- Email: [email protected]
Special considerations for the community-based elderly
Special Considerations for the
Community-BasedElderly Individualized teaching, support, and follow-up can enable these adults to take their medicine wisely.
cial problems that contribute significantly to their use of drugs. Data published by the National Center for Health Statistics in 1977 indicate that 86 percent of the elderly (more than 18 million persons) have chronic health problems(l). Most older people who are living independently or in a semidependent environment--with family or friends, in adult foster care or boarding homes--have little if any supervision with respect to their
J A N E T PAVKOV BETSY S T E P H E N S In the United States, about 95 percent of older adults live in the community, but many of them contend with physical, psychological, or so-
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medications. Acute illness added to chronic illness frequently creates a dilemma in obtaining proper care. Because of the specialization of medical practice, the elderly may have to see several physicians. More than one physician may prescribe the same drug or additional preparations, which can expose the patient to adverse reactions, interactions, and increased or decreased potentiation of a medicine's desired effects. Many of the elderly treat them-
.
Community health nurse Pal Lane explains diet and drug considerations to a woman who has borderline hypertension.
Problems of a Pill Taker selves with over-the-counter ( O T C ) medications, home remedies, or social d r u g s - - c a f f e i n e and alcohol. Oblivious to the peril o f these practices and of their wellmeaning friends' recommendations for self-treatment, the elderly often become victims of polypharmacy(2). T h e staff at our c o m m u n i t y mental health center define polyp h a r m a c y as the taking of more than one drug to treat the same symptoms. Another problem, noncompliance with prescribed drug treatment, is a leading concern of health c a r e providers. Questions for nurses to consider in working with clients w h o . reject proposed treatment plans are these: 9 Does this person know his or her health problems? 9 Is he or she physically able to c o n s u m e the prescribed pills, capsules, or liquids? 9 Is the client able to pay for ~medication(s) ? 9 Have the emotional status and b e h a v i o r been assessed to determine this person's ability to cope w i t h stress? Is he denying that a p r o b l e m exists, hostile about the !need for treatment, unable or ave r s e to altering daily activities in !order to carry out prescribed treatiment? 9 Is the person engaged in polyp h a r m a c y that has induced confu:sion about when to take which drug o r which look-alike drug was taken ;last? 9 Has the client experienced side effects, interactions, or toxic effects f r o m previous drug t r e a t m e n t ? 9 Has this person been told that :he has the right to refuse medicaition? T h e nurse who discusses these questions openly with clients o f t e n Fan identify the reasons for nonicompliance. If the nurse then inivolves the person in planning an act [ceptable treatment program, he
i Janet Pavkov, R.N., M.A., is coordinator of 'geriatric outpatient services and Betsy Stephens, R.N., M.S.N., is director of outpatient services at the Columbus Area Community Mental Health Center, Columbus, Ohio.
Five years ago, at the age of 60, I had the misfortune of being hospitalized for a hypertensive crisis with congestive heart failure. This happened after more than 25 years of being extremely healthy and not missing a single day of work for illness. After a week, I was discharged with several large bottles of pills. From then on, my life-style changed. I found myself having to adjust to a schedule that meant taking one pill every six hours, one pill every eight hours, and two more pills m o r n i n g and e v e n i n g - 11 pills during each 24-hour period. I never had been a pill taker and this seemed a bit too much, especially since I was feeling fine, back at work every day, and eating heartily. Handling this schedule wasn't easy. With advancing age, m y m e m o r y for recent events tends to play tricks, so I had to develop a reminder system both to take the pill and to assure me that the pills had been taken. With time, I managed to take all 11 drugs consistently, but changes in daily routine, such as an invitation to lunch or dinner or overnight guests, tended to present problems. Traveling into a different time zone was another problem. A trip to the West Coast from N e w York, for instance, usually resulted in my missing at least two pills because of the three-hour time difference. After adhering to this rigorous schedule for two years, I had a heart-to-heart discussion with my doctor and convinced him that I was perhaps overmedicated. H e cut m y medication down to four pills in the morning, and two at suppertime, a schedule that still continues. In 1980, I reached retirement age and moved to Vermont. This meant having a different doctor, a different p h a r m a c y contact, and a different way of living. Adjusting my pill schedule to
the new life-style wasn't too difficult, but persuading local p h a r m a cists not to put the pills in childproof bottles was. The caps were more than my arthritic fingers and wrists could cope with. I finally turned to the p h a r m a c y operated by the American Association of Retired Persons, which provides openable bottles on request.
