1 High Risk Medication Management and the Elderly Lisa Uhlenkamp, RN, BA, LNHA Nurse Consultant Assisted Living Partners 2 As a person ages, gradual physiologic changes occur. Some of these age related changes may alter the therapeutic and toxic effects of drugs. 1
3 Proportions of fat, lean tissue, and water in the body changes with age. Total body mass and leas body mass tend to decrease, but the proportion of body fat tends to increase. Changes in the body composition affects the relationship between drug concentration and distribution in the body. 4 GI Function Decrease in gastric acid secretion and GI motility slow the emptying of stomach content and movement through the GI tract. Elderly may have more difficulty absorbing drugs than younger individuals. This especially significant problem with drugs that have a narrow therapeutic range. Example: Digoxin (which any change in absorption can be crucial) 2
5 Hepatic Function The livers ability to metabolize certain drugs decrease with age. The decrease is caused by diminished blood flow to the liver. Which results from and age-related decrease in cardiac output and decreased activity of certain liver enzymes. Decrease hepatic function may result in more intense drug effects Higher drug levels, longer lasting drug effects because of prolonged levels and greater risk of drug toxicity. 6 Renal Function Elderly individual s renal function is usually sufficient to eliminate excess body fluid and water. The ability to eliminate some drugs my be reduced by 50% of more. Many common drugs used by the elderly are excreted primarily through the kidneys. If the kidneys abilities to excrete the drug decreases, high blood levels may result. 3
7 Aging is usually accompanied by a decline in organ function that can affect drug distribution and clearance. Physiologic decline is likely to be worsen by a disease or chronic disorders. Together these factors can significantly increase the risk for adverse reactions and drug toxicity as well as noncompliance. 8 Adverse Reaction Compared with younger people elderly experience twice as many adverse drug reactions, mostly from: Greater drug use Poor compliance Physiologic changes 4
9 Diuretic Toxicity Total body water content decreases with age. A normal dosage of potassium wasting diuretic (hydrochlorothiazide and Furosemide) may result in fluid loss and dehydration in the elderly. These diuretics may deplete their potassium level, making them feel weak, may raise uric acid and glucose levels complicating gout and diabetes. 10 Antihypertensive Toxicity Elderly experience light headiness or fainting when taking antihypertensive. Partly in response to atherosclerosis; decrease elasticity of the blood vessels. Antihypertensive can lower blood pressures to rapidly, resulting in insufficient blood flow to the brain, which can cause dizziness, fainting or even strokes. 5
11 Digoxin Toxicity As the body s renal function and rate of excretion decline, the digoxin level n the blood of the elderly may increase to the point causing: Nausea Vomiting Diarrhea Most seriously cardia arrhythmias Need to monitor their digoxin levels and observe for early signs and symptom of toxicity such as: Appetite loss Confusion Depression 12 Anticoagulant Effects An elderly taking an anticoagulant have an increase risk of bleeding, especially when they take NSAIDs at the same time. They are also at increase risk for bleeding and bruising, because they are increase risk of falls. Watch their INRs carefully and monitor for bleeding and other signs of bleeding. 6
13 Sleeping Aid Toxicity Sedatives and sleeping aid may cause excessive sedation/drowsiness. Consuming alcohol may increase depressant effects, even if the sleeping aid was taken the previous evening. Use the drugs sparingly in the elderly. 14 OTC Drug Toxicity Prolonged indigestion of aspirin, aspirin-containing analgesic and other OTC NSAIDs (example: ibuprofen and Naproxen) may cause: GI Irritation Ulcers Gradual blood loss and resulting in anemia Prescription NSAIDS may cause similar problems Both OTC and prescription NSAIDs can cause renal toxicity in the elderly 7
15 Laxatives May cause diarrhea in elderly who are extremely sensitive to drugs such as bisacodyl. 16 Antihistamines Antihistamines such as Benadryl have anticholinergic effect in the elderly, they can cause: Confusion Mental status change Dizziness Sedation hypotension OTC decongestions can have systemic effect such as: Hypertension Anxiety Insomnia Agitation 8
