too fast, too slow, of just right? thyroid disorders in ...sensation of well-being clyde, et al....

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Too Fast, Too Slow, of JustRight?

Thyroid Disorders in the Elderly

Lindsay Saum, PharmD, BCPS, BCGP

Associate Professor of Pharmacy Practice, Butler University

Clinical Pharmacy Specialist- Internal Medicine, St. VincentHospital

The speaker has no conflict of interest

• Define hypothyroidism, hyperthyroidismand subclinical thyroid disorders.

• Identify differences in the management ofthyroid disorders in the elderly comparedto younger patients.

• Recognize the proper management ofsubclinical hypothyroidism and subclinicalhyperthyroidism in elderly

Objectives

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• Prevalence in elderly (>60 years):

– Hypothyroidism: 2-5%

– Hyperthyroidism: 0.5-3%

• More common in women

• Normal values:

– TSH: 0.5 to 4.5 mIU/L

– Free T4: 0.8 to 1.8 ng/dl

– Free T3: 2.3 to 4.2 pg/ml

Thyroid Disorders and the Elderly

Indian J Endocrinol Metab 2018;16(4):542-47.Clin Geriatr Med. 2018;34:259-77.

https://www.youtube.com/watch?v=iNrUpBwU3q0

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4

Fibrosis andatrophy of

thyroid gland

Increase inautoantibodies

Decreaseddietary iodide

intake

Decreasediodide uptake by

thyroid gland

Decreasedmetabolism of

T4Decreased TSH

Changes in Thyroid Function


Thyroid Pathophysiology


Hypothalamus Pituitary Gland

Thyroid Gland

Thyrotropinreleasing hormone(TRH)

Thyroid stimulatinghormone (TSH)

T4

T3

Deiodinase

Too Fast:Hyperthyroidism

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• Most common causes of hyperthyroidism:

– Inappropriate stimulation of thyroid gland

– Excess activation of thyroid synthesis

– Stores are inappropriately released

– Iatrogenic

• Diagnosis:

– Low TSH and high T3 and T4

– TSH alone cannot be used due to interactingmedications

Background


Endotext [Internet].Hyperthyroidism in Aging.

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YoungerPatients

Weight Loss

Sweating/ Heat Intolerance

Agitation

Tremor

Palpitations

Shortness of Breath

ElderlyPatients

Weight loss

Depression

Agitation

Apathy

Cognitive decline

Cardiovascular (Atrial Fibrillation)

Presentation Differences



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• Beta blockers should be given to:

– Elderly patients with symptoms

– Other patients with HR >90 bpm or CVdisease

• Treatment is radioactive Iodine, anti-thyroid medications or thyroidectomy

• Elderly specific recommendations:

– Anti-thyroid medications should be first line

– Beta-blockers and methimazole should begiven prior to radioactive iodine

2016 ATA Guidelines

Thyroid 2016;26(10):1343-1421

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• Anti-thyroid Medications (Thionamides)

– Methimazole

– Propylthiouracil

• Adjunct Medications

– Beta-blockers

– Iodides

• Radioactive iodine

Treatment Options

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• In elderly, anti-thyroid medications or radioactiveiodine are preferred due to risk of surgery

• Remission rates are higher in elderly compared toyounger patients taking anti-thyroid medications

• Common class ADRs: pruritic rash, fever, arthralgias

Anti-thyroid Medications



Methimazole

20-30 mg PO daily

Preferred anti-thyroidmedication

Propylthioruacil

50-100 mg PO TID

Higher rates ofagranulocytosis and hepatitis

Preferred agent in thyroidstorm

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• Beta-blockers

– Non-selective agents (propranolol and nadolol)may inhibit T4 to T3 conversion

– Longer acting agents (metoprolol and atenolol)may provide better control of HR, and greatersafety in respiratory disorders

• Iodides

– Used in thyroid storm or pre-treatment forsurgery

– Large doses may exacerbate hyperthyroidism

– Potassium iodide (SSKI or Lugol’s solution)

Adjunct Medications



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• Better cure rates compared to thionamides

• Need to consider feasibility of radiationprotection regulation

• Benefits of early control outweigh risk ofthyroid storm during ablation withradioactive iodine

– Patients with severe disease or iatrogenichyperthyroidism are increased risk of stormduring ablation

Radioactive Iodine



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• Hyperthyroidism is associated withincreased mortality and cardiovascularevents

• Atrial Fibrillation

– Three fold increased risk in development

– Less likely to convert to NSR

– ~5% of new A. fib diagnoses

– Greater conversion success if euthyroid

Cardiovascular Risk and Hyperthyroidism



Ischemicheart disease

Hypertensiveheart disease

Dysrhythmias

• Not a common condition in the elderly

• Anti-thyroid medications or radioactiveiodine is preferred over surgery

• Adjunct beta blockers are needed in allelderly patients

• Significant cardiovascular risk withhyperthyroidism, especially in the elderly

Hyperthyroidism Summary

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Too Slow:Hypothyroidism

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• Common causes of hypothyroidism inelderly patients

– Age related decline in thyroid mass

– Increased levels of autoantibodies

– Iatrogenic after surgery

• Slight hypothyroidism is associated withprolonged life span

• Diagnosis:

– High TSH (>10 mIU/L)

– Caution during critical illness

Background


Clin Interv Aging. 2012;7:97-111.

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YoungerPatients

Weight gain

Paresthesias

Heat intolerance

Weakness

Dry skin

Bradycardia

ElderlyPatients

Fatigue

Mental slowness

Drowsiness

Depression

Constipation

Cerebellar dysfunction

Presentation Differences



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• Screening in asymptomatic patients:

• Treatment with Levothyroxine when TSH >10mIU/L

• Elderly specific recommendations:

– Lower doses in elderly patients (not weight based)

– Goal TSH: 4-6 mIU/L

2014 ATA Guidelines

American Thyroid Association Women and Men >35 years of age

American Association of ClinicalEndocrinologists

Older patients, especially women

American Academy of FamilyPhysicians

Patients > 60 years of age

Thyroid 2014;24(12):1670-1751.

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• Elderly more sensitive to exogenous thyroidhormones

• Dose increases every 4-6 weeks

• TSH may take longer to normalize

• Options

– L-thyroxine (T4): Levothyroxine

– Triiodothyronine (T3): Liothyronine

– Dessicated thyroid (T3 and T4)

Treatment



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• Peripherally converted to active T3

• Dosing: traditional: 1.6 mcg/kg daily

– 50 mcg PO daily

– 12.5 to 25 mcg PO daily in patients withcardiac comorbidities

• Pearls

Levothyroxine

Half life of 6days

Given onempty

stomach

Druginteractions



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Interfere with absorption

• Bisphosphonates

• PPI

• Calcium containing products

• Iron

• Fluoroquinolones

Hormone production

•Amiodarone

•Sulfonylureas

•Lithium

•Glucocorticoids

Increased Clearance

•Phenytoin

•Rifampin

•Sertraline

•Quetiapine

Peripheral metabolism

• Glucocorticoids

• Amiodarone

• Beta Blockers (propranolol,nadolol)

Select Interactions with Levothyroxine

Endocr Pract 2012;18(6):989-1028

• Levothyroxine and triiodothyronine

• Theory to improve persistent symptoms

Combination Therapy

Bunevicius, et al

Cognition

Sensation of well-being

Clyde, et al.

Body weight

Serum lipid levels

Symptoms

Cognition

Mixed outcomes in literature

Clin Interv Aging. 2012;7:97-111.N Engl J Med. 1999;340(6):424-29.

JAMA. 2003;290(22):2952-58.

• Large number of patients have persistentsymptoms and are either under or over treated

• Patients were evaluated for differences in TSHwhen taking liquid levothyroxine 30 minutesbefore breakfast or with breakfast

• Once euthyroid, patients were followed for 6months

Timing of Levothyroxine

J Endocrinol Invest 2018;doi.org/10.1007/s40618-018-0867-3.

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• Hypothyroidism due to Hashimotos orthyroidectomy

• Median dose: 75 mcg

• Mean age: 46.2 years

• No difference in TSH levels in the two groups

Results

Fasting With Food P value

Mean TSH, SD 2.54 + 1.86 mIU/L 2.61 + 1.79 mIU/L 0.455

Subgroup: Interacting Medications, Fiber or Milk products (n=202)

Mean TSH, SD 2.63 + 1.53 mIU/L 2.69 + 1.96mIU/L

0.732

J Endocrinol Invest 2018;doi.org/10.1007/s40618-018-0867-3.

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• Common causes of treatment failure:

– Non-compliance

– Absorption concerns

• Pharmacokinetic properties

– 60-80% of the dose is absorbed in first 3-4hours

– Elimination half life of 7 days

Alternative Administration Schedules

Eur Thyroid J 2017;6:250-4.

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Literature

Study (n) Strategy MeanAge

Result

Rajput, et alN=100

Daily vs. Weekly

Weekly: 7 times dailydose

36 years Significant decrease inT4 and increase in TSH

Altuntas, et al.N=20

Daily vs. 2x/week

2x/wk: 4 times dailydose on Monday and3 times on Friday

39 years No difference in s/s ofhypothyroidism

Significant increase inTSH and decrease inT3/T4

Grebe, et al.N=12

Daily vs. weekly

Weekly: 7 times dailydose

51 years Significant increases inTSH and decreases inT3/T4

Eur Thyroid J 2017;6:250-4.Turk J Endocrinol Metab 2004;1:25-34.

Clin Endocrinol Metab 1997;82(3):870-5.

