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Lifespan Considerations in Pharmacotherapy PART 2 Prepared By Jonathan Q. Ibalio, MD College Pharmacotherapy of Preschoolers and School-Aged Children  The preschool child ranges in age from 3 to 5 years. During this period,...

Lifespan Considerations in Pharmacotherapy PART 2 Prepared By Jonathan Q. Ibalio, MD College Pharmacotherapy of Preschoolers and School-Aged Children  The preschool child ranges in age from 3 to 5 years. During this period, the child begins to refine gross and fine motor skills and develop language abilities. The child initiates new activities and becomes more socially involved with other children. Preschoolers can sometimes comprehend the difference between health and illness and that medications are administered to help them feel better. Nonetheless, medications and other potentially dangerous products must still be safely stowed out of the child’s reach. Lifespan Considerations in Pharmacotherapy  In general, principles of medication administration that pertain to the toddler also apply to this age group. Preschoolers cooperate in taking oral medications if they are crushed or mixed with food or flavored beverages. After a child has been walking for about a year, the ventrogluteal site may be used for IM injections, as it causes less pain than the vastus lateralis site. The scalp veins can no longer be used for IV access; peripheral veins are used for IV injections. Lifespan Considerations in Pharmacotherapy  Like the toddler, preschoolers often physically resist medication administration and a long, detailed explanation of the procedure will promote anxiety. A brief explanation followed quickly by medication administration is usually the best method. Uncooperative children may need to be restrained, and clients over 4 years of age may require two adults to administer the medication. Lifespan Considerations in Pharmacotherapy  Before and after medication procedures, the child may benefit from opportunities to play-act troubling experiences with dolls. When the child plays the role of doctor or nurse by giving a “sick” doll a pill or injection, comforting the doll, and explaining that the doll will now feel better, the little actor feels safer and more in control of the situation. Lifespan Considerations in Pharmacotherapy  The school-aged child is between 6 and 12 years of age. Some refer to this period as the middle childhood years. This is the time in a child’s life when there is progression away from the family-centered environment to the larger peer relationship environment. Rapid physical, mental, and social development occur and early ethical-moral development begins to take shape. Thinking processes become progressively logical and more consistent. Lifespan Considerations in Pharmacotherapy  During this time, most children remain relatively healthy, with immune system development well under way. Respiratory infections and GI upsets are the most common complaints. Because the child feels well most of the time, there is little concept of illness or the risks involved with ingesting a harmful substance offered to the child by a peer or older person. Lifespan Considerations in Pharmacotherapy  The nurse is usually able to gain considerable cooperation from school- aged children. Longer, more detailed explanations may be of value because the child has developed some reasoning ability and can understand the relationship between the medicine and feeling better. When children are old enough to welcome choices, they can be offered limited dosing alternatives to provide a sense of control and encourage cooperation. The option of taking one medication before another or the chance to choose which drink will follow a chewable tablet helps to distract children from the issue of whether they will take the medication at all. It also makes an otherwise strange or unpleasant experience a little more enjoyable. Lifespan Considerations in Pharmacotherapy  Making children feel that they are willing participants in medication administration, rather than victims, is an important foundation for compliance. Praise for cooperation is appropriate for any pediatric client and will set the stage for successful medication administration in the future. School-aged children can take chewable tablets and may be able to swallow tablets or capsules. Lifespan Considerations in Pharmacotherapy  Many still resist injections; however, an experienced pediatric nurse can usually administer parenteral medications quickly and compassionately, without the need to restrain the child. The ventrogluteal site is preferred for IM injections, although the muscles of older children are developed enough for the nurse to use other sites. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Adolescents  Adolescence is the time between ages 13 and 18 years. A person in this age group is able to think in abstract terms and come to logical conclusions based on a given set of observations. Rapid physical growth and psychological maturation have a great impact on personality development. The adolescent relates strongly to peers, wanting and needing their support, approval, and presence. Physical appearance and conformity with peers in terms of behaviour, dress, and social interactions is important. Lifespan Considerations in Pharmacotherapy  The most common needs for pharmacotherapy in this age group are skin problems, headaches, menstrual symptoms, and sports-related injuries. There is an increased need for contraceptive information and counselling about sexually related health problems. Since bulimia occurs in this population, the nurse should carefully question adolescents about their eating habits and their use of OTC appetite suppressants or laxatives. Lifespan Considerations in Pharmacotherapy  Tobacco use and illicit drug experimentation may be prevalent in this population. Teenage athletes may use amphetamines to delay the onset of fatigue, as well as anabolic steroids to increase muscle strength and endurance. The nurse assumes a key role in educating adolescent clients about the hazards of tobacco use and illicit drugs. The adolescent has a need for privacy and control in drug administration. The nurse should seek complete cooperation and communicate with the teen more in the manner of an adult than a child. Lifespan Considerations in Pharmacotherapy  Teens usually appreciate thorough explanations of their treatment, and ample time should be allowed for them to ask questions. Adolescents are often reluctant to admit their lack of knowledge, so the nurse should carefully explain important information about their medications and expected side effects, even if the client claims to understand. Teens are easily embarrassed, and the