Medications and the older person

Medicines are frequently a contributing factor in acute admissions for older patients. In later life, the body’s response to medications can differ due to age-related physiological changes and result in a greater susceptibility to the effects of drugs (Table 6.2). Older persons are particularly subject to altera- tions in pharmacokinetics (how medications are absorbed, distributed, metabolised and excreted) and pharmacodynamics (drug effects at target receptors or organs). They are also more likely to take

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Table 6.2 Examples of age-related physiological changes and impacts on medication Body system Age-related alteration Examples of consequences Gastrointestinal Decreased gastric peristalsis

and motility, and delayed emptying

Decreased gastric blood flow Increased gastric pH

Slower drug absorption

Renal Reduced blood flow, glomerular filtration and number and efficiency of the nephrons

Affects the rate and level of drug excretion and may result in an accumulation of drugs excreted through the renal system

Circulatory Decreased cardiac output and circulation

Reduction in serum albumin

Increased time needed for drug transportation Potential for increased level of unbound drugs in the blood

Competition between multiple protein-binding drugs alters effectiveness

Musculoskeletal Reduction in skeletal muscle

mass Alterations to drug absorption following

intramuscular injection Hepatic Reduction in hepatic mass

Alterations in enzyme function and liver blood flow

Slower rate of drug metabolism

Accumulation of drugs leading to potential toxicity

Data from Galbraith et al. (2007), Kee et al. (2009) and Miller (2012).

Box 6.4 Nursing interventions to support older persons with confusion in the acute setting

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Completion of a patient profile to get to know the person

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Minimisation of overstimulation, including appropriate lighting and noise reduction

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Use of a model to interpret and manage behaviour that challenges

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Continuity of care staff

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Supervision of, and where necessary assistance with, activities of living

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Consideration of the patient’s placement in the ward setting, e.g. within view of staff

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Risk assessment and safety promotion, e.g. bed safety, ensuring clutter-free spaces, patient identi- fication, etc.

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Environmental modification to ease walking and way-finding, e.g. appropriate signage

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Promotion of orientation, e.g. frequent introductions to people and explanations of nursing interventions

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Working with the family and significant others to ensure that familiarity in terms of routines is maintained as far as is possible

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Facilitation of open family visiting

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Use of appropriate communication strategies and sensory aids

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Liaison with community and primary care professionals

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Polypharmacy is ‘the prescription, administration, or use of more medications than are clinically indicated in a given patient’ (Charles & Lehman 2010, p. 262).

Definition

Polypharmacy may also result in drug–drug or drug–disease interactions, and admission to hospital offers the opportunity to review the safety, efficacy and necessity of the patient’s current medications (Miller 2012). The Department of Health (2001) recommends medicine reviews for all older persons, particularly those over 75 and those who have been prescribed four or more medications. As members of the interdisciplinary team, nurses should be knowledgeable about drugs that are commonly pre- scribed for older persons and how to recognise adverse drug reactions, and should be able to com- municate medication-related concerns to prescribers.

Non-adherence to medications is also a concern in older persons, particularly those who take mul- tiple drugs. This occurs where the taking of medications departs from prescribed formats, for example under- or overdosage, incorrect time spans between dosages, self-medication and unfilled prescrip- tions. According to Reddy (2006/2007), non-adherence can lead to avoidable consequences such as poor health, premature death, hospital admission and health system costs. The factors that contribute to older patients’ difficulties with medication regimens include:

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cognitive, sensory or functional difficulties;

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a lack of knowledge or understanding;

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^cost;

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unwanted or feared side effects;

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complicated drug regimens;

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the use of herbal remedies;

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using multiple pharmacies or prescribers;

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taking over-the-counter medications.

Nurses need to be able to discuss medication usage with older patients and their families or significant others, and to engage in individualised education on medications in conjunction with the multiple medications (Fulton & Allen 2005). The interactive effects of these can predispose older persons to adverse drug reactions, reduced drug effectiveness and medication errors.

As many medication-related issues are preventable, they are a priority for all nurses caring for older patients. Careful individualised management is required, and care planning should consider the poten- tial impact of age-related physiological changes (National Medicines Information Centre 2010). The nurse is responsible for the safe and effective administration of prescribed medicines, which can be achieved using the principles outlined in Chapter 2 and the nine ‘rights’ of medication administration (Elliott & Liu 2010):

1. Right patient 2. Right drug 3. Right time 4. Right route 5. Right dose

6. Right documentation 7. Right action

8. Right form 9. Right response.

Due to the higher potential for comorbidities, older patients may be prescribed multiple medications.

This can lead to polypharmacy, which can result in negative consequences for the person, including cognitive impairment, falls and malnutrition (Kee et al. 2009).

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pharmacist. There are also a range of practical interventions to promote adherence to medication that can be used, depending on the needs of the patient (Box 6.5).

Box 6.5 Examples of interventions to increase adherence to medication

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Care planning with the older patient, family and/or significant other

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Coordination with the interdisciplinary team

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Multifaceted education on medications in conjunction with the pharmacist using appropriate and age-specific educational materials

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Promoting awareness of side effects, adverse reactions and how to seek advice

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Use of reminders (e.g. written reminders, phone calls or alarms)

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Use of aids (e.g. pill or dossette boxes, blister packaging and medication-dispensing systems)

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Monitoring medication-related behaviour

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Regular medication reviews

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Self-administration of medication programmes

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Discharge planning

Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 6.2 to think more about this topic.