Geriatric Education for Rural Health Professionals: Online Training Modules Development Report

Transcription

1 Geriatric Educatin fr Rural Health Prfessinals: Online Training Mdules Develpment Reprt Spnsred by the Health Fundatin fr Western and Central New Yrk and the Finger Lakes Geriatric Educatin Center at the University f Rchester

2 Prject Title: Geriatric Educatin fr Rural Health Prfessinals Cnference Prject Directr cntact Infrmatin: Jurgis Karuza, PhD Directr, Finger Lakes Geriatric Educatin Center E mail: jurgis_karuza@urmc.rchester.edu Thmas Capri, MD, MPH Prject C Directr, Finger Lakes Geriatric Educatin Center E Mail: thmas_capri@urmc.rchester.edu Karen McDwell Mrrisn Prject Crdinatr E mail: karen_mcdwellmrrisn@urmc.rchester.edu Laura Rbinsn, MPH Prject Crdinatr E mail: LauraM_Rbinsn@urmc.rchester.edu Finger Lakes Geriatric Educatin Center University f Rchester Mnre Cmmunity Hspital 435 East Henrietta Rad Rchester, NY (fax) Page 1

3 Backgrund This prject ffers asynchrnus cntinuing educatin in geriatrics t primary care practitiners wh practice in the rural cunties f Western New Yrk. We designed this nline learning prject t prvide a prf f cncept fr develping an extensive nline based geriatric educatin series aimed at primary care practitiners in Western and Central New Yrk which is free t participants and can be accessed at any time that is cnvenient t these prviders. The additinal advantage f nline training mdules, particularly in rural regins f New Yrk State, is that it des nt necessitate travel t attend training prgrams and cnferences. Develped by a cre grup f cntent experts, this nline training library prvides the best evidence based recmmendatins fr the assessment and management f cmmn health and scial prblems f lder adults (including the cre geriatric syndrmes). The prject was develped and implemented by the Finger Lakes Geriatric Educatin Center (FLGEC) at the University f Rchester Medical Center. The FLGEC is a federally funded (Health Resurces and Services Administratin) geriatric educatin center (GEC) that first received funding in The FLGEC articulates five bjectives: 1) prvide cntinuing educatin f health prfessinals wh prvide geriatric care, 2) prvide students with clinical training in geriatrics in nursing hmes and ther venues 3) supprt training and retraining f faculty, 4) imprve training f health prfessinals, and 5) develp and disseminate curricula, which address the five statutry purpses fr GECs mandated by Cngress. The FLGEC, as its name suggests, primarily serves the Finger Lakes regin and Mnre Cunty, althugh several f its educatinal activities extend int Western New Yrk and the Syracuse regin. As part f the university, the FLGEC draws upn the resurces f the University f Rchester including the Divisin f Geriatrics, the Department f Psychiatry, the Schl f Nursing, the Simn Schl f Business, and the Warner Schl f Educatin t execute its missin. While based at the University f Rchester, the FLGEC administratively partners with several cnsrtium members t develp and implement ur educatinal activities. The cnsrtium members are: Center n Aging at Ithaca Cllege, which fcuses n rural based geriatric educatin, the Scial Wrk department at SUNY Brckprt, which fcuses n geriatric scial wrk educatin, the Wegmans Schl f Pharmacy at Saint Jhn Fisher Cllege in Pittsfrd, NY, that fcuses n pharmacy based geriatric educatin, and New Yrk Chirpractic Cllege in Seneca Falls, NY, which has an innvate fcus n chirpractic based geriatric educatin. We chse these partners because f their cmmitment t ur target regin and their disciplinary expertise, which cmplements the expertise at the University f Rchester. Our educatinal activities cnsist f bth disciplinary based and interprfessinal educatinal fferings and span the variety f educatinal methds, ranging frm cnferences, seminars, and curses t hands n clinical training in ur geriatric assessment clinic. In 2012, HRSA awarded the FLGEC a supplemental grant specifically aimed prviding primary care practitiners with Alzheimer s disease educatin, including diagnsis, wrking with families, and accessing resurces. With the frthcming funding fr ur secnd year, this cntinues t be an imprtant theme fr ur FLGEC. Fr this nline learning prject we have develped and launched a distance learning management system, in cperatin with NP Training Wrks that allws practitiners and students t access mdules thrugh the Internet. Page 2