nurse should be sensitive to their need for self-expression, privacy, and individuality, particularly when parents, siblings, or friends are present. Lifespan Considerations in Pharmacotherapy Pharmacotherapy in Adulthood  When considering adult health, it is customary to divide this period of life into three stages: young adulthood (18 to 40 years), middle adulthood (40 to 65 years), and older adulthood (older than 65 years). Within each of these divisions are similar biophysical, psychosocial, and spiritual characteristics that affect nursing and pharmacotherapy. Lifespan Considerations in Pharmacotherapy  Pharmacotherapy of Young and Middle-Aged Adults The health status of younger adults is generally good; absorption, nmetabolic, and excretion mechanisms are at their peak. There is minimal need for prescription drugs unless chronic diseases such as diabetes or immune-related conditions exist. The use of vitamins, minerals, and herbal remedies is prevalent in young adulthood. Prescription drugs are usually related to contraception or agents needed during pregnancy and delivery. Medication compliance is positive within this age range, as there is clear comprehension of benefit in terms of longevity and feeling well. Lifespan Considerations in Pharmacotherapy  Pharmacotherapy of Young and Middle-Aged Adults Substance abuse is a cause for concern in the 18 to 24 age group, with alcohol, tobacco products, amphetamines, and illicit drugs (marijuana and cocaine) being a problem. For young adults who are sexually active with multiple partners, prescription medications for the treatment of herpes, gonorrhea, syphilis, and human immunodeficiency virus (HIV) infection may be necessary. The physical status of the middle-aged adult is on par with the young adult until about 45 years of age. During this period of life, numerous transitions occur that often result in excessive stress. Lifespan Considerations in Pharmacotherapy  Pharmacotherapy of Young and Middle-Aged Adults Middle-aged adults are sometimes referred to as the “sandwich generation” because they are often caring for aging parents as well as children and grandchildren. Because of the pressures of work and family, they often take medication to control health alterations that could best be treated with positive lifestyle modifications. The nurse must emphasize the importance of lifestyle choices, such as limiting lipid intake, maintaining optimum weight, and exercising, to overall health. Lifespan Considerations in Pharmacotherapy  Pharmacotherapy of Young and Middle-Aged Adults Health impairments related to cardiovascular disease, hypertension, obesity, arthritis, cancer, and anxiety begin to surface in middle age. Gender-related differences in pharmacokinetics and disease comorbidity may influence pharmacotherapy. The use of drugs to treat hypertension, hyperlipidemia, digestive disorders, erectile dysfunction, and arthritis is becoming more common. Lifespan Considerations in Pharmacotherapy  Pharmacotherapy of Young and Middle-Aged Adults Respiratory disorders related to lifelong tobacco use or exposure to secondhand smoke and environmental toxins may develop that require drug therapies. Adult onset diabetes mellitus often emerges during this time of life. The use of antidepressants and antianxiety agents is prominent in the over-50 population. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults During the 20th century, an improved quality of life and the ability to effectively treat many diseases contributed to increased longevity. The risk of chronic health disorders is greater in older adults, and they are more likely to be prescribed drugs to treat them. The taking of multiple drugs concurrently, known as polypharmacy, has become commonplace among many older adults. Polypharmacy dramatically increases the risk of drug interactions and side effects. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults Although predictable physiological and psychosocial changes occur with aging, significant variability exists among clients. Cognitive decline and memory loss may occur in older adults. However, many older adults are healthy and live independently. The nurse should avoid preconceived notions that elderly clients will have physical or cognitive impairment simply because they havereached a certain age. Careful assessment is always necessary. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults When administering medications to older adults, offer the client the same degree of independence and dignity that would be afforded middle-aged adults, unless otherwise indicated. Like their younger counterparts, older clients have a need to understand why they are receiving a drug and what outcomes are expected. Accommodations must be made for older adults who have certain impairments. Visual and auditory changes make it important for the nurse to provide drug instructions in large type and to obtain client feedback to be certain that medication instructions have been understood. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults Elderly clients with cognitive decline and memory loss can benefit from aids such as alarmed pill containers, medicine management boxes, and clearly written instructions. During assessment, the nurse should determine if the client is capable of self-administering medications or whether the assistance of a caregiver will be required. As long as small children are not present in the household, older clients with arthritis should be encouraged to ask the pharmacist for medication bottles with caps specially designed for ease of opening. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults Older clients experience more adverse effects from drug therapy than any other age group. Although some of these effects are due to polypharmacy, many of the adverse events are predictable, based on normal physiological and biochemical processes that may occur during aging. The principal complications of drug therapy in the older adult population are degeneration of organ systems, multiple and severe illnesses, multiple drug therapy, and unreliable compliance. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults By understanding these changes, the nurse can avoid many adverse drug effects in older clients. In older clients, the functioning of all major organ systems slowly declines. For this reason, all phases of pharmacokinetics are affected, and appropriate adjustments in therapy need to be implemented. Although most of the pharmacokinetic changes are due to reduced hepatic and renal drug elimination, other systems may also show a variety of changes. For example, immune system function diminishes with aging, so autoimmune diseases and infections occur more frequently in elderly clients. Therefore, there is an increased need for influenza and pneumonia vaccinations. