Adverse Drug Effects on Elderly Patients Homework Help
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Reasons why elderly patients are prone to adverse drug effects
- Smaller bodies and different body composition
Older people generally weigh less. Their bodies have a smaller amount of water compared to the bodies of younger adults and have a larger proportion of fat. Due to increased fat, people between 40-60 years will increase their body weight.
Around 60-70 years, bodyweight starts to decrease and decreases even more once a person is over 70 years. This means that the quantity of drug per pound of body water or pound of body weight is higher in older adults than it would be if the same quantity of the drug was given to a younger adult.
Drugs that concentrate on fat tissue will remain in the body of an elderly person because their body has more fat for more accumulation of drugs.
- the Decreased ability of the liver to process drugs
In elderly people, the liver does not work as effectively as it used to at their younger age. This interferes with how drugs are used to treat high blood pressure and heart conditions in addition to other drugs that are processed by the liver. A decrease in liver function affects the body’s ability to get rid of drugs like Librium and valium.
- the Decreased ability of the kidneys to clear drugs out of the body
Between the age of 35 and 40 years, the kidneys’ ability to clear out drugs from the body decreases. The ability of the kidney to filter out drugs reduces by almost 30 % by the time a person is 65 years old.
Other functions of the kidney continue to decline as well as the person continues to grow old. This has a great effect on the safety of a lot of drugs.
- Increased sensitivity to a lot of drugs
Problems such as changes in body composition, reduced body size, and reduced liver and kidney function cause the accumulation of many drugs in the bodies of older people. Sometimes this accumulation is at very dangerous levels. This dangerous accumulation also lasts longer in older adults than it would in younger adults.
Older adults are usually more sensitive to the effects of drugs even at normal blood levels. This problem is worsened by problems related to old age. This may result in harm. A good example of such a case is the use of drugs that affect the nervous system like strong painkillers, alcohol tranquilizers and sleeping pills, and drugs that have anticholinergic effects.
- Decreased blood pressure maintaining the ability
Older adults are more vulnerable to adverse drug effects because their bodies are less able to compensate for some of these effects. Additionally, they are more sensitive to the intended effects of drugs.
A good example of the reduced ability of older adults to compensate for some effects of drugs is when they suddenly rise from a seated position or get out of bed. As you rise, the blood pressure falls and this reduces the flow of blood to the head which reduces the flow of blood to the brain.
The bodies of younger people can compensate for this. The receptors found in the neck sense the decrease in blood pressure as they rise. These receptors tighten up blood vessels in other parts of the body to ensure the overall blood pressure high enough.
In older adults, however, the receptors are not as efficient. This is why when older adults suddenly rise, they will feel lightheaded, giddy, and even feel dizzy. In some cases, they may faint if blood pressure in the head reduces rapidly.
The ability of older adults to maintain proper blood pressure is weakened by the use of several drugs the most common being high blood pressure drugs. Antiarrhythmics, sleeping pills, antipsychotic drugs, antihistamines, and tranquilizers cause an exaggerated drop in blood pressure.
The sudden decrease in blood pressure when a person stand is called postural hypotension. Postural hypotension is mostly caused by a combination of drugs and old age. Postural hypotension can be catastrophic if it causes falls that can lead to hip fractures or serious injuries that may result in death.
- Decreased temperature compensation
The ability to withstand very high or very low temperatures is better in younger adults compared to older adults. Younger adults sweat and their blood vessels dilate to get rid of heat when it is hot. Their blood vessels constrict when it is cold
However, older adults, their bodies are not able to do the same. Just like the issue of blood pressure compensation is worsened by other factors such as age and drugs, difficulty in regulating temperatures can also be worsened by several drugs.
At times, this can result in life-threatening changes in body temperature and can be fatal. A lot of old people’s deaths during prolonged cold spells and heat waves are caused by drugs that interfere with their bodies’ ability to regulate temperatures.
This is because they were unable to sense that they were at increased risk. Drugs with anticholinergic effects warning have this harmful effect especially on withstanding heat waves.
