I Hope you find this information helpful for providing best practice care to the geriatric population.
Peck, M. (2017). Trends in Geriatric Best Practice for Nursing Care. Podium presentation for Indian
American Nurses Association.
Current Trends in Nursing Practice and
Pharmacology Conference; Houston, Texas.
2. What is NOT normal about aging
Aging Changes: Organ Systems
Aging Changes: Pharmacokinetics &
Pharmacodynamics
Adverse Medication Events & Beers Criteria
Let’s Discuss
5. Clinical Case
5
Mr. Doe is 73 years old
Past Medical History: BPH & HTN
Visits grandchildren & develops viral URI
Takes decongestant + diphenhydramine
Unable to urinate
Blood pressure 190/80
What happened?
6. Urinary Retention & Hypertension
Parasympathetic Nervous System
Mediates detrusor muscle contraction
Blocked by anticholinergic medications like diphenhydramine (Benadryl)
Sympathetic Nervous System
α-adrenergic activity causes urethral sphincter contraction (retains urine)
α-adrenergic activity increases systemic vascular resistance (raises BP)
Decongestants are alpha-adrenergic agonists
(ex. pseudoephedrine and phenylephrine) 6
7. Clinical Case
7
Since Mr. Doe has a history of BPH,
his clinician prescribes Hytrin
(terazosin), a peripherally-acting
α1-adrenergic antagonist, to help
with his urinary retention and to help
reduce his blood pressure
Two days later, Mr. Doe falls in the
middle of the night, on the way to
the bathroom
He fractures his hip
Why did he fall?
8. Orthostatic Hypotension &
Fall With Hip Fracture
Age decreases baroreceptor sensitivity
α-adrenergic blockade can worsen
postural hypotension, increase risk of falls
Mr. Doe’s hospital course is complicated
by delirium & pneumonia
Falls, hip fractures, delirium, and
pneumonia are all associated with
significant morbidity & mortality
11. Older Adults: The Problem
A given dose of a given
medication produces a
different & sometimes
unexpected, response in
an elderly person
compared to someone
younger of the same
gender and body weight.
12. Normal Aging
Changes in
Structure &
Function of
Organ
Systems
• Etiology
• Implications
• Assessment & parameters
• Evidence-based nursing
care strategies for best
practice
14. Aging Effects on the
CV System
Etiology:
Arterial wall thickening, stiffening, decreased compliance
Hypertrophy – Left Ventricular & Atrial
Sclerosis – Atrial & Mitral Valves
Strong arterial pulses, diminished peripherally
(Boltz, Capezuti, Fulmer, & Zwicker, 2012)
15. Aging Effects on the CV
System
Implications:
Decreased Cardiac Reserve
At rest no change in HR or CO
Under stress – decreased max HR and CO
Fatigue, SOB, slow recovery from tachycardia
Risk of Isolated Systolic Hypertension, inflamed varicosities
Arrhythmia risk, postural + diuretic-induced hypotension, syncope
(Boltz et al., 2012)
16. Aging Effects on the
CV System
Assessment:
ECG, monitor rate (40-100 bpm within normal limits), rhythm (regular or
irregular), heart sounds (S1 S2 or extra sounds S3 in heart
disease or S4 as a common finding), murmurs
Peripheral pulses assessed bilaterally
BP should be monitored at least twice (repeated after 5 minutes of rest)
(Boltz et al., 2012)
17. CV System
Nursing Care Strategies
Referrals
irregularities of rhythm & decreased, asymmetric peripheral pulses
Risk of postural hypotension need increased safety precautions
wait 1-2 minutes after position changes to stand/transfer
monitor for signs of hypotension
fall prevention strategies
sufficient fluid intake
(Boltz et al., 2012)
18. CV System
Nursing Care Strategies
Education:
Healthy body weight
Normal BP
Healthful diet
Physical activity
No exposure to tobacco
(Boltz et al., 2012)
19. Aging Effects on the
Renal & GU Systems
Etiology:
Renal Mass declines, loss of functional glomeruli and tubules,
reduced blood flow, GFR (10% decrease per decade after
age 30) decreased blood clearance
Reduced bladder tone, elasticity, capacity
Increase in post void residual, nocturia
Prostate enlargement risk for BPH
(Boltz et al., 2012)
20. Aging Effects on the
Renal & GU Systems
Implications & Parameters:
Reduced reserve, increased complication risk illness
Nephrotoxic injury risk from drugs
Risk of volume changes, electrolyte imbalances
Increased risk urinary urgency, incontinence, UTI,
nocturia, falls
(Boltz et al., 2012)
21. Decreased Creatinine Clearance
Decreased:
• concentrating/diluting
• renal blood flow/mass
• drug clearance
How does kidney function decrease with age?