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• Hypothyroidism is common in elderly

• Presentation includes more psychiatricchanges in elderly

• Treat with levothyroxine when TSH >10mIU/L, combination therapy with T3 notrecommended

• May not need to worry about administrationin fasting state

• Daily administration leads to more consistentcontrol of TSH, T3 and T4

Hypothyroidism Summary

Just Right?: SubclinicalThyroid Dysfunction

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• 1-5% of elderly patients

• Subnormal TSH and normal T4 and T3

• Most common cause: exogenous T4supplementation

• Typically asymptomatic

• Treatment: per ATA guidelines

Subclinical Hyperthyroidism (SHyper)

Indian J Endocrinol Metab 2018;16(4):542-47.Endotext [Internet].Hyperthyroidism in Aging.

Thyroid 2016;26(10):1343-1421.

All patients withTSH<0.1 mIU/L

TSH 0.1 to 0.5 mIU/L

-Duration > 3 months

-Cardiac disease

-Symptomatic

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• Excess thyroid hormones and the CV system

– T3 has positive chronotropic and inotropiceffects

– T3 increases the speed of diastolic relaxation

– Excess leads to enhanced myocardialcontractility

– Changes in performance of calcium, sodiumand potassium channels in the heart

– Modulates adrenergic receptor actions

– Vasodilation in periphery

SHyper and CV disease

Horm Metab Res 2017;49:723-31.

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• Strong link between overthyperthyroidism and atrial fibrillation

• Multiple studies have found an increasedrisk of atrial fibrillation in patients withSHyper

SHyper and Atrial Fibrillation

Study Outcome

Sawin, et al 3 fold increased risk

Auer, et al 13% vs. 2% prevalence

Heeringa, et al 2 fold increased risk


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• Numerous studies that link SHyper and elevatedblood pressure

SHyper and Blood Pressure


Study Result Notes

Busselton ThyroidStudy

Reduced TSH (<0.4mIU/L) is associated withincreased HTN and meanSBP

Small sample size(n=35)

Kaminski, et al Higher nocturnal SBP,mean DBP, and MAP

When adjusted for CVcofounders, nodifference found

Volzke, et al Increased SBP, increased 5year HTN incidence

Adjusted forcofounders foundlower mean values andno difference inincidence

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• Stroke

– No association between ischemic stroke andSHyper

– Some association between embolic stroke dueto increased atrial fibrillation risk

• Heart Failure

– Mixed results

– Believe that any association is due to other CVdiseases with known correlation (A. Fib)

Other CV disease


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• Cognitive impairment is associated with overtdysfunction

• Part of the Health, Aging and Body CompositionStudy: 3075 community dwelling adults aged 70-79 when enrolled

• Primary outcome was the incidence of dementia

– >1.5 standard deviation decline on Modified Mini-Mental State (3MS)

– Primary or secondary diagnosis on hospital records

– Prescription for dementia drug

SHyper and Dementia

Clin Endocrinol 2017;87:617-26.

Clin Endocrinol 2017;87:617-26.36

• Larger decline in3MS score

• Adjusted HR forSHyper (TSH < 0.1mIU/L: 2.41 (1.14-5.10)

• Adjusted HR forSHyper (TSH 0.1-0.45 mIU/L): 0.8(0.46 to 1.39)

• Adjusted HR forSHypo: 0.89 (0.68 to1.17)

Results

SH

yper

SH

yp

o

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• Overt hyperthyroidism is associated withdecreased BMD and fractures

• 70,298 Individual Participant data cohortstudy

– 5458 patients with baseline TSH and serialbone mineral density (BMD) screenings

• Primary outcome: annualized % change inBMD based on TSH (euthyroid, SHyperand SHypo)

SHyper and Bone Mineral Density

J Intern Med 2018;283:56-65

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• Median age: 72 years

• 49% female

• Median follow up: 6.7 years

Results

% Change BMDFemoral Neck:

-0.18%*

% Change BMDSpine: 0.03%

% Change BMDHip: -0.14%

% Change BMDFemoral Neck:

-0.59%*

% Change BMDSpine: 0.44%

% Change BMDHip: -0.46%*

TS

H<

0.4

5m

IU/L

TS

H<

0.1

mIU

/L

J Intern Med 2018;283:56-65

• SHyper with TSH <0.1 mIU/L

– Significant CV adverse events

– Cognitive abnormalities

– Bone mineral density abnormalities

– Warrants treatment

• Treatment in mild SHyper should bedecided patient by patient

SHyper Summary

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• 8 to 18% of elderly patients

• Elevated TSH with normal T3 and T4

• Most common cause: autoantibodies

• Typically asymptomatic

• Treatment:

Subclinical Hypothyroidism (SHypo)

Indian J Endocrinol Metab 2018;16(4):542-47.Clin Interv Aging. 2012;7:97-111.Thyroid 2014;24(12):1670-1751.

SymptomaticAutoantibody

positiveHeart failure

• Randomized, double-blind studycomparing levothyroxine and placebo inSHypo

• Elderly patients (>65 years) with TSH of4.6 to 19.99 mIU/L and normal T3

• Levothyroxine 50 mcg daily

– 25 mcg daily if weight <50 kg or CHD

Levothyroxine for Older Adults with SHypo

N Engl J Med 2017;376(26):2534-44.

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Results

N Engl J Med 2017;376(26):2534-44.

• Outcome: change from baseline to 12 months inThyroid Related Quality of Life Patient ReportedOutcome Measure (ThyPRO) scores

– Hypothyroid symptoms

– Tiredness

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• Some studies suggest protective effects ofSHypo in elderly

• Case-control study from medical database inIsrael

• Evaluated the effects levothyroxine treatmentfor SHypo on mortality in elderly patientswith a TSH between 4.2 and 10 mIU/L

• Matched based on gender, age, Charlsoncomorbidity index, and TSH

SHypo Treatment and Mortality

Eur J Intern Med 208;50:65-8.

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• 419 patients died within the time frameand were matched to 1558 controls

Results

Eur J Intern Med 208;50:65-8.

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• Known impact on heart failure andatherosclerosis

• Prospective observational study todetermine the impact of SHypo on heartfailure prognosis

• Divided patients based on TSH andevaluated ECG, cardiopulmonary exercisetesting, cardiac catheterization, follow-upevent rate and mortality

SHypo and Heart Failure

Can J Cardiolo 2018;34(1):80-7.

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Results

Can J Cardiolo 2018;34(1):80-7.

• Cardiac catheterization findings andcardiopulmonary exercise tolerance were worsein SHypo group

• Treatment with levothyroxine in SHypo

– Not associated with improved symptomsscores

– May be associated with increased mortality

• Consider treatment in patients withknown heart failure, or significant cardiacrisk

SHypo Summary

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Hyperthyroidism

-Methimazole

-Beta blocker

Hypothyroidism

-Levothyroxine(lower dose)

SHyper

Treat when TSH<0.1 mIU/L

SHypo

Generally don’ttreat

Treatment Summary

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Too Fast, Too Slow, of JustRight?


Lindsay Saum, PharmD, BCPS, BCGP

Associate Professor of Pharmacy Practice, Butler University

Clinical Pharmacy Specialist- Internal Medicine, St. VincentHospital

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TSH

<0.5 mIU/L

T3/T4 normal

SubclinicalHyperthyroidism

TSH <0.1 mIU/L

Methimazole

Beta-blocker

TSH 0.1 to 0.5mIU/L

Methimazole if:-Duration > 3

months-Cardiac disease-Symptomatic

T3/T4 elevated

Hyperthyroidism

Methimazole or Radioactive

Iodine

Beta-Blokcer

0.5 to 4.5 mIU/L

Euthyroid

>4.5 mIU/L

T3/T4 decreased

Hypothyroidism

Levothyroxine 50mcg

-12.5 to 25 mcg with comorbid cardiac disease

T3/T4 normal

Subclinical Hypothyroidism

No treatment unless:

-Antibodypositive

-Heart failure

References:1. Ajish TP, et al. Geriatric Thyroidology: An update. Indian J Endocrinol Metab 2018;16(4):542-47.2. Bensenor IM, et al. Hypothyroidism in the elderly: diagnosis and management. Clin Interv Aging. 2012;7:97-111.3. Higgins K. Thyroid disorders in the elderly: An overall summary. Clin Geriatr Med. 2018;34:259-77.4. Jonklaas J, et al. Guidelines for the treatment of hyperthyroidism: Prepared by the ATA task force on thyroid hormone replacement. Thyroid 2014;24(12):1670-1751.5. Ross DS, et al. 2016 ATA Guidelines for diagnosis and management of hyperthyroidism and other thyrotoxicosis. Thyroid 2016;26(10):1343-1421.

Too Slow, Too Fast, Or Just Right?

Kahoot Questions

1. 2018 is the ______ Annual ASCP Midwest Regional Meeting. (Review question to get

used to Kahoot)

a. 9th

b. 19th

c. 29th

d. 39th

2. What is the recommended Antithyroid medication in the elderly?

a. Methimazole

b. Propylthiouracil

c. SSKI

d. Propranolol

3. Which dose of levothyroxine would be most appropriate for an elderly patient with no

comorbidities (Wt 75 kg)?

a. 12.5 mcg

b. 50 mcg

c. 75 mcg

d. 125 mcg

4. Which comorbidity would necessitate treatment of SHypo in the elderly?

a. Osteoporosis

b. Diabetes

c. Heart Failure

d. BPH

5. At what TSH would you recommend treating SHyper in the elderly

a. 0.4 mIU/L

b. 0.3 mIU/L

c. 0.2 mIU/L

d. <0.1 mIU/L

6. Which subclinical thyroid dysfunction potentially has increased mortality with treatment?

a. Subclinical Hyperthyroidism

b. Subclinical Hypothyroidism

c. Neither

Answer Key: 1-c; 2-a; 3-b; 4-c; 5-d; 6-b

6/27/2018

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Opioids in the GeriatricPopulation

Darin Ramsey, PharmD, BCPS, BCACP

Director of Assessment

Associate Professor of Pharmacy Practice

Butler University, College of Pharmacy & HealthSciences

No Actual or Potential Conflicts of Interest

Objectives

• Recognize challenges associated with painmanagement as it relates to the aging population.

