Journal of Gerontological Nursing

More Than They Bargained For Adverse Drug Effects

Ann K Carruth, RN, MSN; Barbara J Boss, RN, PhD

Abstract

Aging involves many changes in physical status, and the onset of one or more chronic illnesses may occur as well. The illness may produce varying degrees of disability, preventing function at previous levels. The onset of the chronic illness may be the first time the individual has been exposed to physicians, nurses, the use of medications, and many other aspects of health care on a continuous basis. Although the elderly make up approximately 11.5% of the population, their use of medication accounts for 25% to 30% of the drug expenditures in the United States.1 One third of these expenditures are for nonprescription drugs.2 Although these substances can stabilize or improve health status, the use or misuse of the drugs can also result in adverse reactions.

How medication affects the elderly in terms of fulfillment of later maturity adult tasks and how medication affects the use of coping strategies and social support systems are examined in this article. The purpose is to explore the possible consequences of drug therapy on the elderly individual's ability to maintain and achieve development, adaptation, and social support.

THE USE OF MEDICATION AMONG ELDERLY PATIENTS

Potential for iatrogenesis exists to a greater extent in the elderly because of age-related changes in physiology that affect absorption, distribution, metabolism, and excretion of drugs.3 tor example, the elderly client with a reduced concentration of plasma albumin has fewer molecules for the protein binding of drugs such as warfarin sodium (Coumadin), furosemide (Lasix), and digoxin (Lanoxin). Therefore, higher concentrations of the medication cross the cellular membrane, resulting in toxicity.2

Many drugs, such as nasal decongestants, antihypertensives, and anti-anxiety drugs, cause sedation. The elderly individual may be aware of the decrease in mental alertness but may attribute it to many causes, for example, normal aging, lack of motivation or energy, the disease itself, or another disease such as dementia. Anxiousness may result if the individual begins to feel that perhaps another disease process is present. If not recognized as an undesirable effect of medication, the individual may discontinue the medication or attempt to maintain a sense of control by purchasing over-the-counter drugs to correct the side effects.

Table

In regard to coping strategies, it was found that persons substitute one coping activity for another as a way to deal with changes in life. One individual who had been in the hospital 3 months used drawings and active thinking to cope when unable to work on a project in which he was engaged at home.

Generally, side effects can distract from the individual's normal coping routine and activities. If the person is occupied with thoughts of "what is wrong with me" or "why do I have to feel bad," then the ability to cope with environmental, psychological, and social stressors has been reduced. The individual's ability to cope may be interrupted due to the adverse effects of medication.

EFIKTS ON SOCIAL SUPPORTS

Interviewed persons related that medication initiated for the management of chronic illnesses contributed to die feeling of increased control in their ability to seek and use support from friends and family. Most individuals reported that prior to the onset of adverse réactions, they were able to pursue needed support. For example, many individuals had friends through church and community activities. However, once their physical activity was limited, the ability to actively pursue support systems became limited, which frequendy caused feelings of loneliness and isolation.

Even though the ability to independently pursue support may change, elderly individuals' control over their life situation can be facilitated by die support of family and friends. The ability to independently continue making decisions can be…

Aging involves many changes in physical status, and the onset of one or more chronic illnesses may occur as well. The illness may produce varying degrees of disability, preventing function at previous levels. The onset of the chronic illness may be the first time the individual has been exposed to physicians, nurses, the use of medications, and many other aspects of health care on a continuous basis. Although the elderly make up approximately 11.5% of the population, their use of medication accounts for 25% to 30% of the drug expenditures in the United States.1 One third of these expenditures are for nonprescription drugs.2 Although these substances can stabilize or improve health status, the use or misuse of the drugs can also result in adverse reactions.

How medication affects the elderly in terms of fulfillment of later maturity adult tasks and how medication affects the use of coping strategies and social support systems are examined in this article. The purpose is to explore the possible consequences of drug therapy on the elderly individual's ability to maintain and achieve development, adaptation, and social support.