4 Finger Lakes Geriatric Educatin Center's Online Learning Prgrams The Finger Lakes Geriatric Educatin Center (FLGEC) has develped a library f Online Learning Prgrams relating t the care f Older Adults which are ffered free f charge by the FLGEC thrugh the NP Training Wrks (CypherWrx) learning management system accessible thrugh the internet using a secure lg in n the wrld wide web. Participants in the nline training must register in rder t access the nline training which invlves creating a user accunt, prviding an e mail address fr user access, and cmpleting participant demgraphic infrmatin. E mail address are never shared r used fr marketing, nly t prvide lg in infrmatin r fr passwrd recvery The website is: The currently available nline curse mdules are: Geriatric Assessment Dementia, Delirium, and Depressin (the 3 D s) Aging and Develpmental Disabilities Plypharmacy Mdules that are currently in develpment and beta testing are: Suicide Risk Assessment Persistent Pain in the Older Adult Scial Assessment Chirpractic Care fr Older Adults Geriatric Onclgy Oral Health/Dentistry Elder Abuse Training Target Audience: These nline training mdules are intended fr Medical/Nursing and Scial Wrk Prviders wh wrk mainly with lder adults. Page 3

5 Appendix A: Sample Mdule Outlines ( stry bards ) Geriatric Assessment 1. Cmmn Geriatric Syndrmes 2. Fur Pillars f Assessment a. Medical Assessment b. Functinal Assessment c. Psychlgical Assessment d. Cgnitive Assessment 3. Other Imprtant Tpics a. Scial Assessment b. Ecnmic Assessment c. Preventive Health d. Advance Care Planning The 3D s: Depressin, Delirium, and Dementia Intr General Overview Depressin Dementia, Delirium, and Depressin are the 3 mst prevalent mental disrders in the lder persn. Symptms Emtinal Sadness (mre ften hpelessness) Inability t cncentrate Recurrent thughts f death (nt the same as a seriusly ill persn s desire fr a natural death) Physical Bdy aches Headache Pain Fatigue Change in sleep habits Weight change (either increase r decrease) Definitin Depressin is a term used when a cluster f depressive symptms (as identified n the SIG E CAPS depressin criteria) is present n mst days, fr mst f the time, fr at least 2 weeks and when the symptms are f such intensity that they are ut f the rdinary fr that individual. Page 4

6 Depressin is a bilgically based illness that affects a persn s thughts, feelings, behavir, and even physical health Why Depressin is very cmmn in late life. Affects nearly 5 millin f the 31 millin Americans aged 65 and lder with clinically significant depressive symptms reaching 13% in lder adults aged 80 and lder. Majr depressin is reprted in 8 16% f cmmunity dwelling lder adults. 5 10% f lder medical utpatients seeing a primary care prvider % f medical surgical hspitalized lder adults with 23% mre experiencing significant depressive symptms. Recgnitin in lng term care facilities is pr and nt cnsistent amngst studies. Depressin is nt a natural part f aging. Depressin is ften reversible with prmpt recgnitin and apprpriate treatment. If left untreated, depressin may result in the nset f physical, cgnitive, functinal, and scial impairment, as well as decreased quality f life, delayed recvery frm medical illness and surgery, increased health care utilizatin, and suicide. Best Tl fr Diagnsis There is als a Geriatric Depressin Scale in Lng Frm. (30 questins) Geriatric Depressin Scale: Shrt Frm (Chse the best answer fr hw yu have felt ver the past week) 1. Are yu basically satisfied with yur life? YES/NO 2. Have yu drpped many f yur activities and interests? YES/NO 3. D yu feel that yur life is empty? YES/NO 4. D yu ften get bred? YES/NO 5. Are yu in gd spirit mst f the time? YES/NO 6. Are yu afraid that smething bad is ging t happen t yu? YES/NO 7. D yu feel happy mst f the time? YES/NO 8. D yu ften feel helpless? YES/NO 9. D yu prefer t stay at hme, rather than ging ut and ding new things? YES/ NO 10. D yu feel yu have mre prblems with memry than mst? YES/NO 11. D yu think it is wnderful t be alive nw? YES/NO 12. D yu feel pretty wrthless the way yu are nw? YES/NO 13. D yu feel full f energy? YES/NO 14. D yu feel that yur situatin is hpeless? YES/NO 15. D yu think that mst peple are better ff than yu are? YES/NO Answers in bld indicate depressin. Scre 1 pint fr each blded answer. A scre > 5 pints is suggestive f depressin A 10 pints is almst always indicative f depressin. A scre > 5 pints shuld warrant a fllw=up cmprehensive assessment. Page 5