• Identify barriers associated with adequate painmanagement in the elderly.

• Recognize key CDC guidelines and identify whythe geriatric population is at risk for harm withopioid therapy.

• Select an appropriate nonpharmacologic andnonopioid therapy in the geriatric patient.

About the Speaker

• Butler University College of Pharmacy &Health Sciences– Associate Professor– Director of Assessment

• Starting August 1, 2017

• Richard L. Roudebush VA Medical Center– Clinical Pharmacy Specialist– Ambulatory Care– Co-Director of PGY2 Ambulatory Care/Education

Residency• Until July 31, 2017

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What challenges exist whenmanaging pain?

Despite these efforts……

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John D. Loeser & Michael E. Schatman (2017) Chronic pain managementin medical education: a disastrous omission, Postgraduate Medicine, 129:3, 332-335, DOI:10.1080/00325481.2017.1297668

Students want more………

https://www.statnews.com/2016/05/17/opioid-addiction-medical-schools/

State Boards are requesting it for licensure

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• Who is it intended for?

– Primary Care Clinicians

– Treating patients with chronic pain

– Apply to patients 18 years and older with chronic pain

• Does not apply to the following:

• Cancer Treatment

• Palliative care

• End-of-Life Care

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

CDC Guidelines forPrescribing Opioids

Self-Assessment

How well do you know the CDCOpioid Guidelines?

Opioid and Nonopioidmedications are first-line therapyin the treatment of chronic pain,

according to the CDC?

A) TRUE

B) FALSE

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6/27/2018

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When starting opioids for chronicpain, which is the preferred

prescribing practice?

A) Use Extended Release OpioidsB) Use Immediate Release Opioids

C) Start with Immediate Release Opioids thentransition to Immediate Release

D) Use Extended Release scheduled + ImmediateRelease PRN

Clinicians should avoid opioids >___ MME/day unless there is

cautious justification anddocumentation to use beyond

this dose.

A) 30 MME/day

B) 50 MME/day

C) 90 MME/day

When opioids are used for acutepain, ____ days should be

sufficient with no more than ___days.

A) 3 days & 5 daysB) 3 days & 7 daysC) 5 days & 7 daysD) 5 days & 10 days

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Clinicians should evaluatebenefits and harms within 1-4weeks of starting opioids for

chronic pain. Patients on stabledoses should be evaluated

every?

A) Every month

B) Every 3 months

C) Every 5 months

Clinicians should consideroffering naloxone for doses > ___

MME/day.

A) 30 MME/dayB) 50 MME/dayC) 90 MME/day

D) 120 MME/day

It is recommended for cliniciansto perform urine drug screens

initially and…..

A) MonthlyB) Every 3 monthsC) Every 6 months

D) Yearly

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Clinicians should avoidprescribing opioids with which of

the following?

A) NSAIDsB) Acetaminophen

C) SSRIsD) Benzodiazepines

This concludes the Self-Assessment!

How did you do?

Recommendation #1Opioids are NOT first-line therapy

So what is?

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Nonpharmacologic Therapy

• Weight Loss

• Exercise Therapy

• Cognitive Behavioral Therapy

• Interventional Approaches

When Nonpharmcologic Therapy Alone is NOT Enough…..

• NSAIDs

• Acetaminophen

• Selected Antidepressants

• Anticonvulsants

PRO

• Not associated withsubstance use disorders

• Less likely to causeoverdose

CON

• Not without risks in ourgeriatric population:– Cardiovascular

– Renal

– Gastrointestinal

– Liver

Nonopioids

• If opioids are determined to be appropriate, theySHOULD be combined with nonpharmacologic therapyand nonopioids

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Recommendation #2Establish Goals for Pain and

Function

How do we do that?

Pain Assessment

Pain Assessment: The 5th Vital Sign

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How do we set realistic goalswith our patients?

Establishing Pain Goals: Apply SMART Principles

• Specific – Do the goals outline what the patient hopesto achieve?

• Measurable – Is there a way to evaluate whether thegoal has been achieved?

• Achievable – Is this goal reasonable based on thepatient’s current health status or physical limitations?

• Relevant – Are the goals realistic and relevant to thepatient?

• Time Bound – Provide feedback on the amount of timeit may take to achieve their goals.

www.painmed.org/PatientCenter/Facts_on_Pain.aspxN Engl J Med. 2015;373:2098-99

Recommendation #3Discuss Risks and Benefits

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Recommendation #4Use immediate-release opioids

when starting

What about ER/LA opioids?

IR opioids before ER/LA opioids

• The risk of overdose is higher with ER/LAopioids.

• No difference in efficacy or safety has beenobserved between continuously scheduledER/LA opioids + intermittent use of IRopioids.

• ER/LA opioids should be RESERVED forpatients with severe, continuous pain whohave received IR opioids daily for at least 1week.

Recommendation #5Use the lowest effective dose

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Lowest effective dose

• Use caution when prescribing opioids atany dose

• Reassess evidence of individual benefitsand risks when increasing doses to > 50MME/day

• Avoid increasing doses to > 90 MME/day– Carefully justify decision to titrate > 90

MME/day

Recommendation #6Prescribe a short duration for

acute pain

Guidance on opioid duration

• Opioid use for acute pain has beenassociated with long term opioid use.

• CDC recommends providing a duration that isappropriate for the expected duration of pain.

• 3 days or less of opioid therapy is sufficient.

• More than 7 days is rarely needed.

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Pharmacies enforce the CDC Guidelines

Recommendation #7Evaluate benefits & harms

frequently

Evaluation of Benefit & Harm

• Clinicians should evaluate patients 1-4 weeksof starting opioid therapy for chronic pain or adose escalation.

• Clinicians should continue to evaluatebenefits and harm with patients every 3months or more frequently.

• If benefits do not outweigh harm of continuedtherapy, clinicians should optimize othertherapy and taper opioids to lower dosagesor taper and discontinue.

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Recommendation #8Use strategies to mitigate risk

Mitigating risks with opioids

• Before starting and periodically duringcontinuation of opioid therapy, cliniciansshould evaluate risk factors for opioid-related harm.

• Consider naloxone when factors areincreased for opioid overdose:– History of overdose

– Substance Use Disorder

– Higher opioid dosages (> 50 MME/day)

– Concurrent benzodiazepine use

SleepDisorderedBreathing

Pregnancy,Breast-Feeding

Renal orHepatic

Insufficiency

Age > 65Mental Health

ConditionsSubstance Use

Disorders

Previous Non-Fatal

Overdose

High-Risk Groups and Opioid Use

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High-Risk Groups

Sleep Disordered Breathing

• Risk Factors: CHF, Obesity

• Carefully monitor during opioid therapy

• Cautious opioid dose titration

• Avoid if moderate-severe disorders

Renal or Hepatic Insufficiency

• Use caution and increase monitoring to minimize risks due to opioid accumulation

AGE > 65 Years

• Risks: Inadequate pain management, reduced renal function, opioid accumulation, cognitiveimpairment, drug interactions

• Use caution and increase monitoring

• Educate patients to avoid obtaining opioids from multiple providers

• Initiate exercise and bowel regimens to prevent constipation, risk assessment for falls, and monitorfor cognitive impairment

Considerations for Naloxone

History ofOverdose

History ofSubstance Use

Disorder

BZD use withOpioids

Patients noLonger Tolerantto High Doses

Patient’s taking> 50 MME/day

Naloxone for Opioid Overdose

Evzio®

FDA approved April 2014

Narcan®

FDA approved November 2015

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Naloxone

Naloxone injection Naloxone intranasal

Naloxone 101 {Training & Resources}

• Indiana State Department of Health

• Substance Abuse and Mental Health ServicesAdministration {SAMHSA}

https://www.in.gov/isdh/27386.htm

https://store.samhsa.gov/shin/content/SMA14-4742/Overdose_Toolkit.pdf

Naloxone Demonstration on Campus

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Recommendation #9Review PDMP data

Prescription Drug Monitoring Program (PDMP)

• Clinicians should review the patient’s historyof controlled substances to determine if thepatient is receiving opioid dosages ordangerous combinations that place thepatient at risk for an overdose.

• PDMP should be reviewed when startingopioid therapy for chronic pain & periodically.

– Ranging from every prescription to every 3months

Prescription Drug Monitoring Programs (PDMPs)

• Purpose of PDMPs is to reduce prescription drugabuse and diversion

• The DEA reports that PDMPs do discourage drugdiversion and the states that have implementedthese programs report decreases in abuse anddiversion of the drugs

• Pharmacists & Prescribers that use these programsreport that they feel more confident whendispensing/prescribing controlled substances

https://www.cdc.gov/drugoverdose/pdmp/providers.html

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https://www.cdc.gov/drugoverdose/pdmp/providers.html

Recommendation #10Urine drug testing

How often?

Urine Drug Screening (UDS)

• Clinicians should use urine drug testingbefore starting opioid therapy and repeatat least annually to assess for prescribedmedications and other controlledprescription drugs or illicit drugs.

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Recommendation #11Avoid concurrent opioid andbenzodiazepine prescribing

What other drugs should beavoided with opioids?

Medications to avoid with opioids

• In general, Benzodiazepines (BZDs) shouldNOT be prescribed in patients using opioidsfor chronic, non-cancer related pain.

• BZDs require a gradual taper in patients whohave been on long-term therapy to avoid:– Rebound anxiety– Hallucinations– Seizures– Delirium

• Other CNS depressants

Recommendation #12Offer treatment for opioid use

disorder

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Medication Assisted Therapies (MATs)

Opioid Agonists:

Methadone

Opioid Partial Agonists:

Buprenorphine, Buprenorphine/Naloxone

Opioid Antagonists:

Naltrexone

CDC Mobile App

Case Example #1

A 65 year old male is currently on Fentanyl50 mcg/hr Transdermal Patch to be changedevery 3 days.