THE USE OF MEDICATION AMONG ELDERLY PATIENTS

Potential for iatrogenesis exists to a greater extent in the elderly because of age-related changes in physiology that affect absorption, distribution, metabolism, and excretion of drugs.3 tor example, the elderly client with a reduced concentration of plasma albumin has fewer molecules for the protein binding of drugs such as warfarin sodium (Coumadin), furosemide (Lasix), and digoxin (Lanoxin). Therefore, higher concentrations of the medication cross the cellular membrane, resulting in toxicity.2

Many drugs, such as nasal decongestants, antihypertensives, and anti-anxiety drugs, cause sedation. The elderly individual may be aware of the decrease in mental alertness but may attribute it to many causes, for example, normal aging, lack of motivation or energy, the disease itself, or another disease such as dementia. Anxiousness may result if the individual begins to feel that perhaps another disease process is present. If not recognized as an undesirable effect of medication, the individual may discontinue the medication or attempt to maintain a sense of control by purchasing over-the-counter drugs to correct the side effects.

Table

TABLE 1ASSESSMENT TOOL TO EVALUATE EFFECTS OF ADVERSE DRUG REACTIONS

TABLE 1

ASSESSMENT TOOL TO EVALUATE EFFECTS OF ADVERSE DRUG REACTIONS

A pattern of polypharmacy may be established as a result of experiencing many common side effects such as dizziness, nausea, diarrhea, confusion, and restlessness. These side effects are common, and yet the individual may not feel they warrant investigation by a healthcare professional. Additionally, the over-the-counter medications may cause side effects. For example, bromide in drugs such as Sominex can accumulate in the body and cause symptoms that resemble dementia.4

Approximately 12.9% of geriatric admissions to the hospital occur because of ad verse drugreactions . 5 Additionally , approximately 33% of patients 66 to 75 years of age developed adverse reactions after hospitalization.6 Modern medications are used to manage many chronic illnesses; unfortunately, the same medications can cause death due to iatrogenesis. It has been estimated that 30,000 people die each year due to adverse reactions to medications. l

Although it is essential to assess and intervene wim a person's physical response to medication, health-care professionals also need to be aware of how adverse drug reactions affect the development, adaptation, and social support of the individual. To evaluate the adverse drug effects on elderly individuals, a cross section of elderly individuals were interviewed during a 2-month period.

DEVELOPMENTOFAN ASSESSMENTTOOL

To evaluate geriatric clients with recent initiation of a medication, an assessment tool was developed (Table 1). The tool was used to interview clients receiving services in a hospital setting, an outpatient clinic, and a home health agency. The purpose of the development of the tool was to ensure consistent and complete evaluation of individuals' existing developmental level, coping stratégies, and social support as well as evaluating die effects of adverse drug interactions on these subsystems.

NORMAL OLDER ADUlT DEVELOPMENT

Individuals interviewed expected to live to at feast the age of their parents, and they frequently expected to live to 100 years. In reality, a possibility does exist that individuals may live 30 to 40 years as older adults. All individuals interviewed wanted to pursue meaningful activities regardless of their age.

For many of those interviewed, the older adult developmental stage had begun at retirement. In an attempt to cope wim retirement, some individuals enjoyed working at a part-time job or as a volunteer. In later years or with the onset of chronic illness, even though the physical activities might have been restricted, meaningful activities were still achieved by the individual participating in active thinking (critical thinking, reasoning) and interaction related to family and friends. Even with major or minor chronic illness, meaningful activities, with consideration given to physical limitations, allowed the individual to establish and achieve goals.

Active involvement provided social and psychological well-being and contributed to the development of the individuals interviewed. During the interviews, it was noted that all elderly individuals reported pursuing meaningful activities such as walking, volunteering, reading, telling stories to children, traveling, active thinking, participating in social events, and counseling others about decisions or problems.

Elderly individuals interviewed continued to need meaningful life experiences to develop and to have purpose in life. These needed experiences were in concert with the characteristics of egointegrity of aging identified by Erikson7 and included accepting one's life cycle as inevitable, feeling a comradeship with the ways of distant times, having adapted oneself to the triumphs and disappointments of being, possessing a love of humankind rather than self, and finally, achieving a spiritual sense that eliminates the fear of death.

