Considerations in Geriatric Pharmacology: Episode 157 | Straight A Nursing
Summary
TLDRIn this episode of the Straight A Nursing Podcast, Nurse Moe delves into geriatric pharmacology, focusing on how aging affects medication absorption, distribution, metabolism, and excretion. She emphasizes that drug dosages often need to be lower in the elderly due to these changes. The episode also covers the challenges of polypharmacy, the Beers list for potentially inappropriate medications in older adults, and the importance of deprescribing. Nurse-driven interventions for improving medication adherence in the elderly are also discussed, with practical tips for nurses to enhance patient care.
Takeaways
- 📚 Aging affects pharmacokinetics, requiring lower drug dosages; start low and go slow.
- 💊 Geriatric patients face changes in drug absorption due to factors like decreased gastric emptying and increased gastric pH.
- 🩺 Transdermal medications are often preferred for the elderly due to consistent drug concentrations and ease of use.
- 🧠 Aging alters drug distribution, especially for lipophilic drugs, leading to prolonged effects and potential toxicity.
- 🍎 Decreased serum albumin in the elderly can lead to higher levels of unbound drugs, increasing the risk of adverse effects.
- 🛡️ Reduced liver function in elderly patients affects drug metabolism, often requiring lower doses to prevent toxicity.
- 🚰 Renal function decline in older adults reduces drug excretion, necessitating careful dosage adjustments for certain medications.
- ❗ The Beers list identifies drugs potentially inappropriate for older adults, emphasizing the importance of medication safety.
- 📉 Deprescribing aims to reduce polypharmacy risks in the elderly, improving cognitive function, fall risk, and overall safety.
- 📝 Nurses can improve medication adherence in elderly patients through education, written instructions, and the use of medication management tools.
Q & A
What is the main topic of episode 157 of the Straight A Nursing Podcast?
-The main topic of episode 157 is considerations with geriatric pharmacology and medication administration.
What does the acronym 'ADME' stand for in pharmacokinetics?
-ADME stands for Absorption, Distribution, Metabolism, and Excretion, which are the four pillars of pharmacokinetics.
Why is the principle of 'start low and go slow' important when administering medication to the elderly?
-The principle of 'start low and go slow' is important because many times drug dosages need to be lower in the elderly due to age-related changes in pharmacokinetics.
What are some factors that can affect drug absorption in the elderly?
-Factors affecting drug absorption in the elderly include changes in gastric emptying, active transport, intestinal surface area, and gastric pH.
Why might transdermal medication delivery be beneficial for the elderly?
-Transdermal medication delivery is beneficial for the elderly because it provides a steady rate of administration, is easy to use, and circumvents hepatic first-pass metabolism.
How does aging affect the distribution of highly lipophilic drugs?
-Aging increases body fat and decreases total body water, which can lead to an increased distribution and half-life of highly lipophilic drugs, potentially causing increased levels and prolonged effects.
What is the significance of the 'Beers List' in geriatric pharmacology?
-The Beers List identifies medications that are potentially inappropriate for use in older adults due to risks of adverse effects and aims to increase medication safety in this population.
What is the process of 'deprescribing' and why is it important for elderly patients?
-Deprescribing is the process of evaluating and removing unnecessary or inappropriate medications from a patient's regimen to enhance medication safety, improve adherence, and reduce risks of adverse effects.
How can nurses improve medication adherence and safety among elderly patients?
-Nurses can improve medication adherence and safety by providing patient education, using the teach-back method, providing written instructions and schedules, utilizing medication management tools, and assessing all medications during home visits.
What are some examples of nurse-led interventions to enhance medication adherence in the elderly?
-Examples of nurse-led interventions include teaching the appropriate person, using the teach-back method, providing written instructions, using medication management tools like pill organizers or electronic dispensers, and setting reminders via telephone or electronic devices.
Outlines
🎙️ Introduction to Geriatric Pharmacology
In this episode of the Straight A Nursing Podcast, Nurse Moe introduces the topic of geriatric pharmacology, discussing the unique considerations needed when administering medication to the elderly. She acknowledges a listener's success in passing the NCLEX and emphasizes the importance of understanding how aging affects drug absorption, distribution, metabolism, and excretion. The episode promises to delve into pharmacokinetics, the concept of 'start low and go slow,' and the complexities introduced by multiple diseases and polypharmacy in the elderly.