Using the CDC Mobile Calculator app, Whatis the MME?

Is this patient a candidate for Naloxonebased on the MME calculated?

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Case Example #2

A 67 year old female is currently onOxycodone 10mg BID.

Using the CDC mobile app, what is theMME?

If the dose is increased to 20mg BID what isthe MME?

What is the CDC recommendation?

3 Principles are KEY to Improving Patient Care

Generation Rx

https://www.generationrx.org/

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Book Club

Advocacy

http://www.pharmacist.com/

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https://news.aamc.org/for-the-media/key-issues/academic-medicines-response-opioid-epidemic/

Opioids in the GeriatricPopulation

Darin Ramsey, PharmD, BCPS, BCACP

Director of Assessment

Associate Professor of Pharmacy Practice

Butler University, College of Pharmacy & HealthSciences

No Actual or Potential Conflicts of Interest

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The Road AheadASCP Engagement Issues

IntroductionChad Worz, PharmD, BCGP

Chad is CEO of the American Society of Consultant Pharmacists

His career included the founding of Medication Managers, LLCand RxConcile.com. He has over 20 years of experience in themanagement of pharmacy and pharmacist services in the seniorcare and developmentally disabled populations.

Chad has always been an innovator in consulting pharmacy andwas instrumental in the founding of the nation’s first full servicecharitable pharmacy in Cincinnati, Ohio.

Chad has no financial disclosures with regards to this program.

Learning ObjectivesAt the conclusion of this activity, participants should be able to:

1. Recognize current legislative and regulatory issues

2. Identify DEA regulatory changes

3. Define the “Triple Aim” concept and “Value based care”

4. Identify opportunities for consultant pharmacists in the currenthealth care environment

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Identity

I can…

I have…

I like…

I am…

I remember…

In April 1888, Associated Charities of Cincinnati invited agroup of civic leaders to meet and discuss the need for a“home for incurables.

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Medical Resort

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Changing IdentityInception – unconsciously incompetent – Excited

- blissfully ignorant

Deception – consciously incompetent – Fear

- the mind seeks familiar

Transformation – consciously competent – Aware

- noticing success

Identity – unconsciously competent

- Who you are

Senior Care Pharmacy Practice

An Aging Nation

www.census.gov/population/projections/data/national/2014.html

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Seniors in America

65-6936%

70-7425%

75-7919%

80-8415%

>845%

Population 2012

65-69 70-74 75-79 80-84 >84

65-6924%

70-7421%

75-7918%

80-8416%

>8421%

Population 2050

65-69 70-74 75-79 80-84 >84

Source: https://www.census.gov/prod/2014pubs/p25-1140.pdf

https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf

2022Born 1942

80 yoa

2040Born 1960

80 yoa

2018Born 1938

80 yoa

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Prescription Use in Seniors

https://www.imshealth.com/files/web/IMSH%20Institute/Reports/US_Use_of_Meds_2013/Percent_population_prescriptions_per_capita.pdf

0 10 20 30 40 50 60 70 80 90 100

<64

65+

Rx % Population %

Polypharmacy and Aging:Predictors of Potential Drug Interactions

13

58

82

0

20

40

60

80

100

Pro

bab

ility

of

Inte

ract

ion

(%)

Number of Concurrent Medications

2 5 >7

Age

Number of ConcurrentMedications

Chronic Disease

Severity of Disease

Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet 2007;370:185–91.

Variable Influencing Drug Outcomes

Adapted from Hansten. Science & Medicine. 1998;5:16-25.

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BiosimilarsFDA – Draft Interchangeability Guidance

CMS – Medicare Part B Coding & Reimbursement

State Activity

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Medicare Advantage &Medicare Part D Proposed Rule

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Drug ManagementPrograms

Medication TherapyManagement

Benefit Design &Utilization

Management

HIT & DataInteroperability

Fraud, Waste, & Abuse Any Willing Provider

The “MEGARULE”

Medicare Conditions of Participation (SOM)

DRR/MRR recommendation & actiondocumentation in patient medical record

Antibiotic Stewardship: systems to monitor use;antibiotic protocols

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Medicare Conditions first published in 1989

Set standards for health care and safety

Proposed rule published July, 2015

Final rule published October 4, 2016

Phased Implementation

◦ Phase 1 – 11/28/2016

◦ Phase 2 – 11/28/2017

◦ Phase 3 – 11/28/2019

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The “MEGARULE”

Phase 1 –

◦ Documentation of DRR recommendations and prescriber response

◦ Updates definition of medication “irregularity”

Phase 2 -

◦ Antibiotic Stewardship Program

◦ Re‐defines “psychotropic drugs”

◦ PRN antipsychotic & psychotropic drug rules (14 days)

◦ “F‐TAGS” RE‐NUMBERED

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The “MEGARULE”

On 11/24/17, just prior to Phase 2 implementation, CMS released a memo tosurveyors

◦ An 18‐month temporary moratorium on imposing enforcement remedies for certain Phase 2 requirements, including Behavioral Health Services (F740),Psychotropic Medications (F758), Antibiotic Stewardship Program (F881), aswell as 5 other areas of care

◦ Health Inspection Star Ratings Frozen for one year

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The “MEGARULE”

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Impact Act 2014“Improving Medicare Post-Acute Care Transformation Act”

IMPACT Act 2014Standardized patient assessment data across all four PAC settings – Quality

Measures Defined by CMS

Defines PAC providers to include : Home Health Agencies, LTACHs, SNFs and IRFs

Requires PAC providers to report standardized patient assessment data by 10/2018

Documentation of Medication Reconciliation at Admission & Discharge

Communication of “Med Rec” to◦ Patient

◦ Family

◦ Primary Care Doc

◦ Community Pharmacy

InpatientRehabilitation

Facilities - PatientAssessment

Instrument (IRF-PAI)

IRF-PAI

Skilled NursingFacilities -

Minimum DataSet (MDS)

MDS

Home HealthAgencies -

Outcome &Assessment

Information Set(OASIS)

OASIS

Long-Term CareHospitals -Continuity

AssessmentRecord &

Evaluation (CARE)Data Set (LCDS)

LCDS

MedicationReconciliation




IMPACT Act 2014

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Quality Domain SNF Due Date

Functional Status October 2016

Skin Integrity October 2016

Medication Reconciliation October 2018

Major Falls October 2016

Patient Preference October 2018

Standard Data Collection Timeline

ASCP DEA Task force

ASCP established its DEA Task Force in 1998 to address ambiguitieswithin the CSA◦ Hospital vs. Community vs. LTC Pharmacy

◦ CSA and the practice standards of LTCPs represented a potential “regulatory compliance risk”

◦ DEA Task Force ‐ mission of working with the DEA to resolve issues and challenges - Balance patient care vs. regulatory compliance

◦ Over the years, changes made to DEA regulations such as time required for follow-up written Rx for verbal CII orders and faxing of CII Rx’s

Task Force – working directly with DEA staff since 2015on list of issues, focused on Nurse Agency issue.

Resolved: Obtained written clarification from DEA:

◦ Electronic e‐kits: use for 1st dose only do not require separateDEA registration (11/30/16).Comprehensive Addiction & Recovery Act (CARA)

◦ DEA Clarification: CARA 30‐day fill limitation does not apply tolong-term care and hospice patients (1/13/17)

◦ DEA verified, partial‐fills for CII prescription medications with up to 60-days to complete.

ASCP DEA Task force

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Current Nurse Agent Overview

Authority of Agent (under current DEA guidance)

◦ Prepare CII‐CV prescription for practitioner to sign

◦ Transmit CII‐CV prescription that is signed by practitioner to pharmacy via fax

◦ Take a verbal CIII‐CV prescription from the physician and communicate that prescription via telephone to the pharmacy

Agents are employed by the authorized prescriber and may be:◦ A nurse located in the prescribers office◦ A non‐licensed receptionist◦ Hospital employees (b/c hospitals are DEA registrants)◦ NOT LTCF Nurses for CDS. Nurses in a facility today remain the

agent of the prescriber for non-controlled medications

Current Nurse Agent Overview

October 6, 2010 DEA issues Policy Statement that addressed the nurseas an agent of the prescriber

LTCF employees may become agents but only through a veryprescriptive and detailed process that documents such delegation

Each Nurse must be contracted with each prescriber and the pharmacyand the facility must maintain records of all contracts◦ ASCP DEA‐TF Recommended that DEA issue a revised Nurse Agent

Policy which specifically addresses an alternative policy approach forthe LTC setting

◦ Continued meetings with DEA in 2018 (Chart Orders, etc)

Recent Activity

•Affordable Care Act 2010

•Mega Rule (Medicare Conditions of Participation)

•Impact Act 2014

•Enhanced MTM, CMMI Demonstration

•PPS Revisions, Request for Comments• RUGs to RCS to PDPM

•Chronic Care Management Models• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

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The Triple Aim

Lower Cost

Patient Centered Care

Value Based Reimbursement

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Drug PricingSome debate continues around the value of drug importation from countries like Canada andMedicare drug price negotiation

Drug price transparency bills targeting both manufacturers and PBMs have limited support

Bipartisan work groups have formed on the issue, though no definitive action has been taken

Chronic Care Act LegislationSenate Finance Committee Bipartisan Effort

Addresses chronic disease in Medicare

Improves flexibility and predictability to better serve chronically ill beneficiaries by allowing MAplans & ACOs to tailor coordination and benefits to specific patient groups.

Telemedicine- Allows beneficiaries receiving dialysis treatments at home to do their monthlycheck-in with their doctor via telehealth, rather than travelling to the doctor’s office or hospital.