70
80
90
100
110
120
130
140
30 40 50 60 70 80
Progressive linear decline in clearance.
Age
CrCl
(Fillit et al., 2010)
22. Renal & GU Systems
Nursing Care Strategies
Monitor nephrotoxic and renal cleared drug levels
Maintain fluid/electrolyte balance
min 1,500-2,000 ml/day from fluid & food
Nocturia – limit evening fluids, avoid caffeine, prompted voiding
Fall prevention
(Boltz et al., 2012)
23. Aging Effects on the
Pulmonary System
Etiology:
Decreased respiratory muscle strength, stiffer chest wall
Diminished ciliary and macrophage activity
drier mucosa, decreased cough reflex
Decreased response to hypoxia and hypercapnia
(Boltz et al., 2012)
24. Aging Effects on the
Pulmonary System
Implications:
Reduced pulmonary function reserve - with exertion
dyspnea & decreased exercise tolerance
Less effective exhalation (resp. rate 12-24 breaths/min)
Dec. cough, mucus & foreign matter clearance
Inc. risk infection & bronchospasm/airway obstruction
(Boltz et al., 2012)
25. Pulmonary System
Nursing Care Strategies
Maintain patent airways upright positioning, suctioning
Provide Oxygen as needed, maintain hydration, mobility
Incentive Spirometry *if immobile/declining function
Education
Cough enhancement
Smoking cessation
(Boltz et al., 2012)
27. Aging Effects on the
Nervous System
Etiology:
Decrease in neurotransmitters & neurons
Compromised thermoregulation
Modifications in cerebral dendrites & synapses
(Boltz et al., 2012)
28. Aging Effects on the
Nervous System
Implications:
General muscle strength, deep tendon reflexes, nerve conduction
velocities are impaired
Decreased temperature sensitivity
Blunted or absent fever response (baseline oral temp 97.4)
Slowed cognitive processing
Inc. risk of sleep disorders, delirium, neurodegenerative diseases
(Boltz et al., 2012)
29. Nervous System
Nursing Care Strategies
Assess with baseline status with periodic reassessment
Monitor for delirium and functional status during illness
Assess impact of age-related changes on daily tasks
Assess temperature & fall prevention strategies
Maintain cognitive function: regular exercise, healthful diet,
intellectual stimulation
Behavioral interventions for sleep disorders
(Boltz et al., 2012)
30. Aging Effects on the
GI System
Etiology:
Mastication muscles, taste, thirst perception are decreased
Gastric Motility decreased and emptying time are delayed
Atrophy of protective mucosa
Malabsorption of carbs, Vitamins B12, D, Folic acid & calcium
Reduced hepatic reserve, decreased metabolism of drugs
Impaired defecation sensation
(Boltz et al., 2012)
31. Aging Effects on the
GI System
Implications:
Risk chewing problems, fluid imbalances, poor nutrition
Gastric: Altered drug absorption, risk of GERD, maldigestion, ulcers
Constipation not a normal finding
Stable LFTs risk of adverse drug reactions
(Boltz et al., 2012)
32. GI System
Nursing Care Strategies
Assess abdomen, oral cavity, chewing, swallowing, lungs for aspiration
Monitor weight, calculate BMI (18.5 to 24.9 Healthy)
Determine dietary intake
Assess for GERD, constipation, incontinence, impaction
Monitor drug levels ands LFTs
Educate on lifestyle modifications, bowel frequency, diet, activity
Use laxatives if on constipating medications
(Boltz et al., 2012)
33. Aging Effects on the
Musculoskeletal System
Etiology:
Sarcopenia (decline in muscle mass and strength) increases weakness
Lean body mass replaced with fat
Bone loss peaks after age 30 to 35
Ligament and tendon strength decreases
Intervertebral disc degeneration & articular cartilage erosion
Changes in stature kyphosis, height reduction
(Boltz et al., 2012)
34. Aging Effects on the
Musculoskeletal System
Implications:
Risk of falls, disability, unstable gait increases
Osteopenia and osteoporosis risk increases
Limited ROM & joint instability
Risk for osteoarthritis increases
(Boltz et al., 2012)
35. Musculoskeletal System
Nursing Care Strategies
Encourage physical activity through health education
Set goals to maintain function
Pain medication to enhance function
Fall prevention
Adequate intake of Calcium and Vitamin D, smoking cessation
Advise routine bone mineral density screening
(Boltz et al., 2012)
36. Normal Aging Changes in
Pharmacokinetics &
Pharmacodynamics
• Etiology
• Implications
• Assessment & parameters
• Evidence-based nursing
care for best practice
38. Pharmacokinetics Absorption
Increased gastric pH
Delayed gastric emptying
Reduced intestinal motility and blood flow
Despite these changes medication absorption is largely unchanged
Exceptions are Iron, Calcium absorb more slowly
