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Chapter 8Medication and
Laboratory Values
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Demographics
• Today, the geriatric population makes
about 13% of the general population.
• It is expected to increase to greater than
20% by the year 2030.
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• Elderly patients however, consumes about
33% of all prescription and OTC drugs .
• Overall, the elderly have more disease
states than the other age groups and
therefore require the use of moremedications.
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• Thus effective and safe drug therapy is
one of the greatest challenges within the
elderly population.
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The effects of Aging on Drugs
• Normal aging is associated with certain
physiological changes that can
significantly influence drug response. Bothpharmacokinetics and pharmacodynamics
play a role in how a person will respond to
drug.
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Pharmacokinetics
• Is the time course by which the body
absorbs, distributes, metabolizes and
excrete drugs.
• In other words, it speaks to how drugs
move through the body and how quicklythis occurs.
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Absorption
• Is defined as the movement of a drug from
the site of administration, across biological
barriers, into the plasma.
• But as the age increases, it decreases the
rate of absorption.
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Distribution
• Is the movement of a drug from the
plasma into the cells. As patient age, total
body water declines and fat storesincreases.
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Pharmacodynamics
• Is the time course and effect of drugs on
cellular and organ function. In other words,
it is what drugs do once they’re in thebody.
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Drug related problems in the Elderly
• About one third of drug related hospitalizations
occur in persons over 65 years old.
• Even though medications provide benefit by
preventing and treating disease, older people,
are more susceptible to drug related problems
including adverse drug reactions, polypharmacy,inappropriate prescribing and non compliance
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Adverse Drug Reactions
• The World Health Organization defines
ADR as “any noxious, unintended and
undesired effect of a drug, which occurs atdoses used in humans for prophylaxis,
diagnosis or therapy”.
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Polypharmacy
• It is defined as the prescription,
administration, or use of more medications
than are clinically indicated in a givenpatient.
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Disease Drugs Adverse Reaction
Benign Prostatic hyperplasia Anticholinergics Urinary Retention
COPD B-Blockers Bronchoconstriction, repiratory
depression
Dementia Opioids Confusion, Delirium
Depression Corticosteroids Precipitation or exacerbation
ofdepression
Diabetes Corticosteroids Hyperglycemia
Glaucoma Anticholinergics Exacerbation of glaucoma
HPN NSAIDS Increase BP
HypoKalemia Digoxin Cardiac arrythmias
Hyponatremia Diuretics,SSRI Decreased Sodium
concentrationsOrthostatic Tricyclic anti dep Dizziness, falls, hip fracture
Ostopenia Corticosteroids Fracture
Parkinson’s Antipsychotics Worsening movement disorder
Peptic ulcer Anticoagulants,NSAIDS Upper GI bleeding
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Compliance
• Although age does not affect compliance,
about 40% of elder persons do not adhere
to their medication regimen.
• The more complex the medication
regimen, the less likely the patient willcomply.
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Reasons for not complying to
medications in the elderly
• Trying to avoid the side effects and
therefore reducing the amount of drug
consumed.
• Lack of money
• Forgetfulness (early dementia)
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Compliance can be encourage by
• Establishing a good relationship with the
patient.
• Providing education about possible side
effects
• Providing clear instructions for how themedication should be taken.
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• Encouraging questions from the patient
• And providing home nursing support asneeded.
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Potentially inappropriate medications for
Geriatric patients
• There is a benefit/risk relationship with
consumption of any medication. The
benefit of medication is use to providepositive outcomes; the risk may include
unwarranted side effects.
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• There are several medications available
on the market that provide excellent
results but are not ideal for use in elderlypatients.
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Laboratory Values
• Lab results for older adults differ from
those younger adults thus reference
ranges or “normal’s” may be different.