7 Target Ppulatin The GDS may be used with healthy, medically ill and mild t mderately cgnitively impaired lder adults. It has been used extensively in the cmmunity, bth lngterm and shrt care settings. Validity and Reliability Fund t have 92% sensitivity and 89% specificity when evaluated against diagnstic criteria. Validity and Reliability have the tl have been supprted thrugh clinical practice and research. Bth the Lng and Shrt frm f the GDS were successful in finding depressin in adults with a high crrelatin. Strengths and Limitatins GDS is NOT a substitute fr a diagnstic interview by mental health prfessinals. Better used as a screening tl. It des NOT assess suicidality Cnsequences f Untreated Depressin Increase risk fr mental illness and cgnitive decline Fatal cnsequences in terms f suicide and nn suicide mrtality The highest rate f suicide is amng white men Tragically many have reached ut fr help 20% see the dctr the DAY they die 40% the WEEK they die 70% in the MONTH they die Nursing Strategies Keep patient safe Review medicatins Mnitr and prmte physical health, nutritin and sleep. Pain Cntrl Identify and reinfrce strengths Encurage pleasant reminiscences Listen, listen, listen Prvide infrmatin abut it Encurage family supprt Bttm Line! The presence f depressin warrants prmpt interventin and treatment. The GDS may be used t mnitr depressin ver time in all clinical settings. Any psitive scre abve 5 n the GDS Shrt Frm shuld prmpt an in depth psychlgical assessment and evaluatin fr suicidality. Delirium Symptms Persn is riented t persn but nt time r place Page 6

8 Disrganized thinking Inattentin and inability t shift fcus r sustain attentin Altered perceptin visual illusins r hallucinatins, which may lead t misinterpretatin f the envirnment (i.e. feeling threatened by shadws n the wall) May be agitated, lethargic r hypervigilant. Definitin Delirium is a medical emergency which is characterized by an acute and fluctuating nset f cnfusin, disturbances in attentin, disrganized thinking and/r decline in level f cnsciusness. Delirium cannt be accunted fr by a preexisting dementia; hwever, can c exist with dementia. Causes? Cnsider these first. Drugs 30% Endcrine/metablic Lcatin change Infectins Respiratry/cardiac disease Impactin (cnstipatin) Unrelieved pain, especially in dementia Malignancy Cnsider these secnd. SAD MATES Strke Alchl Depressin Malnutritin Anemia Trauma Epilepsy Sensry Deprivatin Why Delirium is present in 10 31% f lder medical inpatients upn hspital admissin and 11 42% f lder adults develp delirium during hspitalizatin. Delirium is assciated with negative cnsequences including prlnged hspitalizatin, functinal decline, increased use f chemical and physical restraints, prlnged delirium pst hspitalizatin, and increased mrtality. May als have lasting negative effects including the develpment f dementia within tw years and the need fr lng term nursing hme care. Page 7

