Common Errors
Incompatible route: Medications must be appropriate for the oral route for immediate action and crushable. All prod- ucts intended for slow or extended release are not crush- able as they are intended for only partial dissolution in the stomach; administration may lead to an
excessive dose. Watch for extensions such as: CD, CR, ER, LA, SA, SE, TD, TR, XL, and XR as warnings for noncrushable drugs (this list is not inclusive). See the
“do-not-crush” lists available from the pharmacy or online (http://www.ismp.org/Tools/DoNotCrush.pdf).
Improper preparation: Medications administered via an enteral feeding tube must be in a liquid or semiliquid form in order to pass through the tube and not adhere to the lining of the tube. Each medication should be dissolved individually in a product that will not change the product* and will not clog the tube. Watch for oral suspensions and tincture; drug remaining on tubing means reduced dose administered.
Improper administration: Be sure to know where the distal end of the tube is resting. A drug that requires partial absorption in the stomach cannot be used when it will be administered directly into the duodenum or jejunum. Do not combine with feeding unless directions are to “administer with food.”
When more than one tablet is crushed or capsule opened and mixed together before administration, a new “product”
has been prepared and may not have the same effect as the two products taken separately. Find “compatibility informa- tion” from pharmacists to determine which medications may be mixed in this way.
*See Medication Safety Alert at http://www.ismp.org/Newsletters/
acutecare/articles/20100506.asp for more information.
psychiatric and cognitive problems, especially dementia, depression, anxiety, and psychosis. The rate of depression for older persons living in the community is significant, and even more so for those living in long-term care facili- ties (see Chapter 22). Anxiety is also common and when treated with benzodiazepines, increases the older person’s risk for adverse effects and drug interactions. Unfortu- nately the use of psychotherapy is very limited, first because of the rarity of persons with a specialty training in gerontological psychiatry or counseling, and second because of the very low reimbursement rates established by Medicare and other insurance plans.
Finally a small group of elders, especially those with neurological conditions or any one of the dementias, may develop psychosis at some time in their illnesses. Psychosis is also seen in delirium from an infection or from an ADR and in the few elders with schizophrenia. Persons with psychoses are often treated with antipsychotics that call for special attention and skills from the gerontological nurse in cooperation with a psychiatrist or a psychiatric nurse practitioner specializing in geriatrics (see Chapter 22.) Antidepressants
Antidepressants, as the name implies, are drugs used to treat depression. In the past, the major drugs used were monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), especially amitriptyline (Elavil) and doxepin (Sinequan). These drugs required high doses to be effective and had significant anticholinergic side effects such as dry mouth, constipation, sedation, and urinary retention. Since the development of the newer drugs, such as selective serotonin reuptake inhibitors (SSRIs) and SNRIs (serotonin-norepinephrine reuptake inhibitors), the MAOIs and TCAs are rarely seen for the treatment of depression in older adults. When the later drugs are seen they should be questioned.
The SSRIs (e.g., Zoloft, Prozac, Lexapro, Celexa, etc.) and SNRIs (e.g., Effexor) have been found to be highly effective, with minimal or manageable side effects, and are the drugs of choice for use in older adults. Most of these cause initial problems with nausea or a dry mouth. While effective, these must be used with caution especially related to serum sodium levels. The SSRIs should also be used with caution in persons with a history of falls due to the potential to produce ataxia or dizziness (AGS, 2012). One side effect of the SSRIs that does not resolve with time, if experienced, is sexual dysfunction. The SNRIs and other antidepressants are less likely to cause this problem and may be preferred by elders who are sexually active. Bupro- pion (under the brand name of Zyban) has also been found
to reduce nicotine cravings, and the combined effect may be very helpful to some; it cannot be used for persons with a history of seizures. When sleep is a problem, the patient may be prescribed the tetracyclic antidepressant mirtazap- ine (Remeron) which is often well tolerated in older adults.
Most older adults are sensitive to these medications and may find significant relief from depression at low doses.
Although it sometimes takes time to find the optimal dose, the nurse can help the elder monitor target symptoms and advocate for continued dose adjustments or changes until relief is obtained rather than the depression being simply reduced.
Antianxiety Agents
Drugs used to treat anxiety are referred to as anxiolytics or antianxiety agents. These agents include benzodiazepines, buspirone (BuSpar), and beta blockers. Antihistamines, especially diphenhydramine (Benadryl), are often used but not recommended owing to their significant and highly dangerous anticholinergic effects. The decision to treat anxiety pharmacologically is based on the degree to which the anxiety interferes with the person’s ability to function and subjective feelings of discomfort.
