Geriatric Education for Rural Health … Education for Rural Health Professionals: Online Training...
Transcript of Geriatric Education for Rural Health … Education for Rural Health Professionals: Online Training...
Geriatric Education for
Rural Health Professionals:
Online Training Modules
Development Report
Sponsored by the Health Foundation for Western and Central New York and the
Finger Lakes Geriatric Education Center at the University of Rochester
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Project Title: Geriatric Education for Rural Health Professionals Conference
Project Director contact Information:
Jurgis Karuza, PhD
Director, Finger Lakes Geriatric Education Center
E‐mail: [email protected]
Thomas Caprio, MD, MPH
Project Co‐Director, Finger Lakes Geriatric Education Center
E‐Mail: [email protected]
Karen McDowell‐Morrison
Project Coordinator
E‐mail: [email protected]
Laura Robinson, MPH
Project Coordinator
E‐mail: [email protected]
Finger Lakes Geriatric Education Center
University of Rochester
Monroe Community Hospital
435 East Henrietta Road
Rochester, NY 14260
585‐760‐6354
585‐760‐6376 (fax)
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BackgroundThis project offers asynchronous continuing education in geriatrics to primary care practitioners who
practice in the rural counties of Western New York. We designed this online learning project to provide
a “proof of concept” for developing an extensive online‐ based geriatric education series aimed at
primary care practitioners in Western and Central New York which is free to participants and can be
accessed at any time that is convenient to these providers. The additional advantage of online training
modules, particularly in rural regions of New York State, is that it does not necessitate travel to attend
training programs and conferences. Developed by a core group of “content experts,” this online training
library provides the best evidence‐based recommendations for the assessment and management of
common health and social problems of older adults (including the core geriatric syndromes).
The project was developed and implemented by the Finger Lakes Geriatric Education Center (FLGEC) at
the University of Rochester Medical Center. The FLGEC is a federally funded (Health Resources and
Services Administration) geriatric education center (GEC) that first received funding in 1997. The FLGEC
articulates five objectives: 1) provide continuing education of health professionals who provide geriatric
care, 2) provide students with clinical training in geriatrics in nursing homes and other venues 3) support
training and retraining of faculty, 4) improve training of health professionals, and 5) develop and
disseminate curricula, which address the five statutory purposes for GECs mandated by Congress.
The FLGEC, as its name suggests, primarily serves the Finger Lakes region and Monroe County, although
several of its educational activities extend into Western New York and the Syracuse region. As part of
the university, the FLGEC draws upon the resources of the University of Rochester including the Division
of Geriatrics, the Department of Psychiatry, the School of Nursing, the Simon School of Business, and the
Warner School of Education to execute its mission. While based at the University of Rochester, the
FLGEC administratively partners with several consortium members to develop and implement our
educational activities. The consortium members are: Center on Aging at Ithaca College, which focuses
on rural based geriatric education, the Social Work department at SUNY Brockport, which focuses on
geriatric social work education, the Wegmans’ School of Pharmacy at Saint John Fisher College in
Pittsford, NY, that focuses on pharmacy based geriatric education, and New York Chiropractic College in
Seneca Falls, NY, which has an innovate focus on chiropractic based geriatric education. We chose these
partners because of their commitment to our target region and their disciplinary expertise, which
complements the expertise at the University of Rochester.
Our educational activities consist of both disciplinary based and interprofessional educational offerings
and span the variety of educational methods, ranging from conferences, seminars, and courses to
hands‐on clinical training in our geriatric assessment clinic. In 2012, HRSA awarded the FLGEC a
supplemental grant specifically aimed providing primary care practitioners with Alzheimer’s disease
education, including diagnosis, working with families, and accessing resources. With the forthcoming
funding for our second year, this continues to be an important theme for our FLGEC. For this online
learning project we have developed and launched a distance learning management system, in
cooperation with NP Training Works that allows practitioners and students to access modules through
the Internet.