👵 Age-Related Changes in Drug Absorption
This paragraph explores how the aging process impacts the absorption of drugs. It discusses conflicting research findings on the reliability of intramuscular administration due to variable absorption in the elderly. The general consensus is that while there are some changes, absorption may not be the most significant factor. The paragraph also covers gastrointestinal changes in the elderly, such as altered gastric emptying, decreased intestinal surface area, and increased gastric pH, and how these can affect the absorption of specific medications like levodopa, digoxin, and calcium carbonate. The benefits of transdermal drug administration for the elderly are highlighted, including steady drug release and ease of use.
💊 Distribution and Metabolism in Elderly Patients
The discussion moves on to the distribution of drugs within the body, noting that as body water decreases and body fat increases with age, the distribution of lipophilic drugs is affected. Examples of such drugs are provided, and the potential for increased half-life and prolonged effects are explained. The paragraph also addresses the impact of decreased serum albumin on drug binding, which can lead to higher levels of unbound drugs and increased risk of adverse effects. Metabolism is then covered, focusing on the liver's role in drug metabolism and the first-pass effect, which is reduced in the elderly, often necessitating lower doses of medication.
🚰 The Impact of Aging on Drug Excretion
This section delves into the excretion or elimination of drugs, with a focus on the renal system's role. It explains how creatinine clearance and glomerular filtration rate decline with age, affecting the kidneys' ability to eliminate drugs. Medications that rely heavily on renal clearance, such as morphine, metformin, and certain diuretics, require careful dosing considerations in the elderly. The importance of starting with lower doses and the concept of deprescribing to enhance medication safety are emphasized.
🧠 Pharmacodynamics and the Elderly
The paragraph discusses pharmacodynamics, particularly the increased sensitivity of elderly individuals to the central nervous system effects of medications, especially those with cognitive impairments. It uses diphenhydramine as an example, highlighting the potential for acute confusion and other adverse effects in the elderly. The BEERS list is introduced, noting drugs that are potentially inappropriate for older adults due to heightened risks, such as anticholinergics, ACE inhibitors, Warfarin, and benzodiazepines.
📋 Improving Medication Adherence in the Elderly
This paragraph focuses on strategies to improve medication adherence and safety among the elderly. It discusses the challenges faced by the elderly in adhering to medication regimens, including cognitive decline and swallowing difficulties. Nurse-led interventions are suggested, such as patient education, the use of medication management tools, and regular assessment of medications. The importance of deprescribing to reduce polypharmacy and its associated risks is reiterated.
📝 Conclusion and Study Resources
The final paragraph wraps up the episode with a quick summary of key points, emphasizing the importance of adjusting medication dosages for the elderly and the role of deprescribing. It introduces a new members-only podcast, 'Straight A Nursing Study Sesh,' which offers in-depth study materials, including pod quizzes, drills, case studies, and power hour sessions. Interested listeners are directed to a website for more information and to access these study resources.
Mindmap
Keywords
💡Geriatric Pharmacology
💡Pharmacokinetics
💡Polypharmacy
💡Deprescribing
💡Pharmacodynamics
💡Beers List
💡Absorption
💡Distribution
💡Metabolism
💡Excretion
💡Medication Adherence
Highlights
Introduction to the topic of geriatric pharmacology and medication administration considerations.
Congratulation to Rebecca for passing the NCLEX, emphasizing the podcast's role in her success.
The concept that pharmacology is not 'one size fits all', especially in the elderly.
Explanation of pharmacokinetics and its four pillars: absorption, distribution, metabolism, and excretion.
The importance of starting medication dosages low and increasing slowly in elderly patients.
Discussion on the complexities of pharmacology in the elderly, including polypharmacy.
Impact of aging on drug absorption, including changes in the gastrointestinal tract.
Examples of drugs affected by decreased gastric emptying and active transport in the elderly.
The benefits of transdermal drug administration for the elderly.