9 Predispsing risk factrs fr delirium include lder age, dementia, severe illness, multiple c mrbidities, alchlism, visin impairment, hearing impairment, and a histry f delirium. Precipitating risk factrs include: acute illness, surgery pain, dehydratin, sepsis, electrlyte disturbance, urinary retentin, fecal impactin, and expsure t high risk medicatins. Delirium is ften unrecgnized and undcumented by clinicians. Early recgnitin and treatment can imprve utcmes. Therefre, patients shuld be assessed frequently using a standardized tl t facilitate prmpt identificatin and management f delirium and underlying etilgy. Best Tl fr Diagnsis The Cnfusin Assessment Methd (CAM) is a standardized evidence based tl that enables nn psychiatrically trained clinicians t identify and recgnize delirium quickly and accurately in bth clinical and research settings. There als is a CAM ICU versin fr use with nn verbal mechanically ventilated patients. The CAM includes fur features fund t have the greatest ability t distinguish delirium frm ther types f cgnitive impairment 1. [Acute Onset] Is there evidence f an acute change in mental status frm the patients baseline? 2A. [Inattentin] Did the patient have difficulty fcusing attentin, fr example, being easily distractible, r having difficulty keeping track f what was being said? 2B. [If present r abnrmal] Did this behavir fluctuate during the interview, that is, tend t cme and g r increase and decrease in severity? 3. [Disrganized thinking] Was the patient s thinking disrganized r incherent, such as rambling r irrelevant cnversatin, unclear r illgical fllw f ideas, r unpredictable switching frm subject t subject? 4. [Altered level f cnsciusness] Overall, hw wuld yu rate this patient s level f cnsciusness? Alert: Nrmal Vigilant: Hyperalert, verly sensitive t envirnmental stimuli, startled very easily Lethargic: Drwsy, easily arused Stupr: Difficulty t aruse Cma: Unarusable Uncertain 5. [Disrientatin] Was the patient disriented at any time during the interview, such as thinking that he/she was smewhere ther than the hspital, using the wrng bed, r misjudging the time f day? Page 8

10 6. [Memry impairment] Did the patient demnstrate any memry prblems during the interview, such as inability t remember events in the hspital r difficulty remembering instructins? 7. [Perceptual disturbances] Did the patient have any evidence f perceptual disturbances, fr example: hallucinatins, illusins, r misinterpretatins (such as thinking smething was mving when it was nt?) 8A. [Psychmtr agitatin] At any time during the interview did the patient have an unusually increased level f mtr activity such as restlessness, picking at bedclthes, tapping fingers r making frequent sudden changes f psitin? 8B.[Psychmtr retardatin] At any time during the interview did the patient have an unusually decreased level f mtr activity such as sluggishness, staring int space, staying in ne psitin fr a lng time r mving very slwly? 9. [Altered sleep wake cycle] Did the patient have evidence f disturbance f the sleep wake cycle, such as excessive daytime sleepiness with insmnia at night? The Cnfusin Assessment Methd (CAM) Diagnstic Algrithm The diagnsis f delirium by CAM requires the presence f features 1 and 2 and either 3 r 4. Feature 1: Acute Onset r Fluctuating Curse This feature is usually btained frm a family member r nurse and is shwn by psitive respnses t the fllwing questins: Is there evidence f an acute change in mental status frm the patient s baseline? Did the (abnrmal) behavir fluctuate during the day, that is, tend t cme and g, r increase and decrease in severity? Feature 2: Inattentin This feature is shwn by a psitive respnse t the fllwing questin: Did the patient have difficulty fcusing attentin, fr example, being easily distractible, r having difficulty keeping track f what was being said? Feature 3: Disrganized Thinking This feature is shwn by a psitive respnse t the fllwing questin: Was the patients thinking disrganized r incherent, such as rambling r irrelevant cnversatin, unclear r illgical Page 9

11 Dementia flw f ideas, r unpredictable switching frm subject t subject? Feature 4: Altered Level f Cnsciusness This feature is shw by any answer ther than alert t the fllwing questin: Overall, hw wuld yu rate this patient s level f cnsciusness? Alert: Nrmal Vigilant: Hyperalert Lethargic: Drwsy, easily arused Stupr: Difficult t aruse Cma: Unarusable Validity and Reliability Bth the CAM and the CAM ICU have demnstrated sensitivity f %, specificity f 89 95% and high inter rater reliability. Strengths and Limitatins The CAM can be incrprated int rutine assessment and has been translated int several languages. The CAM was designed and validated t be scred based n bservatins made during brief but frmal cgnitive testing, such as brief mental statues evaluatins. Training t administer and scre the tl necessary t btain valid results. The tl identifies the presence r absence f delirium but des nt assess the severity f the cnditin, making it less useful t detect clinical imprvement r deteriratin. Nursing Strategies (be a detective!) Lk fr underlying cause Keep day/night cycle cnsistent Fster familiarity, encurage family t stay at bedside Maintain mbility and avid restraints Prevent inapprpriate stimulatin Use sensry aids Rerient ften Reassure and educate family Bttm Line! The presence f delirium warrants prmpt interventin t identify and treat underlying causes and prvide supprtive care, Vigilant effrts need t cntinue acrss the healthcare cntinuum t preserve and restre baseline mental status. Definitin Dementia is a gradual and prgressive decline in mental prcessing ability that affects shrt term memry, cmmunicatin, language, judgment, reasning, and abstract thinking. Page 10

