Peck trends in geriatric best practice for nursing care
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I Hope you find this information helpful for providing best practice care to the geriatric population. Peck, M. (2017). Trends in Geriatric Best Practice for Nursing Care. Podium presentation for Indian American Nurses Association. Current Trends in Nursing Practice and Pharmacology Conference; Houston, Texas.
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Peck trends in geriatric best practice for nursing care
- 1. Trends in Geriatric Best Practice for Nursing Care Michelle Peck, MPH, MSN, RN, AGPCNP-BC Michelle.R.Peck@uth.tmc.edu
- 2. What is NOT normal about aging Aging Changes: Organ Systems Aging Changes: Pharmacokinetics & Pharmacodynamics Adverse Medication Events & Beers Criteria Let’s Discuss
- 3. What is NOT normal about aging? This Photo by Unknown Author is licensed under CC BY-SA
- 4. Geriatric Syndromes Diagnoses multiple etiologies, frequently seen in older population • Dementia • Delirium • Depression • Falls • Incontinence • Constipation • Polypharmacy • Malnutrition/FTT • Dizziness/Syncope • Insomnia • Skin Breakdown • Osteoporosis • Substance & Elder Abuse • Disability
- 5. Clinical Case 5 Mr. Doe is 73 years old Past Medical History: BPH & HTN Visits grandchildren & develops viral URI Takes decongestant + diphenhydramine Unable to urinate Blood pressure 190/80 What happened?
- 6. Urinary Retention & Hypertension Parasympathetic Nervous System Mediates detrusor muscle contraction Blocked by anticholinergic medications like diphenhydramine (Benadryl) Sympathetic Nervous System α-adrenergic activity causes urethral sphincter contraction (retains urine) α-adrenergic activity increases systemic vascular resistance (raises BP) Decongestants are alpha-adrenergic agonists (ex. pseudoephedrine and phenylephrine) 6
- 7. Clinical Case 7 Since Mr. Doe has a history of BPH, his clinician prescribes Hytrin (terazosin), a peripherally-acting α1-adrenergic antagonist, to help with his urinary retention and to help reduce his blood pressure Two days later, Mr. Doe falls in the middle of the night, on the way to the bathroom He fractures his hip Why did he fall?
- 8. Orthostatic Hypotension & Fall With Hip Fracture Age decreases baroreceptor sensitivity α-adrenergic blockade can worsen postural hypotension, increase risk of falls Mr. Doe’s hospital course is complicated by delirium & pneumonia Falls, hip fractures, delirium, and pneumonia are all associated with significant morbidity & mortality
- 10. The Prescribing Cascade Arthritis Dementia Agitation NSAID Cholinesterase Inhibitor Antipsychotic BP EPS BP Rx Anticholinergic Rx Incontinence Parkinson Rx INITIAL CONDITION THERAPY NEW SYMPTOM SUBSEQUENT Rx
- 11. Older Adults: The Problem A given dose of a given medication produces a different & sometimes unexpected, response in an elderly person compared to someone younger of the same gender and body weight.
- 12. Normal Aging Changes in Structure & Function of Organ Systems • Etiology • Implications • Assessment & parameters • Evidence-based nursing care strategies for best practice
- 14. Aging Effects on the CV System Etiology: Arterial wall thickening, stiffening, decreased compliance Hypertrophy – Left Ventricular & Atrial Sclerosis – Atrial & Mitral Valves Strong arterial pulses, diminished peripherally (Boltz, Capezuti, Fulmer, & Zwicker, 2012)
- 15. Aging Effects on the CV System Implications: Decreased Cardiac Reserve At rest no change in HR or CO Under stress – decreased max HR and CO Fatigue, SOB, slow recovery from tachycardia Risk of Isolated Systolic Hypertension, inflamed varicosities Arrhythmia risk, postural + diuretic-induced hypotension, syncope (Boltz et al., 2012)
- 16. Aging Effects on the CV System Assessment: ECG, monitor rate (40-100 bpm within normal limits), rhythm (regular or irregular), heart sounds (S1 S2 or extra sounds S3 in heart disease or S4 as a common finding), murmurs Peripheral pulses assessed bilaterally BP should be monitored at least twice (repeated after 5 minutes of rest) (Boltz et al., 2012)
- 17. CV System Nursing Care Strategies Referrals irregularities of rhythm & decreased, asymmetric peripheral pulses Risk of postural hypotension need increased safety precautions wait 1-2 minutes after position changes to stand/transfer monitor for signs of hypotension fall prevention strategies sufficient fluid intake (Boltz et al., 2012)
- 18. CV System Nursing Care Strategies Education: Healthy body weight Normal BP Healthful diet Physical activity No exposure to tobacco (Boltz et al., 2012)
- 19. Aging Effects on the Renal & GU Systems Etiology: Renal Mass declines, loss of functional glomeruli and tubules, reduced blood flow, GFR (10% decrease per decade after age 30) decreased blood clearance Reduced bladder tone, elasticity, capacity Increase in post void residual, nocturia Prostate enlargement risk for BPH (Boltz et al., 2012)