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults Normal physiological changes that affect pharmacotherapy of the older adult are summarized as follows: – Absorption: In general, absorption of drugs is slower in the older adult because of diminished gastric motility and decreased blood flow to digestive organs. – Increased gastric pH can delay absorption of medications that require high acidity to dissolve. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults – Distribution: Increased body fat in the older adult provides a larger storage compartment for lipid-soluble drugs and vitamins. – Plasma levels are reduced, and the therapeutic response is diminished. – Older adults have less body water, making the effects of dehydration more dramatic and increasing the risk for drug toxicity. For example, elderly clients who have reduced body fluid experience more orthostatic hypotension. – The decline in lean body mass and total body water leads to an increased concentration of water-soluble drugs because the drug is distributed in a smaller volume of water. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults – The aging liver produces less albumin, resulting in decreased plasma protein binding ability and increased levels of free drug in the bloodstream, thereby increasing the potential for drug-drug interactions. – The aging cardiovascular system has decreased cardiac output and less efficient blood circulation, which slow drug distribution. This makes it important to initiate pharmacotherapy with smaller dosages and slowly increase the amount to a safe, effective level.. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults – Metabolism: The liver’s production of enzymes decreases, liver mass decreases, and the visceral blood flow is diminished, resulting in reduced hepatic drug metabolism. – This change leads to an increase in the half-life of many drugs, which prolongs and intensifies the drug response. The decline in hepatic function reduces first-pass metabolism. (Recall that first-pass metabolism relates to the amount of a drug that is metabolized during the first circulation through the liver after the drug has been absorbed by the intestinal tract.) – Therefore, plasma levels are elevated, and tissue concentrations are increased for the particular drug. This change alters the standard dosage, the interval between doses, and the duration of side effects. Lifespan Considerations in Pharmacotherapy Pharmacotherapy of Older Adults – Excretion: Older adults have reductions in renal blood flow, glomerular filtration rate, active tubular secretion, and nephron function. – This decreases excretion for drugs that are eliminated by the kidneys. – When excretion is reduced, serum drug levels and the potential for toxicity markedly increase. Administration schedules and dosage amounts may need to be altered in many older adults because of these changes in kidney function. – Keep in mind that the most common cause of adverse drug reactions in older adults is the accumulation of toxic amounts of drugs secondary to impaired renal excretion. Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Drug adherence or compliance is the willingness and ability to take medications as instructed on the label or by the healthcare provider. ▪ Healthcare providers often assume that clients leaving the clinic or hospital will be adherent, fill their prescriptions, and take their medications as directed. ▪ It may be surprising to learn that more than a third of clients report that they are often nonadherent with drug therapy. Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Reasons for nonadherence are many and varied but include the following client responses (Martin et al., 2010): ▪ Did not have the medicine on hand when it was time to take the dose (31%) ▪ Ran out of medicine (29.5%) ▪ Bothered by side effects (22.4%) ▪ Change in daily routine (21.4%) ▪ Felt better (16.4%) Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Although nonadherence is not unique to older adults, this population is especially vulnerable. Older adult clients are more likely to have visual impairment, functional disabilities, and cognitive dysfunction that may be sources of medication errors and nonadherence. ▪ Functional hearing loss can prevent older adults from understanding the verbal instructions given by the healthcare provider. ▪ The large number of drugs taken by some older adults makes for a complicated dosing schedule that can be confusing for clients of any age.. Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Successful management of medical problems depends on a client’s adherence to the regimen. ▪ One of the main responsibilities of the nurse is to assess barriers to medication adherence in the older adult. ▪ Studies suggest that nonadherence is affected by three factors: the individual client, the healthcare provider, and the client’s social support network Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Adherence at the client level requires the client’s comprehension and commitment to the treatment. ▪ The client must be able to afford the medication, believe in its efficacy, appropriately selfadminister, and adjust to lifestyle changes that may be required. ▪ The healthcare provider must be able to effectively instruct the client regarding a medication’s efficacy, prescribe cost-effective medication, decrease the complexity of the regimen, and provide manageable and understandable instructions. ▪ Nurses play a key role in assessing the client’s understanding of the medications that have been ordered and assessing client concerns about cost or adverse effects. Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ The nurse should provide the older adult’s spouse or caregiver with adequate information about the client’s medication regimen, expected lifestyle changes, and the need for emotional support and monitoring. ▪ Drug misuse is a specific form of nonadherence that is common among older adults. Misuse includes overuse, underuse, or in some cases, erratic use. This misuse may be accidental or deliberate. Self-adjusting the medication dose is a common practice: clients change their dose level depending on how they feel. Lifespan Considerations in Pharmacotherapy Adherence to the Therapeutic Regimen ▪ Some believe that taking extra doses will speed their recovery. Clients rarely report such practices to their healthcare provider. ▪ Drug misuse may have serious consequences: many older adult visits to emergency departments are drug related, with nonadherence accounting for a substantial percentage Lifespan Considerations in Pharmacotherapy Lifespan Considerations in Pharmacotherapy Thank you…