12 Dementia eventually affects lng term memry and the ability t perfrm familiar tasks. Smetimes there are changes in md and behavir. What is this? This Try This dcument suggests ways hspitals can increase recgnitin f dementia in their lder patients, t lessen r avid any f these prblems. NOTE: At the time f hspital intake, it is very difficult t differentiate dementia frm delirium, as many lder patients have bth. Nne f the appraches rule ut delirium, s yu need t d mre assessments. Why Abut ne furth f lder hspital patients have dementia and may never be fully diagnsed, and if it is it may nt be nted n their hspital recrds. Because f stress caused by acute illness and being in an unfamiliar setting, sme lder patients shw symptms f dementia fr the first time in a hspital. Older hspital patients with dementia are at a much higher risk than ther lder hspital patients fr delirium, falls, dehydratin, inadequate nutritin, untreated pain, and medicatin related prblems. They are mre likely t wander, exhibit agitated and aggressive behavirs, have t be physically restrained, and t experience functinal decline that des nt reslve fllwing discharge. Target Ppulatin Dementia shuld be cnsidered a pssibility in every hspital patient age 75 and ver, and can smetimes be in yunger patients. Peple with dementia usually cme int the hspital fr treatment f their ther medical cnditins, althugh sme cme in because f cmplicatins BECAUSE f their dementia. 30% f peple with dementia als have crnary artery disease. 28% cngestive heart failure. 21% diabetes. 17% chrnic bstructive pulmnary disease. Best Practices One apprach is t ask the persn and family f the persn has severe memry prblems. Anther is t ask if a dctr has ever said the persn has Alzheimer s disease r dementia. The easiest way t d this is t add the items severe memry prblems, Alzheimer s disease, and dementia t the list f diseases and cnditins patients and families are rutinely asked abut n intake frms and in intake interviews. Best Tl fr Diagnsis When n prir diagnsis f dementia is reprted Family Questinnaire A family member r friend wh accmpanies the patient t the hspital can be handed a print cpy f the 7 item Family Questinnaire. Page 11

13 This questinnaire is intended t identify memry prblems that interfere with day t day activities a sign f pssible dementia. (Nt at all, Smetimes, Frequently, N/A) 1. Repeating r asking the same thing ver and ver. 2. Frgetting appintments, family ccasins, r hlidays? 3. Writing checks, paying bills, r balancing a checkbk? 4. Shpping independently fr clthing r grceries? 5. Taking medicatins accrding t instructins? 6. Getting lst while walking r driving in familiar places? 7. Making decisins that arise in everyday living? Nt at all r N/A = 0 Smetimes = 1 Frequently = 2 3 = further assessment 3 6 = pssible dementia 7 10 = prbable dementia Patient Behavir Triggers fr Clinical Staff This tl includes signs and symptms that suggest the need t cnsider dementia. The intake interviewer and ther hspital staff can be asked t recrd r reprt their wn bservatins f these signs and symptms. Seems disriented Is a pr histrian Defers t a family member t answer questins directed at the patient. Repeatedly and apparently unintentinally fails t fllw instructins. Has difficulty finding the right wrds r uses inapprpriate r incmprehensible wrds Has difficulty fllwing cnversatins When the results f any f these appraches indicate pssible dementia, further assessment is needed t measure the level f cgnitive impairment and identify delirium, depressin, and ther cnditins that can cause cgnitive impairment. Cmmn frms f Prgressive Dementia Alzheimer s disease 65% 5.3 millin Americans have Every 70 secnds smebdy develps AD 6 th leading cause f death in this cuntry (tied with diabetes) 5 th leading cause f death amng peple 65 and lder African Americans 2 times mre likely t have Page 12