Although they are usually contraindicated, the most frequently used agents are benzodiazepines. Despite the fact that benzodiazepines have been available for over 30 years, only minimal research has been done with older adults (Madhusoodanan & Bogunovic, 2004). What we do know is that older adults metabolize these drugs slowly and renal excretion is compromised, even in health, so they persist in the blood stream for long periods and can easily reach toxic levels more quickly than anticipated (see p. 109). Side effects include drowsiness, dizziness, ataxia, mild cognitive deficits, and memory impairment. Signs of toxicity include excessive sedation, unsteady gait, confu- sion, disorientation, cognitive impairment, memory im- pairment, agitation, and wandering. Because these symp- toms resemble dementia, people can easily be misdiagnosed when they start taking benzodiazepines.
Benzodiazepines are highly addicting yet very popular because of their quick sedating effects for the highly anx- ious or agitated person. However, because of the problems noted earlier they should be avoided except in extreme cases. If necessary, lorazepam (Ativan) appears to be the least problematic, when prescribed in very low doses and for short periods. It has the shortest half-life of the benzodiazepines and no active metabolites.
Buspirone is a safer alternative. Although a side effect is dizziness, this is often dose-related and resolves with time. Buspirone is not addicting and may have an additive
effect to some of the SSRIs, so lower doses can be used.
No therapeutic effect may be felt by the patient or observed by the nurse for 5 to 7 days, and the drug may be mistakenly discontinued because of its apparent lack of effect. Buspirone is best used for chronic anxiety and is not indicated for acute needs (see Chapter 22.)
Antipsychotics (Neuroleptics)
The term “psychosis” covers a range of thinking and behav- ioral disorders that are based on responses of the ill person to a private reality—a reality that may be distressing and problematic for the patient and those around him or her.
Characteristically, psychosis occurs in schizophrenia but can also occur in mania, depression, delirium, dementia, and paranoid states. When psychosis occurs in the person with dementia it is often seen in a cluster of neuropsychi- atric symptoms, especially agitation, physical aggression, and wandering.
Antipsychotics, formerly known as major tranquilizers and now often referred to as neuroleptics, are drugs used to treat psychotic symptoms and used for their mood stabiliz- ing effects. The second generation of these drugs is referred to as atypical (second generation) antipsychotics (e.g., res- peridone, Seroquel, Zyprexa, etc.). Due to their danger, especially risk of cardiovascular events, stroke, and even death, they are used as drugs of last resort and can only be prescribed following a careful assessment and search for any potential underlying cause of the problem. Inappropri- ate use of antipsychotic medications is a significant prob- lem in long-term care settings. In addition to the risk for ADR they may mask a reversible cause for the problem, such as a thyroid disturbance, infection, dehydration, fever, electrolyte imbalance, an ADR, or a sudden change in the environment (Bullock & Saharan, 2002).
However, when no other approaches have been successful they may be necessary and must be used very cautiously in true psychiatric disorders. Antipsychotics can provide a person with relief from what may be frightening and distressing symptoms. When used, drugs with the lowest side effects profile and at the lowest dose possible and for the shortest length of time should be prescribed.
In most states the prescribing and use of antipsychotics in long-term care settings is carefully monitored.
There are different classes and potencies of antipsychot- ics. First generation antipsychotics (Thorazine, Prolixin, Mellaril, and Haldol) are less sedating than some of the second generation but cause more extrapyramidal reactions and are considered inappropriate medications (AGS, 2012).
The older one is, the more susceptible one is to developing extrapyramidal reactions, particularly neuroleptic-induced
parkinsonian symptoms. They can cause orthostatic hypo- tension, thereby increasing the risk for falls and the anticholinergic effects include dry mouth, constipation, urinary retention, hypotension, and confusion, all of which can significantly and negatively impact quality of life. A permanent side effect for this class of antipsychotics is tardive dyskinesia (see “Tardive Dyskinesia” later in this chapter).
Another potential concern with the use of neuroleptics is the rare but potentially life-threathening ADR neurolep- tic malignant syndrome (NMS). The most typical symptoms are fever greater than 100.4° F, muscle rigidity, autonomic instability (e.g., labile BP, tachycardia), and altered mental status. Onset is rapid and unless treated appropriately and quickly death can ensue. The drugs most associated with NMS are the high-potency neuroleptics such as haloperi- dol, but others such as chlorpromazine (Compazine) and promethazine (Phenergan) have been implicated. While it occurs most often in the first 2 weeks of the start of treatment it must also be considered whenever a dose is increased. NMS is also seen if anti-Parkinson’s medications are stopped abruptly. In most instances the person is hospi- talized in an intensive care unit while being treated. The immediate response is to recognize that what is being seen may be an adverse reaction, stop the offending medication and promptly and safely cool the patient.
Appropriate preventive interventions include adequate hydration, activity in a cool area away from direct sunlight, and use of a fan or sponge bath if overheating should occur.