Frances Rowe Gearing M y last adjustment was to recognize that some favorite overthe-counter remedies for colds and aches and pains--aspirin, antihistamines, and Neo-Synephrine nose d r o p s - - d i d not mix with the other drugs. Recently, my dentist was forced to alter his medication when I had some bridgework done. M a n y people forget to let their dentists know what medication they are taking. This omission could be disastrous. To close on a cheerful note. Despite the adjustments and problems, I lead a normal active life. I do some professional work; take care of a three-bedroom house; plant, hoe, and weed m y small garden; and shovel my front steps and driveway when it snows. I haven't taken up cross-country skiing yet. M a y b e next year. - - F R A N C E S ROWE GEARING, M.D.,
M.P.H., associate professor (ret.),
Columbia University School o f Public Health, N.Y.
!
i
Augustana
I i
Z
HOSPITAL AND HEALTH CARE CENTER 411 WEST OiC~v~rJr AVENUE CHICAGO, ILLINOIS 60614
(312i i
M Y MEDICATIONS
MEDICATION
FOR WHAT CONDITION
(Prescription & Over-the-Counter)
DOSAGE
WHEN A N D H O W TO TAKE
1.
2.
2.
2.
3.
3.
3.
The personal medication card above, which folds to wallet size, and the check list below aid clients in managing their medications wisely. (Both tools are used at Augustana Hospital and Health Center, Chicago, III.)
PERSONAL CHECKLIST FOR MEDICATION
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7
9 Do not etrsctch your medicine by trying to make it last linger than it was prescribed for. 9 Never borrow or lend medicine--only take your own. 9 Ask for a complete label on all prescriptions and h a v e it pdnted so you can read it. Labels should include: Your name Date prescription Your doctor's name was filled Name of the drug Expiration date Instructions for use for drugs 9 Carry a list of all your medications with you. Keep it up to date. Share it with doctors, nurses and phen'nacists at each visit.
9 Know the name of each of your medicines and why you ere taking them. 9 Know exact directions for taking your medicines. Such as between meals--with f o o d - - s w a l l o w e d whol e- - chew e d . 9 Know side effects of your medicine. Some show it is working; others are danger signs to warn you to talk with your doctor. 9 Know where to store your medicine. Usually in a dark, cool, dry place. Sometimes in the refrigerator.
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9 Childproof bottles are difficult to open. You can request easyto-open bottle caps. 9 Do not use medicine that is several years o l d - - t h r o w it out. 9 U s e a system to help you remember to take your medi c i n e - - a checklist or an association with a dailly habit (haircombing, plant watering, etc.) 9 - Over-the-counter (non-prescriptlin) drugs are for the relief of minor conditions. Do not use these for prolonged pedods unless advised by your physician. 9 Ask your physician to prescribe genedc rather than brand _ _ l k , a . l l n u ~ t'~'aatlLm,_JHLmnvu ~ t D .
li*'lll ~ _ _
usually responds favorably to this demonstration of confidence that he can assume responsibility for carrying out the proposed drug regimen consistently.
Inadvertent Misuse Older persons from all socioeconomic levels and ethnic groups may misuse drugs quite unintentionally. Four of the principal reasons are identified here. First, medication misuse can be a result of confusion due to unclear instructions, It is the person's right to have verbal and written instructions about the drugs prescribed and the opportunity to ask questions, about them and the reasons for prescribing them. A second contributing factor to misuse is ignorance about a drug's desired effects. It may take a few or many minutes of nursing time to discuss these factors with a client. Take the time and allow the client time to assimilate your statements. Lack of knowledge about specific precautions to be taken is a third factor in drug misuse. Point out the hazards in deviating from the preScribed regimen. When explaining Which liquids, foods, Or other drugs to avoid while taking a particular k:lrug, ensure that clients understand which adverse reactions, decreased benefits, synergistic effects, and so forth may occur. i A fourth factor that greatly affects drug therapy is self-treatment. This may be with OTC :lrugs; with drugs "shared" by helpful friends, for whom they were prescribed; home remedies; or with hoarded (often outdated) medica:ions.
Nursing Responsibilities L
i Nurses who work with communi-, !y-based elders need a p a r t i c u l a r l y horough knowledge of the normal Ind pathological changes of aging is described in the preceding arti:le by Jean Hayter. We say "paricularly thorough" because these ndependently living elderly have ewer resource persons than the intitutionalized aged. Knowing that some age-related
changes may alter the absorption, distribution, metabolism, and excretion of drugs, the nurse assesses the elderly person's health and obtains an accurate drug history(3). At our center, we then start a drug flow sheet for the client's health record, and compile data for a wallet-size card for him to carry (a similar personal medication record, from a Chicago seniors' program, appears on the page to the left).