17 Non-compliance Poor compliance can be a problem with individuals at any age. Many hospitalizations result from non-compliance with a medical regimen. In the elderly. In the elderly factors linked to aging can make compliance a special problem such as : Diminished visual acuity Hearing loss Forgetfulness Multiple drug therapy Socioeconomic factors 18 Non-compliance About 1/3 of the elderly fail to comply with their prescribed drug therapy. They may fail to take prescribed doses or follow the correct schedule. They may take prescribed drugs from a previous disorder, Stop drugs prematurely Indiscriminately use drugs that are taken as needed. Elderly may also have multiple prescriptions for the same drug and inadvertently take an overdose. 9
19 High alert medications Medications that have a high risk of causing significant patient harm when they are used in error; including death. Several classifications of drugs fall into this category. 20 Opioids/Schedule II Narrow Therapeutic Index Anticoagulants Anticholinergics Proton Pump Inhibitors Diabetic Treatments (Oral and Insulin) Antipsychotics 10
21 Opioids/Schedule II Dilaudid Morphine MS Contin OxyContin Percocet Fentanyl 22 Opioids/Schedule II Increase risk for diversion Build-up and overdose may occur Many are look alike sound alike Ease of causing respirator and CNS depression Severe depression and fecal impaction 11
23 High Risk Drug Narrow Therapeutic Index Digoxin Methotrexate Dilantin Phenobarbital 24 Narrow Therapeutic Index Methotrexate Often is dosed weekly and misinterpreted to be given daily. Digoxin The dose is small and laden with decimals (0.125 mg or 125mcg), Odd dosing regimens (every other day or half to equal 0.0625mg) Mistakes can easily occur 12
25 Anticoagulants Coumadin Heparin Fragmin Prodaxa Lovenox Eliquis Xarelto 26 Anticoagulants These are high alert medications because they have a narrow therapeutic range. Some have food interactions Many have drug-drug interactions Dosing regimen can be complex/change often Them may go on longer than needed 13
27 Anticoagulants Increase monitoring, especially for signs and symptoms of bleeding and mental status change is important. 28 Anticoagulants Make sure you have good systems in place to administer anticoagulants or such drugs in relationship to required labs. Consider having your consultant pharmacist do a medication regimen review as soon after admission as possible with any resident admitted with anticoagulants to avoid potential interactions. Reconcile medication orders carefully. 14
29 Anticholinergics Anticholinergics are problematic because: Medications in many categories contain anticholinergic properties. The use of multiple medications increase the change of cumulative effects. Anticholinergic side effects are very common and problematic for the older individual. 30 Anticholinergic Medications with anticholinergic properties: Antihistamines Trimeton, Benadryl, Hydroxyzine Antidepressants Amitriptyline, Doxepin, Nortriptyline, Amoxapen, Paroxetine Cardiovascular medication Digoxin, Furosemide, Niefedipine, Norpace GI medications Atropine, Lomotil, Levsin, Bentyl, Probanthine, Cimetidine, Ranitidine 15
31 Anticholinergic Medications with anticholinergic properties: Muscle Relaxant Cyclobenzaprine, Norgesic Urinary Incontinence Medications Oxybutynin, Probantheline, Vesicare, Detrol Antiparkinson Medication Amantadine, Biperiden, Benztropine Antivertigo Medication Meclizine, Scopolamine Antiemetics Promethazine, Compazine 32 Anticholinergic side effects: Unsteadiness Bloating Decreased bowel mobility Nausea and vomiting Dry mouth/swallowing difficulties Delirium Drowsiness Convulsion Distress/nervousness Impaired attention Cognitive decline Confusion/disorientation Hallucination Memory loss Restlessness/irritability Dizziness Lethargy/fatigue Muscle weakness Excessive warmth Urinary retention Increased heart rate Slurred speech Vision impairment 16
33 Proton Pump Inhibitors These drugs reduce stomach acid production and use is indicated for active peptic ulcer disease or stress ulcer prophylaxes. Nexium Prevacid Prilosec Protonix Aciplex 34 Proton Pump Inhibitors Can increase the absorption of digoxin. Can decrease the absorption of warfarin, causing elevated INRs. Can be a risk factor for developing C-Diff. Long-term use may predispose the elderly to hip fractures. When active peptic disease in not present the consideration of the discontinuation of these medication is recommended. 17