Passed out of Senate and awaiting House movement

Opioid EpidemicWhite House Opioid Commission

◦ President’s declaration of state of emergency

Congressional Action◦ Committee hearings in House E&C and Senate HELP

Dec. Appropriations Bill Drug Issues in Budget

Implementation of CARA Grants

Action in the States◦ State‐based initiatives

◦ State AG, County, City Lawsuits

◦ Potential for future action

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The 2018 Elections: SenateSenate ― 100 Senators ― 60 votes important

Senate ― 52 current Republican Senators

Senate ― 48 current Democra� c Senators

2018 Senate elec� on ― Democrats overexposed; Majority unlikely to change

Dems defending 25 of the 34 seats up for reelection, including 10 seats in Trump states.

GOP has only one seat up in 2018 in a Clinton state

Dems ― Need 3 seats to gain majority

The 2018 Elections: HouseAll 435 seats up

239 – Current Republican Seats

194 – Current Democratic Seats

2 – Open Seat

Democrats likely to pick up a handful of seats

Narrower majority after 2018 (likely R)

Federal Legislative Advocacy

“Provider Status for Pharmacists” - The Patient Access to Pharmacists’ Care

Coalition’s (PAPCC) mission is to develop and help enact a federal policy

proposal that would enable patient access to, and payment for, Medicare Part

B services by state-licensed pharmacists in medically underserved

communities. Our primary goal is to expand medically-underserved patients’

access to pharmacist services consistent with state scope of practice law.

PAPCC – organizations representing patients, pharmacists, pharmacies &

interested stakeholders (around 40 groups)

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Provider Status in 115th Congress

•Senate-S.109 introduced in January by Sen. Charles Grassley(R-IA) with 45 co-sponsors• Referred to the Senate Finance Committee

•House-H.R.592 (same bill number as 114th Congress, buttotally new bill) introduced by Brett Guthrie (R-KY) with 226co-sponsors.• Referred to Energy and Commerce Committee and Ways And Means –

Sub-committee on Health

Are there too many pharmacists?

https://pharmacymanpower.com

Why Is it Important?The Impact of Senior Care Pharmacists

Reduced health care costs◦ For every $1 spent on pharmacist intervention, the healthcare system saves

$12.1

◦ Pharmacist‐provided MTM in Medicare Part D reduced medication costs an average of $840 per patient in year 1 and $1,061 per patient in year 2.2

Reduced hospital admissions◦ Pindola et al showed a 60% reduction for Dx of bleeding ulcers

($5,000/admission) in patients who received MTM.2

1. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc.2008;48(2):203–11.2. Pindolia VK, Stebelsky L, Romain TM, Luoma L, Nowak SN, Gillanders F. Mitigation of medication mishaps via medication therapy management. Ann Pharmacother.

2009;43(4):611–20. https://www.pharmacist.com/sites/default/files/EvidenceforPharmacistsSerivces2000-2015.pdf

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Why Is it Important?Opportunities for Senior Care Pharmacists

Medicare is changing payment models from Fee for Service(FFS) to shared risk bundles.

Opportunity for pharmacists to participate in these sharedrisk models. (ACO, Medicaid, Managed Care).

Self insured employers need to control costs while keepingtheir employees healthy and productive.

Opportunity for Innovation

Expanding Horizons

MTM

Self Insured Employers

Physician’s Offices

Transitions of Care –Hospital Clinics

Industry Consulting

Individuals

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Questions

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ASCP and Legislative Update: The Road Ahead

Self-Assessment Questions

1. What is the approximate increase in people over the age of 65 years from now until 2030:

a. 10 Million

b. 20 Million

c. 30 Million

d. 100 Million

2. What approximate percentage of all prescription medications dispensed do people over

the age of 65 consume?

a. 10%

b. 20%

c. 33%

d. 50%

3. Value Based Care is tied to the number of prescription medications that pharmacists can

discontinue

a. True

b. False

4. The Triple Aim involves:

a. Good patient satisfaction

b. Quality care

c. Lower cost

d. All of the above

5. Provider status legislation is now being attached to bills involving what national crisis?

a. Medical Marijuana

b. Opioid Management

c. Tele-pharmacy

d. DIR Fee elimination

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Experts in geriatric medication management. Improving the lives of seniors.Experts in geriatric medication management. Improving the lives of seniors.

A Collaborative Approach to Falls Prevention: Using the ASCP/NCOA Toolkit

Part 1


Disclosures

Sharon Clackum, PharmD, CDM, BCGP, FASCP – None

Michelle Fritsch, PharmD, BCGP, BCACP – None


Learning Objectives

Define the role of comprehensive falls risk assessment and intervention in their practice utilizing falls prevention toolkits from the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative and the American Society of Consultant Pharmacists–National Council on Aging.

Identify common risk factors for falls in the senior population.

Utilizing patient cases, develop individualized recommendations for fall prevention based on a medication review.

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1. Assessment Question

When performing a comprehensive falls risk assessment, which of the following would not be performed by a pharmacist?A. Obtaining a medical history

B. Referring to a physical therapist

C. Performing a home safety assessment

D. Communicating medication adjustments to a prescriber



Which of the following is not a risk factor for falls?

A. Living alone

B. Depression

C. 2‐3 chronic medications

D. Frailty



Which of the following antidepressants is most associated with falls and increased fragility?

A. Duloxetine

B. Paroxetine

C. Selegiline

D. Bupropion

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The safest example of appropriate opiate prescribing to reduce falls would be which of the following?A. Use of a short‐acting opiate at a dose greater than 50

morphine milligram equivalents per day

B. Use of long‐acting opiates for greater than 7 days

C. Preferentially using long‐acting opiates after a joint replacement surgery

D. Alternating opiate with non‐opiate analgesics for up to 3 days for acute pain.


AgendaPart 1 Review of general falls risk factors Exploration of falls‐risk associated medical conditions and medications Overview of CDC STEADI Toolkit Introduction to components of the ASCP‐NCOA Falls Risk Reduction Toolkit Case Study Work– Pharmacologic and Medical Issues

Part 2• Strength, Balance, and Gait Assessments• Interprofessional Fall and Fall Risk Management: Introduction to the Role of Physical and Occupational Therapy

• National and State Initiatives• Case Work and Discussion• Incorporating Falls Prevention Into Practice• Wrap‐Up


Acronyms/abbreviations used in this presentation

BDZ BenzodiazepineBUN Blood urea nitrogenCNS Central nervous systemCVA Cerebrovascular accidentCVD Cardiovascular diseaseESRD End‐stage renal diseaseFRID Fall risk increasing drugMAI Medication appropriateness indexMS Multiple sclerosisMVA Motor vehicle accident

NSAID Nonsteroidal anti‐inflammatory drugSCr Serum creatinineSSRI Selective serotonin reuptake inhibitorSTART Screening tool to alert doctors to right treatmentSTOPP Screening tool of older person’s prescriptionsTCA Tricyclic antidepressantUI Urinary incontinenceUTI Urinary tract infection

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What We Know About Falls and Fall‐Related Injuries and Deaths

Common

Costly

Impactful

Predictable

Largely Preventable

Everyone has a role to play and can make a difference within their own sphere of influence.


It Takes A Village

“It takes a village of stakeholders working together to prevent falls and reduce falls risk, tasks that no one stakeholder can accomplish alone”

Ganz,DA, Alkema,GE, and Wu,E. Injury Prevention, 2008


Falls General Risk Factors

Advanced age

Frailty

Para‐transitions

Lives alone/minimal support system

Ambulation status

Sensory deficits

#1 FactorHistory of a Fall

Patient feels unsteadyPatient worries about falling

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CDC STEADI

Toolkit for professionals

Toolkit for patients

https://www.cdc.gov/steadi/index.html


STEADI Professional Components



STEADI Patient Components


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ASCP/NCOA Toolkit Components

Falls Risk Checklist

Falls Application Cases

Communications Documents

Build Your Referral Network

Bibliography

Support provided by Sanofi


Medical Conditions Associated with Falls


Medical Conditions Gait and Balance Altering Parkinson’s Disease

Alzheimer’s Disease

Obesity

Pain‐Related Gait and Balance Changes Lower extremity arthroplasty

Lower extremity injury

Lower extremity neuropathy

Osteoarthritis

Rheumatoid arthritis/other autoimmune arthritis

Infections (eg, UTI)

Organ Function

Vascular‐Related Conditions Cardiovascular disease

Myocardial infarction

Arrhythmias (eg, atrial fibrillation)

Cerebrovascular disease

Cerebrovascular accident

Cerebellar ataxia

Hemophilia

Central Nervous System Depression

Epilepsy/Seizures

Multiple Sclerosis

Incontinence

Malnutrition, dehydration

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Gait & Balance Altering Conditions

Parkinson’s Disease‐ Manage on/off phenomena‐ Orthostasis with Parkinson’s therapy‐ Avoid anticholinergic therapy options

(e.g. benztropine or trihexyphenidyl)

Alzheimer’s Disease‐ Falls increased with multi‐tasking‐ Cholinesterase inhibitors increase risk of syncope and falls‐ Brain atrophy, declined frontal cognitive functions, and sleep

Associated Risk Factors‐ Physical & neurological changes which impact gait or balance

‐ Muscle weakness

‐ Obesity ‐ Proprioception changes


Pain Related Gait & Balance Changes

Lower extremity injury‐ Foot pain, physical changes, muscle weakness‐ Anything that alters gait or balance

Arthritis‐ Osteoarthritis lower extremity__2‐5 times increased falls risk

‐ Rheumatoid arthritis and other autoimmune arthritis‐ Risk further increased with inflamed lower extremity joints, fatigue, use of FRIDs

Lower extremity arthroplasty‐ High falls rate especially in days 1‐3 post operative

‐ Associated with bathroom use and more advanced age

Pain itself is distracting, changes gait, and increases falls risk

Arthritis‐ Osteoarthritis lower extremity – 2 to 5 times increased falls risk‐ Rheumatoid arthritis and other autoimmune arthritis‐ Risk further increased with inflamed lower extremity joints, fatigue, use of FRIDs