Nurses can disseminate or clarify drug information through one-toone counseling, with drug information sheets like that illustrated on this page and in group education programs(4). Periodic follow-up is essential to assess the older person's current status, review medications in use, and update the flowsheet. We encourage clients to speak frankly about any problems they have with
their medications and help them update their own drug cards. Managing Drug Problems
The nurse who suspects or identifies, a drug-related problem acts as an advocate for the client or the physician. If the nurse suspects, for instance, that a clien~ is deliberately engaging in polypharmacy, the nurse immediately discusses this with the client. If he does not agree to stop taking the duplicate drugs, the nurse informs the physician(s) involved.
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On the other hand, if a nurse suspects that a client is being subjeered inadvertently to polypharmacy, she consults the physician(s) at once. This advocacy role requires diplomacy, an accurate description of the client's current problem and medication data, and willingness to invest time with patient, family, or both to explain the risks of continuing polypharmacy. Frequently the involved physicians are not aware of the client's other prescribers and the drugs or
treatments ordered. By conscientiously gathering the data from a client, systematizing and evaluating them, and then sharing the information with the physician(s) and the client, the nurse may prevent a serious drug reaction. The types of medication included in the polypharmacy of four new clients at our center and their dismaying effects are shown in the table. These clients are a tiny sample of a large group of elders who live in the community and who take multiple drugs for identical health
problems. Among the possible results may be confusion, delirium, depression, hallucinations, oversedation, dyskinesias, urinary retention, constipation, cardiac arrhythmias, blurred vision, tinnitus, hypoglycemia, hypotension, lethargy, respiratory depression, electrolyte imbalance, anaphylactic shock, coma, or death. To determine the etiology of our four new patients' symptoms, nurses contacted the prescribing physicians to discuss the patients'
current problems. We taught each patient about drug actions, interactions, side effects, and precautionary measures; gave each a drug information card, and encouraged each person to ask any future prescriber the reason for taking medication, how and when to take it, the dose, desired effects, side effects, and precautions to observe. The clients were urged to ask pharmacists to type the drug name on the prescription label. We discussed the proper storage of their drugs and their expiration dates.
MEMORY AIDS FOR DRUG TAKING 9
9 In large print, identify drug and times of admiilistmtion. 9
Code bottles and caps with small strips of colored tape. Use same color tape on a chart that states name of drug and the time to be taken. Post the chart.
9
ClearlY mark each day's drugs, dosages, end time on 9 large calendar. Cross out the time after taking the dose.
9
Keep e one-day supply of medications in plastic pill boxes clearly marked with drug name, dose, and time of administration.
9
Purchase several sets of pill containers with compartments for each day of the week. (If the drug is taken three times daily, have three sets; if four times daily, have four sets. A visiting relative, nurse, or the client can prepare these containers for one week in advance.)
9
Put medications in egg cartons. Mark drug name, dose, and the times for administration on inside of carton lid opposite the specific depression in the carton.
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Attach color-coded cardboard tag to neck of drug bottle. Use bdght, primary colors; avoid green or blue.