14 Hispanics 1.5 times mre likely. Symptms ccur GRADUALLY ver mnths and years Vascular Dementia 23% Incidence dubles every 5 years after 65 Nursing Strategies Mnitr and dcument change (6 behavir triggers) Mnitr efficacy f medicatins Prvide safe envirnment (rutine) Avid ver stimulatin Use multiple channels i.e. instead f saying wash yur face put wash clth in the hand r instead f brush yur teeth put tth brush in their hand, demnstrate shw teeth etc. Summary Caring fr smene with mental status deficits is a challenge Differentiating between depressin, dementia, and delirium is essential t prvide the best pssible care. Realize that 2 cnditins can ccur simultaneusly may prevent decline in the persn with dementia by treating and/r preventing a secndary cnditin. At least 2 have the ptential fr reversal. D assess D Investigate D mnitr and dcument Aging and Develpmental Disabilities Overview f Aging and Intellectual and Develpmental Disabilities (IDD) Histrical backgrund Current statistics and trends Factrs f aging and ID The factrs f aging make a difference n the health and well being f each persn in ld age. Aging cmes dwn t 4 main factrs, Genetics Envirnment Lifestyle (diet, exercise, habits, and educatin) Attitude Page 13

15 Types f Aging Successful Minimal r n effects frm disease r age assciated cnditins. Nrmal r Average Sme effects frm disease pre existing cnditins. Or age assciated changes with changes in lifestyle r activities likely. Pathlgical Majr effect frm disease, pre existing cnditins, r age assciated changes. Everybdy has the ptential fr successful aging regardless f pre existing cnditins. Successful aging r at least average aging shuld be the gal fr everybdy as they age. Specific Syndrmes and Aging Dwn syndrme and aging Pssible changes with abut a 20 year earlier nset fr risk factrs. Increased sensry impairments Increased stmach, intestinal and cardivascular prblems Increased risk fr Alzheimer s dementia due t trismy 21(Dwn syndrme) Decreased resistance t disease Reduced thyrid functin Affects Increased risk fr misdiagnsis f Alzheimer s dementia Earlier nset f disease and changes with pssible reductin in functining as a result Preventin Educatin f staff, family, and advcates n risk factrs and bservatinal skills Increase need fr health care advcacy with prviders Advcacy fr differential diagnsis Opprtunities ver lifespan t exercise the brain and bdy Other Increased incidence after age 55 (but nt 100%) Earlier nset than general ppulatin with quicker regressin Increased risk fr misdiagnsis due t assumptins f if DS must have AD Need fr structure and rutine thrughut a lifetime? Impact n incidence? Cerebral palsy and aging Pssible Changes Earlier nset fr arthritis, steprsis Difficulties with swallwing and chking Increased seizures Increased sensry impairments Page 14

16 Increase urinary incntinence and urinary tract infectins Affect Increased pain and discmfrt that culd exhibit as behavirial prblems Increased risk fr respiratry prblems Increased mbility prblems Increased fatigue Preventin Opprtunities fr mvements and weight bearing Vitamin and mineral supplements if the diet cannt supply needed amunts Opprtunities fr rest interspersed with activities Epilepsy and IDD Increased risk fr seizures with age, already cmprmised because f preexisting ccurrence f seizures Increased risk fr falls due t seizures and aging Medicatins that have blcked the absrptin f Vitamins C & D thus increasing the risk fr arthritis and steprsis Increased risk fr a sedentary lifestyle thus reducing vitality in the bdy systems especially bne density and strength as well as stamina Increased risk fr besity due t lack f weight bearing exercise Health Care Disparities Health care challenges and disparities fr adults with IDD Lack f training n adults with IDD fr health care prviders Lack f research n aging and IDD thus impacting the capacity fr infrmed chices fr assessment & interventins by the health care prvider, advcates, and adults with IDD Challenges fr reprting symptms by the adult with IDD, increased difficulty in interpreting symptms Assumptin f autmatic lss and decline with aging by the health care prviders and caregivers with misdiagnsis r lack f diagnsis fr underlying decline The mre severe the disability r if the adult has Dwn syndrme an increased likelihd f assumptin f dementia Wmen with IDD and health care disparities All f the abve Medical tests and interventins have been nrmed fr men with wmen with IDD nt part f the clinical trials Higher risk fr side effects f medicatins with less knwn abut pssible side effects Lack f training n wmen s health in general and specifically fr wmen with IDD Page 15