Vascular Related Conditions

Cerebrovascular Disease‐ Impaired balance post stroke‐ Fall risk even if no gait impairment immediately post CVA‐ Cerebellar dysfunction is associated with gait variability

Hemophilia‐ Balance impairment can be linked to brain or muscle bleeds ‐ Mobility impairment, especially if there are joint changes due to bleeding in the joint‐ Reduced physical activity due to fear of falling‐ Incontinence (risk similar to all older adults)

Cardiovascular Disease‐ Falls can be an atypical presenting symptom of acute MI‐ Syncope due to disease and treatment‐ Atrial fibrillation increased risk of falls and falls‐related mortality

Follow CVD treatment guidelines; do not undertreat those with fall risk due to increased CVD mortality

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Central Nervous System Conditions

Epilepsy/Seizures‐ Any syncopal or ictal episode typically leads to a fall (esp. with loss of consciousness) ‐ Ictal bradyarrhythmias or arrhythmogenic epilepsy‐ Post stroke seizures are associated with falls

Multiple Sclerosis‐ >60% annual fall rate‐ Falls risk factors associated with MS are multi‐factorial

Depression‐ Depressed patients have a higher incidence of falls‐ Depression is often not detected and diagnosed


Incontinence, Malnutrition & Infection

Infection‐ Associated with confusion & debilitation which increases falls risk‐ UTI & pneumonia common infections (all infections are a risk)

Malnutrition‐ Muscle mass loss, weakness, debilitation, fatigue‐ Nutrient deficiencies >>cognitive impairment, reduced concentration‐ Associated arrhythmias

Incontinence‐ UI treatment (anticholinergic) increase falls risk‐ Urgency leads to hurry and falls‐ UTI risk increased with UI


Renal & Hepatic Impairment Associated

Hepatic Impairment‐ Impact on medication dose‐ Alcohol‐related falls due to acute and chronic changes‐ Associated with non‐alcoholic fatty liver disease (again, frailty association)‐ Falls associated with cirrhosis, hepatic encephalopathy

Renal Impairment‐ Impact on medication dose‐ Falls associated with ESRD and patients on hemodialysis‐ Frailty likely underlying cause

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Falls Risk Inducing Drugs (FRIDs)


Falls Risk Inducing Drugs (FRIDs)

CNS Depressants

Antidepressants

Benzodiazepines

Sedative/hypnotics

Neuroleptics

Antispasmodics

Anticonvulsants

Antihypertensives

Hypoglycemic Agents

Over‐The‐Counter

Anticholinergics

Incontinence

Depression

Parkinson’s

Pain Therapy

Opioids

Muscle relaxants


CNS Depressants

Antidepressants‐ Tricyclic antidepressants have several side effects which increase falls risk

‐ Selective serotonin reuptake inhibitors are associated with increased fragility fracture risk as well as falls risk, especially paroxetine

Benzodiazepines‐ Long half‐life / prolonged effect / accumulation‐ Short half‐life / quick onset also problematic‐ Long vs. short acting BDZ = similar falls rate ‐ Taper slowly if discontinuing and monitor closely

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CNS Depressants (Continued)

Sedative/HypnoticsZolpidemZopicloneZaleplon

‐ All associated with falls and driving impairment‐ Impact balance, gait, and equilibrium

Neuroleptics‐ First generation antipsychotics‐ Atypical (2nd generation) psychotics‐ Both associated with falls


Anticholinergic Medications

Incontinence Therapies‐ Urinary anticholinergics‐ Oxybutynin and others

Parkinson Disease Therapies‐ Benztropine‐ Trihexyphenidyl

Depression Medications‐ TCA (esp. amitriptyline)‐ SSRI's (esp. paroxetine)

Antispasmodics‐ First generation antihistamines‐ Hydroxyzine


Pain Medications

Opioids‐ Risk higher with high potency‐ Risk higher with use of long‐acting without first using short‐acting‐ Risk higher with new prescription‐ Impact balance, gait, and equilibrium

Muscle Relaxants‐ Associated with falls‐ Little evidence of benefit

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Anticonvulsants & Antihypertensives

Anticonvulsants‐ Decreased bone density with chronic use‐ Fall and fracture risks increase with longer use‐ Both falls and MVA risk

Antihypertensives‐ Diuretics/beta‐blockers/alpha‐blockers/vasodilators‐ Data is mixed—Epidemiologic data links antihypertensives to falls‐ Risk of falls higher in prior fallers‐ Weigh risks and benefits; use lowest possible dose

Reminder –Dopaminergic agents can cause syncope


Hypoglycemics & OTC Agents

Hypoglycemics‐ Falls associated with hypoglycemia‐ Sulfonylureas ‐ Insulin

OTC Agents‐ Sedative/anticholinergic & antihistamine agents‐ Diphenhydramine‐ Doxylamine and other sedating antihistamines


Medication Overview & Lab Assessment

Lab Values‐ Critically important labs‐ Electrolytes, glucose, SCr, BUN, & hepatic enzymes‐ Calculate estimated creatinine clearance (Cockcroft‐Gault)‐ Possibly medication concentrations

Medication Overview‐ Number of medications (routine / as needed) > 4‐6 (polypharmacy = falls risk)‐ Number of doses per day & complex regimens associated w/ falls risk‐ Recent medication changes

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Medication Assessment

Geriatric Appropriate Medication‐ Beer’s List‐ STOPP‐ START‐ MAI

Medication Related Problems‐ Each medication is necessary‐ Safest evidence‐based therapy‐ Dose too low to be effective‐ Dose too high causing adverse effects or

unnecessary risk‐ Interactions between medications, food, medical

conditions‐ Ability to effectively administer each medication‐ Allergies and intolerances‐ Indication without an associated therapy


ASCP/NCOA Toolkit Components


Falls Application Cases

Communications Documents

Build Your Referral Network

Bibliography

Support provided by Sanofi



Four key areas of the checklist

Get to know your patient

Medical conditions

Medication assessment

Fall Risk Inducing Drugs (FRIDs) http://www.ascp.com/default.asp?page=fallstoolkit

http://www.ascp.com/resource/resmgr/docs/toolkits/falls/bibliography.pdf

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http://www.ascp.com/default.asp?page=fallstoolkithttp://www.ascp.com/resource/resmgr/docs/toolkits/falls/bibliography.pdf





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1

23

45

Tally the

Risks


Considerations

Number per class/risk type

< 2 CNS depressing medications

Limit anticholinergic burden

Medical conditions, medications, other factors

Patient specific

Pharmacists are uniquely suited for this in‐depth analysis

Consider all risks and benefits

AGS Beers Criteria. J Am Geriatr Soc 2015.


Alternatives

Newer generation options with fewer side effects Avoid benzodiazepines and “Z drugs” Avoid tricyclic antidepressants, paroxetine Topical in place of systemic Acetaminophen in place of skeletal muscle relaxants, NSAIDs, or opioids whenever possible Short‐acting over long‐acting options (e.g. hypoglycemics, opiates) Lowest possible dose to achieve therapeutic goal Use nonpharmacologic approaches whenever possible

Hanlon JT, et al. J Am Geriatr Soc 2015. Ferrari S, et al. J Geriatric Pharmacother 2008.

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Documentation & Communication

Patient & family


http://www.ascp.com/resource/resmgr/docs/toolkits/falls/bibliography.pdf

Falls Bibliography Resource


Cases

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When performing a comprehensive falls risk assessment, which of the following would not be performed by a pharmacist?A. Obtaining a medical history

B. Referring to a physical therapist

C. Performing a home safety assessment

D. Communicating medication adjustments to a prescriber



Which of the following is not a risk factor for falls?

A. Living alone

B. Depression

C. 2‐3 chronic medications

D. Frailty



Which of the following antidepressants is most associated with falls and increased fragility?

A. Duloxetine

B. Paroxetine

C. Selegiline

D. Bupropion

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The safest example of appropriate opiate prescribing to reduce falls would be which of the following?A. Use of a short‐acting opiate at a dose greater than 50

morphine milligram equivalents per day

B. Use of long‐acting opiates for greater than 7 days

C. Preferentially using long‐acting opiates after a joint replacement surgery

D. Alternating opiate with non‐opiate analgesics for up to 3 days for acute pain.

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A Collaborative Approach to Falls Prevention:

Using the ASCP/NCOA Toolkit

Part 2


Disclosures• Alice Bell, PT, DPT, GCS – None• Sharon Clackum, PharmD, CDM, BCGP, FASCP – None• Michelle Fritsch, PharmD, BCGP, BCACP – None• Michael O’Donnell – none• Jacqueline Wilson, MS, OTR/L – None


Learning Objectives Explain the key roles of other disciplines in a multifactorial approach to

falls prevention.

Identify four functional assessments pharmacists can use to assess a patient’s fall risk.

Name three potential collaborative partners to contact to enhance falls prevention services.

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1. Assessment Question• Mrs. Smith is a 78-year old woman who is a long-time client of

your pharmacy. When she comes in with her daughter to pick up a prescription refill, you notice she is using a cane. She also has trouble rising from the chair in your waiting area. Of the following, who is most appropriate to perform an assessment?

A. A physical therapistB. An occupational therapistC. A trained pharmacistD. A trained pharmacy technician


2. Assessment Question• Mrs. Smith’s daughter confides to you that she is worried about

her mother, who lives alone. She is wondering what she might do to make her mother’s home safer. You suggest a home assessment. Of the following, who is most appropriate to perform a home assessment?