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Medications to avoid in the Elderly
Medication Effect
Propoxyphene(Darvon)and
combination products(Darvon with
ASA etc)
Offers few advantages over
acetaminophen yet has the same
adverse effects as other narcotic meds Amitriptyline Strong cholinergic and sedation
effects
Benadryl May cause confusion and sedation
All barbiturates Highly addictive
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Medications to avoid in the Elderly
Medication Effect
Demerol May cause confusion
Catapres Potential for orthostatic HPN and CNS
adverse effects
Mineral Oil Potential for aspiration and adverse
effects
Estrogens only Lack of cardioprotective effect in older
women; evidence of carcinogenic
potential
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Medications to avoid in the Elderly
Medication Effect
Macrodantin Potential for renal impairement
Cimetadine (tagamet) CNS effects including confusion
Indomethacin CNS adverse effects; other NSAIDS
available with fewer adverse effects
Methacarbamol Anticholinergic effects, sedation,
weakness
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Changes in Lab Values with Age
Increased with Age Decreases with Age Unchanged with Age
Alkaline phosphate Albumin Hepatic function test
ANA Aldosterone Coagulation tests
C-reactive protein Serum Calcium Biochemical test (serum
electrolytes, total protein.)
Cholesterol, total HDL cholesterol (women) Arterial blood tests
Clotting factors VII and
VIII
Creatinine kinase Renal function tests
Copper Creatinine clearance Thyroid function tests
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Changes in Lab Values with Age
Increased with Age Decreases with Age Unchanged with Age
D-dimersen Dihydroepiandrosterone CBC ( HCT, HGB,
erythrocyte indices)
Ferritin 1,25-dihydroxyvitamin D
Fibrinogen Estradiol
Gastrin Growth hormone
2 h pp glucose IGF-1
Interleukin 6 Interleukin 1
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Changes in Lab Values with AGE
Increased with Age Decreases with Age Unchanged with Age
PSA Magnesium
PTH PaO2
Rheumatoid factor Phosphorus
Sedimentation rate Platelets
Triglycerides Free testosterone
Uric Acid Total protein
Zinc, serum
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Lab values and Medication
Administration• Laboratory values and medication
administration go hand in hand. Lab work
may be done to:
• Monitor compliance w/ medication
administration
• Check for therapeutic or toxic levels of
medication in blood
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• Evaluate the body’s ability to metabolize
medications.
• Evaluate the need for medications to treat
a condition.
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Medication blood levels
(Therapeutic blood levels)
• The amount of medication circulating in
the blood can be monitored for some
medications.
• This may include monitoring for blood
levels of medications taken on a routinebasis or in an emergency situation where
drug overdosed is suspected.
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• Measuring medication blood levels is
important for monitoring the metabolism of
the medication so that the correct dosagecan be given at the correct intervals to
obtain the best results without side effects
or adverse effect or adverse drug
reactions.
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Random medication level in
blood
• Random levels are not dependent upon
the administration time of the medication.
• The blood level is drawn the order is
received.
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Trough medication levels in the
blood
• Are dependent the administration times of
the medication.
• Is drawn at the time that the blood level is
expected to be at its lowest: right before a
dose is due.
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Peak medication level in blood
• Are also dependent upon the time of
administration.
• This varies according to the route of
administration.
• The peak is typically drawn within a set of
time after a dose is given and trough
follows right before the next dose is given
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Renal and Hepatic Function
• Drugs are metabolized differently in older
adults.
• The kidneys and liver may not function
well as in younger persons. This can affect
how medication are cleared from the bodyand likelihood of side effects or toxic levels
of medications.
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Lab test that is used to monitor the function
of kidneys and liver
• Blood Urea Nitrogen (BUN) it is used as a
gross measure of glomerular function and
the production and excretion of urea.
• Creatinine is a substance removed from
the body by the kidneys. Measurement of the creatinin level will give a clue as to the
function of the kidneys.
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• Alkaline phosphatase is an indicator of
liver disease. Levels in the blood will rise
when excretion of this enzyme is impaired.
