how much you drink?

  • After a few drinks, have you sometimes not eaten because you don’t feel hungry?

  • Does having a few drinks help decrease your shakiness or tremors?

  • Does alcohol sometimes make it hard for you to remember parts of the day or night?

  • Do you usually take a drink to relax or calm your nerves?

  • Do you drink to take your mind off your problems?

  • Have you ever increased your drinking after experiencing a loss in your life?

  • Has a doctor or nurse ever said they were worried or concerned about your drinking?

  • Have you ever made rules to manage your drinking?

  • When you feel lonely, does having a drink help?

Potential nursing d iagnoses

Potential Nursing Diagnoses

  • Ineffective coping

  • Risk for suicide

  • Disturbed thought processes

  • Acute/chronic confusion

    (also, “Risk for”)

  • Decisional conflict

To begin the process

To begin the process….

  • Chose your nursing case study for use throughout the semester

  • Selected case studies are on the website

  • Identify 2 different diagnoses within the case:

    • 1 diagnosis must concern the patient’s physiological status

    • 1 diagnosis must addressing an identified learning need

  • Identify pertinent subjective and objective triggers

  • Determine appropriate functional health pattern

  • Use the standard nursing care plan format you have been provided…first installment due per syllabus!

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