Chapter 1, Part C

Chronic Obstructive Pulmonary Disease (COPD)

A group of progressive diseases---those that get worse over time---chronic obstructive pulmonary disease (COPD) makes it difficult to breathe. Although it is a term for several chronic lung conditions that obstruct the airways in the lungs, it most often refers to obstruction caused by chronic bronchitis and emphysema. These obstructions hinder one's capacity to exhale, trapping air in the lungs---thus making it hard to breathe in normally (Mayo 2007b).

However, COPD is now considered a disease of a multisystemic nature, not just limited to the lungs. Research has found elevated Picture courtesy of A.D.A.M.                                    degrees of systemic inflammation and cardiovascular, neurologic, psychiatric, endocrine system dysfunction, and skeletal muscle dysfunction associated with COPD (Stone and Nici 2007).

Chronic obstructive pulmonary disease is the fourth-leading cause of death in the United States (NHLBI 2009). In most cases, long-term smoking is the cause of COPD. Not smoking or quitting smoking soon enough could prevent COPD. Unfortunately, once symptoms arise, the lung damage cannot be reversed. There is no cure. The primary focus of treatments for COPD is to control symptoms and prevent further damage (Mayo 2007b). The lowest percentage (8.8%) of adults that currently smoke is the elderly, folks age 65 and over (Nazir et al 2007).

However, the mean inpatient, outpatient, and pharmacy costs of patients aged 65+ who have COPD are more than twice those of age- and gender-matched control subjects who do not have COPD (Mapel et al 2000).

Risk factors for COPD are (Nazir et al 2007):

·        Smoking---accounts for 89-90% of the risk in the U.S.

·        Alpha-1 antitrypsin deficiency

·        Occupational, environmental, and domestic air pollution, particularly in developing countries

·        Mucous hypersecretion

·        Possibly airway hyper-responsiveness and asthma

Treatment for COPD includes (Nazir et al 2007):

·        Smoking cessation---most clients will agree with Mark Twain when he said, "Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times."

·        Pharmacologic management---After smoking cessation, pharmacologic treatment focuses on improving symptoms, exercise tolerance, and rates and severity of exacerbations. At this time, no existing medication for COPD has been proven to modify the long-term decline in lung function.

o       Bronchodilators

o       Inhaled corticosteroids

o       Combination therapy of inhaled corticosteroids and bronchodilators

o       Aerosol formulations and delivery devices

·        Nonpharmacologic interventions

o       Long-term oxygen therapy

o       Pulmonary rehabilitation

o       Immunizations for flu and pneumonia

o       Nutrition

For a client that resists quitting smoking, you might try the "5 R's" (PHS 2000; Radin and Cote 2008):

·        Relevancy: "Smoking affects your health and your family."

·        Risks: “Smoking leads to COPD, heart disease, lung cancer.”

·        Rewards: “Cessation will bring better health, money savings, improved taste, better smelling clothes/car/home, reduced aging/wrinkles.”

·        Roadblocks: “We can limit withdrawal effects and weight gain.”

·        Repetition: “I know we've already talked about this, but…”

·        Realism +1: “Yes, quitting is hard, relapses are common, and smoking is one of the best feel-good drugs … but [see 5 R's above] and remember that we can help you.”

Counseling is generally recommended to help a client stop smoking (Radin and Cote 2008). The success for someone trying to stop smoking with no counseling is 13%, whereas intensive counseling has a 22% success rate. Most insurance companies

now reimburse for smoking-cessation counseling visits. There are two types of counseling that seem to be most helpful in smoking cessation: cognitive and behavioral. Cognitive counseling aids clients to reframe the way they think about smoking by using distraction, positivism, relaxation, and mental imagery, as well as offered encouragement and motivation.

Behavioral counseling helps smokers recognize and avoid particular smoking trigger stimuli:

§      Alcohol

§      First morning coffee

§      Stress

§      The influence of other smokers.

There is a powerful correlation between the intensity and duration of the counseling and its effectiveness. Professionally led group counseling sessions are more effective than self-help, and often more than individual counseling. The best choice, however, is a combination of individual and group counseling.

