Gerontological & Community Based Nursing:

1. Gerontological & Community Based Nursing: Safety and Security Issues of Aging

2. Safe Medication use in Older Adults Age related changed in relation to : • Pharmacokinetics- absorption, distribution, metabolism, excretion of drug • Pharmacodynamics - • Chronopharmacology

3. Diminished gastric pH  Delayed stomach emptying  ↑GI motility ↓GI motility Note: antacids & iron preparations affect drug absorption ↓action of acid-dependent drugs diminished effectiveness of short-acting drugs diminished effects due to short contraction time ↑ ‘s absorption of drug & possible adverse reactions Effects of aging on drug absorption

4. Changes in body composition i.e. Lean body mass; ↓’d total H2O  ↑’d (adipose tissue) body fat  Higher serum levels of certain H20 -soluble drugs Lipid-soluble drugs stored in fatty tissue ↑’d effects (valium, ativan, haldol) Effects of aging on distribution

5. ↓in liver mass, activity, volume, and blood flow ↓’d ability for liver to metabolize drugs ↑’d half-life (i.e. valium- from 37 hrs.young adult) -83 hours-older adult) Effects of aging on metabolism

6. ↓kidney function ie. glomerular filtration rate ***Estimation of Creatinine Clearance –important in evaluation renal function for drug clearance (see formular p222 text) ↑’d half-life of drug potential toxicity/adverse effects Effects of aging on excretion

7. Aging process  ↓response to beta adrenergic receptor stimulants& blockers; ↓barorecptor sensitivity; ↑’d sensitivity to many types of medications i.e. Benzodiiazapines, anticholinergics, narcotic analgesics, warfar, & certain cardiac drugs Refer to tables 14-1 & 14-2 Ebersole/Hess (herbal –medication interactions) Pharmacodynamics in agingdrug-body interaction

8. Time of med administration Consider elders bio-rhythms Elders may benefit from decrease in individual dose/frequency of administration. ↓toxicity effects Chronopharmacology in agingbio-rhythms –body’s response

9. Prescription drug use in the elderly

10. Nursing home patients receive an average of 6 drugs/day • 45% take 7 or more/day • 20% take more than 10/day • 60% of all visits to a physician for pts age>50 include renewal, continuation, or prescription of at least one medication • Prescription use increases with age • One in 13 prescriptions received from office –based physicians involves a potentially inappropriate medication

11. The- good news – advances in medications  improved quality of life The bad news- the wrong combination or the wrong doses of medication can cause serious problems i.e. permanent injuries and even death. Older adults are particularly vulnerable to adverse drug side effects. The Good, the Bad and the Ugly

12. Polypharmacy- The excessive use or unnecessary medications Causes of problems in older adults • Inadequate diagnosis • Inappropriate prescribing • Multiple prescribers w/out adequate communicating • Failure to d/c medications that are no longer necessary • Failure to agree on therapeutic endpoint • Inadequate or ineffective family/patient education

13. Adverse Drug Reactions • Any undesirable or unintended effect occurring with medication dosages • 2-3 times more likely to occur in older than in younger adults • Drug-drug interactions • Drug-nutrient interactions • OTCs, vitamins, and foodstuffs • Drug-disease interactions

14. Toxic characteristics of specific drugs • Aspirin can increase the effect of anticoagulants, penicillins • Antacids can decrease the effect of aspirin • Antidepressants can increase the effect of narcotics • Meperidine can decrease the effect of glaucoma medication

15. Noncompliance • Non-adherence to medication prescription • Risk factors • Multiple medications • Recent prescription changes • Inability to name prescriptions • Multiple practitioners • Vision defecits • Inability to perform a simple calculation • Inability to judge an appropriate twice-daily dosing schedule

16. Assessment of Medication use in older adults • Review all medications (prescriptions, OTC, herbal supplements, folk remedies, etc.) at least Q 6 months • What is the purpose of the drug? • Has the aphorism “start low, go slow” been followed? • Are there any patient allergies that have not been reported? • Are there drug-drug interactions that need to be checked? • Has the most effective route of administration been selected?

17. Assessment -- cont’d • Assess elder client and/or family knowledge of medications and the ability to: • Follow instructions • Monitor for adverse effects • Make decisions about contacting the physician • Assess environment -- proper storage, delivery systems, and memory enhancing devices

18. Nursing Diagnoses • Noncompliance with medication regimen: r/t to visual deficit • Self-care deficit, medication: r/t diminished cognitive functioning • Injury, risk for: r/t adverse drug reaction (e.g. hypotension, dehydration, dizziness)

19. Nursing Interventions • Medication administration • Help elder to locate/ create memory devices, i.e. pill dispensers, calendars, check-off systems • Medication management • Understand the therapeutic goal & pathophysiology of disease being treated • Continually monitor/evaluate the efficacy of the drug

20. Nursing Interventions cont’d • Medication prescribing • Recognize principles of pharmaco-economics that may affect the drug selection behaviors of the primary care provider (Medicare D, HMO’s PPO’s) • Unit cost of the drug • Cost of administering the drug (special skills or assistance needed) • Costs associated with managing side effects • Costs associated with monitoring the patient (lab work, home/physician visits)

