Drug therapy for elderly patients presents a special set of
problems rooted in age-related changes. Physiologically, aging alters body
composition and triggers changes in the digestive
system, liver, and kidneys. These changes
affect drug metabolism, absorption, distribution, and excretion and,
consequently, may lead to the need for altered drug dosages and administration
techniques. They also potentiate adverse reactions to drugs and may interfere
with therapeutic compliance.
Even when an elderly patient receives the optimum drug dosage, he's
still at risk for an adverse drug reaction. Ongoing physiologic changes, poor
compliance with the drug regimen, and greater drug consumption contribute to
elderly patients experiencing twice as many adverse reactions as younger
patients. In fact, about 40% of the people who experience adverse drug reactions
are over age 60.
Many older patients who experience signs and symptoms of adverse
drug reactions (such as confusion, weakness, and lethargy) blame them on the
disease rather than on the drugs they're taking. If the adverse reaction is
unidentified or misidentified, the patient will probably continue taking the
drug. To compound the problem, if the patient has multiple physical dysfunctions
or adverse drug reactions or both, he may consult several physicians or
specialists who—unknown to one another—may prescribe more drugs. If the
patient's drug history remains uninvestigated and the patient takes additional
nonprescription drugs to relieve common complaints (such as indigestion,
dizziness, and constipation), he may innocently fall into a pattern of
inappropriate and excessive drug use. Known as polypharmacy, this pattern imperils the patient's safety and
the drug regimen's effectiveness.
Although many drugs can cause adverse reactions, most serious
reactions in elderly patients result from relatively few drugs—namely
diuretics, antihypertensives, digitalis glycosides, corticosteroids, sleeping
aids, and nonprescription drugs.
Finally, the elderly patient may have difficulty complying with his
drug regimen because of hearing and vision deficits, forgetfulness, the need for
multiple drug therapy, poor understanding of dosage and directions, and various
socioeconomic factors (such as poverty and social isolation). Ensuring
successful compliance with drug therapy requires involving family members, the
pharmacist, and other caregivers in supervision and teaching tailored to the
patient's needs.
Equipment
Patient's medication record • appropriate drugs • written
dosage instructions • optional: compliance aids (pill containers, calendar or
other large-print teaching aids, premeasured injections).
Implementation
Noncompliance in elderly patients is so prevalent that it's no
wonder that most nurses rank handling it as a top priority when planning nursing
care. Follow these procedures to assess the patient's ability
or motivation to follow a drug regimen.
Assessing compliance ability
Preventing reactions that impede compliance
Boosting therapeutic compliance
Special considerations
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Advise the patient to contact you or his physician before taking
any nonprescription medications to avoid adverse drug
interactions. If necessary, regularly monitor serum levels of such drugs
as digoxin and potassium to avoid toxicity.
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When the physician advises discontinuing a drug, instruct the
patient to discard it—in the toilet if possible. This
prevents others from using the drug and ensures that the patient won't continue
taking it by mistake.
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To avoid improper storage and possible drug
deterioration, advise the patient to keep all prescribed drugs in their
original containers. Tell him to keep in mind that some drugs deteriorate when
exposed to light and that others decompose if they come in contact with other
drugs, for example, in a pillbox. Before the patient stores drugs together,
advise him to consult his pharmacist or physician.
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Suggest that the patient store his medications in an area that's
well-lighted (but protected from direct sunlight), not too warm or humid (not
the bathroom medicine cabinet), and some distance from his bedside (not on a
bedside table). If he keeps drugs at his bedside, he could
accidentally overdose by taking them before he's fully awake and
alert.
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Instruct patients to notify health care professionals of the
medications they're taking when planning diagnostic testing, procedures, surgery
or epidural injections because some medications (such as
diabetic agents and anticoagulants) must be discontinued before the event to
avoid adverse effects.
Home care
If the patient is discharged from the facility with a new drug
regimen, schedule him for follow-up care by a visiting nurse to assess his ability to follow the regimen and to monitor his
response to therapy.
Documentation
Document all assessment findings and laboratory test results in the
patient's chart. Record all instructions and teaching materials given to the
patient, family members, or other caregivers. Keep a record of all drugs,
dosages, and adverse reactions and interventions. Describe the patient's
understanding of his drug regimen. Note all health and social service agency
referrals.
