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Chapter 8Medication and

Laboratory Values



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.



• 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.



• Thus effective and safe drug therapy is

one of the greatest challenges within the

elderly population.



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.



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.



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.



Distribution

• Is the movement of a drug from the

plasma into the cells. As patient age, total

body water declines and fat storesincreases.



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.



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



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”.



Polypharmacy

• It is defined as the prescription,

administration, or use of more medications

than are clinically indicated in a givenpatient.



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



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.



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)



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.



• Encouraging questions from the patient

• And providing home nursing support asneeded.



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.



• There are several medications available

on the market that provide excellent

results but are not ideal for use in elderlypatients.



Laboratory Values

• Lab results for older adults differ from

those younger adults thus reference

ranges or “normal’s” may be different.



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




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




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



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



Changes in Lab Values 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



Changes in Lab Values with AGE


PSA Magnesium

PTH PaO2

Rheumatoid factor Phosphorus

Sedimentation rate Platelets

Triglycerides Free testosterone

Uric Acid Total protein

Zinc, serum



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



• Evaluate the body’s ability to metabolize

medications.

• Evaluate the need for medications to treat

a condition.



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.



• 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.



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.



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.



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



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.



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.



• Alkaline phosphatase is an indicator of

liver disease. Levels in the blood will rise

when excretion of this enzyme is impaired.



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



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.



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.



• 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.



• 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.



• 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.



• Funding

– Many older adults have difficulty purchasing

medications due to costs.



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.



• 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



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



• 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.



• 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.



• 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.



• 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.



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



• Antiresorptives

– Slows the rate of bone remodeling but cannot

rebuild bone.

– Medications in this category include

biphosphonates, hormone replacement

therapy and SERMs



• Anabolic or bone formation agents

– Medication include:

– parathyroid hormone and flouride



Medications for Anxiety

• Benzodiazepine

• Antidepressants

• Buspirone



Chapter 9

• Teaching Older Adults



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.



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.



• This theory states that “self efficacy and

outcome expectations affect behavior,

motivational level, thought patterns and

emotional reactions in response to anysituation”.



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



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.



• 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.



• 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



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



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’



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



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



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



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



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.



Chapter 10

Promoting Independence in Later Life



• 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.



• 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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