- 20. Aging Effects on the Renal & GU Systems Implications & Parameters: Reduced reserve, increased complication risk illness Nephrotoxic injury risk from drugs Risk of volume changes, electrolyte imbalances Increased risk urinary urgency, incontinence, UTI, nocturia, falls (Boltz et al., 2012)
- 21. Decreased Creatinine Clearance Decreased: • concentrating/diluting • renal blood flow/mass • drug clearance How does kidney function decrease with age? 70 80 90 100 110 120 130 140 30 40 50 60 70 80 Progressive linear decline in clearance. Age CrCl (Fillit et al., 2010)
- 22. Renal & GU Systems Nursing Care Strategies Monitor nephrotoxic and renal cleared drug levels Maintain fluid/electrolyte balance min 1,500-2,000 ml/day from fluid & food Nocturia – limit evening fluids, avoid caffeine, prompted voiding Fall prevention (Boltz et al., 2012)
- 23. Aging Effects on the Pulmonary System Etiology: Decreased respiratory muscle strength, stiffer chest wall Diminished ciliary and macrophage activity drier mucosa, decreased cough reflex Decreased response to hypoxia and hypercapnia (Boltz et al., 2012)
- 24. Aging Effects on the Pulmonary System Implications: Reduced pulmonary function reserve - with exertion dyspnea & decreased exercise tolerance Less effective exhalation (resp. rate 12-24 breaths/min) Dec. cough, mucus & foreign matter clearance Inc. risk infection & bronchospasm/airway obstruction (Boltz et al., 2012)
- 25. Pulmonary System Nursing Care Strategies Maintain patent airways upright positioning, suctioning Provide Oxygen as needed, maintain hydration, mobility Incentive Spirometry *if immobile/declining function Education Cough enhancement Smoking cessation (Boltz et al., 2012)
- 27. Aging Effects on the Nervous System Etiology: Decrease in neurotransmitters & neurons Compromised thermoregulation Modifications in cerebral dendrites & synapses (Boltz et al., 2012)
- 28. Aging Effects on the Nervous System Implications: General muscle strength, deep tendon reflexes, nerve conduction velocities are impaired Decreased temperature sensitivity Blunted or absent fever response (baseline oral temp 97.4) Slowed cognitive processing Inc. risk of sleep disorders, delirium, neurodegenerative diseases (Boltz et al., 2012)
- 29. Nervous System Nursing Care Strategies Assess with baseline status with periodic reassessment Monitor for delirium and functional status during illness Assess impact of age-related changes on daily tasks Assess temperature & fall prevention strategies Maintain cognitive function: regular exercise, healthful diet, intellectual stimulation Behavioral interventions for sleep disorders (Boltz et al., 2012)
- 30. Aging Effects on the GI System Etiology: Mastication muscles, taste, thirst perception are decreased Gastric Motility decreased and emptying time are delayed Atrophy of protective mucosa Malabsorption of carbs, Vitamins B12, D, Folic acid & calcium Reduced hepatic reserve, decreased metabolism of drugs Impaired defecation sensation (Boltz et al., 2012)
- 31. Aging Effects on the GI System Implications: Risk chewing problems, fluid imbalances, poor nutrition Gastric: Altered drug absorption, risk of GERD, maldigestion, ulcers Constipation not a normal finding Stable LFTs risk of adverse drug reactions (Boltz et al., 2012)
- 32. GI System Nursing Care Strategies Assess abdomen, oral cavity, chewing, swallowing, lungs for aspiration Monitor weight, calculate BMI (18.5 to 24.9 Healthy) Determine dietary intake Assess for GERD, constipation, incontinence, impaction Monitor drug levels ands LFTs Educate on lifestyle modifications, bowel frequency, diet, activity Use laxatives if on constipating medications (Boltz et al., 2012)
- 33. Aging Effects on the Musculoskeletal System Etiology: Sarcopenia (decline in muscle mass and strength) increases weakness Lean body mass replaced with fat Bone loss peaks after age 30 to 35 Ligament and tendon strength decreases Intervertebral disc degeneration & articular cartilage erosion Changes in stature kyphosis, height reduction (Boltz et al., 2012)
- 34. Aging Effects on the Musculoskeletal System Implications: Risk of falls, disability, unstable gait increases Osteopenia and osteoporosis risk increases Limited ROM & joint instability Risk for osteoarthritis increases (Boltz et al., 2012)
- 35. Musculoskeletal System Nursing Care Strategies Encourage physical activity through health education Set goals to maintain function Pain medication to enhance function Fall prevention Adequate intake of Calcium and Vitamin D, smoking cessation Advise routine bone mineral density screening (Boltz et al., 2012)
- 36. Normal Aging Changes in Pharmacokinetics & Pharmacodynamics • Etiology • Implications • Assessment & parameters • Evidence-based nursing care for best practice
- 37. 37 Physiologic Changes Normal Aging Less Water More Fat Less Muscle Mass Slowed Hepatic Metabolism Decreased Renal Excretion Decreased Responsiveness & Sensitivity Baroreceptor Reflex