How age-related changes in the body affect drug distribution and the impact on lipophilic drugs.
The role of plasma proteins in drug binding and the risks associated with decreased serum albumin in the elderly.
An overview of how the liver's metabolic activity and first-pass effect change with age.
The significance of renal function decline with age and its effect on drug excretion.
Introduction to pharmacodynamics and increased sensitivity to CNS effects in the elderly.
The Beers List and its purpose in identifying potentially inappropriate medications for older adults.
The practice of deprescribing to enhance medication safety in the elderly.
Challenges in medication adherence among the elderly and factors affecting it.
Nurse-led interventions to improve medication adherence and safety in geriatric patients.
Announcement of a new members-only podcast for nursing students focusing on study sessions.
Upcoming podcast episode on newborn assessment and the Apgar score.
Transcripts
[Music]
well hello there again everyone this is
Nurse Moe and welcome back to the
straight a nursing podcast this is
episode 157 and today we are talking
about some considerations with geriatric
pharmacology and medication
administration so before we dive into
this really interesting topic I do want
to take a moment for our listener shout
out and this one goes out to Rebecca so
Rebecca says I wanted to thank you just
past my NCLEX in 75 questions you were
integral in that success Rebecca I mean
I'm sorry nurse Rebecca congratulations
that is amazing I cannot wait to hear
about all the amazing things that you do
so please reach out touch base send us
an email let us know where you land and
how you're loving your new job
so I have a big news flash for you guys
pharmacology is not one size fits all
okay if you have already listened to the
episode on pediatric pharmacology you
definitely understand this concept so
now we're going to look at the other end
of the spectrum
to discuss how aging affects medication
administration pharmacological
considerations in the elderly and then
at the end we'll be doing some of those
pod quiz questions that you love so much
and I have an exciting announcement
about that as well
so recall that pharmacokinetics is
essentially what the body does to a drug
after it's administered so the four
pillars of pharmacokinetics are
absorption
distribution
metabolism and excretion you may also
hear elimination so adme absorption
distribution metabolism excretion
today we'll be talking about the
age-related changes that occur in each
of these pillars so the short version is
that many times drug dosages will need
to be lower in the elderly so the name
of the game is start low and go slow and
after we get through this episode you'll
understand why so complexities of
pharmacology and the elderly it's often
compounded you guys by the presence of
multiple disease conditions leading to
polypharmacy and we're going to talk
about that some more as well so let's
dive down into the details
absorption what is absorption it is the
process of the drug basically moving
from the site where it was administered
into the bloodstream so it can you know
get to where it needs to go and do what
it needs to do
so as I was researching this for you
guys I was really surprised to see there
is a lot of conflicting information out
there about how aging affects drug
absorption some of the materials
suggested that intramuscular route is
really unreliable because the absorption
can be so variable and then other
studies said not so much so the general
consensus is that yes there are some
changes in absorption but may not be the
biggest factor for the elderly patient
but I do want to look at po medications
because there are some things that we
need to talk about with that the general
differences in the GI tract of the
elderly is changes to gastric MTM time
decreased small bowel surface area and
increases in gastric pH but again most
cases the absorption of drugs is not
significantly different that's what the
studies are saying right now but there
are definitely differences in how long
it takes for the drugs to have an effect
but let's talk a little bit about some
prime examples of how the GI tract is
different in the elderly and how it
could be affected as far as
pharmacokinetics go
so decreased gastric emptying
can lead to altered absorption of some
drugs such as levodopa and digoxin so
that would be two prime examples of
drugs where decreased gastric emptying
does affect the absorption
and then decreased active transport can
lead to a decrease in the transport of
vitamins and electrolytes
and then that decreased intestinal
surface area that I mentioned a moment
ago leads to a general decrease in drug
absorption for some medications again
digoxin is another really great example
of this
and then that increased gastric pH can
affect medications that do rely on a
specific pH level so one example is
calcium carbonate which does need a more
acidic environment for optimal
absorption so for this reason elderly
patients are sometimes prescribed
calcium citrate instead because it
dissolves more easily in higher gastric
pH levels