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Normal Laboratory Values
(Serum)
Test Body System Normal Levels
Blood Urea Nitrogen Renal 7-23 mg/dl
Creatinine Renal Male, 13 yrs –adult 0.7-1.7mg/dl
Female, 13 yrs -adult 0.4-1.4mg/dl
Albumin Hepatic 3.2-5.2 g/dl
Alkaline phosphate Hepatic 34-122 u/l
ALT Hepatic 9-51 u/l
AST Hepatic 13-38 u/l
Direct bilirubin Hepatic 0.0-0.3 mg/dl
Indirect bilirubin Hepatic 0.1- 1.1 mg/dl
Total Protein Hepatic 6.0-8.0 g/dl
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Challenges to successful medication regimens for
the older adult
• For medication to work properly, the right
drug must be taken in the right amount, by
the right route at the right time by the right patient.
• Failure to follow these five rights can delayor prevent the outcome intended by the
health care provider.
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Other issues that interfere with Medication
Administration
• Hearing
– The ability to hear instructions given by the
health care provider or pharmacist is a veryimportant part of the ability to take
medications accurately and safely.
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• Vision
– Another sense that is important to help ensure
adherence to prescribed medication to
regimens.
– The ability to find and read the label of
medication.
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• Memory/Cognition
– Impaired memory can be a barrier to
adherence with medication routiness. – Remembering which medications to take and
at what times can be difficult if memory is
impaired.
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• Motivation
– Is important in adherence to a medication
routine. There must be motivation to obtain
the medication, to learn about the medication,
to take the medication on time and to report
inability to take the medication to the
physician.
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• Funding
– Many older adults have difficulty purchasing
medications due to costs.
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Nursing Intervention
• Nurses in all settings have a responsibility
to help ensure that the five rights are
followed for each patient. Specific
interventions include:
• Medication review• Education - ensures that the patient
understands the medication instructions
etc.
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• Accommodation – note sensory, motor,
cognitive limitations that the patient may
have that could interfere in the medication
• Funding – assess the patients ability to
pay for medications
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Medications for Dementia
• There are several drugs on the market for
dementia, although there is as yet no cure
these medications help to slow the
progress of the disease.
• Four medications commonly used inpatients with Alzheimer’s dementia are
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• Tacrine (cognex)
– Is taken 4 times a day
– Can potentially affect the liver, so liver enzymes must be closely monitored.
– Side effects: Nausea, vomiting, diarrhea,
abdominal pain, rash and indigestion.
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• Donepezil (Aricept)
– Probably the most widely used drug although
it does not cure Alzheimer or keep it from
getting worse. It does help relieve some of the
memory loss.
– Most effective in early stages of the disease.
– 5mg-10mg per day OD – Side effects diarrhea, vomiting, nausea,
fatigue, insomnia and weight loss.
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• Galantamine (Reminyl)
– Prevents breakdown of acetylcholine and
stimulates nicotinic receptors to release more
acetylcholine in the brain.
– Taken twice a day
– Side effects diarrhea, vomiting, nausea,
fatigue, insomnia and weight loss.
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• Rivastigmine tartrate (Exelon)
– It prevents breakdown of acetylcholine and
butyrycholine in the brain
– Taken twice a day
– Side effects diarrhea, vomiting, nausea,
fatigue, insomnia and weight loss, upset
stomach and muscle weakness.
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Medications for Osteoporosis
• Osteoporosis makes the older person more
susceptible to fractures and changes the
posture, thus placing strain and stress on
muscles and joints and it can even affect height.
• There are two main types of drugs that are used
to prevent and treat osteoporosis:antiresorptives and anabolic or bone forming
agents
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• Antiresorptives
– Slows the rate of bone remodeling but cannot
rebuild bone.
– Medications in this category include
biphosphonates, hormone replacement
therapy and SERMs
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• Anabolic or bone formation agents
– Medication include:
– parathyroid hormone and flouride
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Medications for Anxiety
• Benzodiazepine
• Antidepressants
• Buspirone
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Chapter 9
• Teaching Older Adults
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Adult Learning theory
• Develop by Malcom Knowles
• Which is commonly used in teachingadults, has motivation and relevance as
two key concepts.