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Finger Lakes Geriatric Education Center's Online Learning Programs
The Finger Lakes Geriatric Education Center (FLGEC) has developed a library of Online Learning
Programs relating to the care of Older Adults which are offered free of charge by the FLGEC through the
“NP Training Works” (CypherWorx) learning management system accessible through the internet using a
secure log‐in on the world wide web. Participants in the online training must register in order to access
the online training which involves creating a user account, providing an e‐mail address for user access,
and completing participant demographic information. E‐mail address are never shared or used for
marketing, only to provide log‐in information or for password recovery
The website is: http://nptrainingworks.com/flgec
The currently available online course modules are:
Geriatric Assessment
Dementia, Delirium, and Depression (the 3 D’s)
Aging and Developmental Disabilities
Polypharmacy
Modules that are currently in development and beta testing are:
Suicide Risk Assessment
Persistent Pain in the Older Adult
Social Assessment
Chiropractic Care for Older Adults
Geriatric Oncology
Oral Health/Dentistry
Elder Abuse Training
Target Audience: These online training modules are intended for Medical/Nursing and Social Work
Providers who work mainly with older adults.
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Appendix A: Sample Module Outlines (“story boards”)
Geriatric Assessment
1. Common Geriatric Syndromes 2. Four Pillars of Assessment
a. Medical Assessment b. Functional Assessment c. Psychological Assessment d. Cognitive Assessment
3. Other Important Topics a. Social Assessment b. Economic Assessment c. Preventive Health d. Advance Care Planning
The 3D’s: Depression, Delirium, and Dementia
‐ Intro
‐ General Overview
o Dementia, Delirium, and Depression are the 3 most prevalent mental disorders in the older
person.
‐ Depression o Symptoms
Emotional
Sadness (more often hopelessness)
Inability to concentrate
Recurrent thoughts of death (not the same as a seriously ill person’s desire
for a natural death)
Physical
Body aches
Headache
Pain
Fatigue
Change in sleep habits
Weight change (either increase or decrease)
o Definition
Depression is a term used when a cluster of depressive symptoms (as identified on
the SIG E CAPS depression criteria) is present on most days, for most of the time, for
at least 2 weeks and when the symptoms are of such intensity that they are out of
the ordinary for that individual.
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Depression is a biologically based illness that affects a person’s thoughts, feelings,
behavior, and even physical health
o Why
Depression is very common in late life.
Affects nearly 5 million of the 31 million Americans aged 65 and older with clinically
significant depressive symptoms reaching 13% in older adults aged 80 and older.
Major depression is reported in 8‐16% of community dwelling older adults.
5‐10% of older medical outpatients seeing a primary care provider.
10‐12% of medical‐surgical hospitalized older adults with 23% more
experiencing significant depressive symptoms.
Recognition in long‐term care facilities is poor and not consistent amongst studies.
Depression is not a natural part of aging.
Depression is often reversible with prompt recognition and appropriate treatment.
If left untreated, depression may result in the onset of physical, cognitive,
functional, and social impairment, as well as decreased quality of life, delayed
recovery from medical illness and surgery, increased health care utilization, and
suicide.
o Best Tool for Diagnosis
There is also a Geriatric Depression Scale in Long Form. (30 questions)
Geriatric Depression Scale: Short Form (Choose the best answer for how you have
felt over the past week)
1. Are you basically satisfied with your life? YES/NO
2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO
5. Are you in good spirit most of the time? YES/NO
6. Are you afraid that something bad is going to happen to you? YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new
things? YES/ NO
10. Do you feel you have more problems with memory than most? YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are? YES/NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression
A ≥ 10 points is almost always indicative of depression.
A score > 5 points should warrant a follow=up comprehensive assessment.
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o Target Population
The GDS may be used with healthy, medically ill and mild to moderately cognitively
impaired older adults. It has been used extensively in the community, both long‐
term and short care settings.
o Validity and Reliability
Found to have 92% sensitivity and 89% specificity when evaluated against diagnostic
criteria.
Validity and Reliability have the tool have been supported through clinical practice
and research.
Both the Long and Short form of the GDS were successful in finding depression in
adults with a high correlation.
o Strengths and Limitations
GDS is NOT a substitute for a diagnostic interview by mental health professionals.