Clients who had difficulty opening safety caps were advised to ask for regular caps." (In some states this request must be written on the prescription by the physician.) We suggested that clients ask their health care provider or pharmacist about using OTC drugs be z f o r e purchasing them, and urged clients to read the OTC drug label carefully. The OTC label identifies active ingredients, indications for using the drug, specific contraindications, usage directions, warnings against misuse, amount of drug in the container, and the name and address of the manufacturer or distributor. We advised clients to inform their physicians if they chose not to comply with a suggested treatment, that is, by not filling the prescription, not taking the drug after purchasing it, or not following the spe-
cific instructions for its use. With all four clients we prepared a schedule sheet to help t h e m rem e m b e r whether they had taken their medication. A simple chart can include a sample of the drug, its name, the schedule for taking it and w h y - - f o r blood pressure, chest pain, constipation, shortness of breath, and so on. ( O t h e r m e m o r y aids a p p e a r in the box, page 427.) W e reminded t h e m to call i m m e diately if any adverse reactions de-
veloped or if they suspected this m i g h t happen, based on a change in their usual function or behavior. Comment
Older adults' errors in taking medication at h o m e occur most frequently as a result of forgetfulness, lack of directions or misunderstanding of directions, interruptions at dosage time, and misread or unread labels. Most of these mistakes can be prevented by the ac-
MEDICATION
TEACHING
Films/Slides ,4 Time For Caring. 16ram. color, sound film. The management of confusion in an older adult who is taking neuroleptic medications. (Contact: NcNeil Pharmaceuticals, Spring House, Pa. 19477) Confusion in the Elderly. A two, 16 mm. color film series that highlights experiences in working with disturbed elderly patients. The first film shows how acute confusion resulted from respiratory infection. The second analyzes confusion and presents information on diagnosis and treatment. (Contact: C. T. Currie, M.D., DukeWatts Family Medicine Program, 407 Crutchfield St., Durham, N.C. 27704) Elder-Ed: The Wise Use o f Drugs. 16 mm. film or 3/4" videocassette, color. This three-section film identifies drug problems of the elderly, discusses the wise purchase of drugs and the need for careful management in using drugs. (Contact: Prevention Branch, National Institute 9 on Drug Abuse, Rm. 10-A-3.0, Rockville, Md. 20857) Psychogeriatrics. 16 ram., t/2" videotape, 3/4" videocassette, color film. The assessment, nursing intervention, and care planning for the person with a chronic psychiatric syndrome. (Contact: American Journal of Nursing Co., Educational Services Div., 555 W. 57th St., New York, N.Y. 10019) Books
Bachinsky, Marc, and others. Practical Guide to Geriatric Medication. Oradell, N.J. (07649), Medical Economics, 1980. Bartilucci, A., and Durgin, J. Giving Medications Correctly and Safely. Oradell, N.J. (07649), Medical Economics, 1978. DiPalma, Joseph, and others. Drug Interactions. Oradell, N.J. (07649), Medical Economics, 1976. Hamilton, Helen, ed. Nursing Eighty-One Drug Handbook. Horsham, Pa. (19044), InterMed Communications, 1981. Weibert, Robert, and Dee, Donald. Improving Patient Medication Compliance. Oradell, N.J. (07649), Medical Economics, 1980.
tions we have r e c o m m e n d e d . And despite the changes in drug response associated with aging and chronic illness, it is entirely possible for most of the elderly to use medications safely and beneficially. Enabling t h e m to surmount the difficulties of m a n a g i n g a drug regimen broadens the learning of us a l l - - n u r s e s , physicians, p h a r m a cists, and clients. GN References: See page 441
AIDS
Articles
Bakdash, Diane. Essentials the nurse should.know about chemical dependency. J.Psychiatr.Nurs. 16:33-37, Oct. 1978. Donahue, Elizabethl and others. A drug education program for the well elderly. Geriatr.Nurs. 2:140-142, Mar.-Apr. 1981. Psychotropic drugs. ,4m.J.Nurs. 81:1304-1334, July 1981. Romanki.ewicz, J. A., and others. To improve patient adherence to drug regimens: an interdisciplinary approach. ,4m.J.Nurs. 78:1216-1219, July 1978. Rosenbaum, Janet. Widows and widowers and their medication use: nursing implications. J.Psychiatr.Nurs. 19:17-19, Jan. 1981. Other Printed .Materials ,4 Guide to Medical Self-Care and Self-Help Groups for the Elderly. U.S. National Institute on Aging. (DHEW Publ. (NIH) No. 80-1687) Washington, D.C. (20402), U.S. Government Printing Office, 1979. Consumer Information. Washington, D.C. (1155 15th St., N.W. 20005), Pharmaceutical Manufacturers Association. Geriatric Drug Interactions. East Hanover, N.J. (07936), Sandoz Pharmaceuticals Training and Education Services. Instruction Sheets (English and Spanish). [Analgesics (narcotic), anticoagulants, antihistamines, benzodiazepines, digitalis, diuretics, nitroglycerin, penicillin, potassium supplements, propoxyphene, sedatives/hypnotics, and tetracyclines.] St. Paul, Minn. (2469 University Ave. 55114), Minnesota State Pharmaceutical Assoc. Medication and You--,4 Handbook for Older Adults and Others, ed. by Ellie Vogt. Milwaukee, Wis. (929 North Sixth St. 52303), University of Wisconsin--Extension. Psychotropic Medication Instruction Sheets, ed. by Betsy Stephens. Columbus, Ohio (1515 E. Broad St. 43205), Columbus Area Community Mental Health Center, 1980. Read the Label on Nonprescription Medicines. Washington, D.C. (1700 Pennsylvariia Ave., N.W. 20006), The Proprietary Assoc.