It is also essential that there be continuous social support from spouses, friends, coworkers, and professionals such as the physician or yourself.

Tips for patients trying to quit smoking:

o       Key Steps:

1.   Set a firm quit date, ideally within 2 weeks

2.   Tell friends and family that you wish to quit and ask for their support

3.   Anticipate challenges, limit/abstain from alcohol, and avoid high-risk situations associated with smoking (e.g., social events where alcohol will be served)

4.   Remove all tobacco products and reminders from the home, car, and work place

o       New Skills:

·        Recognize the danger situations for relapse (e.g., being around peer smokers, drinking alcohol, negative moods, time pressure)

·        Develop coping skills for danger situations (e.g., avoid specific settings, alter lifestyle to reduce stress and enhance pleasure/mood)

·        Create new rewards or distractions for times of intensive craving (e.g., use behavior modification techniques to deal with periods of stress)

·        Know what to expect (e.g., withdrawal symptoms such as negative mood, urges to smoke, and difficulty concentrating typically peak within 1–3 weeks)

·        Stay positive (50% of all people who have ever smoked have now quit; treatment is now available)

(Reprinted from JAMA; see Schroeder, 2005)

Although stopping or decreasing the amount of smoking will not promote recovery of lost lung function, it does reduce the rate of decline in the ratio Forced Expiratory Volume (FEV) (the amount of air that a person can forcibly blow out in one second, measured in liters) to Forced Vital Capacity (FVC) (the total amount of air that can forcibly be blown out after full inspiration, measured in liters).

Changes in lung function after age 25 in smokers, nonsmokers, and ex-smokers, based

on FEV₁ (forced expiratory volume in 1 second). (Doherty and Briggs 2004)

"Early diagnosis by spirometry is essential since patients at risk may dismiss telltale symptoms as the normal consequences of smoking. Prompt initiation of smoking cessation therapy can help improve airflow, partially reverse impaired lung function, slow the accelerated annual decline of FEV₁ caused by tobacco smoke, and reduce the premature morbidity and mortality associated with COPD and other tobacco-related diseases. Initiation of appropriate interventions earlier rather than later, especially bronchodilator therapy, can improve symptoms, quality of life, and exercise capacity while decreasing the acute exacerbation rate and perhaps help to slow the progressive accelerated decline in lung function at minimal cost" (Doherty and Briggs 2004).

Oncology in the Aging

The most important risk factor for cancer is aging. The occurrence of common malignancies increases with age; more than 60% of all carcinomas occur in those aged 65 or older and is expected to increase to 70% by 2030 (Balducci and Beghé 2008).

The death rate for surgery and the risk of other complications increase with age; however, even in patients older than eighty, elective surgery seems to be generally safe. The elderly from age 70 on do, however, seem to be greatly more susceptible to complications of emergency surgery, especially those related to the digestive tract. Therefore, a regular screening for colorectal cancer may reduce the need for emergency surgery.

Recent advances in surgery (e.g., fewer surgical excisions, less invasive procedures) and in anesthesia (anesthetics with a shorter half-life and minimal respiratory suppression) have made cancer surgery safer than ever for the elderly. Combined chemotherapy and radiation therapy in the management of cancers of the head and neck, the esophagus, the bladder, and the lung also appear to be well tolerated up to the age of 80 at least (Balducci and Beghé 2008).

Balducci and Beghé (2008) states that the key to effective and safe treatment of elderly patients with cancer is informed decision making. Two components need to be looked at in the decision: the person and the malignancy. He asserts that cytotoxic chemotherapy is generally not indicated in a 90-year-old woman with stage 1 or 2 breast cancer because any benefit would be negligible and the risk of treatment would be considerable. He goes on to report that studies have shown that chemotherapy is of benefit to an 80-year-old woman whose chances of dying of breast cancer are only about 30% and if a 1% reduction in the cancer-related mortality is advantageous.