Better used as a screening tool.
It does NOT assess suicidality
o Consequences of Untreated Depression
Increase risk for mental illness and cognitive decline
Fatal consequences in terms of suicide and non‐suicide mortality
The highest rate of suicide is among white men
Tragically many have reached out for help
20% see the doctor the DAY they die
40% the WEEK they die
70% in the MONTH they die
o Nursing Strategies
Keep patient safe
Review medications
Monitor and promote physical health, nutrition and sleep.
Pain Control
Identify and reinforce strengths
Encourage pleasant reminiscences
Listen, listen, listen
Provide information about it
Encourage family support
o Bottom Line!
The presence of depression warrants prompt intervention and treatment. The GDS
may be used to monitor depression over time in all clinical settings. Any positive
score above 5 on the GDS Short Form should prompt an in‐depth psychological
assessment and evaluation for suicidality.
‐ Delirium
o Symptoms
Person is oriented to person but not time or place
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Disorganized thinking
Inattention and inability to shift focus or sustain attention
Altered perception – visual illusions or hallucinations, which may lead to
misinterpretation of the environment (i.e. feeling threatened by shadows on the
wall)
May be agitated, lethargic or hypervigilant. o Definition
Delirium is a medical emergency which is characterized by an acute and fluctuating
onset of confusion, disturbances in attention, disorganized thinking and/or decline
in level of consciousness.
Delirium cannot be accounted for by a preexisting dementia; however, can co‐exist
with dementia.
o Causes? Consider these first.
Drugs 30%
Endocrine/metabolic
Location change
Infections
Respiratory/cardiac disease
Impaction (constipation)
Unrelieved pain, especially in dementia
Malignancy
Consider these second. SAD MATES
Stroke
Alcohol
Depression
Malnutrition
Anemia
Trauma
Epilepsy
Sensory Deprivation
o Why
Delirium is present in 10‐31% of older medical inpatients upon hospital admission
and 11‐42% of older adults develop delirium during hospitalization.
Delirium is associated with negative consequences including prolonged
hospitalization, functional decline, increased use of chemical and physical restraints,
prolonged delirium post hospitalization, and increased mortality.
May also have lasting negative effects including the development of dementia
within two years and the need for long term nursing home care.
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Predisposing risk factors for delirium include older age, dementia, severe illness,
multiple co‐morbidities, alcoholism, vision impairment, hearing impairment, and a
history of delirium.
Precipitating risk factors include: acute illness, surgery pain, dehydration, sepsis,
electrolyte disturbance, urinary retention, fecal impaction, and exposure to high risk
medications.
Delirium is often unrecognized and undocumented by clinicians.
Early recognition and treatment can improve outcomes. Therefore, patients should
be assessed frequently using a standardized tool to facilitate prompt identification
and management of delirium and underlying etiology.
o Best Tool for Diagnosis
The Confusion Assessment Method (CAM) is a standardized evidence‐based tool
that enables non‐psychiatrically trained clinicians to identify and recognize delirium
quickly and accurately in both clinical and research settings. There also is a CAM‐ICU
version for use with non‐verbal mechanically ventilated patients.
The CAM includes four features found to have the greatest ability to distinguish
delirium from other types of cognitive impairment
1. [Acute Onset] Is there evidence of an acute change in mental status from
the patients baseline?
2A. [Inattention] Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty keeping track of what
was being said?
2B. [If present or abnormal] Did this behavior fluctuate during the
interview, that is, tend to come and go or increase and decrease in severity?
3. [Disorganized thinking] Was the patient’s thinking disorganized or
incoherent, such as rambling or irrelevant conversation, unclear or illogical
follow of ideas, or unpredictable switching from subject to subject?
4. [Altered level of consciousness] Overall, how would you rate this
patient’s level of consciousness?
o Alert: Normal
o Vigilant: Hyperalert, overly sensitive to environmental stimuli,
startled very easily
o Lethargic: Drowsy, easily aroused
o Stupor: Difficulty to arouse
o Coma: Unarousable
o Uncertain
5. [Disorientation] Was the patient disoriented at any time during the
interview, such as thinking that he/she was somewhere other than the
hospital, using the wrong bed, or misjudging the time of day?