The patient may or may not communicate his or her discomfort from the heat, so assessment for signs and symptoms is left to the nurse or other caregiver. Any circumstance resulting in dehydration greatly increases the risk of heatstroke with the morbidity and mortality increas- ing with age. Diuretics, coffee, alcohol, lithium, and uncon- trolled diabetes decrease vascular volume, thereby decreasing the body’s ability to handle antipsychotics. Concurrent use of medications with anticholinergic properties are especially contraindicated.
Movement Disorders
Although neuroleptic malignant syndrome is not com- monly seen, the most significant potential side effects of antipsychotics (especially of first generation) are move- ment disorders, also referred to as extrapyramidal syndrome (EPS) reactions. These include acute dystonia, akathisia, parkinsonian symptoms, and tardive dyskinesia.
Acute Dystonia. An acute dystonic reaction is an abnormal involuntary movement consisting of a slow and continuous muscular contraction or spasm. Involuntary muscular contractions of the mouth, jaw, face, and neck are common. The jaw may lock (trismus), the tongue may roll
back and block the throat, the neck may arch backward (opisthotonos), or the eyes may close. In an oculogyric crisis, the eyes are fixed in one position. Often this creates a feeling of needing to look up constantly without the abil- ity to make the eyes come down. Dystonias can be painful and frightening. An acute dystonic reaction may occur hours or days following antipsychotic medication adminis- tration, or after dosage increases, and may last minutes to hours. It is considered a medical emergency.
Caregivers or others unfamiliar with these EPS reactions often become alarmed. Although frightening, acute dystonia is not usually dangerous and is quickly re- lieved by anticholinergic medication, such as benztropine (Cogentin), trihexyphenidyl (Artane), or diphenhydramine (Benadryl), providing relief within minutes if given intra- venously, within 10 to 15 minutes if given intramuscularly, and within 30 minutes if given orally. These medications should be readily available to treat an EPS reaction for all persons taking antipsychotics. Although they are not recommended for use in persons over 65 years of age, anticholinergics and amantadine (Symmetrel), a dopamine agonist, are sometimes prescribed to prevent dystonic reac- tions, but because of slow onset of action, they are not used for acute treatment.
Akathisia. Akathisia refers to the compulsion to be in motion and may occur at any time during therapy. Patients describe feeling restless, being unable to be still, having an unrelenting desire to move, and feeling “like crawling out of my skin.” Often this symptom is mistaken for worsen- ing psychosis instead of the ADR that it is. Pacing, aimless walking, fidgeting, shifting weight from one leg to the other, and marked restlessness are characteristic behaviors for a person experiencing akathisia. Safety is the primary concern.
Parkinsonian Symptoms. The use of neuroleptics may cause a collection of symptoms that mimic Parkinson’s disease. A bilateral tremor (as opposed to a unilateral tremor in true Parkinson’s), bradykinesia, and rigidity may be seen, which may progress to the inability to move. The patient may have an inflexible facial expression and appear bored and apathetic and be mistakenly diagnosed as de- pressed. More common with the higher-potency antipsy- chotics (e.g., Haldol), parkinsonian symptoms may occur within weeks to months of the initiation of antipsychotic therapy.
Tardive Dyskinesia. When neuroleptics have been used continuously for at least 3 to 6 months, patients are at risk for the development of the irreversible movement disorder of tardive dyskinesia (TD). Symptoms of TD usu- ally appear first as wormlike movements of the tongue;
other facial movements include grimacing, blinking, and
frowning. Slow, maintained, involuntary twisting move- ments of limbs, trunk, neck, face, and eyes (involuntary eye closure) have been reported. There is no treatment that reverses the effect of TD; therefore it is essential that the nurse is attentive for early detection so that the health care provider can make prompt changes to the psychotropic regimen.
Response to treatment is the most important consid- eration when psychotropic medications are given. Subjective patient comments about feelings and symptoms and objective observations about the patient’s behavior are important data for evaluating the effectiveness of a drug.
Several tools are available to help the nurse monitor the patient taking antipsychotics. The Abnormal Involuntary Movement Scale (AIMS) was designed to quantify changes in movement. It has been shortened in the Abbreviated Dyskinesia Scale (Taksh, 2006). Other tools include the Barnes Rating Scale for Drug-Induced Akathisia (Barnes, 1989) and the Simpson-Angus Rating Scale for EPS (Simpson & Angus, 1970). All of these can be found on the Internet.
Mood Stabilizers
Mood stabilizers are the group of agents used for the treatment of bipolar disorders, which is seen as uncontrollable fluctuations in mood which affect the person’s day-to-day life. Symptoms of a severe manic phase may include confusion, paranoia, labile affect, pressured speech and flight of ideas, morbid or depres- sive content of thought, increased psychomotor activity resembling agitated depression, and altered orientation and attention span. However, it is now recognized that instead many have periods of hypomania characterized by significantly increased energy and movement and somewhat diminished judgment. For the older adult in the long-term setting the symptoms of bipolar disorders are easily confused with others. For example, wandering is common for persons with moderate dementia, as is emotional lability.
