Chapter 7: Medications and Older Adults

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If you're involved in managing medication for an older adult, you know, it can feel like navigating a real minefield.

It's like a chemical factory running under, well, pretty unpredictable conditions sometimes.

Welcome to the Deep Dive.

We're here to unpack these complex topics and hopefully turn them into essential usable knowledge for you.

And the stakes in this area, which we call geropharmacology, they're just staggering.

Our sources point out that adverse drug events, ADEs, they're linked to maybe one in 10 hospitalizations for older people.

And the really frustrating part, most of those could likely be prevented.

Often the culprit is something seemingly simple, like, you know, non -steroidal anti -inflammatory drugs and essays.

That's really the heart of the issue, isn't it?

Medications that are meant to help to improve life can actually become a major source of harm.

And it's because the aging body just processes them so differently.

Geropharmacology, it's a vital field and it's growing because it finally recognizes this uniqueness.

An 80 -year -old system, it just doesn't handle drugs the same way younger persons does, regardless of how healthy they might seem.

Right.

So today, we're diving deep.

We're looking into the science behind it, the specific risks and the practical safety measures needed.

Our goal here is to give you a clearer map of what's happening chemically, why things like the beers criteria exist, and what critical nursing adjustments are needed for safe medication use, whether that's in a care facility or even at home.

Let's start with the big picture.

What are the layers of risk here?

Well, the risk profile is pretty complex.

It's not just about the number of pills, though that's part of it.

It's often about fragmented care.

You know, an older adult might see multiple doctors who maybe aren't always talking to each other, or maybe they've just come out of the hospital.

That automatically raises the danger level.

And then you layer on physiological changes, money worries, maybe some cognitive decline or sensory issues like poor eyesight.

It all adds up.

And probably the biggest risk factor overall is what we call polypharmacy, which sounds complicated, but it just means using more medications than are actually clinically needed.

Nearly every older adult takes at least one prescription, but the number that really grabs you is that about a third of them are taking five or more.

Five prescriptions.

And that number often doesn't even include the hidden stuff.

The hidden stuff?

Like...

Exactly.

The hidden dangers are all the things they don't get a prescription for.

You know, older adults buy something like 40 % of all over -the -counter drugs, OTCs, but often they just don't think of them as real medicine, so they don't tell their doctor.

And that's where you get serious interactions.

Can you give us an example?

How could something like an herbal supplement, which sounds pretty harmless, cause problems with prescription drugs?

Oh, absolutely.

Think about St.

John's wort.

People often take it for mood, right?

But it's known to actually reduce how well some important heart medications work, like digoxin or take

ginseng.

Besides messing with anticoagulants or diabetes meds, it's been linked to some pretty severe allergic reactions, even potentially damaging the liver.

And we can't skip over alcohol.

Most people definitely don't classify alcohol as a drug, but it's potential to interact with sleeping pills and painkillers.

It's extremely dangerous.

It can even speed up kidney decline.

Wow.

Okay, so beyond the chemistry, there's the human side, too.

Things like money and cognitive issues.

Rationing meds because they're too expensive?

That's a huge reason for non -adherence, isn't it?

Especially for older folks on fixed incomes.

They might skip doses or just not refill things.

Definitely.

And that's even before you consider problems with vision or thinking clearly.

I mean, if you can't read the tiny print on a label, or you can't tell two similar -looking pills apart, mistakes are almost bound to happen.

And for someone with significant cognitive impairment, say advanced dementia, they really shouldn't be managing their own medications.

They just can't reliably follow a complex schedule or even recognize why they need the drug.

That really sets the stage for the science part, because even if cost and confusion weren't issues, the basic chemistry of the aging body is still working differently with these drugs.

So let's unpack pharmacokinetics.

That's the framework, right?

For understanding what the body does to the drug.

Absorption, distribution, metabolism, and excretion ADME.

Yeah, ADME.