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6. [Memory impairment] Did the patient demonstrate any memory
problems during the interview, such as inability to remember events in the
hospital or difficulty remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of
perceptual disturbances, for example: hallucinations, illusions, or
misinterpretations (such as thinking something was moving when it was
not?)
8A. [Psychomotor agitation] At any time during the interview did the
patient have an unusually increased level of motor activity such as
restlessness, picking at bedclothes, tapping fingers or making frequent
sudden changes of position?
8B.[Psychomotor retardation] At any time during the interview did the
patient have an unusually decreased level of motor activity such as
sluggishness, staring into space, staying in one position for a long time or
moving very slowly?
9. [Altered sleep‐wake cycle] Did the patient have evidence of disturbance
of the sleep‐wake cycle, such as excessive daytime sleepiness with insomnia
at night?
The Confusion Assessment Method (CAM) Diagnostic Algorithm
The diagnosis of delirium by CAM requires the presence of features 1 and 2
and either 3 or 4.
Feature 1: Acute Onset or Fluctuating Course
o This feature is usually obtained from a family member or nurse and
is shown by positive responses to the following questions:
Is there evidence of an acute change in mental status from
the patient’s baseline?
Did the (abnormal) behavior fluctuate during the day, that
is, tend to come and go, or increase and decrease in
severity?
Feature 2: Inattention
o This feature is shown by a positive response to the following
question:
Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty
keeping track of what was being said?
Feature 3: Disorganized Thinking
o This feature is shown by a positive response to the following
question:
Was the patients thinking disorganized or incoherent, such
as rambling or irrelevant conversation, unclear or illogical
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flow of ideas, or unpredictable switching from subject to
subject?
Feature 4: Altered Level of Consciousness
o This feature is show by any answer other than “alert” to the
following question:
Overall, how would you rate this patient’s level of
consciousness?
Alert: Normal
Vigilant: Hyperalert
Lethargic: Drowsy, easily aroused
Stupor: Difficult to arouse
Coma: Unarousable
o Validity and Reliability
Both the CAM and the CAM‐ICU have demonstrated sensitivity of 94‐100%,
specificity of 89‐95% and high inter‐rater reliability.
o Strengths and Limitations
The CAM can be incorporated into routine assessment and has been translated into
several languages. The CAM was designed and validated to be scored based on
observations made during brief but formal cognitive testing, such as brief mental
statues evaluations. Training to administer and score the tool necessary to obtain
valid results. The tool identifies the presence or absence of delirium but does not
assess the severity of the condition, making it less useful to detect clinical
improvement or deterioration.
o Nursing Strategies (be a detective!)
Look for underlying cause
Keep day/night cycle consistent
Foster familiarity, encourage family to stay at bedside
Maintain mobility and avoid restraints
Prevent inappropriate stimulation
Use sensory aids
Reorient often
Reassure and educate family
o Bottom Line!
The presence of delirium warrants prompt intervention to identify and treat
underlying causes and provide supportive care, Vigilant efforts need to continue
across the healthcare continuum to preserve and restore baseline mental status.
‐ Dementia o Definition
Dementia is a gradual and progressive decline in mental processing ability that
affects short‐term memory, communication, language, judgment, reasoning, and
abstract thinking.
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Dementia eventually affects long‐term memory and the ability to perform familiar
tasks. Sometimes there are changes in mood and behavior.
o What is this?
This “Try This” document suggests ways hospitals can increase recognition of
dementia in their older patients, to lessen or avoid any of these problems.
o NOTE: At the time of hospital intake, it is very difficult to differentiate dementia from
delirium, as many older patients have both. None of the approaches rule out delirium, so
you need to do more assessments.
o Why
About one fourth of older hospital patients have dementia and may never be fully
diagnosed, and if it is it may not be noted on their hospital records.
Because of stress caused by acute illness and being in an unfamiliar setting, some
older patients show symptoms of dementia for the first time in a hospital.