another very key thing about the pH is
with enteric coated tablets so this
enteric coating is utilized for the
purpose of extended release you remember
that you never Crush an enteric coated
tablet right the coding is designed to
remain intact in that low PH environment
of the stomach in that very acidic
environment of the stomach and then
begin to dissolve in the higher pH
environment of the small intestines so
in the elderly where gastric pH can be
higher these medications could have an
early release causing adverse GI effects
or alterations in absorption
one other route that I think we should
talk about very briefly is the
transdermal route
transdermally delivered medications are
actually typically considered really
beneficial for the elderly because of
that steady rate of administration and
ease of use so some examples include
fentanyl
nitroglycerin estradiol
mean I had to pause there for a minute
and see if I could say that one and
Scopolamine so some of the advantages of
transdermal Administration are they
circumvent hepatic first pass metabolism
which we'll talk about in a moment there
are decreased adverse GI effects and
higher likelihood of compliance and more
consistent drug concentrations
though the skin absolutely changes with
age Studies have shown that these
changes in lipid structure and hydration
really only affect medications with
strongly
hydrophilic properties so in general if
dose alterations are needed in the
elderly it's not typically due to
alterations in absorption it's typically
due to age-related cardiovascular renal
and hepatic changes which will all make
so much more sense as we get into the
other pillars of pharmacokinetics
so the next pillar that we need to talk
about is distribution
so distribution is that process of
transferring a drug from the bloodstream
to the tissues where it can exert its
effect
so as we age total body water decreases
while body fat increases the
distribution of Highly lipophilic drugs
is therefore increased so some great
examples of this are risperidone
atorvastatin
ciprofloxacin
azithromycin and Propofol
so what does this mean for your patient
lipophilic drugs may have an increased
Half-Life when body fat is higher
leading to increased levels and
prolonged effects of these types of
medications
and then distribution is also affected
by the presence or the absence of plasma
proteins as we age or even as we're
malnourished serum albumin decreases and
you guys know a lot of times aging and
malnourishment can go hand in hand
so this decrease in serum albumin leads
to changes in the bindings of some
medications so if you're elderly patient
also has malnutrition then they are very
high risk for alterations and the
bindings of some medications and this
can lead to higher levels of Unbound
drugs like Warfarin and phenytoin and
this in turn can lead to Serious adverse
effects and toxicity
and then metabolism is that third pillar
so in general metabolism is the process
that drugs go through that makes them
either more or less active though
generally metabolism makes drugs less
active because that's how they're
designed there are some that actually
need to be metabolized to become active
but that's pretty rare the process of
metabolism converts the compound from
its original state which is that active
state in general and converts it into
something else which is less active and
then excreted from the body so a key
player in metabolism is the liver not
only does the liver metabolize many many
medications it is also responsible for
something called the first pass effect
so when you take a medication by mouth
it is absorbed through the intestinal
mucosa and then enters hepatic
circulation and taken straight to the
liver for metabolism even before it gets
to the heart for circulation
in some cases the first pass effect can
reduce the medication's efficacy by up
to 90 percent when you compare it to IV
Administration so this explains why IV
doses are sometimes so so much smaller
than po doses so a fantastic example of
this is midazolam
looking at the pediatric dose for
midazolam IV it's
.025 to .05 milligrams per kilogram and
we're you know if we're using it for
something like procedural sedation
versus
po 0.25 to 0.5 milligrams per kilogram
so if that child weighs 30 kilograms
that low end dose for an IV midazolam
would be 0.75 milligrams versus
7.5 milligrams po so you can see how po
doses can sometimes be so much larger
and that's because of first pass
metabolism
so in early patients metabolic activity
is reduced and so is that first pass
effect so for these reasons decreased
doses are often needed in your elderly
patients some examples of medications
that rely on hepatic metabolism and will
require scrutiny or Ibuprofen
diltiazem
Warfarin and levodopa remember the name
of the game start low and go slow
and then that final pillar of
pharmacokinetics is excretion you may
also hear it called elimination and this
part involves how the drug is
essentially removed from the body the
key player here is the renal system and
aging definitely has a significant
impact here
so after about age 40 which it does not
seem that old to me creatinine clearance