However, in a 90-year-old woman, the risk of dying of breast cancer must be close to 70% to legitimize the use of chemotherapy. If the same patient has a chemotherapy-responsive disease, such as large cell non-Hodgkin's lymphoma that may shorten her life, then chemotherapy is definitely indicated.

At times, it's best to go with the intuition of the patient. One 83-year-old man with an aggressive form of prostate cancer, in addition to mild cases of high blood pressure, Type 2 diabetes, depression, and angina---all being treated with medication---felt that hormone and radiation therapy was the way to go. Three months after finishing his therapy, blood tests suggested that the malignancy was eradicated (Brody 2009).

More patients over 80 years undergo major cancer (and other) surgeries, when in the past the recommendation would have been to "let nature take its course" (Tampa Tribune 2009). However, doctors often under-treat the elderly for fear of the results of side effects. Other times they over-treat because of pressure from the family.

Things that should influence treatment decisions are (Brody 2009) the patients':

·        Physical and mental health

·        Financial status

·        Living situation

·        Family support system

·        Ability to get to and from the treatment facility

·        Own wishes and desires

Diseases of the Mind

"Diseases of the mind" is, in a sense, a way of referring to the negative side mental health. When an elderly person seems to be "aging successfully" in mental and emotional areas, the social worker's job is largely one of encourager and cheerleader. When this aging is less successful, then the social worker's job is the same as when a physical illness is present: notice, aid the patient in getting professional help if it is needed, and help the client to engage in self-help strategies that might be useful.

Almost 20% of people ages 55 and older suffer mental disorders that are not part of normal aging. The most common disorders, in the order of predominance are: anxiety, severe cognitive impairment (e.g., dementia and Alzheimer's disease), and mood disorders (e.g., depression) (AAGP 2004).  

There is a difference between anxiety as a feeling or experience, and an anxiety disorder as a psychiatric diagnosis---an individual may feel anxious and not have an anxiety disorder. Primarily for this reason, anxiety is not addressed in this course.

Aging and Depression

Depression in the aged is a significant problem.  Changes in physical abilities, illnesses and diseases, the loss of loved ones, lack of a defining activity, and lack of work can all contribute to significant depressive feelings.  Without a feeling of some purpose, many will not feel that getting out of bed in the morning is worth it, and depression can get worse as health declines. 

Everyone, young or old, feels "down in the dumps" at times. But if they have little joy or pleasure from life, and the "down in the dumps" feeling lasts more than a week or two, they probably are depressed. Depression in the elderly needs to be diagnosed and treated. It could be a side-effect of a medication or a disease such as Parkinson's. But no matter the cause it can likely be treated.

The risk of depression in the elderly increases just as other illnesses do. When the inability to function is more limited than before, they are especially at risk. Estimates of major depression in older people who still live in the community range from less than 1% to about 5%, but it rises to 13.5% in those who require home health care and to 11.5% in elderly hospital patients (Hybels and Blazer 2003).

The percentages of people with clinically relevant depressive symptoms, along with age groups are displayed for 2004 in the following table: 

Source: Federal Interagency Forum 2008, Chart 2008-19b

Depression is one of the conditions most commonly associated with suicide in older adults (Conway and Brent 1995). It is widely under-recognized and undertreated. Studies show that up to 75% of older adults who committed suicide visited a physician within a month before death (Conwell 2001). The rate of suicide is highest among the elderly as compared to any other age group; highest of all is the suicide rate for those 85 years and older---twice the overall national rate (AAGP 2004). These statistics show the urgency of learning to recognize and treat depression among older adults.

Depressive symptoms can be different in older adults than younger, often being masked under the resemblance to changes that occur with age. For example, older adults often have a natural tendency for lower appetite and a change in sleep pattern. It is important to do a complete psychosocial assessment, which includes a history of depressive symptoms.