Older hospital patients with dementia are at a much higher risk than other older
hospital patients for delirium, falls, dehydration, inadequate nutrition, untreated
pain, and medication‐related problems.
They are more likely to wander, exhibit agitated and aggressive behaviors, have to
be physically restrained, and to experience functional decline that does not resolve
following discharge.
o Target Population
Dementia should be considered a possibility in every hospital patient age 75 and
over, and can sometimes be in younger patients.
People with dementia usually come into the hospital for treatment of their other
medical conditions, although some come in because of complications BECAUSE of
their dementia.
30% of people with dementia also have coronary artery disease.
28% congestive heart failure.
21% diabetes.
17% chronic obstructive pulmonary disease.
o Best Practices
One approach is to ask the person and family of the person has “severe memory
problems.”
Another is to ask if a doctor has ever said the person has Alzheimer’s disease or
dementia.
The easiest way to do this is to add the items “severe memory problems,”
“Alzheimer’s disease,” and “dementia” to the list of diseases and conditions patients
and families are routinely asked about on intake forms and in intake interviews.
o Best Tool for Diagnosis ‐ When no prior diagnosis of dementia is reported
Family Questionnaire
A family member or friend who accompanies the patient to the hospital can
be handed a print copy of the 7‐item Family Questionnaire.
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o This questionnaire is intended to identify memory problems that
interfere with day to day activities – a sign of possible dementia.
(Not at all, Sometimes, Frequently, N/A)
1. Repeating or asking the same thing over and over.
2. Forgetting appointments, family occasions, or holidays?
3. Writing checks, paying bills, or balancing a checkbook?
4. Shopping independently for clothing or groceries?
5. Taking medications according to instructions?
6. Getting lost while walking or driving in familiar places?
7. Making decisions that arise in everyday living?
Not at all or N/A = 0
Sometimes = 1
Frequently = 2
o ≥ 3 = further assessment
o 3‐6 = possible dementia
o 7‐10 = probable dementia
Patient Behavior Triggers for Clinical Staff
This tool includes signs and symptoms that suggest the need to consider
dementia. The intake interviewer and other hospital staff can be asked to
record or report their own observations of these signs and symptoms.
o Seems disoriented
o Is a “poor historian”
o Defers to a family member to answer questions directed at the
patient.
o Repeatedly and apparently unintentionally fails to follow
instructions.
o Has difficulty finding the right words or uses inappropriate or
incomprehensible words
o Has difficulty following conversations
When the results of any of these approaches indicate
possible dementia, further assessment is needed to
measure the level of cognitive impairment and identify
delirium, depression, and other conditions that can cause
cognitive impairment.
o Common forms of Progressive Dementia
Alzheimer’s disease 65%
5.3 million Americans have
Every 70 seconds somebody develops AD
6th leading cause of death in this country (tied with diabetes)
5th leading cause of death among people 65 and older
African Americans 2 times more likely to have
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Hispanics 1.5 times more likely.
Symptoms occur GRADUALLY over months and years
Vascular Dementia 23%
Incidence doubles every 5 years after 65
o Nursing Strategies
Monitor and document change (6 behavior triggers)
Monitor efficacy of medications
Provide safe environment (routine)
Avoid over stimulation
Use multiple channels i.e. instead of saying ”wash your face” put wash cloth in the
hand or instead of “brush your teeth” put tooth brush in their hand, demonstrate
show teeth etc.
‐ Summary
o Caring for someone with mental status deficits is a challenge
o Differentiating between depression, dementia, and delirium is essential to provide the best
possible care.
o Realize that 2 conditions can occur simultaneously may prevent decline in the person with
dementia by treating and/or preventing a secondary condition.
o At least 2 have the potential for reversal.
o Do assess
o Do Investigate
o Do monitor and document
Aging and Developmental Disabilities
‐ Overview of Aging and Intellectual and Developmental Disabilities (IDD)
o Historical background
o Current statistics and trends
‐ Factors of aging and ID
o The factors of aging make a difference on the health and well‐being of each person in
old age.
o Aging comes down to 4 main factors,
Genetics
Environment
Lifestyle (diet, exercise, habits, and education)
Attitude
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‐ Types of Aging
o Successful
Minimal or no effects from disease or age‐associated conditions.
o Normal or Average
Some effects from disease pre‐existing conditions. Or age‐associated changes
with changes in lifestyle or activities likely.
o Pathological
Major effect from disease, pre‐existing conditions, or age‐associated changes.
o Everybody has the potential for successful aging regardless of pre‐existing conditions.
o Successful aging or at least average aging should be the goal for everybody as they age.