And if you want the key takeaway for all four stages, it's pretty simple.

The aging body basically slows down the whole pharmacological clock.

Drugs generally take longer to start working.

They stay active in the body longer, and they're much harder for the body to clear out.

Okay, starting with absorption.

A.

If I take a pill, what's the main difference in how it's absorbed?

B.

Well, systemically, the big difference involves the liver's first pass effect.

Normally when you take a drug orally, it goes through the liver first, and some of it gets broken down before it even hits your main circulation.

But in older adults, the liver might be smaller, and blood flow is reduced.

So that first pass metabolism is less effective.

This can actually boost the effect of certain drugs.

Proprianally is a good example.

More of it gets into the system.

And then just in the gut itself, things like increased stomach pH and slower movement or peristalsis mean the absorption process can be irregular and slower overall.

The drug might take longer to kick in.

Interesting.

Okay, moving to distribution.

You mentioned body composition changes.

Less water, more fat.

How does that play out?

Right.

The body's internal environment shifts.

With less total body water, drugs that dissolve in water like lithium or gentamicin tend to stay in the bloodstream at higher concentrations.

That bumps up the toxicity risk.

And on the other side, there's usually an increase in body fat.

This acts almost like a fat trap for drugs that dissolve in fat.

Think benzodiazepines, like Valium.

Once these drugs get into the fat tissue, they get released back into the system really slowly.

This can cause delayed effects, kind of like a hangover, and it dramatically extends the drug's half -life.

Half -life.

That's how long it takes for half the drug to leave the body, right?

Exactly.

And for something like diazepam, the half -life can jump from maybe 36 hours in a younger person to over 100 hours in an older adult.

100 hours.

That's over four days the drug is potentially active.

It can be, yes.

Which also brings us to another key distribution issue, protein binding.

Ah, right.

Albumin levels.

Precisely.

Serum albumin levels often decrease with age or poor nutrition.

Albumin acts like little taxis, carrying drug molecules safely through the bloodstream.

If you have fewer taxis, more of the drug is left walking around freely.

That's the unbound active drug.

And it's the unbound drug that actually has the effect, and potentially the toxic effect.

So you can get increased toxicity even on what seems like a standard or low dose, just because more of it is active.

Wait, hold on.

Are you saying that a standard blood test for a drug that binds strongly to protein, maybe like warfarin, might actually be misleading?

Because it doesn't tell you how much is active versus safely bound.

That's exactly right.

Most standard tests measure the total amount bound and unbound.

They can't distinguish.

And that's why clinical assessment, watching the patient noticing subtle changes, becomes so incredibly important.

It might be your first clue something's wrong before a lab value even changes.

That's a really crucial point.

Okay, let's talk about getting the drug out of the body.

Metabolism, M, and excretion, E.

How much slower is the cleanup crew, so to speak?

Significantly slower, often.

Metabolism, primarily in the liver, is affected because blood flow to the liver can decrease by maybe 40 -45 % compared to younger adulthood.

That reduction means the liver is just less efficient at breaking down drugs.

Things like digoxin or certain antidepressants like tricyclics, they get processed poorly, increasing the risk it'll build up to toxic levels.

Okay, and excretion.

That's mainly the kidneys.

Primarily the kidneys, yes.

And kidney function also tends to decline with age, making them less effective at filtering out drug byproducts.

Now here's a really critical clinical point.

As people age, they often lose muscle mass.

Since creatinine is a byproduct of muscle metabolism,

their serum creatinine level might actually stay stable or look normal, even while their actual kidney function is declining.

It's a potential

because that normal -looking serum level can mask a dangerous decrease in the kidney's ability to clear drugs.

So relying just on serum creatinine isn't enough.

You really need that creatinine clearance test.

Absolutely.

It gives a much more accurate picture of what the kidneys are actually doing.

It's really considered the gold standard for assessing kidney function in this population for drug dosing purposes.