The mood stabilizers include lamotrigine (Lamictal), lithium, and valproic acid (Depakote). Along with these, the anticonvulsants carbamazepine (Tegretol) and gaba- pentin (Neurontin) are used as well as several of the atypi- cal antipsychotics (e.g., Abilify, Zyprexa, Seroquel) even when psychosis is not present. Each of these have very individualized drug-drug interaction profiles and several require blood level monitoring. The nurse who is caring for a patient with a bipolar disorder or who is taking a mood stabilizer should seek guidance from the person’s psychia- trist regarding specific strategies to enhance the person’s
quality of life and which laboratory testing is required for monitoring. If the patient is taking lithium, this is especially important. Lithium interacts with other medications and certain foods and has a narrow therapeutic window. For example, a low-salt diet will elevate the lithium level, and a high-salt diet will decrease it. Likewise, thiazide diuretics and nonsteroidal antiinflammatory drugs (NSAIDs) will elevate the serum lithium level. Side effects include the following: confusion, disorientation, and memory loss;
flattening of T waves on the electrocardiogram; polyuria and polydipsia; nausea, vomiting, and diarrhea; fine resting tremor; benign goiter; and ataxia.
Implications for Gerontological Nursing and Healthy Aging
All the medications presented in this chapter have indica- tions, side effects, interactions, and individual patient reac- tions. The nurse’s advocacy role includes education for the patient and the family or the caregiver. Further, the nurse must determine whether side effects are minimal and tol- erable or serious. Asking the patient produces subjective data; and observing the patient’s interactions, behavior, mood, emotional responses, and daily habits provides objective data. From this compilation of data, patient problems can be delineated, nursing diagnoses developed, outcome criteria planned, and interventions initiated.
Medications occupy a central place in the lives of many older persons; cost, acceptability, interactions, unacceptable side effects, and the need to schedule medications appro- priately all combine to create many difficulties (Box 8-7).
Although nurses, with the exception of advanced practice nurses, do not prescribe medications, we believe that their
having a basic understanding of issues specific to the safe administration and consumption of medications by persons in late life will reduce the use of inappropriate medications and allow the nurse to observe more closely for adverse side effects and interactions. In the role of educator, the nurse might also decrease misuse through personally and culturally appropriate instructions.
The gerontological nurse is a key person in ensuring that the medication use is appropriate, effective, and as safe as possible. The knowledgeable nurse is alert for potential drug interactions and for signs or symptoms of ADRs. The nurse promotes the actions necessary to prevent drugs from becoming toxic and to treat toxicity promptly should it occur. Nurses in the long-term care setting are respon- sible for monitoring the overall health of the residents, including being alert for the need for laboratory tests and other measures to ensure correct dosage of several medica- tions (e.g., Coumadin, vancomycin, thyroxin). The nurse must give prompt attention to changes in physiological function that are either the result of the medication regi- men or are affected by the regimen, such as potassium level to minimize the likelihood of adverse and toxic reactions.
The nurse is often the person to initiate assessment of medication use, evaluate outcomes, and provide the teach- ing needed for safe drug use and self-administration. In most settings the nurse is also in a position to influence the timing of prescribed doses so residents might more easily benefit from the findings from the developing knowledge of chronopharmacology (Barry et al., 2007). In all settings, a vital nursing function is to educate patients and to ensure that they understand the purpose of, the side effects of, and the time to call the provider regarding their medications.
KEY CONCEPTS
• As we age, the way our body responds to medications changes.
• Any medication has side effects. The therapeutic goal is to reduce the targeted symptoms without undesirable side effects.
• Drug-drug and drug-food incompatibilities are an increasing problem of which nurses must be aware.
• Polypharmacy is one of the most serious problems of elders today, and this is usually the first area to investi- gate when adverse physiological events occur.
• Drug misuse may be triggered by prescriber practices, individual self-medication, individual physiology, altered biodegradability, nutritional and fluid states, and inade- quate assessment before prescribing.
• Nurses must consider the occurrence of a possible adverse medication effect immediately if a change in the person’s condition is observed, including mental BOX
8-7
The Right Medications for Older AdultsEfficacy is established
Compatible with other medications currently taking Low likelihood of adverse events
Half-life no longer than 24 hours No or minimally active metabolites
No adjustments needed for renal or hepatic functioning Dosing once or twice a day
Strength and dosage available match that which is recommended for use in older adults
Patient is able to afford the medication
From Reuben DB, Herr KA, Pacala JT, et al.: Geriatrics at your fingertips.
New York, 2008, American Geriatrics Society.