3. Assessment Question• Which of the following indicates an increased risk for

falling?A. A TUG test of 10 secondsB. A 30-second chair stand assessment of less than 10 in an

83-year old maleC. Inability to hold the tandem stand for at least 15 secondsD. A drop in diastolic blood pressure of 5 mmHG when

measuring orthostatic blood pressure

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4. Assessment Question• Besides an occupational and/or physical therapist,

a pharmacist may want to work with which of the following in a fall reduction program? A. Geriatric nurse practitionerB. Geriatric psychiatristC. Clinical psychologistD. Genetic counselor


Part 1• Review of general falls risk factors• Exploration of falls-risk associated medical conditions and medications• Overview of CDC STEADI Toolkit• Introduction to components of the ASCP-NCOA Falls Risk Reduction Toolkit• Case Study Work– Pharmacologic and Medical IssuesPart 2• Strength, Balance, and Gait Assessments• Interprofessional Fall & Fall Risk Management: Physical & Occupational Therapy• National and State Initiatives• Case Work and Discussion• Incorporating Falls Prevention Into Practice• Wrap-Up

Agenda


ACL Administration for Community LivingAGS American Geriatrics SocietyALF Assisted living facilityCMS Centers for Medicare & Medicaid

ServicesCPT Current procedural terminologyED Emergency departmentFCM Falls care managerFPAD Falls prevention awareness dayNIH National Institutes of Health

Acronyms/abbreviations used in this presentation

OT Occupational therapyPCORI Patient-centered Outcomes Research

InstitutePCP Primary care providerPT Physical therapyRCT Random controlled trialROI Return on investmentSNF Skilled nursing facilitySTRIDE Strategies to reduce injuries and

develop confidence in elders

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Occupational and Physical Therapy in Fall PreventionAlice Bell, PT, DPT, GCS

Jacqueline Wilson, MS, OTR/L


Causes of Falls

• Not part of aging process

• Occur due to:– Physical dysfunction– Cognitive deficits– Medications– Environmental hazards


What to Consider

• Prepare Your Home

• Prepare Your Body

• Prepare Your Plan

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Preparing Your Home

If we consider successful aging in place to be:

The ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level. (US CDC)

Then the concept of person-environment fit helps to determine “safely, independently and comfortably”…


Indications for Therapy Referral/Consultation

– Changes in or difficulty in mobility• Unsteady gait• Reduced spatial awareness

– Use of new or different mobility device– Report of a fall– Difficulty rising from a chair

• Muscle weakness– Report of change in environment


– Observed change in self care management• Grooming• Dressing• Medication management

– Noticeable cognitive/motor challenges• Handling money• Payment for medications• Organizing thoughts in conversation• Problem solving and direction following

Indications for Therapy Referral/Consultation

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Physical Therapy• Maximize Movement

– Movement experts who can identify, diagnose, and treat movement problems.

• Manage Pain– Physical therapy offers a safe alternative to opioids and other

medications that can increase fall risk.• Avoid Surgery

– For some conditions, including meniscal tears and knee osteoarthritis, rotator cuff tears, spinal stenosis, and degenerative disk disease, treatment by a physical therapist has been found to be as effective as surgery.


APTA Clinical Summary• Examination Recommendations• Risk Factors• Tests and Measures• Interventions


Occupational Therapy Evaluation• Occupational profile• Assessments• Identification of strengths and needs• Collaborative development of goals• Consultation with the client and caregiver

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Occupational Therapy Interventions• Medication management

– Secure a prescription– Fill a prescription– Understanding the prescription– Taking medications– Medication apps

• Falls management– Assessment of home environment– Sensorimotor education and activities


General Considerations for Safety in the Home Environment

• Remove clutter from the walkways

• Arrange furniture so that the pieces can safely provide support when navigating a path

• Remove or secure throw rugs

• Be visually aware of the location of pets in the room

• Do NOT stand on chairs to reach an object

• Do use a ladder or reacher to obtain objects from overhead

• Do not use towel bars or sink edges for support as they can pull away from the wall

• Use a nightlight in the bedroom, bathroom, and hallway

• Use LED bulbs to maximize visibility in the room


Where to Go for Home Modifications• Recommendations from an occupational therapist may include room

modifications, the addition of railings, or installation of grab bars• Look for builder and OT with Certified Aging-in-Place Specialist (CAPS)

certification• http://www.nahb.org/en/learn/designations/certified-aging-in-place-

specialist.aspx• Contact your state’s association for occupational therapy or for physical

therapy• Contact the national associations: American Occupational Therapy

Association or American Physical Therapy Association

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Evidence Based Interventions

Dose Specific Exercise Prescription


Inter-Professional Fall Risk ManagementQuestions?



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National and State Falls Prevention Programs and Initiatives

Michael O’DonnellExecutive Director


About The National Council on Aging

Who We Are: NCOA is the national voice for every person’s right to age well

Our Vision:A just and caring society in which each of us, as we age, lives with dignity, purpose, and security

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Our Mission:Improve the lives of millions of older adults, especially those

who are struggling

Our Social Impact Goal:Improve the health and economic security of 10

million older adults by 2020


Falls: A Growing Public Health Issue among Older Adults

• The leading cause of injuries and injury deaths.• 27,000 die annually from a fall – one every 19

minutes.• 2.8 million ED visits annually– one every 11

seconds.• Falls cause 800,000 hospitalization yearly.• $50 billion is spent on direct medical costs

related to falls; 75% of costs paid for by Medicare and Medicaid

Among people who fall, less than half talk to their healthcare provider about it. Pharmacists can fill this gap by playing a key role in falls prevention.

Huge impact on quality of life.


What We Know About Falls and Fall-Related Injuries and Deaths

• Common• Costly• Impactful• Predictable• Largely Preventable

Everyone has a role to play and can make a difference within their own sphere of influence.

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National Falls Prevention Resource Center

• Funded by the U.S. Administration for Community Living/Administration on Aging

• Increase public awareness and educate consumers and professionals about falls risks and how to prevent falls.

• Serve as the national clearinghouse of tools, best practices, and other information on falls and falls prevention

• Support the implementation, dissemination, and sustainability of evidence-based falls prevention programs and strategies

• Began September 2014• www.ncoa.org/healthy-aging/falls-prevention/


National Falls Free® Initiative• A thousands-strong and growing network • National Action Plan developed in 2005; updated in 2015• Strong partnerships

– ACL and the Aging Network– CDC’s National Center for Injury Prevention and Control– National professional and consumer organizations– State and local public health entities

• Falls Free® is a critical effort to meet Healthy People 2020 goals of reducing older adult fall-related ED visits by 10%

• 43 State Falls Prevention Coalitions


National Fall Prevention Awareness Day (FPAD)• September 22, 2018: 1st day of fall • 11th Annual FPAD in 2018• U.S. Senate Resolution passed unanimously in 2017• 2017 Reach:

– 42 State Falls Prevention Coalitions, D.C. Falls Free® Coalition, and 7 additional states participated

– National awareness and education media efforts reached an estimated 99 million individuals

– State coalition efforts reached nearly 2 million individuals through education, awareness, and advocacy efforts, as well as fall prevention programs and fall-risk screenings

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State and Local FPAD Activities• Proclamations – state and local• Public awareness activities• Professional education• Physical activity events• Falls risk screening fairs• Medication review• Enrolling older adults in evidence-based falls prevention programs• State and local advocacy activities


NCOA Resources & Handouts• 6 Steps to Prevent a Fall infographic and video• 6 Steps to Protect Your Loved One From a Fall• Winterize to Prevent Falls• Osteoporosis and Falls• Osteoarthritis and Falls• Falls Prevention Conversation Guide for Caregivers• Myths About Falls• All available at no cost:

https://www.ncoa.org/healthy-aging/falls-prevention/preventing-falls-tips-for-older-adults-and-caregivers/


PresentsEvidence-Based Falls Prevention in IllinoisJuly 14, 2018

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Mission and Vision

• The Illinois Community Health and Aging Collaborative seeks to improve the health status of older adults and persons with disabilities in Illinois by leveraging the strengths of community-based organizations and elevating their provision of cost-effective, high quality, evidence-based healthy aging programs.

• We envision that evidence-based, healthy aging programs will be accessible to all adults across Illinois, making Illinois a healthier state in which to live.


The Collaborative

• The Illinois Community Health and Aging Collaborative:

• Founded in 2013;• Established in 2015 as a non-profit organization; • Supported and governed by a Board of Directors

comprising experienced, trusted, and progressive leaders in the field of health and aging in Illinois.


Our Founding Partners• AgeOptions – the Area Agency on Aging for Suburban Cook County• AgeSmart Community Resources- the AAA for Southwestern Illinois• CIMPAR – Chicago Medical Practice and Research• East Central Illinois Area Agency on Aging• Illinois Aging Services, Inc.• Northeastern Illinois Area Agency on Aging• Rush University Medical Center• Western Illinois Area Agency on Aging• White Crane Wellness Center

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13 Planning and Service Areas in

Illinois


Illinois Pathways to Health

The Collaborative and our community-based partners

provide…

Illinois Pathways to Health - a statewide integrated delivery

system for evidence based programs. All members of the Illinois Community Health and

Aging Collaborative are participating in the system.

Since 2006, our partners have enrolled over 15,000 older

adults in a variety of evidence-based healthy aging programs.

Our strategic goal is to reach over 21,000 older adults and persons with disabilities by

2021.


Illinois Pathways to better health outcomes• Achieve the Triple Aim:

– Improve the patient experience of care (including quality and satisfaction);– Improve the health of older adults and adults with disabilities;– Reduce the per capita cost of health care.

• Empower adults to manage chronic diseases and disabilities;• Empower adults to manage diabetes;• Empower adults to manage activities of daily living at home;• Reduce unplanned hospital admissions;• Reduce emergency department admissions;• Reduce admissions to long term care facilities;• Prevent falls, manage falls, and increase self confidence.

