Four of five persons over age 65 have one or more chronic disorders. This helps explain why elderly patients consume more drugs than any other age-group. Although elderly adults represent only 12% of the population, they take 30% to 40% of the prescription drugs issued. That’s about 400 million prescriptions a year, or twice the number of prescriptions filled for persons 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 dosage and administration techniques. They also potentiate adverse reactions to drugs and may interfere with therapeutic compliance. (See How age affects drug action and Modifying I.M. injections.)
Even when the 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.
Signs and symptoms of adverse drug reactions (such as confusion, weakness, and lethargy) are typically blamed on disease. 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 doctors or specialists who — unknown to one another — may prescribe more drugs. If the patient’s drug history remains uninvestigated and if 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, anticoagulants, 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 requires involving family members, the pharmacist, and other caregivers in supervision and teaching tailored to the patient’s needs.
Patient’s medication record. Appropriate drugs. Written dosage instructions. Optional:
compliance aids (pill containers, calendar or other large-print teaching aids, premeasured injections).
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
- Review the patient’s complaint, and obtain a comprehensive health and drug history. Question the patient about use of herbal preparations or other complementary therapies.
- Keeping in mind that discharge planning begins at admission, evaluate the patient’s physical ability to take drugs. Can he read drug labels and directions? Does he identify drugs by sight or by touch? Can he open drug bottles easily? If he’s disabled by Parkinson’s disease or arthritis, for example, or if he lacks manual dexterity for any reason, advise him to ask his pharmacist for snap or screw caps (rather than childproof closures) for his drug containers.
- Evaluate the patient’s cognitive skills. Can he remember to take prescribed drugs on time and regularly? Can he remember where he stored his drugs? If not, refer him to appropriate community resources for supervision.
- Assess the patient’s lifestyle. Does he live with family or friends? If so, include them in your patient-teaching sessions if possible. Does he live alone or with a debilitated spouse? If so, he’ll need continuing support from a visiting nurse or other caregiver.
- Keep in mind that inadequate supervision may result in drug misuse. Make appropriate referrals and contact appropriate social agencies to ensure compliance and safety and to provide financial assistance if necessary.
- Assess the patient’s beliefs concerning drug use. For example, the patient may believe that chronic use of medication is a sign of illness or weakness and therefore may take his medications erratically.
- Ask the patient whether his prescribed medication regimen interferes with his daily routine.
Preventing reactions that impede compliance
- Discuss the patient’s drug therapy with him. As he receives drugs, name them, explain their intended effect, and describe possible adverse reactions to watch for and report. (See Recognizing common adverse reactions in elderly patients.)
- Tell the patient that you’ll ask questions to help identify (or reduce the risk of) harmful food or drug interactions (such as those caused by alcohol or caffeine) that may interfere with compliance.
- Ask the patient about all drugs — prescription and nonprescription — he is currently taking and those he’s taken in the past. If possible, ask to see samples. Have him name each drug and tell you why, when, and how often he takes it. Remember, the patient may have drugs prescribed by more than one doctor. Also ask whether he’s taking any drugs originally prescribed for another person (a common occurrence).
- If your facility has a specially designed computer program, use it to help prevent possible drug interactions. Enter all the data you’ve collected on drug dosage, frequency, and administration route into a master file of drugs commonly used by elderly patients, such as anticoagulants (warfarin), benzodiazepines (diazepam), beta blockers (propranolol), calcium channel blockers (verapamil), digitalis glycosides (digoxin), and diuretics (furosemide). From this information the computer compiles a list of the patient’s drugs, possible adverse reactions, potential interactions, and suggested interventions. Then review the findings with the patient. If he knows what to expect, he’ll be more likely to comply with treatment. (If you don’t have access to such technology, you can compile a similar list using a reputable drug reference.)
- Alternatively, encourage the patient to purchase drugs from only one pharmacy, preferably one that maintains a drug profile for each customer. Advise him to consult the pharmacist, who can anticipate drug interactions before they occur.
- Inform the patient about specific food-drug interactions. Based on the information in your drug history, provide a list of food items to avoid.
Boosting therapeutic compliance
- To circumvent noncompliance caused by visual impairment, provide dosage instructions in large print, if necessary.
- To alter eating habits that lead to noncompliance, emphasize which drugs the patient must take with food and which he must take on an empty stomach. Explain that taking some drugs on an empty stomach may cause nausea, whereas taking some drugs on a full stomach may interfere with absorption. Also find out whether the patient eats regularly or skips meals. If he skips meals, he may be skipping doses, too. As needed, help him coordinate his drug administration schedule with his eating habits.
- To correct problems related to drug form and administration, help the patient find easier ways to take medicine. For example, if he can’t swallow pills or capsules, switch to a liquid or powdered form of the drug if possible. Or, suggest that he slide the tablet down with soft food such as applesauce. Keep in mind which tablets you can crush and which you can’t. For example, enteric-coated tablets, timed-release capsules, and sublingual or buccal tablets shouldn’t be crushed. Doing so may affect absorption and effectiveness. Some crushed drugs may taste bitter and may stain or irritate oral mucosa.
- Suggest the use of compliance aids, such as pill containers and premeasured injections.
- If mobility or transportation deters compliance, help the patient locate a pharmacy that refills and delivers prescriptions. If appropriate, consider using a mail-order pharmacy.
- If forgetfulness interferes with compliance, devise a system for helping the patient remember to take his drugs properly. Suggest that the patient or a family member purchase or make a scheduling aid, such as a calendar, checklist, alarm wristwatch, or compartmented drug container. (See Using compliance aids.)
- Some patients may try to save money by not having prescriptions filled or refilled or by taking fewer doses than ordered to make the drug last longer. If financial considerations are preventing your patient’s compliance, help him explore available resources. Suggest using less-expensive generic equivalents of name-brand drugs whenever possible. Also, explore ways that family members can help, or refer the patient to the social service department and appropriate community agencies. Many states have programs to help low-income, elderly patients buy needed drugs.
- Advise the patient to contact you or his doctor before taking any nonprescription drugs to avoid adverse drug interactions. If necessary, regularly monitor serum levels of drugs, such as digoxin or potassium, to avoid toxicity.
- When the doctor 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; 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 doctor.
- Suggest a storage area that’s well-lighted (but protected from direct sunlight), not too warm or humid (not the bathroom medicine chest), and some distance from the patient’s bedside (not on a bedside table). If he keeps drugs at his bedside, he may give himself an accidental overdose by taking them before he’s fully awake and alert.
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.
Reference: Procedures version 2.1