Older Adult (OA)

How a drug interacts at the receptor site or at target organ.

Time, course, and affect of the drug on the cells

Noncompliance/Nonadhearance

Not taking prescribed drugs as indicated.

With a drug regimen can be a problem in client age groups. Fails to ask questions during interactions w/ health care providers; there for the regimen may not be fully understood or precisely followed. Can cause under or over dosing.

• Bleeding may occur with chronic use in OA's
• Warfarin (Coumadin) is 99% protein bound; with a decrease in serum albumin, which is common in OA, there is an increase in free, unbound ciurculating warfarin and a potential risk for bleeding
• OA should have their prothrombin time (PT) or international normalized ratio (INR) checked periodically
• Nurse should be aware of any bleeding and check regularly

• Penecillins, cephalosporins, tetracyclines, and sulfonamides are normally considered safe for OA's
• If renal drug clearance is decreased and the drug has a prolonged t½, the dose should be reduced
• Aminoglycosides, fluoroquinolones (quinolones), and vancomycin are excreted in urine and are not frequently prescribed for people 75yrs and older, but if prescribed it is usually a reduced dosage

• Histamine (H2) blockers and sucrafate are safer drugs than other antiulcer agents for the treatment of peptic ulcers
• Cimetidine (Tagamet) was the first histamine blocker or antagonist and is not suggest for OA's because of its side effects and multiple potential drug interactions
• Ranitidine, famotidine, and nizatidine may be prescribed for the OA instead of Cimetidine
• Laxatives are frequently taken by OA's in LTC
• 75% of residents take them on a daily basis, which may cause fluid and electrolyte imbalances with excessive use
• Increased GI motility with laxative use could decrease other drug absorptions
• Nonpharmacologic measures such as increase fluid, consume high-fiber foods like prunes, and exercising should be encouraged

• Dose for OA is normally 30%-50% of the dose for young/middle age adults
• Should gradually increase acordding to tolerance and desired therapeutic effect
• Closely monitor for adverse reactions
• Trycyclic antidepressants are fenerally effective in the OA population, but they have anticholinergic properties that can cause side effects: dry mouth, tachycardia, constipations, and urinary retention and can also contribute to narrow angle glaucoma
• Fluoxetine (Prozac), a bicyclic antidepressant, has fewer side effects than tricyclic, and the side effects are usually related to the dosing
• Monoamine Oxidase (MAO) inhibitors are not often prescribed for OA's because of adverse reactions to such as drug-food interactions which could result in hypertensive crisis and severe orthostatic hypotension

• Narcotics can cause dosing adverse reactions when taken by OA's
• Hypotension and respiratory depression may result
• Close monitoring of vital signs is essential when OA is on these meds

• Prescribed for insomnia and sleep disorders, they are sleep inducing drugs
• Insomnia is a freqent problem in OA's
• 2nd most common group of drugs prescribed or OTC
• 5 Benzodiazepine Hypnotics (Flurazepam, quazepam, temazepam, trazolam, and estazolam) have been approved by the FDA as hypnotics and used to control insomnia
• For OA's. low doses of benzodiazepines w/ a short or intermediate t½ are usally prescribed
• Short term therapy is suggested
• Higher doses for sedative and hypnotic effects and lower doses for anti-anxiety effects
• About 35% of OA population takes a hypnotic 
• Extremely long t½ in OA (often days), producing prolonged sedation, and increased incidence of falls and fractures
• Medium/Short acting benzodiazepines are preferred
• Other benzodiazepines are more effective as anxiolytics (anti-anxiety) than hypnotics

• 1st benzodiazepine hypnotic
• 3 metabolites and shot/long acting hypnotic
• Principal Metabolite: Desalkylfurazepam: Long acting, t½ is long, and slowly eliminated
• Not suggested for OA's
• Drug hangover is a problem

• Effects similar to flurazepam
• Precursor of desalkylflurazepam and has a prolonged t½

• Because of its biotransformed in the liver by conjugation and not by oxidation, prescribed frequently for OA's
• Principle metabolite: glucuronide: conjugated w/ no pharmacologic effects and excreted in the urine
• slowly absorbed, 1-2 hrs before bedtime
• Intermediate-acting benzodiazepine
• Food delays action
• More efective for frequent awakenings during the night than for falling asleep

• Intermediate-acting benzodazepine
• short life and at low doese (0.0625 to 0.125 mg)
• Safe for OA's
• Metabolized by hepatic microsomal oxidation
• Helps with problems falling asleep, decreases frequent awakenings
• should be tapered rather than abruptly stopped to avoid rebound insomnia

• Intermediate/long acting drug
• Metabolized in the liver to 2 metabolites that are not highly potent

• Intermediate t½, taken 1 hr before bed time

• Diuretics are frequently prescribed for treatment of hypertension or Heart Failure (HF)
• Dose is usually reduced because of dose related side effects
• Hydrochlorothiazide (HydroDIURIL): generally prescribed in low doses of 12.5 mg/day, higher doses of 25-50 mg/day with chronic use can lead to electrolyte imbalances (e.g. hypokalemia, hyponatremia, hypomagnesemia, hypercalcemia), hyperglycemia, hyperuricemia, and hypercholestrolemia
• Non-pharmacologic methods to reduce BP such as exercise, wt reduction if obese, reduction of salt and alcohol intake, and adequate rest are suggested
• These actions can reduce the systolic and diastolic pressure by 8-10 mmHg
• Drugs such as diuretics, beta-andrenergic blockers, or antagonists, calcium channel blockers, angiotensin-converting (ACE) inhibitors, angiotensin II receptor antagonists (AII-blockers), and centrally acting alpha-2 agonists are used as anti-hypertensives

• Calcium blockers, angiotension-converting inhibitors, and AII blockers are frequently the agents of choice because of their low incidence of electrolyte imbalance and CNS side effects
• Antihypertensives dosing for OA's begin with reduced doses that are gradually increased according to need, tolerance, and adverse reactions
• Because of adverse reactions such as orthostatic hypotension, alpha-1 blockers or antagonists (prazosin and terazosin) and centrally acting alpha 2 agonists (mehtyldopa, clonidine, guanabenz, and guanfacine) are frequently prescribed to OA's

• Digoxin is commonly prescribed for OA, however long term use of the drug should be carefully monitored because of its narrow therapeutic range (0.5-2 ng/ml) and the possibility of digitalis toxicity
• Digoxin is given for left ventricular heart failure, chronic atrial fibrilation, and atrial tachycardia

• t½ is doubled (70hrs) in people 80yrs and older

• Eliminated by kidneys, decrease of kidney function (decreased GFR) could cause drug accumulation

• Close monitoring of serum digoxin levels, creatinine clearance test, and vital signs (pulse should not be <60 bpm)

• Safe for OA's