- 38. Pharmacokinetics Absorption Increased gastric pH Delayed gastric emptying Reduced intestinal motility and blood flow Despite these changes medication absorption is largely unchanged Exceptions are Iron, Calcium absorb more slowly Enteric Coated medications may take action in the stomach Pharmacokinetics Distribution Those with low lean body mass have more narrow therapeutic index (digoxin) Often more body fat than water Reduces volume of distribution of water-soluble drugs giving higher concentrations (digoxin) Accumulation fat-soluble Rx, prolong elimination (lidocaine, diazepam) Reduced plasma protein binding inc. free fraction (warfarin, furosemide) (Durso, Bowker, Price, & Smith, 2010; Fillit, Rockwood & Woodhouse, 2010)
- 39. Pharmacokinetics Metabolism Reduced hepatic mass and blood flow can affect overall function Slow metabolism drugs (theophylline, acetaminophen, diazepam, nifedipine) Drug undergoing extensive first-pass are most affected (propranolol, nitrates) Many factors interact with liver metabolism • Nutritional state, acute illness, smoking, other medications • CHF can lead to hepatic congestion impairing metabolism Pharmacokinetics Excretion Renal mass decline 20-25% age 30-80, GFR dec 10%/decade after age 30 Active metabolite Rx mainly kidney excreted: allopurinol, digoxin, furosemide, gabapentin, gentamicin, lithium, metformin, ranitidine, tetracycline Dose adjust for renal impairment (urosepsis & dehydration can exacerbate) Normal serum creatinine can be misleading (use GFR, Cr Clearance) • Low muscle mass can decrease creatinine production (Durso et al., 2010; Fillit et al., 2010)
- 40. Pharmacodynamics Physiological interactions of drug and the body Increased risk of unreliable pharmacodynamics Anticholinergic side effects- increased injury risk
- 41. Factors effecting medication response in the elderly include which one of the following? A. Decreased total body fat B. Increased total body water C. Decreased renal excretion D. Increased hepatic mass
- 42. 7 Top Reasons Medication AE 1. Altered pharmacokinetics (reduced metabolism/excretion) and altered pharmacodynamics (what drug does to body) 2. Polypharmacy 3. Incorrect doses (more or less than therapeutic dosage) 4. Using medications for treatment of symptoms not disease dependent (prescribing cascade) 5. Iatrogenic causes (ADE and inappropriate prescribing) 6. Medication adherence problems 7. Medication errors (Boltz et al., 2012)
- 43. Beers Criteria & Adverse Medication Events (Fick et al., 2015)
- 44. Beers Criteria & Adverse Medication Events Up-to-date recommendations, preventing medication-related problems Developed to bring attention & action to inappropriate prescribing Categorizes Medications: Some indications (but often misused) Rarely appropriate Should always be avoided (Fick et al., 2015)
- 46. The safest OTC pain medication for those over age 65 is… A. B. C.
- 47. Evidence-based Nursing Care Identifying those at risk for AE Recognizing ADE Recognizing drug-drug interactions Recognizing drug-disease interactions Correct timing of medications Assessing for urgency & adherence Communicating to prescribers Educating patient & caregivers (Boltz et al., 2012; Fillit et al., 2010)
- 48. Evidence-based Nursing Care Give lowest dose possible Discontinue unnecessary therapy Attempt nondrug approaches first Give the safest drug (Beers Criteria) Assess renal (GFR) & Liver function Always consider the risk-to-benefit ratio Assess for new interactions Avoid the prescribing cascade (Boltz et al., 2012; Fillit et al., 2010)
- 49. Assess Drug Regimen Adherence Brown Bag Approach Can they afford the medications? Can they obtain the medications and refills? Whose the decision-maker regarding use? Are they getting drugs from other people? Do they still have discontinued drugs? Do they remember to take their medications? Is liver and kidney function being monitored? Can they manipulate the medication? (Boltz et al., 2012; Fillit et al., 2010)
- 50. Boltz, M., Capezuti, E., Fulmer, T., & Zwicker, D. (Eds.). (2012). Evidence-based geriatric nursing protocols for best practice (4th ed.). New York, New York: Springer Pub. Co. Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford American handbook of geriatric medicine (First ed.). New York, New York: Oxford University Press Inc. Fick, D. M., Semla, T. P., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C. E., Eisenberg, W., Epplin, J. J., Flanagan, N., Giovannetti, E., Hanlon, J., Hollmann, P., Laird, R., Linnebur, S., Sandhu, S., & Steinman, M. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American geriatrics society 2015 updated beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-2246. doi:10.1111/jgs.13702. Fillit, H., Rockwood, K., Woodhouse, K. W., & Brocklehurst, J. C. (2010). Brocklehurst's textbook of geriatric medicine and gerontology (7th ed.). Philadelphia, PA: Saunders/Elsevier. References Thank You!