17 Lack f accessible ffices and equipment fr standardized tests like a mammgram The imprtance f health care advcacy fr adults with IDD acrss the lifespan Because f all f the abve it is essential that care prviders and self advcates understand their wn aging prcess and have the skills fr Health care advcacy Aging and IDD nt taught in medical schls, nt a requirement in mst schls, IDD in general let alne aging prcess, this FLGEC is the nly GEC in the cuntry with an IDD cmpnent Summary Yu can make a difference fr each persn as each ages by understanding aging and develping preventin activities acrss the lifespan. Successful aging is pssible fr every persn and shuld be ur gal. Enjy aging yurself and serve as a rle mdel t thers. Treat each day as a gift, regardless f the diagnsis r age. Plypharmacy Objectives Understand future changes in the U.S. ppulatin and hw they impact healthcare. Review age related physilgic changes. Outline age related pharmackinetics and pharmacdynamics changes. Pharmackinetics What the bdy des t the drug. Pharmacdynamics The study f the bichemical and physilgical effects f the drugs n the bdy. Identify ptential drug related prblems in lder adults. Apply strategies t ensure safe medicatin use in lder adults. Older adults 65 years ld and n Yung ld (65 74 years) Middle ld (75 84 years) Old ld (85 years ld and lder) Age Related Physilgic Changes Decreased ability t preserve hmestasis Decreased ability t tlerate physilgic stresses Small stress may result in majr mrbidity and mrtality Cardivascular, musculskeletal, and central nervus systems are mst affected. Cardivascular Mycardial sensitivity t ß adrenergic stimulatin. Decreased barreceptr activity Barreceptrs are sensrs lcated in bld vessels. They detect differences in pressure changes. Page 16

18 Decreased cardiac utput. Increased ttal peripheral resistance. Increased valvular stiffness. Valvular stiffness heart valves stiffness Lwer plasma rennin and urine aldsterne. Aldsterne A sterid hrmne prduced by the uter sectin f the adrenal crtex. Plasma rennin The measure f activity f the plasma enzyme rennin, which plays a majr rle in the bdy's regulatin f bld pressure Central Nervus System Decreased brain weight and vlume. Decreased rate f cnductin and strength f transmissin. Decreased adaptatin t physilgic stress. Increased autnmic nervus system recvery time. Increased neurnal lss. Increased bld, brain barrier permeability. Age Related Physilgic Changes Endcrine Thyrid disease. Increased incidence DM. Oral Altered dentitin Decreased ability t taste sweet, sur, and bitter. Skin Decreased turgr and elasticity. Skin turgr the ability t change shape and return t nrmal. Increased melancytes. Cells in the skin that is mstly respnsible fr skin clr. Epithelial thinning. Sensry Hearing lss frm decreased cnductin velcity. Accmmdatin f the lens f the eye. Geniturinary Older wmen Vaginal atrphy with decreased estrgen Older men Prstatic hypertrphy Decline in teststerne Hypspermia Incntinence Gastrintestinal Delayed gastric emptying Page 17

19 Renal Decreased GI bld flw Slwed intestinal transit Decreased liver size and bld flw Decreased pancreatic secretins Decreased renal bld flw Decreased renal mass Decreased GFR rate Decreased tubular secretry functin Decreased functinal nephrns Decreased ability t cncentrate urine Decreased acid base adaptin under stress **Age Related Pharmackinetic and Pharmacdynamic Changes** Absrptin Unchanged passive diffusin Minimal change in biavailability fr mst drugs. Distributin Decreased P glycprtein activity within bld brain barrier. Increased expsure t drugs and txins. Increased adipse tissue. Increased VD fr lpphilic drugs (eg. Diazepam, amidarne) Increased ptential fr accumulatin and delayed peak effect. Decreased ttal bdy water and lean muscle mass. Decreased VD fr hydrphilic drugs, increased peak levels. Bdy water Vancmycin, Aminglycsides Muscle Dignxin Hypalbuminemia Occurs in 10 20% f lder adults Highly prtein bund acidic drugs Warfarin, phenytin, fursemide, naprxen. Increased cncentratins f unbund medicatins Increased drug activity Alpha 1 acid glycprtein Increase with aging, physilgic stress, inflammatin. Binds t lipphilic basic drugs Methadne, lidcaine, prpranll, imipramine Decreased free fractin f basic drugs Metablism Decrease in hepatic bld flw and liver size Page 18

