Gerontological Nursing

1. Gerontological Nursing Pharmacology and the Older Adult Psychological and Cognitive Function

2. 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

3. 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

4. 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.

5. 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

6. Cognitive changes • Changes in mood (anxiety, depression) from antihypertensives, antiparkinsonians, narcotics, NSAIDs, steroids • Central anticholinergic effects—agitation, confusion, disorientation, hallucinations, psychosis (e.g., diphenhydramine, furosemide, digoxin, anti- diarrheals)

7. 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

8. 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

9. 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 orders

10. 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)

11. 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?

12. 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

13. 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 discontinued

14. 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.

15. 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?

16. 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

17. 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)

18. 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

19. Practices to discourage • Sharing medications • Using imported medications • Using outdated medications

20. 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

21. 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

22. 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

23. 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

24. Adjusting to changes • Most adults adjust successfully • A life of continuous adjustment makes it easier in the future • Inability to adjust can be frustrating and/or depressing • Assess for signs of depression with every life challenge

25. 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

26. Maladaptation to stress in the elderly • Sleep problems • Chronic high anxiety • Substance use/abuse • Irritability • New onset HTN • Depression • Chronic fatigue • Chronic pain, discomfort

27. 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

28. 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

29. 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 disorder

30. 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

31. 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 depression • Can be associated with medications (Box 7-2)

32. Geriatric depression scale • Long version—30 items • Short version—15 items • Can be used on healthy, ill, or those with cognitive impairment • Patients who score >10 should be referred

33. Suicide • 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

34. 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

35. 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)

36. Risk factors for suicide • Previous suicide attempt • Alcohol or substance abuse • Psychiatric illness • Auditory hallucinations • Living alone • Guns at home • Exposure to suicide

37. Consider alcohol problems if: • Memory problems • Frequent falls • Changes in sleep patterns • Irritability, sadness, depression • Trouble concentrating • Chronic pain • Smell of alcohol • Isolation

38. 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?

39. Potential Nursing Diagnoses • Ineffective coping • Risk for suicide • Disturbed thought processes • Acute/chronic confusion (also, “Risk for”) • Decisional conflict

40. 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!