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Our Menu of

Programs

• Illinois Pathways to Health offers older adults and persons with disabilities a menu of evidence-based programs to help them achieve their personal goalsfor health and wellness, including:

• Take Charge of Your Health (Chronic Disease Self-Management Program)

• Take Charge of Your Diabetes (Diabetes Self-Management Program)

• Tomando Control de su Salud (Spanish CDSMP)• Tomando Control de su Diabetes (Spanish DSMP)• Take Charge of Your Diabetes Plus (8-week clinical

wrap-around workshop for Medicare beneficiaries, with Medical Nutrition Therapy, accredited by AADE)

• A Matter of Balance (Falls Prevention Program)


Program Partners in

Illinois

• 13 Area Agencies on Aging• Public Health Departments• Community-Based Organizations• Care Coordination Units• Hospital Systems and Community Hospitals• Centers for Independent Living• Adult Day Services Centers• Senior Centers and Nutrition Sites• Independent Living and Assisted Living

Facilities• Fire Departments


A Matter of Balance – Falls Prevention

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Progress Report: A Matter of Balance• Rush University Medical Center has a grant from the Administration for

Community Living for evidence-based falls prevention in Illinois.• Since August 2016, Rush and 28 local host organizations have delivered 71

Matter of Balance workshops in 12 of 13 PSAs in Illinois.• We have trained 51 Master Trainers and 120 Coaches.• We have enrolled 979 older adults in workshops.• 742 participants have completed 5 of 8 sessions.• We have achieved a completion rate of 76%.


Participants value A

Matter of Balance

Testimonial from – Ed (age 95) and Karen (age 75) who completed MOB class together in LaGrange Park, IL

• “Interesting and educational. Introduced light exercises. Better balance when walking, and more confidence going up and down stairs. We met new friends and learned tips from one another. We go to the gym three times a week.” Our advice to people at risk of falling: “You own it. It doesn’t own you. Take care of it. Complete all the classes. You’ll enjoy it.”


Return on Investment

• Research has shown that A Matter of Balance participation was associated with a-$938 decrease in total medical costs per year. This finding was driven by a $517 reduction in unplanned hospitalization costs, a $234 reduction in skilled nursing facility costs, and an $81 reduction in home health costs.

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Collaboration with

Pharmacist Partners in

Illinois

As part of National Falls Prevention Awareness Day, the University of Illinois Chicago College of Pharmacy conducts fall risk screenings – using the STEADI Tool - with older adults at senior centers in Chicago and refers participants with moderate fall risk to White Crane Wellness Center for enrollment in A Matter of Balance workshops.


Contact Us• You can find scheduled A Matter of Balance workshops

and coach trainings on our website -www.ilpathwaystohealth.org

• For more information, please contact:

Michael O’Donnell, Execut

Mike O’Donnell, Executive Directoremail: [email protected]: (309) 531-2816


Cases

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Incorporating Falls Risk

Assessment into Practice


Who’s Involved in Falls Prevention?• Physicians, nurses • Physical therapists• Occupational therapists• SNFs and ALFs• Senior housing• Home health• Emergency Medical

Services/1st responders

• Hospitals and Trauma Centers

• Public health/injury prevention

• Schools of pharmacy, nursing, OT, PT

• The Aging Network


Payment for Falls Prevention?• Primary Care Practices• Accountable Care Organizations• Medicare Advantage Plans• Patient Centered Medical Homes• Hospitals• Others

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CPT CodesOutpatient Visit Type Billing Codes Considerations

Welcome to Medicare ExaminationA falls risk assessment is a required element of the Welcome to Medicare examination (Initial Patient Preventative Physical Exam).

G0402 Billable within first 12 months of enrollment only

Annual Wellness VisitA review of individual functional level and safety (falls) is included in the initial Annual Wellness Visit (AWV).

G0438 Initial AWV

G0439 Subsequent follow-up to an AWV

Evaluation and Management (E/M)Falls-related assessment may be completed as part of a scheduled office visit if >50% of visit was face-to-face education/counseling and documented (time) or by an identified and appropriately documented reimbursable medical condition. (complexity)

99201-99205 New-patient

99211-99215 Established Patient

[

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Edits-Physicians-Items/CMS046391.html


Quality MeasuresMIPS/PQRS Measures/CPT Codes: Falls screening, assessment, and plan of care

MIPS/PQRS Measure 154, 155, 318

0 falls in past year 1101F1 fall in past year with no injury 1101F1 fall in past year with injury 1100F2 or more falls in past year 1100FFall risk assessment completed within 12 months in persons with fall history

3288F

Fall Care Plan documented within 12 months in persons with fall history

0518F

ACO MeasuresScreening for future fall risk at least once within 12 months 13

HEDIS Measures for Medicare AdvantageReducing the Risk of Falling Measure C18

https://www.ncoa.org/resources/current-procedural-terminology-cpt-code-flyer/


Next Step–Action Plan

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ASCP-NCOA Falls Risk Reduction ToolkitAccess to Online Materials

http://www.ascp.com/fallstoolkit

Wrap Up


1. Assessment Question• Mrs. Smith is a 78-year old woman who is a long-time client of

your pharmacy. When she comes in with her daughter to pick up a prescription refill, you notice she is using a cane. She also has trouble rising from the chair in your waiting area. Of the following, who is most appropriate to perform an assessment?



2. Assessment Question• Mrs. Smith’s daughter confides to you that she is worried about

her mother, who lives alone. She is wondering what she might do to make her mother’s home safer. You suggest a home assessment. Of the following, who is most appropriate to perform a home assessment?


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3. Assessment Question• Which of the following indicates an increased risk for

falling?A. A TUG test of 10 secondsB. A 30-second chair stand assessment of less than 10 in an

83-year old maleC. Inability to hold the tandem stand for at least 15 secondsD. A drop in diastolic blood pressure of 5 mmHG when

measuring orthostatic blood pressure


4. Assessment Question• Besides an occupational and/or physical therapist,

a pharmacist may want to work with which of the following in a fall reduction program? A. Geriatric nurse practitionerB. Geriatric psychiatristC. Clinical psychologistD. Genetic counselor

Fall Risk Case StudiesCase #1

1

Chief Complaint: “I’m just here for my normal visit, but I have some questions about falling.”

History of Present Illness: Mrs. Green is a 74-year-old female who is seeing her primary care provider for her annual wellness visit. She has no acute complaints, but is nervous about falling because her neighbor fell last week and is currently in the hospital. She has a history of a stroke one year ago, and has some residual left-sided weakness. Her stroke was due to a subtherapeutic INR while taking warfarin; and she was switched to Pradaxa at that time. She states that she is fearful of falling, but has not fallen yet; she walks with a cane and does not leave the house much any more due to a fear of falling.

Past Medical History: • Atrial fibrillation (A. Fib) [Diagnosed age 71]• Depression [Diagnosed age 73]• Hypothyroidism [Diagnosed age 52]• Thromboembolic cerebrovascular accident [1 year ago secondary to A. Fib]

Social History:Lives aloneDenies any use of alcohol, tobacco or illicit substances

Allergies: NKDA

Medications: • Sertraline 50 mg by mouth daily [1 year]• Atenolol 100 mg by mouth daily [3 years]• Pradaxa (dibigatran) 150 mg by mouth twice daily [1 year]• Levothyroxine 75 mcg by mouth daily [5 years]• Atorvastatin 40 mg by mouth daily [3 years]• Zolpidem 10 mg by mouth each night at bedtime [1 year]

Self-Risk Assessment: Mrs. Green completes the Stay Independent* brochure in the waiting room. She circles “Yes” to the following questions, “I use or have been advised to use a cane or walker to get around safely,” “Sometimes I feel unsteady when I am walking”, “I am worried about falling,” “I have some trouble stepping up onto a curb,” and “I take medicine to help me sleep or improve my mood.” Her total risk score is six (6).

Gait, Strength & Balance Assessment** Timed Up and Go: 15 seconds with a cane on left, minimal arm swing noted. 30-Second Chair Stand Test: Able to rise from the chair 7 times without using her arms. 4-Stage Balance Test: Able to stand for 10 seconds in Position 1(feet side by side) and Position 2 (semi-tandem). However, she loses her balance after 3 seconds in Position 3 (tandem).

ASPC

American Society ofC O N S U LTA N TPHARMACISTS

© American Society of Consultant Pharmacists 2017

Fall Risk Case StudiesCase #1

2

Physical Exam Constitutional: This is a frail, alert, elderly woman, in no apparent distress. Vitals: Sitting BP – 114/60 mmHg, HR 62 bpm, RR 16 rpmHeight: 62 inches; Weight: 132 pounds HEENT: pupils equal, round, react to light, accommodation; extraocular movements intact; tympanic membranes within normal limits.CV: Regular rate and irregular rhythm; normal S1/S2 without murmur, rub, gallop, lift, or heave. Respiratory: Clear to auscultation throughout.GI: Normal bowel tones, soft, non-tender, non-distended. Musculoskeletal: No knee joint laxity or joint swelling. Neurology: Alert and oriented x 3. Cranial nerves II-XII grossly intact. Tone/abnormal movements: Tone normal throughout. Deep tendon reflexes are normal and symmetric. Psych: PHQ-2 depression screen = 3/6. Cognitive screen 3/3 items recalled.

Labs: Na 137 mEq/L (136-145 mEq/L)K 4.2 mEq/L (3.5-5 mEq/L)Cl 103 mEq/L (95-105 mEq/L)CO2 23 mEq/L (22-28 mEq/L)BUN 21 mg/dL (7-18 mg/dL)SCr 0.9 mg/dL (0.6-1.2 mg/dL)Gluc 92 mg/dL (70-99 mg/dL, fasting)TSH 7.4 µU/mL (0.6-6 U/mL)

* Stay Independent Brochure can be found as a component of the Center for Disease Control STEADI Toolkit.** Gait, Strength and Balance Assessments can be found as components of the Center for Disease Control STEADI Toolkit.

ASPC

American Society ofC O N S U LTA N TPHARMACISTS

© American Society of Consultant Pharmacists 2017