Common symptoms of depression are (Gallo and Katz n.d., MDConsult 2008):

·        Depressed or irritable mood; temper, agitation

·        Fatigue (tiredness or weariness)

·        Loss of interest in self-care and/or following medical advice

·        Little interest in social activities

·        Feeling "empty" inside

·        Trouble sleeping and/or anxiety

·        Trouble concentrating or remembering things

·        Unexplained aches and pains

·        Change in appetite and weight

·        Feeling hopeless about the future

·        Feelings of helplessness

·        Feeling worthless or sad

·        Easily irritated and/or listless

·        Feeling that one is a burden---excessive or inappropriate guilt

·        Abnormal thoughts about death

·        Irresponsible behavior

·        Thoughts about suicide, plans to commit suicide or actual attempts

The cause(s) of clinical depression are not known. No biologic event or gene has been associated with depression; however, if there is a family history of depression, there seems to be an increased risk. Cerebrovascular disease, which is more common among the elderly, appears to play a role in late-onset depression---this has led to the "vascular depression hypothesis" (Conway and Steffens 1999).

Treatment for Depression

Depression may be a result of events (situational) or may have a more neurological or psychological cause. The elderly are at risk for situational depression because of the many losses they suffer (death of loved ones, loss of job, hearing impairment, memory impairment, independence, poor health, etc.). It is important to find out when the depressive symptoms started, how long they have lasted and how severe they are.  You should also find out if there was a precipitating event. The presence of such an event can help direct treatment. The patient should also receive a complete medical examination to determine what illnesses may be contributing to the depression in addition to what medications may be contributing to the symptoms.

The doctor will perform a complete physical examination, obtain laboratory tests, and assess mental status (ability to think clearly, remember, and make plans). The purpose of this workup is to determine if a medical condition or medication may be causing or contributing to the depression.

Treatments for geriatric depression are much like those for the rest of the population:

·        Antidepressants---often a trial and error period is needed to find the antidepressant that works best for the client (NIMH 2009); it may take four to eight weeks for a medication to work best

·        Psychotherapy

Psychotherapy for depression can include (Alexopoulos et al 2001):

§        Cognitive-behavioral therapy (changing pessimistic thoughts and beliefs)

§        Supportive psychotherapy (providing emotional support to help the person cope with and resolve difficulties)

§        Problem-solving therapy (helps the person learn more effective ways to manage problems)

§        Interpersonal therapy (professional works with the person to improve problems in relationships) 

Educating the person and their family about depression are also important interventions.

Cognitive therapy is one of the more common therapies used to help with depression.  If not contraindicated by a client's mental capacity, it can be effective in alleviating or minimizing the depressive symptoms. In cognitive restructuring the professional helps the client replace faulty thinking or misconceptions with beliefs and thoughts that are more aligned with reality, leading to enhanced functioning.  The therapist helps people improve their self-dialogue, educating them that it is this inner dialogue that is affecting their depressed mood. Sometimes, in working with the elderly, much of their dialogue may be pessimistic and negative about the elderly person's life situation, and thoughts that their life has been a failure. 

The following steps are useful in cognitive restructuring (Cormier and Cormier 1979):

1.   Assisting clients to accept that their statements and beliefs affect their emotional reactions to life's events

2.   Assisting clients to identify dysfunctional beliefs and patterns of thoughts that underlie their problems

3.   Assisting clients to identify situations that engender dysfunctional cognitions

4.   Assisting clients to substitute functional self-statements in place of self defeating cognitions

5.   Assisting clients to reward themselves for successful coping efforts

For other guidelines in helping the elderly and their families with depression, go to the following link:

http://www.psychguides.com/Geriatric%20Depression%20LP%20Guide.pdf

Memory Impairment

Often memory suffers with age.  For the majority, this impairment is mild and does not cause problems beyond being a nuisance.  For others, the impairment is more severe and is troublesome both to family and to the patient.  Sometimes the memory impairment creates an issue of safety when stoves are left on or the person wanders and gets lost.  In even more severe cases the senior may not remember significant life experiences and/or lose the ability to identify loved ones, including children and spouse.  Memory impairment that creates issues of safety often leads to the discussion of the need for alternative long term care. 