- More diseases that affect their response to drugs
Older adults are more likely to have one or more diseases like kidney damage. They are much more likely to have poor circulation and chronic conditions that change the way their bodies respond to drugs. However, not much is known about the effect of multiple diseases on the effects of drugs in the elderly.
A good example is the effect of drug failure on how people handle drugs. Heart failure occurs when the heart is unable to pump as much blood as it used to. When heart failure occurs, the flow of blood to the kidneys also reduces. This reduced flow of blood to the kidneys reduces the ability of the kidney to get rid of drugs from the blood and excrete them through the urine.
- More drugs therefore more adverse reactions and interactions
Compared to younger adults, older adults use more prescription drugs, which increases the odds of a severe drug reaction that can be caused by dangerous interaction between two drugs.
In addition to their usual prescription drugs, older adults may need to take one or more over-the-counter drugs. This increases the possibility of adverse drug interactions. An adverse drug interaction can occur when a drug causes the second drug to accumulate to levels that are dangerous to the body.
- Inadequate testing of drugs in older adults before they are approved
Even though older adults use a large percentage of prescription drugs, very few of these drugs are adequately tested on them before they are approved by FDA. However, the good news is that the FDA now requires that drugs should be tested on those who will use them if it gets approval. In the long run, this will help tackle this problem.
However, most of the drugs in the market today mostly used by older adults were not adequately tested on them before they were approved.
Steps of Minimizing Adverse Drug Effects in Elderly Patients
It is impossible to avoid altered polypharmacy and pharmacokinetics in most elderly patients. When prescribing medication for use by elderly patients, the preferred approach is to respect the individual needs of every patient.
Steps that can help reduce adverse drug effects in elderly patients are:
- Maintaining an accurate record of all medications being used by the elderly patient. Ask them to bring all the medications they are using when they come to the clinic. This should include complementary and over-the-counter medications.
- Monitoring the number of medications to be able to balance the need and avoid polypharmacy as you minimize underuse of the important drugs.
- Reducing individual doses when appropriate. You should titrate them carefully starting with a low dose. This is done when pharmacodynamic sensitivity is the problem.
- Using simple regimens of medication. Choosing the preparation suitable for the patient and minimizing the dose whenever appropriate. Do not advise the patient to break a tablet into two or more pieces.
- Ensuring elderly patients safely manage medications. Patients should be involved when deciding on their therapy and they should be educated on the important side effects and how to handle these side effects.
- Utilizing the available strategies and inter-disciplinary collaboration to improve the quality use of medications.
- Encouraging therapeutic drug monitoring although it should not replace clinical observation. Adverse drug reactions should be considered as the possible cause of the new problems.
Approaches to improving safety
- Incident reporting systems
This is one of the approaches that can be used to address issues to do with patient safety in healthcare. It involves reporting near misses and reporting adverse events. These systems are aimed at understanding why and how these adverse effects occur. People can learn from such events and prevent them from recurring in the future.
Such systems identify causes, differences, similarities, and contributing factors of incidents, and the information gathered is used to develop strategies for preventing such events in the future.
These systems target organizational culture and promote a safety culture. This encourages reporting of errors. Blame is shifted from individuals as people begin to realize that sometimes organizational circumstances too contribute to covering up errors.
Incident reporting systems are more common in secondary care but are being considered for primary care as well due to their potential. Organizational factors that promote incident reporting are fair and open and create a strong safety culture.
They also promote a clear definition of the type of events to report, anonymity, feedback, and the value of reporting. However, the main barrier to reporting using these systems is reporting.
- Investigating errors
The most effective technique for identifying and analyzing adverse events is a significant event analysis. This involves studying clinical databases, root-cause analysis, and chart reviews.
The root-cause analysis involves identifying the conditions that cause adverse events to identify failures in the spot system and hazards. Chart reviews include gathering medical records from different settings and reviewing them to identify adverse events and analyze them for causality and how they can be prevented.