35 Diabetic Treatments Oral Agents Amaryl (glimepiride) Glucotrol (glipizide) DiaBeta (glyburide) Glucophage (metformin) Insulin Regular Isophane Humulin R Humalin N Lispro Isophane insulin suspension combination Humalog Humulin 70/30 Lisproprotamine Humalog mix 36 Diabetic treatments These are High Alert Medications because serious harm and death may occur associated with hypoglycemic and hyperglycemic reactions. Errors in dosing, especially with insulins are easily made. Dosing errors can occur with regard to timing and food with oral and insulin. Lots of look alike sound alike medication in this group. 18
37 Antipsychotics Conventional 1 st Generation Haldol Millaril Stelazine Throazine Atypical 2 nd Generation Abilify Zyprexa Seroquel Risperdal 38 Antipsychotic side effects Sedation Anticholinergic effect Extrapyramidal symptoms Orthostatic hypotension Weight gain Photosensitivity Elevated prolactin levels Neuroleptic malignant syndrome Heatstroke Tardive Dyskinesia Seizures Arrhythmia 19
39 Antipsychotics Many health care professionals and families believe that these behaviors are abnormal and are caused by the dementia and need medications to stop. Most health care professionals and families believe these medications are effective at stopping these abnormal behaviors. 40 Antipsychotics There is poor evidence that antipsychotic use is effective treatment of dementia. Antipsychotic effects takes 3-7 days to start working. FDA Black Box Warning issued in 2005 that there is increased mortality in the elderly who are treated with antipsychotics (heart failure, pneumonia, sudden death). 20
41 Antipsychotics Antipsychotic should only be used for the following conditions or diagnosis: Schizophrenia or schizoaffective disorder Delusional disorder Mood Disorder (mania, bi-polar disorder, depression with psychotic features or major depression) Psychosis NOS, atypical antipsychotic or brief psychotic disorder. 42 Antipsychotic Diagnosis alone does not warrant the use of these antipsychotics. The clinical condition must also meet one of the following: Symptoms are due to mania or psychosis. Behaviors must present a danger to self or others. Symptoms are significant and the resident/tenant is: Inconsolable Has persistent distress Has significant decline in function Has substantial difficulty receiving needed care 21
43 Antipsychotics Inappropriate use: Wandering Poor self care Restlessness Impaired memory Mild anxiety Insomnia Unsociability Indifference to environment uncooperativeness 44 Therapeutic Drug Monitoring ACE Inhibitors Creatinine (0.6 1.3 mg/dl) BUN (5 20 mg/dl) Potassium (3.5 5 meq/l) Digoxin Creatinine (0.6 1.3 mg/dl) Digoxin (0.8 to 2 nanograms/ml) Electrolytes Potassium (3.5 5 meq/l) Magnesium (1.7 2.1 meq/l) Sodium (135 145 meq/l) Chloride (98 106 meq/l) Calcium (8.6 10 mg/dl) 22
45 Therapeutic Drug Monitoring Insulin Fasting glucose (65 115 mg/dl) Glycosylated hemoglobin (5.3% - 7.5% of total hemoglobin) Phenytoin Albumin (3.6 0 5 g/dl) Phenytoin (10 20 mcg/ml) Warfarin 2.5 3.5 46 Recommendation System assessment, process controls technology, staffing education protocols. Ongoing competency assessment. Culture of safety from the top to the bottom and bottom to the top. All input is important including family and visitors. High leverage safety strategies focus of error prevention tools that help fix the system, not the punitive process for individuals who make errors. 23
47 Recommendation Report medication errors and near misses, round table monthly and share storied (published and in the facility), management workaround's and interviews. Provide current drug information Communication of drug information, get these orders right from the get go, verify and read back telephone order. Be aware of look alike and sound alike Request that the pharmacy label look alike sound alike and high alert medication as such. 48 Recommendation Verify and re-verify and triple check before giving medication especially high alert medications the six rights can help, but may not prevent errors.more than this is required. 24
49 Questions? 50 Thank You! luhlenkamp@dybb.com 25