Enteric Coated medications may take action in the stomach
Pharmacokinetics Distribution
Those with low lean body mass have more narrow therapeutic index
(digoxin)
Often more body fat than water
Reduces volume of distribution of water-soluble drugs giving higher
concentrations (digoxin)
Accumulation fat-soluble Rx, prolong elimination (lidocaine, diazepam)
Reduced plasma protein binding inc. free fraction (warfarin, furosemide)
(Durso, Bowker, Price, & Smith, 2010; Fillit, Rockwood & Woodhouse, 2010)
39. Pharmacokinetics Metabolism
Reduced hepatic mass and blood flow can affect overall function
Slow metabolism drugs (theophylline, acetaminophen, diazepam, nifedipine)
Drug undergoing extensive first-pass are most affected (propranolol, nitrates)
Many factors interact with liver metabolism
• Nutritional state, acute illness, smoking, other medications
• CHF can lead to hepatic congestion impairing metabolism
Pharmacokinetics Excretion
Renal mass decline 20-25% age 30-80, GFR dec 10%/decade after age 30
Active metabolite Rx mainly kidney excreted: allopurinol, digoxin, furosemide,
gabapentin, gentamicin, lithium, metformin, ranitidine, tetracycline
Dose adjust for renal impairment (urosepsis & dehydration can exacerbate)
Normal serum creatinine can be misleading (use GFR, Cr Clearance)
• Low muscle mass can decrease creatinine production
(Durso et al., 2010; Fillit et al., 2010)
41. Factors effecting medication
response in the elderly include
which one of the following?
A. Decreased total body fat
B. Increased total body water
C. Decreased renal excretion
D. Increased hepatic mass
42. 7 Top Reasons Medication AE
1. Altered pharmacokinetics (reduced metabolism/excretion) and altered
pharmacodynamics (what drug does to body)
2. Polypharmacy
3. Incorrect doses (more or less than therapeutic dosage)
4. Using medications for treatment of symptoms not disease dependent
(prescribing cascade)
5. Iatrogenic causes (ADE and inappropriate prescribing)
6. Medication adherence problems
7. Medication errors
(Boltz et al., 2012)
44. Beers Criteria &
Adverse Medication Events
Up-to-date recommendations, preventing medication-related problems
Developed to bring attention & action to inappropriate prescribing
Categorizes Medications:
Some indications (but often misused)
Rarely appropriate
Should always be avoided
(Fick et al., 2015)
45.
46. The safest OTC pain
medication for those over
age 65 is…
A. B. C.
47. Evidence-based Nursing Care
Identifying those at risk for AE
Recognizing ADE
Recognizing drug-drug interactions
Recognizing drug-disease interactions
Correct timing of medications
Assessing for urgency & adherence
Communicating to prescribers
Educating patient & caregivers
(Boltz et al., 2012; Fillit et al., 2010)
48. Evidence-based Nursing Care
Give lowest dose possible
Discontinue unnecessary therapy
Attempt nondrug approaches first
Give the safest drug (Beers Criteria)
Assess renal (GFR) & Liver function
Always consider the risk-to-benefit ratio
Assess for new interactions
Avoid the prescribing cascade
(Boltz et al., 2012; Fillit et al., 2010)
49. Assess Drug Regimen Adherence
Brown Bag Approach
Can they afford the medications?
Can they obtain the medications and refills?
Whose the decision-maker regarding use?
Are they getting drugs from other people?
Do they still have discontinued drugs?
Do they remember to take their medications?
Is liver and kidney function being monitored?
Can they manipulate the medication?
(Boltz et al., 2012; Fillit et al., 2010)
50. Boltz, M., Capezuti, E., Fulmer, T., & Zwicker, D. (Eds.). (2012). Evidence-based
geriatric nursing protocols for best practice (4th ed.). New York, New York:
Springer Pub. Co.
Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford
American handbook of geriatric medicine (First ed.). New York, New York: Oxford
University Press Inc.
Fick, D. M., Semla, T. P., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C. E.,
Eisenberg, W., Epplin, J. J., Flanagan, N., Giovannetti, E., Hanlon, J., Hollmann,
P., Laird, R., Linnebur, S., Sandhu, S., & Steinman, M. By the American Geriatrics
Society 2015 Beers Criteria Update Expert Panel. (2015). American geriatrics
society 2015 updated beers criteria for potentially inappropriate medication use in
older adults. Journal of the American Geriatrics Society, 63(11), 2227-2246.
doi:10.1111/jgs.13702.
Fillit, H., Rockwood, K., Woodhouse, K. W., & Brocklehurst, J. C. (2010).
Brocklehurst's textbook of geriatric medicine and gerontology (7th ed.).
Philadelphia, PA: Saunders/Elsevier.
References
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