‐ Specific Syndromes and Aging
o Down syndrome and aging
Possible changes with about a 20 year earlier onset for risk factors.
‐ Increased sensory impairments
‐ Increased stomach, intestinal and cardiovascular problems
‐ Increased risk for Alzheimer’s dementia due to trisomy 21(Down
syndrome)
‐ Decreased resistance to disease
‐ Reduced thyroid function
Affects
‐ Increased risk for misdiagnosis of Alzheimer’s dementia
‐ Earlier onset of disease and changes with possible reduction in
functioning as a result
Prevention
‐ Education of staff, family, and advocates on risk factors and
observational skills
o Increase need for health care advocacy with providers
‐ Advocacy for differential diagnosis
‐ Opportunities over lifespan to exercise the brain and body
Other
‐ Increased incidence after age 55 (but not 100%)
‐ Earlier onset than general population with quicker regression
‐ Increased risk for misdiagnosis due to assumptions of if DS must have
AD
‐ Need for structure and routine throughout a lifetime? Impact on
incidence?
o Cerebral palsy and aging
Possible Changes
‐ Earlier onset for arthritis, osteoporosis
‐ Difficulties with swallowing and choking
‐ Increased seizures
‐ Increased sensory impairments
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‐ Increase urinary incontinence and urinary tract infections
Affect
‐ Increased pain and discomfort that could exhibit as “behaviorial
problems”
‐ Increased risk for respiratory problems
‐ Increased mobility problems
‐ Increased fatigue
Prevention
‐ Opportunities for movements and weight bearing
‐ Vitamin and mineral supplements if the diet cannot supply needed
amounts
‐ Opportunities for rest interspersed with activities
o Epilepsy and IDD
Increased risk for seizures with age, already compromised because of pre‐
existing occurrence of seizures
Increased risk for falls due to seizures and aging
Medications that have blocked the absorption of Vitamins C & D thus increasing
the risk for arthritis and osteoporosis
Increased risk for a sedentary lifestyle thus reducing vitality in the body systems
especially bone density and strength as well as stamina
Increased risk for obesity due to lack of weight bearing exercise
‐ Health Care Disparities
o Health care challenges and disparities for adults with IDD
Lack of training on adults with IDD for health care providers
Lack of research on aging and IDD thus impacting the capacity for informed
choices for assessment & interventions by the health care provider, advocates,
and adults with IDD
Challenges for reporting symptoms by the adult with IDD, increased difficulty in
interpreting symptoms
Assumption of automatic loss and decline with aging by the health care
providers and caregivers with misdiagnosis or lack of diagnosis for underlying
decline
‐ The more severe the disability or if the adult has Down syndrome an
increased likelihood of assumption of dementia
o Women with IDD and health care disparities
All of the above
Medical tests and interventions have been normed for men with women with
IDD not part of the clinical trials
Higher risk for side effects of medications with less known about possible side
effects
Lack of training on women’s health in general and specifically for women with
IDD
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Lack of accessible offices and equipment for standardized tests like a
mammogram
o The importance of health care advocacy for adults with IDD across the lifespan
Because of all of the above it is essential that care providers and self‐advocates
understand their own aging process and have the skills for Health care advocacy
Aging and IDD not taught in medical schools, not a requirement in most schools,
IDD in general let alone aging process, this FLGEC is the only GEC in the country
with an IDD component
‐ Summary
o You can make a difference for each person as each ages by understanding aging and
developing prevention activities across the lifespan.
o Successful aging is possible for every person and should be our goal.
o Enjoy aging yourself and serve as a role model to others.
o Treat each day as a gift, regardless of the diagnosis or age.