starts to decline along with GFR and
tubular function the result is that many
drugs have reduced elimination by the
kidneys so any medication that relies
heavily on renal clearance will need to
be scrutinized for proper dosing so some
great examples of these drugs are
morphine metformin
Gentamicin Gabapentin there's digoxin
again and diuretics like furosemide and
spironolactone again what's the name of
the game start low and go slow
Okay so we've talked about
pharmacokinetics let's talk now a little
bit about pharmacodynamics
the key takeaway here is that elderly
individuals will be more sensitive to
the central nervous system effects of
medications
especially if they have underlying
cognitive impairment
so take diphenhydramine for example
elderly patients are more sensitive to
the CNS effects of diphenhydramine which
is an anticholinergic so one of the main
adverse effects the elderly can have
with diphenhydramine is acute confusion
and it can be very very pronounced they
are also likely to be more strongly
experiencing the adverse effects such as
dizziness urinary retention blurred
vision and tachycardia
so be very careful or even wary of
giving diphenhydramine to your elderly
patient and you might want to talk with
the MD about Alternatives when they are
available
So speaking of diphenhydramine brings us
to the next thing we need to talk about
and that is the beers list so you may
hear
something called a Beer's drug and
that's a pretty common term you'll hear
when you're learning about elderly and
the pharmacology and no it does not mean
that the drug comes with an ice cold
bottle and a wedge of lime okay beers
drugs are those that are marked as
potentially inappropriate for use in
older adults
the goal with the beers list and that's
b-e-e-r-s the goal with the beers list
is to increase medication safety with
this special population that is
absolutely prone to polypharmacy
diphenhydramine and other
anticholinergics are on this list due to
that high risk for cognitive decline in
the elderly
other medications include ACE inhibitors
because of the risk for hyperkalemia
Warfarin due to the increased risk of
bleeding and benzodiazepines for the
increased risk of Falls now it doesn't
mean we don't use these medications in
the elderly because I'm sure you've seen
a lot of elderly patients on Warfarin or
an Ace inhibitor but they have to be
scrutinized very carefully there are
quite a few medications on the beers
list and I will include a link to some
additions and updates in the episode
notes they're also in your Davis drug
guide if you happen to use that
reference
one of the highest pharmacologic risks
for the elderly is polypharmacy like
I've mentioned before and with that
heightened risk for adverse interactions
and effects so we have something called
deprescribing and the practice of
deprescribing involves that practitioner
evaluating the patient's medical
condition and current pharmacologic
regimen to remove as many medications as
possible
the process of removing medications it's
not as cut and dried as just stopping
them all together the practitioner and
the patient must work together in a lot
of cases to taper or withdraw as
appropriate with ongoing monitoring
conducted as it is needed so some
studies show that deprescribing leads to
a fewer medications overall which tends
to improve medication adherence
B improving or preserving cognitive
function
C reducing fall risk and D reducing risk
for hospitalization and even death
so deprescribing is something you may
hear about and it is basically the
opposite of prescribing
okay some special considerations with
your geriatric patients so things to
think about
adherence can be challenging in the
elderly population for a variety of
factors so a 1998 study showed that
adherence to pharmacologic regimens
varies based on the drug dosage itself
the form that the drug comes in its cost
physician patient communication and
insurance coverage
complicated regimens and cognitive
decline also play a very key role here
and then we have to look at swallowing
difficulty many elderly patients have
difficulty swallowing so may even avoid
taking pills or avoid taking them in
their original form so let's say you
have a patient who can't swallow pills
so they Crush everything and then they
add it to you know you have to add it to
applesauce or some pudding have you guys
ever tasted a pill that's been crushed
and you try to disguise it in Pudding it
doesn't taste like pudding okay it's
very very bitter tasting and could cause
a decreased medication adherence
patients may not also understand that
they should not Crush extended release
or enteric coated tablets leading to
Serious adverse effects and even
toxicity
and then medications that require very
close monitoring such as Warfarin may be
utilized in appropriately in patients
who maybe don't have the resources for
regular visits to the lab or visits to
the doctor's office
so what can the nurse do to help improve
medication adherence and safety amongst
this patient population so a 2017
systematic review
showed some basic General guidelines
that are nurse-led interventions and