The following table provides an illustration of the frequency of memory problems among older Americans.  Specifically it reports the percentage of people age 65 and older with moderate or severe memory impairment, by age group.

Source: Federal Interagency Forum 2006, 26

There are different studies that examine what causes memory impairment. According to Marsha K. Johnson (2003), Yale University, source monitoring has great impact in how someone remembers, and this function is processed by the frontal lobes. Being able to process information and then tie these experiences together so they make sense---such as the environment in which the memory occurred---is part of memory. For example, if somebody goes to the beach with friends, they will gather and process information: e.g., the friends there, the sights and sounds of the ocean and the wind, etc. Being able to tie all these details together helps people create accurate memories. Damage to the frontal lobes can cause a person to gather less specific information, resulting in a less accurate memory and even false memories. Johnson elaborates:

"Neuro-imaging experiments along with the patient data suggest that the frontal lobes are important in monitoring the source of memory. So, we . . . know that older adults do less well under certain circumstances in source monitoring tasks than do healthy, young adults. They are poorer on source recognition than on old-new recognition. Investigators have suggested that this occurs because the frontal lobes are among the slower to mature regions, and they are also more likely to show increasing neuropathology with age" (Johnson 2003).

Dementia, Alzheimer's Disease

There are many similarities between dementia and Alzheimer's disease; it is necessary to know what the differences are. Alzheimer's is one kind of dementia---the most common one. In addition to Alzheimer's, dementias related somewhat to age include (Health-cares.net 2005):

·        Vascular dementias (including multi-infarct dementia)---the second most frequent type of dementia, caused by poor circulation to the brain. In multi-infarct dementia multiple mini-strokes (infarcts) take place which cut off the blood supply to parts of the brain. Progress may be slowed by control of blood pressure and diabetes, as well as stopping smoking.

·        Parkinson disease. Not everyone with Parkinson has dementia; it generally occurs when the disease is well-developed. Reasoning, memory, speech, and judgment are most likely to be affected.

·        Lewy body dementia, caused by microscopic deposits of protein in the nerve cells called Lewy bodies. Over time the protein destroys the cells. It can cause symptoms much like Parkinson disease. This type of dementia cannot be reversed or cured.

·        Alcohol-related dementia. Drinking too much alcohol can destroy brain cells, which leads to the dementia. The dementia may not show up until the person is elderly.

Alzheimer's is a progressive and fatal brain disease that gradually destroys a person's memory, ability to learn and make judgments, etc. The disease kills brain cells that eventually will kill a person if they do not die first of something else. The progress of the disease can take from 3-20 years (ALZ 2008). Although a person may have recently been diagnosed with the disease, the progress of the disease may actually be advanced.

Early warning signs of the disease include (ALZ 1999):

v    Memory loss---forgetting recently learned information, forgetting more often and not being able to recall the information later (normal is forgetting names or appointments occasionally)

v    Difficulty performing familiar tasks---e.g., losing track of the steps of preparing a meal, making a phone call, or playing a game (normal is occasionally forgetting why you came into a room or what you planned to say)

v    Problems with language---often forgetting simple words or substituting unusual words (normal is sometimes having trouble finding the right word)

v    Disorientation to time and place---such as getting lost in their own neighborhood, forgetting where they are and how they got there, not knowing how to get back home (normal is forgetting the day of the week or where you were going)

v    Poor or decreased judgment---e.g., dressing improperly for the weather, frequently falling for telemarketers spiels (normal is making a questionable decision occasionally)

v    Problems with abstract thinking---e.g., forgetting what numbers are and how they should be used (normal is finding it challenging to balance a check book)

v    Misplacing things---putting them in unusual places such as a book in the refrigerator or the salt shaker in the medicine cabinet (normal is misplacing keys or a wallet temporarily)

v    Changes in mood or behavior---showing rapid mood swings for no apparent reason (normal is occasionally feeling moody)

v    Personality changes---dramatic changes, becoming extremely confused, suspicious, fearful, mean, or dependant on a family member (normal is slight personality changes with age)

v    Loss of initiative---becoming very passive, sitting in front of the TV for hours---not apparently really watching, sleeping a lot more than usual, not wanting to do usual activities (normal is sometimes feeling weary of work or social obligations)