21. Nursing Interventions cont’d • Elder client/family teaching • Drug names (generic vs. brand) • Drug indications – why is drug being prescribed • Dosage – importance of taking as prescribed • Teach -when & how to administer the medication • Contraindications- when not to use • Teach “adverse effects” and “drug interactions” • Teach where/how to store med • Provide demonstration/ return demonstration opportunities • Provide guidance regarding OTCs drug use • Instruct client to create a portable record of meds to share with all providers

22. Musculoskeletal Problems in older adults • Mobility Problems, Falls, and Fractures • Functional elements needed for mobility • Cognition and motivation • Skeletal system • Muscular system • Neurological system

23. Mobility changes with aging • Loss of bone mass • After age 40-50 there is incremental process of bone absorption without new bone formation => gradual bone loss • Loss of muscle strength • Increase of reaction time • Decreased speed of movement

24. Common health problems affecting mobility in older adults • Osteoporosis • Osteomalacia – (thinning of the bone) • Arthritis • Polymyalgia rheumatica • Fibromyalgia • Foot disorders

25. Osteoporosis — porous bone Body produces fewer hormones, testerone, estrogen, growth hormone- not yet sure which of these play an important role in strong bones Common Bone & Joint Problems in the older adult

26. Exercise i.e. Weight bearing, walking, Muscle building exercise Tai chi Nutrition - Ca & Vit D intake - 1200 mg calcium daily -400-800 iu Vit D daily Life-style changes (smoking cessation) Patient teaching – fall prevention home safety changes - lighting, - safety rails - clutter free home Clothing -shoes Body mechanics Medication use (Fosamax, Boniva,Actonel) Reducing Osteoporosis – related risk and injury

27. DJD –Degenerative Join Disease (most common cause of pain & disability) Knee is the most frequently involved joint Osteroarthritis

28. Chronic systemic condition c/b pain & swelling in multiple joints Osteoarthritis vs Rheumatoid arthritis

30. Disfigurement of hands due to rheumatoid arthritis Common form of inflammatory arthritis r/t ↑uric acid crystals Most common site – great toe Rheumatoid Arthritis and Gout

31. Assessment • Examine joints for tenderness, swelling redness • Crepitus –crackling sound in joint • Passive/active ROM

32. Nursing Interventions • Pain management • Diet/nutrition education-weight reduction • Realistic exercise plan • Non-pharmacological treatments (heat/cold, ultrasound))

33. Environment Older adults want to stay in their own homes independently as long as possible Mobility, transportation and safety factors often affect the living patterns of older adults Mobility &Environmental Safety issues in the Elderly

34. Crime Safety Driving Involved in more motor vehicle accidents than younger people Sensory and cognitive changes have adverse effects on driving ability Fall Risk Safety and Security Issues

35. 2nd leading cause of all accidental deaths Important health issue in those >75 y.o—especially women Causes Physical frailty, visual impairment Environmental hazards Most occur during the day Previous falls, predictor of future falls Falls in the elderly t

36. Why teaching is important!

37. Benefits of exercise

38. Assessment of Fallsin the elderly clients • ~30% of community based older adults fall each year • Most falls occur in the home • Key areas to assess • Adequate lighting and access to switches • Safe flooring—look for cords • Safe stairways • Adequate toilet height • Kitchen-access to items • Smoke alarms • Clutter • Medications--?labeled • Safety of neighborhood • Distance to bathroom • Ease of getting in/out of chair

39. Nursing Diagnoses • Injury, risk for: related to falls • Mobility, impaired physical Goals: prevent injury, promote optimum mobility, prevent deformity Interventions: assistive devices, maintain adequate nutrition & fluid intake; maintain normal elimination

40. Consequences of Falls in older adults - Fractures • Hip fractures have high morbidity and mortality • 50% of patients with a hip fx are unable to return home or live independently again • 15-20% of patients die as a result of complications: • Immobility • Pneumonia • Sepsis/UTI • Pressure ulcers

41. Transportation issues • Transportation assessed as part of IADL • 0=independent, drives a car • 1=arranges own transport, depends on others except for walking • 3=assists in own transport but needs special accommodation e.g. wheelchair • 5=completely homebound even for medical care

42. Alternatives to Driving • Reduced-fare taxis • Volunteer drivers • Public transportation • Chartered buses • Dial-a-ride programs

43. Pain • Definition • Unpleasant sensory and emotional experience associated with actual or potential tissue damage • Whatever the patient says it is. • Incidence • 25-50% of community-based elders have pain • Up to 85% for long-term care residents report pain • 73% of hospitalized medical patients say pain was excruciating

44. Pain AssessmentPain Tool – descriptions - observations

45. Pharmacological pain management • Medications to be avoided in older adults • Demerol • Causes confusion • Talwin • Confusion, disorientation • Methadone • Long half-life; accumulates over time • Darvon • confusion

46. Rule of Thumb Start Low Go Slow

47. Nurses and pain • Nurses fear addicting patients, fear giving narcotics, give less than prescribed dose or minimal doses • Result: Patients suffer!! • Nurses underestimate patients’ pain • Result: Patients suffer!! • Nurses make incorrect assumptions about pts’ pain because pts do not behave according to nurses expectations • Result: Patients suffer!! • Nurses and patients believe that pain is a natural part of aging • Result: Patients suffer!!

48. Nonpharmacologic Management of Pain Touch • Natural method of comforting, promotes relaxation, said to promote healing • Relaxation • Meditation • Imagery • Massage • Heat/cold • Accupuncture/Accupressure • TENS—transcutaneous electrical nerve stimulation • Distraction