Community-BasedElderly Individualized teaching, support, and follow-up can enable these adults to take their medicine wisely.
cial problems that contribute significantly to their use of drugs. Data published by the National Center for Health Statistics in 1977 indicate that 86 percent of the elderly (more than 18 million persons) have chronic health problems(l). Most older people who are living independently or in a semidependent environment--with family or friends, in adult foster care or boarding homes--have little if any supervision with respect to their
J A N E T PAVKOV BETSY S T E P H E N S In the United States, about 95 percent of older adults live in the community, but many of them contend with physical, psychological, or so-
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medications. Acute illness added to chronic illness frequently creates a dilemma in obtaining proper care. Because of the specialization of medical practice, the elderly may have to see several physicians. More than one physician may prescribe the same drug or additional preparations, which can expose the patient to adverse reactions, interactions, and increased or decreased potentiation of a medicine's desired effects. Many of the elderly treat them-
.
Community health nurse Pal Lane explains diet and drug considerations to a woman who has borderline hypertension.
Problems of a Pill Taker selves with over-the-counter ( O T C ) medications, home remedies, or social d r u g s - - c a f f e i n e and alcohol. Oblivious to the peril o f these practices and of their wellmeaning friends' recommendations for self-treatment, the elderly often become victims of polypharmacy(2). T h e staff at our c o m m u n i t y mental health center define polyp h a r m a c y as the taking of more than one drug to treat the same symptoms. Another problem, noncompliance with prescribed drug treatment, is a leading concern of health c a r e providers. Questions for nurses to consider in working with clients w h o . reject proposed treatment plans are these: 9 Does this person know his or her health problems? 9 Is he or she physically able to c o n s u m e the prescribed pills, capsules, or liquids? 9 Is the client able to pay for ~medication(s) ? 9 Have the emotional status and b e h a v i o r been assessed to determine this person's ability to cope w i t h stress? Is he denying that a p r o b l e m exists, hostile about the !need for treatment, unable or ave r s e to altering daily activities in !order to carry out prescribed treatiment? 9 Is the person engaged in polyp h a r m a c y that has induced confu:sion about when to take which drug o r which look-alike drug was taken ;last? 9 Has the client experienced side effects, interactions, or toxic effects f r o m previous drug t r e a t m e n t ? 9 Has this person been told that :he has the right to refuse medicaition? T h e nurse who discusses these questions openly with clients o f t e n Fan identify the reasons for nonicompliance. If the nurse then inivolves the person in planning an act [ceptable treatment program, he
i Janet Pavkov, R.N., M.A., is coordinator of 'geriatric outpatient services and Betsy Stephens, R.N., M.S.N., is director of outpatient services at the Columbus Area Community Mental Health Center, Columbus, Ohio.
Five years ago, at the age of 60, I had the misfortune of being hospitalized for a hypertensive crisis with congestive heart failure. This happened after more than 25 years of being extremely healthy and not missing a single day of work for illness. After a week, I was discharged with several large bottles of pills. From then on, my life-style changed. I found myself having to adjust to a schedule that meant taking one pill every six hours, one pill every eight hours, and two more pills m o r n i n g and e v e n i n g - 11 pills during each 24-hour period. I never had been a pill taker and this seemed a bit too much, especially since I was feeling fine, back at work every day, and eating heartily. Handling this schedule wasn't easy. With advancing age, m y m e m o r y for recent events tends to play tricks, so I had to develop a reminder system both to take the pill and to assure me that the pills had been taken. With time, I managed to take all 11 drugs consistently, but changes in daily routine, such as an invitation to lunch or dinner or overnight guests, tended to present problems. Traveling into a different time zone was another problem. A trip to the West Coast from N e w York, for instance, usually resulted in my missing at least two pills because of the three-hour time difference. After adhering to this rigorous schedule for two years, I had a heart-to-heart discussion with my doctor and convinced him that I was perhaps overmedicated. H e cut m y medication down to four pills in the morning, and two at suppertime, a schedule that still continues. In 1980, I reached retirement age and moved to Vermont. This meant having a different doctor, a different p h a r m a c y contact, and a different way of living. Adjusting my pill schedule to
the new life-style wasn't too difficult, but persuading local p h a r m a cists not to put the pills in childproof bottles was. The caps were more than my arthritic fingers and wrists could cope with. I finally turned to the p h a r m a c y operated by the American Association of Retired Persons, which provides openable bottles on request.