these include lots of patient education
right that's always a component as you
are teaching make sure a that you're
teaching the appropriate person if the
individual you're teaching has severe
dementia you're not teaching the
appropriate person teach the caregiver
the family members whoever it may be and
utilize the teach back method where you
have them teach it back to you that's a
great way to really know okay they got
it
also providing written easy to follow
instructions and written easy to follow
schedules it's not enough just to have
it on the pill bottle have it written
out large print easy to see put it right
there next to the location where they
keep their medications
also the utilization of medication
management tools such as electronic pill
dispensers is really great or simply
those pill organizers that separated out
by day of the week or AM and PM
you can even have reminders via
telephone or electronic devices there
are several apps created specifically
for this purpose
and of course if you are a home health
nurse a visiting nurse assessing all
medications with each home visit and
then when the patient comes into the
inpatient setting or the outpatient
setting like at a clinic or a doctor's
office
so there you have it you guys your basic
guide to pharmacology and the elderly
patient now if you're looking for just
the very basic info let's do a quick too
long didn't read I guess this would be a
too long didn't listen and that is
physiologic changes associated with
aging lead to alterations and absorption
distribution metabolism and excretion of
medications though absorption not as
much a factor as the others the name of
the game is to start low and go slow
the beers list Flags medications that
may be inappropriate for the elderly and
the goal of deprescribing is to enhance
medication safety and adherence in the
elderly and nurse driven interventions
can improve medication adherence and
safety okay you guys who is up for a few
pod quiz questions
if you've never done a pod quiz before I
ask a question I pause for a little bit
give you time to answer and then tell
you the answer basically we are doing
flash cards with our ears and if you
enjoy this format then stay to the end
because I'm going to tell you how you
can get way more pod quizzes in your
life okay so here we go
what are the four pillars of
pharmacokinetics
absorption distribution
metabolism and excretion very good
what is the process of transferring a
drug from the bloodstream into the
tissues
foreign
what is the process drugs go through to
make the drug more or less active and
ready for excretion
that is metabolism
what is the process of the drug moving
from the site of administration into the
bloodstream
that is absorption excellent work
what is the process of removing the drug
from the body
that is excretion you may also hear it
called elimination
what is the key organ in medication
excretion or elimination
that's the kidneys what is the key organ
in metabolism
the liver great job and what is one of
the highest pharmacologic risks for the
elderly
that is polypharmacy and to combat that
we do
deprescribing very very good okay so if
you guys like doing pod quiz questions
and you kind of got a feel for how
beneficial that might be to review
things that you've learned in class or
from listening to this podcast then
you're going to love my new members only
podcast called straight a nursing study
sesh so in this podcast we do a lot of
pod quizzes and not just four or five an
entire episode that dives into a topic
and pod quizzes you on it and then in
addition to that we have drills where we
do recognize there are some things in
nursing school that you need to memorize
for instance if you memorize the blood
flow pathway through the heart and you
know that thing forwards and backwards
then you can apply that to the much
broader concepts of heart failure and
Val of disorders so in drills we drill
things into your head so that when you
do need to memorize something we get it
in there where it belongs and then we
have case studies which is basically
making clinical decisions evaluating
scenario as we go through a patient
situation and then the power hour
sessions are those deep dives into more
extensive Concepts so there's one in
there right now on blood pressure
regulation and it is just amazing and it
comes with a study guide some of the
episodes do come with study guides this
study guide is awesome you guys so I
want you to get your hands on all of
that so you can learn more by going to
straight a nursingstudent.com forward
slash study Dash sesh forward slash
study Dash Sash and all the information
is there there's a bunch of FAQ at the
bottom if you have a question setting it
up is super easy so go check that out
straightynursingstudent.com forward
slash study Dash sesh okay next week you
guys where are the nursing students that
are heading into or in their OB or mom
and baby or whatever they call it at
your school clinical rotation because
we're diving into newborn assessment
specifically the apgar score so I'll see
you back here next week to talk about
that bye for now
[Music]
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