20 Decrease metablism f drugs with high hepatic extractins ratis Mrphine, prpranll, lidcaine N change in phase 2 metablism Glucurnidatin, sulfatin N active metablites Preferred fr lder adults Lrazepam, warfarin, metprll Age related decline in phase 1 drug metablism CYP450 mediated Reduced enzyme activity with decreased hepatic vlume. Ptential active metablites Increased half life and decreased drug clearance Diazepam, thephylline, nritriptyline Additinal factrs t cnsider CYP 450 enzyme inductin r inhibitin frm cncmitant medicatin use Pharmacgenmics Alchl abuse Eliminatin Age related GFR decline Expected 1ml/min/year GFR decline after the age f 40 Decreased renal perfusin Decreased cardiac utput Arterisclertic changes Age related diseases Diabetes, HTN Prtein malnutritin, artificially lw BUN Decreased muscle mass, decreased serum creatinine prductin CrCl and GFR verestimated Cncealed renal insufficiency Cckgraft Gault equatin fr calculating CrCl Patients > 70 years whse Scr < 0.7 mg/dl Adjust Scr t 0.7 mg/dl Cmpensate fr lw muscle mass Patients > 70 years whse SCr > 0.7 mg/dl Use actual SCr Assess patient specific factrs and use clinical judgment Pharmacdynamics(PD) Altered drug respnse r increase sensitivity in lder adults Age related pharmacdynamic changes mre significant than pharmackinetic changes Page 19

21 Majr cntributr t high adverse drug events (ADE) rates amng lder adults. Changes in receptr number and affinity Muscarinic PTH, β adrenergic, α adrenergic, μ piid E.g. increased mrphine sensitivity secndary t decreased number f μ piid receptrs Age related hmestatic mechanism impairment Decreased barreceptr sensitivity and respnsiveness E.g. increased ptential fr rthstatic hyptensin with calcium channel blckers Additive effects with multiple PD changes frm a single medicatin E.g. Orthstatic hyptensin with use f atypical antipsychtics Decreased barreceptr sensitivity and respnsiveness Increased sensitivity t α adrenergic blckade Bttm line Older adults are fragile As pharmacists, we need t Be mindful f lder adult s decreased physical reserve Cnsider ptential physilgic, pharmackinetic, and pharmacdynamic changes. Physilgic, PK (pharmackinetics), and PD (pharmacdynamics) changes influence pharmactherapy recmmendatins. Gals f Care in Older Adults Preserve independence Prevent disability t avid institutinalizatin Imprve r maintain quality f life Treatment Gals in Older Adults Selected disease states have different treatment gals fr lder versus yunger adults Need fr different treatment gals influenced by life expectancy, functinal status, supprt system, pharmactherapy risk versus benefit, physilgic changes, PK/PD changes, ptential drug interactins Classificatin f bld pressure Treatment Gals Example: HTN Seventh Reprt f the Jint Natinal Cmmittee n Preventin, Detectin, Evaluatin, and Treatment f High Bld Pressure (JNC 7) Treatment gals : BP < 140/90 mmhg r BP < 130/80 mmhg if diabetic and/r CKD ACCF/AHA 2011 Expert Cnsensus Dcument n Hypertensin in the Elderly SBP f mmhg reasnable if > 80 years Page 20

22 Avid SBP < 130 mmhg and DBP > 65 mmhg due t risk f hypperfusin Drug Related Prblems and Medicatin Safety in Older Adults Inapprpriate prescribing *Beers Criteria* Tp 200 drugs t avid? Antichlinergics and NSAIDs Overview Adverse Effects (bth Anti and NSAID) Risk Scale STOPP/START Criteria Overview Cardivascular system Central nervus system Gastrintestinal system Respiratry system Musculskeletal system Urgenital system Endcrine system Drugs that adversely affect fallers Analgesic drugs Duplicate drug classes STOPP Criteria and limitatins START Criteria and limitatins Medicatin Apprpriateness Index Cnclusins/Summary Page 21

23 Appendix B: Website Page 22