Frances Rowe Gearing M y last adjustment was to recognize that some favorite overthe-counter remedies for colds and aches and pains--aspirin, antihistamines, and Neo-Synephrine nose d r o p s - - d i d not mix with the other drugs. Recently, my dentist was forced to alter his medication when I had some bridgework done. M a n y people forget to let their dentists know what medication they are taking. This omission could be disastrous. To close on a cheerful note. Despite the adjustments and problems, I lead a normal active life. I do some professional work; take care of a three-bedroom house; plant, hoe, and weed m y small garden; and shovel my front steps and driveway when it snows. I haven't taken up cross-country skiing yet. M a y b e next year. - - F R A N C E S ROWE GEARING, M.D.,
M.P.H., associate professor (ret.),
Columbia University School o f Public Health, N.Y.
!
i
Augustana
I i
Z
HOSPITAL AND HEALTH CARE CENTER 411 WEST OiC~v~rJr AVENUE CHICAGO, ILLINOIS 60614
(312i i
M Y MEDICATIONS
MEDICATION
FOR WHAT CONDITION
(Prescription & Over-the-Counter)
DOSAGE
WHEN A N D H O W TO TAKE
1.
2.
2.
2.
3.
3.
3.
The personal medication card above, which folds to wallet size, and the check list below aid clients in managing their medications wisely. (Both tools are used at Augustana Hospital and Health Center, Chicago, III.)
PERSONAL CHECKLIST FOR MEDICATION
<.;
7
9 Do not etrsctch your medicine by trying to make it last linger than it was prescribed for. 9 Never borrow or lend medicine--only take your own. 9 Ask for a complete label on all prescriptions and h a v e it pdnted so you can read it. Labels should include: Your name Date prescription Your doctor's name was filled Name of the drug Expiration date Instructions for use for drugs 9 Carry a list of all your medications with you. Keep it up to date. Share it with doctors, nurses and phen'nacists at each visit.
9 Know the name of each of your medicines and why you ere taking them. 9 Know exact directions for taking your medicines. Such as between meals--with f o o d - - s w a l l o w e d whol e- - chew e d . 9 Know side effects of your medicine. Some show it is working; others are danger signs to warn you to talk with your doctor. 9 Know where to store your medicine. Usually in a dark, cool, dry place. Sometimes in the refrigerator.
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9 Childproof bottles are difficult to open. You can request easyto-open bottle caps. 9 Do not use medicine that is several years o l d - - t h r o w it out. 9 U s e a system to help you remember to take your medi c i n e - - a checklist or an association with a dailly habit (haircombing, plant watering, etc.) 9 - Over-the-counter (non-prescriptlin) drugs are for the relief of minor conditions. Do not use these for prolonged pedods unless advised by your physician. 9 Ask your physician to prescribe genedc rather than brand _ _ l k , a . l l n u ~ t'~'aatlLm,_JHLmnvu ~ t D .
li*'lll ~ _ _
usually responds favorably to this demonstration of confidence that he can assume responsibility for carrying out the proposed drug regimen consistently.
Inadvertent Misuse Older persons from all socioeconomic levels and ethnic groups may misuse drugs quite unintentionally. Four of the principal reasons are identified here. First, medication misuse can be a result of confusion due to unclear instructions, It is the person's right to have verbal and written instructions about the drugs prescribed and the opportunity to ask questions, about them and the reasons for prescribing them. A second contributing factor to misuse is ignorance about a drug's desired effects. It may take a few or many minutes of nursing time to discuss these factors with a client. Take the time and allow the client time to assimilate your statements. Lack of knowledge about specific precautions to be taken is a third factor in drug misuse. Point out the hazards in deviating from the preScribed regimen. When explaining Which liquids, foods, Or other drugs to avoid while taking a particular k:lrug, ensure that clients understand which adverse reactions, decreased benefits, synergistic effects, and so forth may occur. i A fourth factor that greatly affects drug therapy is self-treatment. This may be with OTC :lrugs; with drugs "shared" by helpful friends, for whom they were prescribed; home remedies; or with hoarded (often outdated) medica:ions.
Nursing Responsibilities L
i Nurses who work with communi-, !y-based elders need a p a r t i c u l a r l y horough knowledge of the normal Ind pathological changes of aging is described in the preceding arti:le by Jean Hayter. We say "paricularly thorough" because these ndependently living elderly have ewer resource persons than the intitutionalized aged. Knowing that some age-related
changes may alter the absorption, distribution, metabolism, and excretion of drugs, the nurse assesses the elderly person's health and obtains an accurate drug history(3). At our center, we then start a drug flow sheet for the client's health record, and compile data for a wallet-size card for him to carry (a similar personal medication record, from a Chicago seniors' program, appears on the page to the left).