The changes that occur as a result of Alzheimer's can affect both the diagnosed individual and loved ones. Reactions to these changes can include depression, anxiety, fear, embarrassment, shame, isolation, loneliness, and feeling of loss. In response to these reactions the Alzheimer's Association suggests the following ways a healthcare professional can help (ALZ 1999):

·        Acknowledge feelings and provide an opportunity to talk and ask questions 

·        Refer the individual and/or their family to an Alzheimer's support group

·        Assess for depression and/or suicidal thoughts; short term counseling and medication may be helpful in some cases

·        Refer families to a physician knowledgeable in dementia for evaluation and treatment

·        Encourage the diagnosed individual and the caregiver to take care of their physical and mental health 

Drugs

This is the age of polymedicine which is the direct result of disease states, multiple healthcare providers, inappropriate and/or self prescribing, and numerous prescriptions (Solomon 2000). This has made administering medications for the elderly one of the most difficult areas in their medical care. Major contributing factors are:

o       The increased possibility of numerous illnesses, often with multisystemic involvement

o       The necessity for these patients to take a number of drugs, often prescribed by different doctors

o       The increasing likelihood of changes in the action of the body on a drug over a period of time (pharmacokinetics) and how the drug acts on the body (pharmacodynamics)

Together, these factors add to the heightened frequency of drug interactions and adverse drug responses in these patients (Diasio 2007). Medications no longer include prescription drugs and aspirin over the counter (OTC), but a multiplicity of OTC and herbal remedies as well.

There are a number of reasons for sometimes dramatic pharmacokinetic changes with age. The most basic are:

·        Change in body composition such as the increase in total body fat with attendant reduction in lean body mass, total body water, and decreased albumin

·        Changes in pharmacokinetically important organs such as the liver or kidneys

·        Slower gastric emptying, decreased gastric acidity, impaired intestinal flow causing decreased rate of absorption, slower onset, and delayed peak of action of drugs

The pharmacodynamic changes with age are basically because of alterations in the responsiveness of the target organ. Even if the pharmacokinetics are unchanged, they necessitate using smaller drug doses in the elderly (Diasia 2007).

Medication Management

Because of the difficulties mentioned above, individuals involved in medication management for the elderly, need to be aware of several things. You, as a social worker or therapist, may need to confront a physician regarding these things, as one therapist did---with negative results to herself.

She was a licensed mental health therapist with an M.S. degree in Counseling and Human Resource Development. At one point she was given the assignment to go to a nursing home to do an annual evaluation for the payor of a patient's care. She was to interview the patient, study all of the patient's records at the

necessary to accomplish this.

On reviewing the records she noted the huge numbers of medications being given and that many were prescribed over the phone when nurses called with a new complaint of the patient. The physician had seldom seen the patient. The therapist called the doctor to ask about the medications, but he was curt and unwilling to give adequate answers.

Being a thorough person, the therapist looked every drug up in the Physicians' Desk Reference (PDR) and found that the concurrent use of two of them required a blood test being taken every six months. No blood tests had ever been taken in the more than eighteen months the two medications were used. This was noted in her report, with quotations from the PDR to substantiate it.

The therapist was remanded for practicing medicine without a license, and the center for which she worked changed the rules to only allow therapists whose degree was in psychology to perform these evaluations in the future. (But the patient's blood was checked!)

With this story in mind, be aware---unhesitatingly---of the following information.

First, there are several basic principles that pertain to drug use in the elderly (Diasio 2007):

·        The drugs eliminated by the kidneys may be reduced by 50%

·        Typically, the only drugs that are eliminated by the liver that need adjustment for age are those with high hepatic clearances

·        Only the lowest effective dose should be used

·        The patient's drug history should be reviewed frequently, including prescription medications, OTC medications, and vitamin or herbal preparations, keeping in mind potential adverse drug interactions and responses

Some steps that can be taken to help prevent drug interactions are (Diasio 2007):

·        All of the drugs the patient is taking, or has recently taken---prescription, OTC, herbal---should be documented.