Okay, so that covers pharmacokinetics, what the body does to the drug.

Now, what about pharmacodynamics, what the drug does to the body?

How does aging change the drug's actual effect?

Well, the short answer is the response becomes much less predictable.

It can go either way.

Receptor sites in the body, especially maybe in the brain, can become hypersensitive.

This means even small doses of psychotropic medications could cause really profound, sometimes toxic reactions.

Yeah, and so are sensitive.

Okay.

But conversely, other receptors, like some in the heart muscle, might become less sensitive.

So you might actually need higher doses of certain cardiac meds, like propranolol again, to get the desired therapeutic effect.

Higher doses, which could also mean higher risks.

Exactly.

It creates a tricky balancing act.

You can't just assume the standard response.

You absolutely have to monitor the individual patient closely for both effect and side effects.

Given this whole minefield of risks we've discussed, these standardized safety tools become just essential, don't they?

Let's talk about those clinical safeguards prescribers and nurses use.

Yeah, absolutely critical.

In the US, the main one people know is probably the beers criteria.

It started back in 1991, but it gets updated regularly.

I think the latest was 2019.

It's basically a list of medications that are considered potentially inappropriate for older adults.

Either they should generally be avoided or the dose needs careful adjustment based on the patient's specific conditions or kidney function.

It's a really important guide to help reduce risky prescribing.

And I know outside the US, especially in Europe, there's another tool, right?

The stop P start criteria.

That's right.

Stop P start is a great approach because it looks at two sides of the coin.

Stop PP stands for screening tool of older person's prescriptions.

It helps identify drugs they probably shouldn't be taking, like for example, using high dose digoxin if kidney function is poor, or maybe using an NSAI if someone has significant hypertension or heart failure, things to stop.

Okay, STATP is for inappropriate meds.

What's start?

Start is the screening tool to alert doctors to right treatment.

This prompts clinicians to consider medications that might be missing, but are actually necessary.

So it might flag the need to start warfarin for someone with chronic atrial fibrillation to prevent stroke, or maybe starting calcium and vitamin D if they have osteoporosis.

It's about ensuring they get beneficial treatments too.

That makes a lot of sense.

Checking for both overprescribing and underprescribing.

These tools seem to underpin some basic rules for prescribing for older adults.

They do.

There are sort of six guiding principles often cited first and maybe most famously.

Start low and go slow.

Begin with a low dose and increase it very gradually, watching closely.

Okay, start low, go slow.

What else?

Second, try to live by the mantra, start one drug, stop two, meaning whatever you add a new medication, really scrutinize the existing list to see if anything could be discontinued, perhaps because the new drug addresses multiple issues or an older one is no longer needed.

Right, deprescribing is key.

Definitely.

Third, avoid drugs where the potential side effects seem worse than the condition you're trying to treat.

Fourth, use as few drugs as possible, always considering non -drug approaches first.

Fifth, assess the patient's response frequently and regularly.

And sixth, consider planned drug holidays, scheduled breaks from certain medications to reevaluate if they're still truly necessary and effective.

Those seem like really solid principles.

How do they translate into the day -to -day practice of actually giving medications, especially for nurses?

Well, those principles have to inform everything.

It brings us to how nurses adapt the traditional six rights of medication administration for geriatric care.

They all need a bit of adjustment.

Okay, let's go through them.

The right patient, what's the key adaptation there?

The Joint Commission requires two patient identifiers, always.

But for older adults, you can't just glance at a wristband that might be smudged or assume the person in room 20B is the right one.

You really need to actively confirm.

If the patient is alert and oriented, the best way is to ask them to state their full name and maybe date of birth.

Make sure they confirm who they are.

Make sense.

What about the right amount or right dose?

This goes back to start low, go slow, but also requires meticulous attention to detail.

Decimal points are notorious sources of error.

A misplaced decimal can mean a tenfold overdose.

And following the Joint Commission's do not use list for abbreviations is critical.