Polypharmacy
‐ Objectives
o Understand future changes in the U.S. population and how they impact healthcare.
o Review age related physiologic changes.
o Outline age related pharmacokinetics and pharmacodynamics changes.
Pharmacokinetics – What the body does to the drug.
Pharmacodynamics – The study of the biochemical and physiological effects of
the drugs on the body.
o Identify potential drug‐related problems in older adults.
o Apply strategies to ensure safe medication use in older adults.
Older adults – 65 years old and on
“Young” old (65‐74 years)
“Middle” old (75‐84 years)
“Old” old (85 years old and older)
‐ Age Related Physiologic Changes
o Decreased ability to preserve homeostasis
o Decreased ability to tolerate physiologic stresses
Small stress may result in major morbidity and mortality
Cardiovascular, musculoskeletal, and central nervous systems are most affected.
‐ Cardiovascular
o Myocardial sensitivity to ß‐adrenergic stimulation.
o Decreased baroreceptor activity
Baroreceptors – are sensors located in blood vessels. They detect differences in
pressure changes.
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o Decreased cardiac output.
o Increased total peripheral resistance.
o Increased valvular stiffness.
Valvular stiffness – heart valves stiffness
o Lower plasma rennin and urine aldosterone.
Aldosterone – A steroid hormone produced by the outer section of the adrenal
cortex.
Plasma rennin – The measure of activity of the plasma enzyme rennin, which
plays a major role in the body's regulation of blood pressure
‐ Central Nervous System
o Decreased brain weight and volume.
o Decreased rate of conduction and strength of transmission.
o Decreased adaptation to physiologic stress.
o Increased autonomic nervous system recovery time.
o Increased neuronal loss.
o Increased blood, brain barrier permeability.
‐ Age‐Related Physiologic Changes
o Endocrine
Thyroid disease.
Increased incidence DM.
o Oral
Altered dentition
Decreased ability to taste sweet, sour, and bitter.
o Skin
Decreased turgor and elasticity.
Skin turgor – the ability to change shape and return to normal.
Increased melanocytes.
Cells in the skin that is mostly responsible for skin color.
Epithelial thinning.
o Sensory
Hearing loss from decreased conduction velocity.
Accommodation of the lens of the eye.
‐ Genitourinary
o Older women
Vaginal atrophy with decreased estrogen
o Older men
Prostatic hypertrophy
Decline in testosterone
Hypospermia
o Incontinence
‐ Gastrointestinal
o Delayed gastric emptying
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o Decreased GI blood flow
o Slowed intestinal transit
o Decreased liver size and blood flow
o Decreased pancreatic secretions
‐ Renal
o Decreased renal blood flow
o Decreased renal mass
o Decreased GFR rate
o Decreased tubular secretory function
o Decreased functional nephrons
o Decreased ability to concentrate urine
o Decreased acid‐base adaption under stress
‐ **Age‐Related Pharmacokinetic and Pharmacodynamic Changes** o Absorption
Unchanged passive diffusion
Minimal change in bioavailability for most drugs.
o Distribution
Decreased P‐glycoprotein activity within blood brain barrier.
Increased exposure to drugs and toxins.
Increased adipose tissue.
Increased VD for lopophilic drugs (eg. Diazepam, amiodarone)
Increased potential for accumulation and delayed peak effect.
Decreased total body water and lean muscle mass.
Decreased VD for hydrophilic drugs, increased peak levels.
Body water
o Vancomycin, Aminoglycosides
Muscle
o Dignoxin
Hypoalbuminemia
Occurs in 10‐20% of older adults
Highly protein bound acidic drugs
Warfarin, phenytoin, furosemide, naproxen.
Increased concentrations of unbound medications
Increased drug activity
Alpha‐1 acid glycoprotein
Increase with aging, physiologic stress, inflammation.