• Using andragogy as common principle.
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Theory of self efficacy
• Sheds some light on the behavior of older
adults.
• Suggest that person’s self efficacy is
related to their belief that their actions
influence outcomes in their life.
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• This theory states that “self efficacy and
outcome expectations affect behavior,
motivational level, thought patterns and
emotional reactions in response to anysituation”.
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Social Cognitive theory
• Also called as social learning theory.
• It suggests that outcome expectations are
beliefs that when a person engages in a
certain behavior, certain outcomes will
result.
Older adults and lifelong
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Older adults and lifelong
learning• Recently, attitudes about aging have
changed for the positive, related to the fact
that there is an increasing number of baby
boomers who see aging as a time in whichquality of life issues are priority. This is
guiding many groups to conduct retirement
education to assist in the transition toretirement.
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• Although older adults still expect the
traditional retirement, 69% plan to work
post retirement in positions related to
teaching, office support, crafts, retail salesor health care.
• Despite the trends that support
postretirement employment, 67% haveconcerns that age discrimination will be a
major barrier in the workplace.
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• Older learners prefer teaching methods
that are easy to access and require small
investments of time and money.
• They expect learning to begin immediatelythrough direct hands on experiences.
• Reading materials such as newspaper
magazines and books are used by 64% of older adults for learning.
Barriers to Older Adult’s
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Barriers to Older Adult s
Learning• Older adults may experience some unique
barriers to learning. These include chronic
illnesses, normal aging changes occurring
with advancing age, health disparities andother factors that may accompany cultural
diversity.
Physical changes in the Older
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Physical changes in the Older
Adults that can affect Learning• Reduced vision
• Reduced hearing
• Impaired cognitive function
• Depressions
• Stress
• Chronic illnesses• Dementia
Technology for Older Adults’
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Technology for Older Adults
Lifelong Learning• According to a 2008 PEW Internet Survey
on older adults and use of the internet,
70% of those age 50-64 and 38% of adults
65 or older reported using the internet.
Problems that can be overcome
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Problems that can be overcome
by older adults using computers
Age Change Effect on Computer Use Possible Solutions
Hearing Sound from computer may
not be heard
Use of earphones to
enhance hearing
Vision Vision declines, need for
glasses.
Adjust monitor’s screen
resolution and fonts.
Motor control, tremors May affect the use of
keyboard and mouse,
consistently click.
Highlight area and press
enter to avoid double
clicking Arthritis May not be able to hold the
mouse and consistently
clicking.
Highlight area and press
enter to avoid double
clicking
Attention span Problems with inability tofocus. Priming- introduceconcepts early on
Cultural diversity and health
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Cultural diversity and health
disparities among older adults• The issues of cultural diversity and health
disparities cannot be ignored when
considering educational issues for older
adults.
• Diversity in terms of age, race, ethnicity,
gender and socioeconomic status is animportant factor to consider.
Implications for Gerontological
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Implications for Gerontological
Educators• Education must meet the needs of the
older adult and these needs may change
over the next several decades.
• The older adult cohort is not a
homogenous group, but is composed of
persons of different cultures, raceseducation levels and socioeconomic
statuses, all that factors can impact
learning
Strategies for teaching Older
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Strategies for teaching Older
Adults Individually• Education of older adults must be flexible.
Nurses may teach in a variety of settings
including one on one instruction at bedside
in acute care or in the home or in groupsettings.
• Older Adults need to have motivation tolearn.
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Chapter 10
Promoting Independence in Later Life
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• This adage, commonly heard, rings true
when considering the factors that influence
independence in later life.
• Health, personality, state of mind, and
emotional, physical and spiritual support
all have a place in the adjustments onemakes to aging process.
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• Although self care and health promotion
are indeed important in maintaining
independence, aging and accompanying
health factors often make this a verydifficult period of life.
• As a person moves from the earlier
adjustments of aging (65-75) to the later ones (75-85), circumstances may become
even more complex.
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