A clinical database involves searching for electronic records from problems that are known using the computer. However, computer systems are not so common in secondary care. This greatly reduces their applicability. A clinical database is an alternative to chart review techniques and is a cheap alternative.
Adverse events can be identified and analyzed using the Failure Modes and Effects Analysis. This method aims at identifying risk factors that may lead to patient safety events and how to reduce their impact.
Despite the many advantages that come with this approach, it is criticized for being expensive and for its high reliance on individual experiences.
- Proactive intervention
3 proactive intervention approaches have proven to be successful in reducing adverse events related to medication. They are the educational outreach interventions, interventions that utilize computer systems, and pharmacist-led medication reviews.
- Pharmacist-led medication review – medications being used by the patient are re-examined. An assessment of the action that can be taken to reduce problems related to drugs is done.
Additionally, an assessment of how benefits related to drugs can be maximized is also done. The practitioner and the patient both make decisions on future treatment and changes in medications.
Pharmacists’ participation during medication rounds especially in secondary care has helped reduce cases of adverse drug effects. The decrease in mortality rates is attributed to clinical pharmacy services.
In primary care, pharmacist-led interventions are not researched as much. However, there is evidence to show they are effective in improving prescribing behavior of pharmacists and in reducing the need for hospitalization.
There is a need for more compelling evidence.
- Educational outreach interventions – educational outreach visits are effective in changing the behavior of professionals and increasing reporting of adverse drug reactions by physicians.
Feedback and audit techniques that are used in educational outreach visits are successful in improving the practice of medical professionals. However, there is little data on how cost-effective this intervention is.
- Utilizing computer systems – examples of computer systems that are used are clinical decision support and computerized physician order entry. In CPOE, physicians enter medication orders into the computer. This information is integrated with additional information about the patient.
Advantages of using computer systems include drug-drug interactions, computerized warnings of possible contraindications, integration of the prescription with the patient’s history, and a systematic way of entering data.
There are reviews supporting the potential of CDSS and CPOE in improving the performance of physicians and reducing medication errors. Experts suggest that these systems are very effective especially when targeting high-risk drugs and high-risk populations.
Other computer systems with potential although not well researched are Bar-coding systems and Laboratory Information Systems. Bar-coding systems involve barcodes for medication packages and barcodes for patients in the form of wristbands. This allows easy access to medication information using a portable scanner.
Laboratory information systems are computer systems that store patient tests information allowing the hospital to keep records of their results. This avails test results to both the doctor and the patient and makes the process more efficient.
Computerized systems however may come with their disadvantages. Such systems currently produce spurious warnings and lack specificity. A lot of safety alerts are over-ridden and there may be errors with the alerting systems. These warnings can add to latent errors and may cause clinicians to ignore even the important warnings.
In addition, there is a likelihood that clinicians may over-rely on warnings. In some cases, they may not be aware of the errors in the prescribing systems. Lack of training and lack of knowledge of systems among GPs is another limitation of these systems.
Therefore, it is safe to say that computers and computer systems cannot replace human judgment even though they have a lot of potential in complementing it. The use of computers is more common in primary care.
Using computer systems takes the need for paper prescriptions which the patient has to carry from one pharmacy to another when buying medications. Computer systems have reduced errors in the transmission of prescriptions between the dispenser and the prescriber.
The use of computer systems in surgery is in its initial stages and there are plans to have it implemented across the world.
- Multi-faceted interventions – multi-faceted interventions are more effective compared to single interventions. They are more effective in bringing behavioral change among healthcare professionals.
Due to this and supporting evidence of its effectiveness, there is a multi-dimensional intervention underway. It aims to improve prescribing safety.
There are significant differences between older patients and younger patients. These differences are not always recognized by patients or doctors. It is important to increase awareness of these differences. This is important because it will result in fewer prescriptions of drugs to older patients.
Increased awareness of these differences will also ensure the drugs prescribed to older adults are prescribed at lower doses most of the time.
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