·        Frequently review the patient's drug list to be sure that each drug is still needed.

·        Be very suspicious when medications used have a low therapeutic index with a high risk of drug interactions (anticoagulants, antiarrhythmics, anticonvulsants, Digoxin, Lithium carbonate, oral hypoglycemics, Theophylline)

·        High-risk clinical settings, such as happen with critically ill patients, should get extra attention.

·        Whenever there is a change in the patient's course, the differential diagnoses should consider adverse drug interactions.

It is very important that you know, or know enough to realize you should find the interactions and side effects of the medications your clients are taking, especially those most commonly prescribed to older adults. Make a chart of the interactions and side effects of these 20 medications most often prescribed to older adults (Solomon 2000):

·        Calcium channel blockers

·        Digitalis preparations

·        Antiarthritics, systemic

·        Diuretics

·        Angiotensin-converting enzyme inhibitors

·        Nitrites and nitrates

·        Beta-blockers

·        Cephalosporins

·        Antispasmodics

·        Diabetes, insulin

·        Diabetes, oral

·        K-sparing diuretics

·        Aspirin

·        Codeine and combinations

·        Antihypertensives

·        Xanthines

·        Potassium supplements

·        Corticoids (oral)

·        Benzodiazepines

·        Diuretics, thiazides

Only a relatively small group of drugs causes most of the well-known adverse drug effects---every drug has side effects and can potentially cause an adverse drug response. Even if a particular drug has not had an adverse response reported, the physician needs to be aware that it could still take place. Diasio (2007) lists the following information about clinical presentations associated with adverse drug responses.

·        Some presentations are obvious, such as a rash in someone who has been prescribed a single drug such as penicillin

·        Some are difficult to distinguish from other disease states

·        Sometimes the adverse effect mimics the illness being treated---e.g., depression from an antidepressant, development of an arrhythmia in a person being given an antiarrhythmic drug

Practitioners need to be aware of the drugs that are potentially contraindicated in elderly patients (Col et al 1990):

Note: This chart is from 1990, so it may need to be updated; updated chart not found.

Some drugs and combinations of OTC, prescription, and herbal drugs should be avoided because of potential drug interactions, for example (Col et al 1990):

·        H2 blockers (e.g., Tagamet)

·        Antihistamines (e.g., Benadryl)

·        Gingko with Coumadin, NSAIDs, aspirin

·        St. John's Wort with antidepressants

·        Garlic with Coumadin, NSAIDs, aspirin

·        Echinacea with Coumadin

For a more complete list, go to the University of Michigan Health System's Website at http://www.med.umich.edu/1libr/aha/umherb01.htm.

Compliance Issues

One definition of medication compliance is "the extent to which a person's behavior coincides with medical or health advice" (Coates n.d.).

Patient compliance to a medication procedure has become more of a problem over time. The reasons are multiple, but perhaps fixed income leads the pack.

However good the reason, noncompliance can lead to a number of problems (Coates n.d.):

o       Possible decline in health

o       Need for additional medical treatment

o       Increased hospitalizations

o       Even death

Herrick (2006) has an outstanding booklet with very specific ways and helps to reduce drug costs. He sums some of it up in the following chart:

From Herrick 2006

Kane et al (2004) offers the following strategies to improve compliance in the geriatric population:

1.   Making drug regimens and instructions as simple as possible

a.   Using the same dosage schedule whenever feasible (e.g., once or twice per day)

b.   Timing the doses in conjunction with a daily routine

2.   Instructing relatives and caregivers on the drug regimen

3.   Enlisting others (e.g., home health aides, pharmacists) to help ensure compliance

4.   Making sure the older patient can get to a pharmacist (or vice versa), can afford the prescriptions, and can open the container