Nurses can disseminate or clarify drug information through one-toone counseling, with drug information sheets like that illustrated on this page and in group education programs(4). Periodic follow-up is essential to assess the older person's current status, review medications in use, and update the flowsheet. We encourage clients to speak frankly about any problems they have with
their medications and help them update their own drug cards. Managing Drug Problems
The nurse who suspects or identifies, a drug-related problem acts as an advocate for the client or the physician. If the nurse suspects, for instance, that a clien~ is deliberately engaging in polypharmacy, the nurse immediately discusses this with the client. If he does not agree to stop taking the duplicate drugs, the nurse informs the physician(s) involved.
Ifl
Z_
ol
o~
Ig es
On the other hand, if a nurse suspects that a client is being subjeered inadvertently to polypharmacy, she consults the physician(s) at once. This advocacy role requires diplomacy, an accurate description of the client's current problem and medication data, and willingness to invest time with patient, family, or both to explain the risks of continuing polypharmacy. Frequently the involved physicians are not aware of the client's other prescribers and the drugs or
treatments ordered. By conscientiously gathering the data from a client, systematizing and evaluating them, and then sharing the information with the physician(s) and the client, the nurse may prevent a serious drug reaction. The types of medication included in the polypharmacy of four new clients at our center and their dismaying effects are shown in the table. These clients are a tiny sample of a large group of elders who live in the community and who take multiple drugs for identical health
problems. Among the possible results may be confusion, delirium, depression, hallucinations, oversedation, dyskinesias, urinary retention, constipation, cardiac arrhythmias, blurred vision, tinnitus, hypoglycemia, hypotension, lethargy, respiratory depression, electrolyte imbalance, anaphylactic shock, coma, or death. To determine the etiology of our four new patients' symptoms, nurses contacted the prescribing physicians to discuss the patients'
current problems. We taught each patient about drug actions, interactions, side effects, and precautionary measures; gave each a drug information card, and encouraged each person to ask any future prescriber the reason for taking medication, how and when to take it, the dose, desired effects, side effects, and precautions to observe. The clients were urged to ask pharmacists to type the drug name on the prescription label. We discussed the proper storage of their drugs and their expiration dates.
MEMORY AIDS FOR DRUG TAKING 9
9 In large print, identify drug and times of admiilistmtion. 9
Code bottles and caps with small strips of colored tape. Use same color tape on a chart that states name of drug and the time to be taken. Post the chart.
9
ClearlY mark each day's drugs, dosages, end time on 9 large calendar. Cross out the time after taking the dose.
9
Keep e one-day supply of medications in plastic pill boxes clearly marked with drug name, dose, and time of administration.
9
Purchase several sets of pill containers with compartments for each day of the week. (If the drug is taken three times daily, have three sets; if four times daily, have four sets. A visiting relative, nurse, or the client can prepare these containers for one week in advance.)
9
Put medications in egg cartons. Mark drug name, dose, and the times for administration on inside of carton lid opposite the specific depression in the carton.
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Attach color-coded cardboard tag to neck of drug bottle. Use bdght, primary colors; avoid green or blue.
