Drug Therapy for Elderly Patients

Four out of five people over age 65 have one or more chronic disorders. This helps explain why elderly people consume more medications than any other age-group. Although elderly adults represent only 12% of the population, they take 30% to 40% of the prescription drugs dispensed. That's about 400 million prescriptions per year, or twice the number of prescriptions filled for people under age 65.

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

• 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.
• 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.
• 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.
• 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.
• 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.