5.   Using aids (such as special pillboxes and drug calendars) whenever appropriate

6.   Keeping updated medication records

7.   Reviewing knowledge of and compliance with drug regimens regularly

To give a little different point of view as to how you can help your clients to improve their medication compliance and thus reduce the risk of adverse reactions, Solomon (2000) suggests:

o       Establishing a rapport with these elderly folks

o       Helping them understand that some medications must be continued whether they feel better or not, e.g., antibiotics, blood pressure medications, and cholesterol medications

o       Having them bring in ("brown bag") all of their medications (prescription, OTC, herbal) for review

o       Aiding them in using a medication calendar, medication organizer, or pillbox. There are even pillboxes that will ring an alarm when it is time to take medication

o       Through this, being sure that they know what they are taking and why they are taking them

o       Keeping the regimen simple, and use once-daily dosing when possible.

Alcohol and Substance Abuse Issues among Elderly

The phrase substance abuse brings to mind out-and-out alcoholics, "shoot 'em up" druggers, and other extremes. Although it is estimated that up to 17% of Americans 65 years or older have problems with alcohol (Task Force n.d.), that does not mean they are all alcoholics. Alcohol used in combination with certain medications can cause harmful effects---including impaired coordination and cognition (Breslow et al 2003)---and elders that use these combinations can be defined as substance misusers and are generally classified as substance abusers. That is possibly why the statistics of alcohol and drug abuse are so high.

Besides potential interactions with medications, there are other reasons why seniors should not use alcohol, or use it very sparingly. Elderly men (and women of all ages) have a smaller volume of total body water than younger men, so they reach a higher blood alcohol concentration from the same amount of alcohol consumption (Kalant 1998). Body composition continues to change with age; therefore, the effects of alcohol may be greater for an 80-year-old than for a 70-year-old (Vestal et al 1977). This tends to result in more harm from the same amount of intake as compared to younger people. Other vulnerabilities of the elderly to the effects of alcohol may be raised by age-related changes in functional status, nutritional status, and psychological and cognitive status (Breslow et al 2003).

With these concerns in mind, it is important to note that heavier use (which is not as heavy for the elderly) of alcoholic beverages has been linked with a number of detrimental health consequences, including cirrhosis of the liver, motor vehicle crashes and other unintentional injuries (NIAAA 2000), as well as with hemorrhagic and ischemic stroke (Reynolds et al 2003). Other reports indicate that the consumption of three to five drinks per day over years has been associated with an increase in the death rate (Yee and Williams 2002, 265). On the other hand, light or moderate consumption (one drink per day at most) has been linked with some health benefits, including reduced rates of coronary heart disease (Mukamal et al 2003)---this may be due to the antioxidants and resveratrol content of red wine which can be obtained through safer means (Mayo 2009a).

Moving from alcohol misuse or abuse to drug abuse---again the biggest problem for seniors is drug misuse. A client who does not take medications as prescribed---forgetting to take them or taking extra because "if a little is good for me, a lot must be better"---is a drug misuser. That is why it is so important to oversee and regularly monitor their medication use.

As with other populations, there are situations that tend to motivate some elderly persons to drink. Four factors that may cause the elderly to be susceptible to drinking alcohol or abusing some drugs are (Brody 1980):

·      Retirement and its boredom, role changes, and financial problems

·      Increased concern with death and losses of relatives and friends

·      Poor health and chronic discomfort

·      Loneliness, particularly among older women

Perhaps the greatest situational motivator of all is depression (Whelan 2003), which has been discussed earlier in this course.

When an older person is amenable to treatment for substance use problems, they usually have better success in treatment than do younger people according to Frederic Blow, professor in the Department of Psychiatry at the University of Michigan and a Huss Research Chair on Older Adults and Alcohol/Drug Problems at Hazelden's Butler Center for Research (Hazelden 2006).

If clients or their relatives need help and intervention for substance use, Hazelden has an outstanding pamphlet with information and suggestions, How to Talk to an Older Person

Who Has a Problem with Alcohol or Medications, available at http://www.hazelden.org/web/public/document/ip_talkolderperson.pdf.