Binds to lipophilic basic drugs
o Methadone, lidocaine, propranolol, imipramine
o Decreased free fraction of basic drugs
o Metabolism
Decrease in hepatic blood flow and liver size
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Decrease metabolism of drugs with high hepatic extractions ratios
o Morphine, propranolol, lidocaine
No change in phase 2 metabolism
o Glucuronidation, sulfation
o No active metabolites
o Preferred for older adults
o Lorazepam, warfarin, metoprolol
Age‐related decline in phase 1 drug metabolism
CYP450 mediated
o Reduced enzyme activity with decreased hepatic volume.
Potential active metabolites
o Increased half‐life and decreased drug clearance
Diazepam, theophylline, noritriptyline
Additional factors to consider
CYP 450 enzyme induction or inhibition from concomitant medication
use
Pharmacogenomics
Alcohol abuse
o Elimination
Age‐related GFR decline
Expected 1ml/min/year GFR decline after the age of 40
Decreased renal perfusion
Decreased cardiac output
Arteriosclerotic changes
Age‐related diseases
Diabetes, HTN
Protein malnutrition, artificially low BUN
Decreased muscle mass, decreased serum creatinine production
CrCl and GFR overestimated
Concealed renal insufficiency
Cockgraft‐Gault equation for calculating CrCl
Patients > 70 years whose Scr < 0.7 mg/dl
o Adjust Scr to 0.7 mg/dl
o Compensate for low muscle mass
Patients > 70 years whose SCr > 0.7 mg/dl
o Use actual SCr
Assess patient specific factors and use clinical judgment
o Pharmacodynamics(PD)
Altered drug response or increase “sensitivity” in older adults
Age related pharmacodynamic changes more significant than
pharmacokinetic changes
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o Major contributor to high adverse drug events (ADE) rates
among older adults.
Changes in receptor number and affinity
Muscarinic PTH, β‐adrenergic, α‐adrenergic, μ‐opioid
o E.g. increased morphine sensitivity secondary to decreased
number of μ‐opioid receptors
Age‐related homeostatic mechanism impairment
Decreased baroreceptor sensitivity and responsiveness
o E.g. increased potential for orthostatic hypotension with
calcium channel blockers
Additive effects with multiple PD changes from a single medication
E.g. Orthostatic hypotension with use of atypical antipsychotics
Decreased baroreceptor sensitivity and responsiveness
Increased sensitivity to α‐adrenergic blockade
o Bottom line
Older adults are fragile
As pharmacists, we need to
Be mindful of older adult’s decreased physical reserve
Consider potential physiologic, pharmacokinetic, and pharmacodynamic
changes.
Physiologic, PK (pharmacokinetics), and PD (pharmacodynamics) changes
influence pharmacotherapy recommendations.
o Goals of Care in Older Adults
Preserve independence
Prevent disability to avoid institutionalization
Improve or maintain quality of life
o Treatment Goals in Older Adults
Selected disease states have different treatment goals for older versus younger
adults
Need for different treatment goals influenced by life expectancy,
functional status, support system, pharmacotherapy risk versus benefit,
physiologic changes, PK/PD changes, potential drug interactions
Classification of blood pressure
Treatment Goals Example: HTN
Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
o Treatment goals : BP < 140/90 mmHg or BP < 130/80 mmHg if
diabetic and/or CKD
ACCF/AHA 2011 Expert Consensus Document on Hypertension in the
Elderly
o SBP of 140‐145 mmHg reasonable if > 80 years
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o Avoid SBP < 130 mmHg and DBP > 65 mmHg due to risk of hypo‐
perfusion
‐ Drug Related Problems and Medication Safety in Older Adults
o Inappropriate prescribing
*Beers Criteria*
Top 200 drugs to avoid?
Anticholinergics and NSAIDs
Overview
Adverse Effects (both Anti and NSAID)
Risk Scale
STOPP/START Criteria
Overview
o Cardiovascular system
o Central nervous system
o Gastrointestinal system
o Respiratory system
o Musculoskeletal system
o Urogenital system
o Endocrine system
o Drugs that adversely affect fallers
o Analgesic drugs
o Duplicate drug classes
STOPP Criteria and limitations
START Criteria and limitations
o Medication Appropriateness Index
‐ Conclusions/Summary