For instance, always writing out the word unit instead of using the abbreviation U, which can easily be mistaken for a zero or a four.

These small things prevent huge errors.

Okay, then there's right route and right dosage form.

Swallowing difficulties, dysphagia must be a big issue here.

Huge.

If a patient has trouble swallowing pills, the first step should always be to ask the prescriber if a liquid form is available.

That's the safest option.

If you do have to crush a pill, and you should only do it if explicitly allowed for that medication, there are absolute no -crush rules.

What shouldn't be crushed?

You never crush enteric -coated tablets because the coating protects the stomach or ensures absorption further down.

Never crush capsules.

The contents might be irritating or designed for specific release.

And definitely never crush any time release formulations.

The ones with letters like LA, long acting,

SR, sustained release, ER, extended release.

Crushing those releases the entire dose at once, which can be incredibly dangerous.

Same goes for sublingual or bilical tabs meant to dissolve under the tongue or in the cheek.

Got it.

No crushing those.

What about patches?

Transdermal patches seem popular.

They are popular, yeah.

They can provide really stable drug levels in the blood and patients often find them easier to stick with than remembering pills.

But there are critical safety points.

You must always remove the old patch before putting on a new one.

Forgetting this leads to overdose.

You also need to rotate the application sites to prevent skin irritation, make sure the skin is clean and dry before applying, and crucially avoid applying heat like a heating pad over the patch.

Heat increases blood flow to the skin and can cause the drug to be absorbed way too quickly.

Good points.

Okay, what about write time?

How does that get adjusted?

It's often adjusted for practicality and to minimize side effects impacting quality of life.

For example, giving diuretics earlier in the day, maybe morning or early afternoon, helps prevent the patient from having to get up multiple times overnight to use the bathroom.

Or giving corticosteroids like prednisone in the morning often aligns better with the body's natural rhythm and can provide a bit of an energy boost while taking them at night might contribute to insomnia.

Right, timing for lifestyle.

So that covers administration in a supervised setting.

What about when people are managing meds themselves at home?

Non -adherence must be a big challenge.

It really is.

The risk of confusion and making mistakes goes up significantly once someone is juggling, say, three or more different medications.

So, nursing interventions become really important for supporting independence.

Helping the person link their medication schedule to daily routines is key, like take this pill with breakfast, take that one right before bed.

Using tools helps too.

Making sure labels are in large, clear, dark print.

Getting the pharmacy to provide easy open caps if arthritis is an issue instead of towel -proof ones.

And patient education material.

Absolutely vital.

Providing clear, simple teaching sheets.

Maybe using pictures, if needed, that cover the drug's name, what it's for, exactly when and how to take it, common side effects to watch for, and crucially, clear instructions on what to do if they accidentally miss a dose.

That empowers them and provides a safety net.

So wrapping this all together, this deep dive really highlights that managing medication risk in older adults isn't just about one thing.

It's this crucial link between understanding the changing physiology, using those safety tools like beers or Stop PP Start diligently, and just maintaining constant clinical vigilance.

Yeah, that vigilance is key.

And it brings us back to that really important point we touched on earlier.

Because standard lab values, like that serum creatinine level,

can sometimes mask underlying decline.

And because most blood tests can't easily tell you how much drug is free and active versus safely bound to proteins, it really leads you to conclude that the ultimate most reliable way to monitor for drug safety and potential toxicity in an older adult is through continuous, hands -on, symptom -focused nursing assessment.

Really noticing those subtle changes in their alertness, their balance, their vision, maybe confusion, often before a lab test flags a problem.

That skill, that careful observation, is probably the most essential tool we have in geropharmacology.

That's a really powerful and practical takeaway for anyone working in this field.

Thank you so much for walking us through this.

It's been incredibly insightful.

And to you, our listener, thank you for joining us for this deep dive.

We hope you found it valuable.

Stay informed, stay safe out there, and we'll catch you next time.