From the interviews, it was also concluded that low self-esteem might result if individuals perceived that they could no longer contribute to society on a full-time basis. Roger's position - tfiat as individuals age, they become more integrated, more complex, and that aging is not a "running down" or a disease but rather a developmental process - was supported.8

CONSEQUENCES

In some individuals who were interviewed, the initiation of medication had not caused adverse effects. The ability to adapt to the chronic illness had been facilitated because the effects of the medication allowed die clients to continue previous meaningful activities. Whereas the medication enhanced the ability to participate in activities for some individuals, activities were altered when side effects occurred in others. Sometimes alternate activities were substituted if the side effects prevented the continuation of the previous activities. One gentleman had experienced orthostatic hypotension. He temporarily discontinued the practice of eating out and read throughout the day to occupy his time. This individual believed that with the medication dosage change, he would eventually be able to resume eating with friends, which allowed socialization.

Other meaningful life experiences were temporarily discontinued because of side effects such as anorexia, dryness of mouth, dizziness, and malaise. For instance, an individual with dizziness was less able to participate in walking. Because of dryness of the mouth or anorexia, an individual's socialization was affected because of an alteration in the eating pattern. If the activities were disrupted due to adverse drug effects, most individuals interviewed found other activities to substitute or they modified their participation in the activity to continue to feel "involved."

The discontinuation of activities was a disruption for the persons interviewed. However, every client who experienced side effects hoped that the symptoms would subside. In light of the interviews, there is a concern that loneliness and isolation might occur if the individual is unable to pursue meaningful activities.

Another aspect of the disruption of meaningful activities was when the individual experiencing an adverse reaction required medical attention in the hospital. Because there was often excessive time to think while the causes of adverse reactions were determined, some individuals perceived that they did not "do something right" and, as a result, must "pay the consequences" by being hospitalized. A period of bargaining appeared to result where the individuals wished they could return to pre-illness state. This can potentially iead to the need for readaptation to an illness that the individual had already accepted. A postponement in meeting developmental tasks may result because of the hospitalization and the energy used to readapt.

Table

TABLE 2POSSIBLE NURSING DIAGNOSESAND INTERVENTIONS FOR PROMOTION OF DEVELOPMENT, ADAPTATION, AND SOCIAL SUPPORT

TABLE 2

POSSIBLE NURSING DIAGNOSESAND INTERVENTIONS FOR PROMOTION OF DEVELOPMENT, ADAPTATION, AND SOCIAL SUPPORT

Additionally with hospitalization, the person is placed in a dependent role and may express anger or hostility toward health-care workers. Individuals must temporarily stop functioning in a meaningful role; they now play the role of patient. In addition, the meaningful life activities that contribute to self-esteem at home are replaced by the forced routine of the hospital.

COPING STRATEGIES AND EFFtCTS

Clearly emerging from the interviews was the finding that the use of medications may facilitate positive adaptation to the chronic illness. In some instances, individuals continued to pursue activities of daily living as well as meaningful activities because the medications contributed to optimal physical functioning. With the ability to continue to pursue activities, these individuals were able to cope with the onset of the disease itself.

Although not found in the interviews, adverse reactions of medication have the potential to cause detrimental effects on the ability of the individual to cope. For example, bleeding complications from the use of anticoagulants may interrupt activities used to cope. If the individual enjoys wood working or carving, which require tools with blunted or sharp edges, the activity may be restricted due to the possibility of trauma. Also, if the individual requires medication that causes sedation, the coping activities associated with alertness would be limited. Such coping activities may include reading, reflecting, driving, shopping, banking, or volunteering time.

Table

TABLE 3PROMOTION OF INDEPENDENCE AND RESPONSIBILITY AMONG THE ELDERLY IN REGARD TO DRUG THERAPY

TABLE 3

PROMOTION OF INDEPENDENCE AND RESPONSIBILITY AMONG THE ELDERLY IN REGARD TO DRUG THERAPY

In regard to coping strategies, it was found that persons substitute one coping activity for another as a way to deal with changes in life. One individual who had been in the hospital 3 months used drawings and active thinking to cope when unable to work on a project in which he was engaged at home.

Generally, side effects can distract from the individual's normal coping routine and activities. If the person is occupied with thoughts of "what is wrong with me" or "why do I have to feel bad," then the ability to cope with environmental, psychological, and social stressors has been reduced. The individual's ability to cope may be interrupted due to the adverse effects of medication.