Clients who had difficulty opening safety caps were advised to ask for regular caps." (In some states this request must be written on the prescription by the physician.) We suggested that clients ask their health care provider or pharmacist about using OTC drugs be z f o r e purchasing them, and urged clients to read the OTC drug label carefully. The OTC label identifies active ingredients, indications for using the drug, specific contraindications, usage directions, warnings against misuse, amount of drug in the container, and the name and address of the manufacturer or distributor. We advised clients to inform their physicians if they chose not to comply with a suggested treatment, that is, by not filling the prescription, not taking the drug after purchasing it, or not following the spe-
cific instructions for its use. With all four clients we prepared a schedule sheet to help t h e m rem e m b e r whether they had taken their medication. A simple chart can include a sample of the drug, its name, the schedule for taking it and w h y - - f o r blood pressure, chest pain, constipation, shortness of breath, and so on. ( O t h e r m e m o r y aids a p p e a r in the box, page 427.) W e reminded t h e m to call i m m e diately if any adverse reactions de-
veloped or if they suspected this m i g h t happen, based on a change in their usual function or behavior. Comment
Older adults' errors in taking medication at h o m e occur most frequently as a result of forgetfulness, lack of directions or misunderstanding of directions, interruptions at dosage time, and misread or unread labels. Most of these mistakes can be prevented by the ac-
MEDICATION
TEACHING
Films/Slides ,4 Time For Caring. 16ram. color, sound film. The management of confusion in an older adult who is taking neuroleptic medications. (Contact: NcNeil Pharmaceuticals, Spring House, Pa. 19477) Confusion in the Elderly. A two, 16 mm. color film series that highlights experiences in working with disturbed elderly patients. The first film shows how acute confusion resulted from respiratory infection. The second analyzes confusion and presents information on diagnosis and treatment. (Contact: C. T. Currie, M.D., DukeWatts Family Medicine Program, 407 Crutchfield St., Durham, N.C. 27704) Elder-Ed: The Wise Use o f Drugs. 16 mm. film or 3/4" videocassette, color. This three-section film identifies drug problems of the elderly, discusses the wise purchase of drugs and the need for careful management in using drugs. (Contact: Prevention Branch, National Institute 9 on Drug Abuse, Rm. 10-A-3.0, Rockville, Md. 20857) Psychogeriatrics. 16 ram., t/2" videotape, 3/4" videocassette, color film. The assessment, nursing intervention, and care planning for the person with a chronic psychiatric syndrome. (Contact: American Journal of Nursing Co., Educational Services Div., 555 W. 57th St., New York, N.Y. 10019) Books
Bachinsky, Marc, and others. Practical Guide to Geriatric Medication. Oradell, N.J. (07649), Medical Economics, 1980. Bartilucci, A., and Durgin, J. Giving Medications Correctly and Safely. Oradell, N.J. (07649), Medical Economics, 1978. DiPalma, Joseph, and others. Drug Interactions. Oradell, N.J. (07649), Medical Economics, 1976. Hamilton, Helen, ed. Nursing Eighty-One Drug Handbook. Horsham, Pa. (19044), InterMed Communications, 1981. Weibert, Robert, and Dee, Donald. Improving Patient Medication Compliance. Oradell, N.J. (07649), Medical Economics, 1980.
tions we have r e c o m m e n d e d . And despite the changes in drug response associated with aging and chronic illness, it is entirely possible for most of the elderly to use medications safely and beneficially. Enabling t h e m to surmount the difficulties of m a n a g i n g a drug regimen broadens the learning of us a l l - - n u r s e s , physicians, p h a r m a cists, and clients. GN References: See page 441
AIDS
Articles
Bakdash, Diane. Essentials the nurse should.know about chemical dependency. J.Psychiatr.Nurs. 16:33-37, Oct. 1978. Donahue, Elizabethl and others. A drug education program for the well elderly. Geriatr.Nurs. 2:140-142, Mar.-Apr. 1981. Psychotropic drugs. ,4m.J.Nurs. 81:1304-1334, July 1981. Romanki.ewicz, J. A., and others. To improve patient adherence to drug regimens: an interdisciplinary approach. ,4m.J.Nurs. 78:1216-1219, July 1978. Rosenbaum, Janet. Widows and widowers and their medication use: nursing implications. J.Psychiatr.Nurs. 19:17-19, Jan. 1981. Other Printed .Materials ,4 Guide to Medical Self-Care and Self-Help Groups for the Elderly. U.S. National Institute on Aging. (DHEW Publ. (NIH) No. 80-1687) Washington, D.C. (20402), U.S. Government Printing Office, 1979. Consumer Information. Washington, D.C. (1155 15th St., N.W. 20005), Pharmaceutical Manufacturers Association. Geriatric Drug Interactions. East Hanover, N.J. (07936), Sandoz Pharmaceuticals Training and Education Services. Instruction Sheets (English and Spanish). [Analgesics (narcotic), anticoagulants, antihistamines, benzodiazepines, digitalis, diuretics, nitroglycerin, penicillin, potassium supplements, propoxyphene, sedatives/hypnotics, and tetracyclines.] St. Paul, Minn. (2469 University Ave. 55114), Minnesota State Pharmaceutical Assoc. Medication and You--,4 Handbook for Older Adults and Others, ed. by Ellie Vogt. Milwaukee, Wis. (929 North Sixth St. 52303), University of Wisconsin--Extension. Psychotropic Medication Instruction Sheets, ed. by Betsy Stephens. Columbus, Ohio (1515 E. Broad St. 43205), Columbus Area Community Mental Health Center, 1980. Read the Label on Nonprescription Medicines. Washington, D.C. (1700 Pennsylvariia Ave., N.W. 20006), The Proprietary Assoc.