EFIKTS ON SOCIAL SUPPORTS

Interviewed persons related that medication initiated for the management of chronic illnesses contributed to die feeling of increased control in their ability to seek and use support from friends and family. Most individuals reported that prior to the onset of adverse réactions, they were able to pursue needed support. For example, many individuals had friends through church and community activities. However, once their physical activity was limited, the ability to actively pursue support systems became limited, which frequendy caused feelings of loneliness and isolation.

Even though the ability to independently pursue support may change, elderly individuals' control over their life situation can be facilitated by die support of family and friends. The ability to independently continue making decisions can be affected by oüier common side effects, such as dizziness , anorexia, and sedation . Although not found during interviews, family and friends may have difficulty understanding changes that occur as a result of the side effects of drugs. Without knowledge of the possibility of adverse reactions, die members of the support group may become embarrassed at inappropriate behavior and withdraw from the individual's life or offer inappropriate support. For example, witìi die side effect of drowsiness, family members may begin to make decisions for the individual without investigating die cause of the change in mental status.

USE OF THE ASSESSMENT TOOL

An identified gain from die use of the assessment tool was that it facilitated die identification of nursing diagnoses. Additionally, once nursing diagnoses have been determined, healm-care professionals could then initiate measures to promote continuation of development, coping strategies, and social support with the onset of adverse drug effects. A care plan addressing potential nursing diagnoses is given in Table 2.

IMPLICATIONS

Other implications for health-care professionals emerged as a result of die interviews. Measures to promote developmental growm, adaptation, and social support are needed. Second, promotion of independence and responsibility among die elderly regarding drug therapy is important to facilitate me opportunity for achieving and maintaining adult development, coping strategies, and social support despite drug therapy and the possibility of adverse effects.

In addition to facilitating development, adaptation, and social support, me professional can also promote independence in drug administration and management among elderly persons. A care plan for this is presented in Table 3.

SUMMARY

As indicated by interviews, elderly persons frequendy desired to maintain a life reflective of their years prior to the elderly stage of life. In most instances, the elderly individual adapted to die chronic illness and accepted the disability. However, adverse reactions to medications affected many activities that were important in maintaining development, adaptation, and social support. Active involvement provided a sense of social and psychological wellbeing and included reflecting and reading as well as otiier physical activities. The onset of adverse side effects caused an interruption in meaningful activities. Interviewed individuals substituted other activities to assist in adapting and mamtaining social support.

The assessment tool can evaluate the adverse effects of medication and die effect on older adult development, coping, and social support, and provide possible diagnoses aid interventions for this group. Wim its use, health-care professionals can facilitate the elderly person's pursuit of meaningful life activities.

REFERENCES

  • 1. Simonson W. Medications and the Elderly: A Guide for Promoting Proper Use. Rockvilk: Aspen Systems Corporation; 1984:7-9. 125.
  • 2. Porterfield L. Geriatrie pharmacology: Therapeutic rationale. Home Health Care Nurse. 1984; 2:33-35.
  • 3. Wallace S, Whiting B, Runcie J. Factors affecting drug binding in plasma of elderly patients. Br J Clin Pharmacol. 1976;3:327-330.
  • 4. Lancaster J. Maximizing psychological adaptation in an aging population. In: Wells, T, ed. Aging and Health Promotion. Rockville, Md: Aspen Systems Corporation; 1982: 31-43.
  • 5. Williamson J, Chopin J. Adverse reactions to prescribed drugs in the elderly: A mufticenter investigation. Age Aging. 1980; 9(2):73-80.
  • 6. Miller RR. Drug surveillance utilizing epidemiologic methods: A report from the Boston collaborative drug surveillance program. Am J Hosp Pharm. 1973;30:584-592.
  • 7. Erikson E. Identity and the life cycle. Psychol Issues. 1959;1:1-171.
  • 8. Interview: Martha Rogers. Journal of Gerontological Nursing. 1985; ll(2):35-36.

TABLE 1

ASSESSMENT TOOL TO EVALUATE EFFECTS OF ADVERSE DRUG REACTIONS

TABLE 2

POSSIBLE NURSING DIAGNOSESAND INTERVENTIONS FOR PROMOTION OF DEVELOPMENT, ADAPTATION, AND SOCIAL SUPPORT

TABLE 3

PROMOTION OF INDEPENDENCE AND RESPONSIBILITY AMONG THE ELDERLY IN REGARD TO DRUG THERAPY

10.3928/0098-9134-19900701-07

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