Module 01: Basic Concepts in Geriatric Pharmacy Current Content Expert Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Legacy Content Expert William Simonson, PharmD, FASCP, CGP Independent Consultant Pharmacist Module Objectives: At the conclusion of this application- based activity, the participant will be able to:
1. Assess the major medical causes of elderly morbidity, mortality, and loss of independence.
2. Examine the major factors that contribute to and detract from wellness and ethical care in the geriatric population.
3. Compare the various types of living arrangements and reimbursement payer plans, including end-of-life planning, available to the elderly.
4. Apply strategies to overcome communication, economic, and social barriers common in geriatric patients.
5. Relate how physiologic changes in the older adult can influence pharmacokinetic and pharmacodynamic drug properties and guide therapeutic decisions.
01.01.01 Prevalence of Chronic Illness in the Older Adult • Incidence of acute disease is greater in younger elderly than older elderly;
opposite is true for chronic disease • Risk of chronic illness increases rapidly with age • 4 out of 5 people 65 and older have at least 1 chronic condition • Multiple conditions common among very old • Chronic conditions likely to
o lead to disability o affect quality of life o decrease functionality
o increase the need for dependence on support services
With advancing age, the prevalence of chronic health conditions increases, compared to younger adults. Seventy-five percent of Medicare recipients age 65 to 69 have no chronic health conditions compared to approximately 90% of those over age 85. Multiple concurrent conditions are common in the elderly with many of these chronic conditions leading to disability, and a significant decline in the individual’s quality of life.
Among community-dwelling older adults, the risks of hospitalization increases with the number of chronic conditions (McNabney, Wolff). Furthermore, strict adherence to published Clinical Practice Guidelines within such patients can produce undesirable effects and even worsen conditions (Boyd, McNabney)
01.01.02 Disease States that Commonly Affect the Older Adult
Common Medical Conditions Among Assisted Living Residents:
• Bladder incontinence (33%)
• Heart disease (28%)
• Bowel incontinence (18%)
• Osteoporosis (16%)
• Diabetes (13%)
• Stroke (11%)
• Parkinson’s Disease (5%)
• Cancer (4%)
Mental Health Conditions Among Assisted Living Residents
• Dementia (mild) (25%)
• Depression (24%)
• Alzheimer’s disease (early stage) (11%)
• Mental retardation; developmental disabilities (10%)
• Alzheimers disease (mid-stage) (8%)
• Alzheimers disease (late stage) (4%)
Disorders That May Present in Unusual Ways in the Older Adult:
• Depression
• Alcoholism
• Myocardial infarction
• Pulmonary embolism
• Pneumonia
• Cancer
The primary reason for moving into Assisted Living for 24% of residents in a 2007 report by Leroi and colleagues was reported to be increased medical needs. Older adults may be affected by a wide variety of health conditions including disorders that have their onset primarily in old age, such as Parkinson’s disease or Alzheimer’s dementia. They may also be affected by conditions that initially occur at a younger age, but have more serious health consequences in the elderly, including hypertension and hyperlipidemia. Some conditions may present in unusual ways when they afflict the older adult where some signs and symptoms may be masked or be vague and non-specific. Some physical condition problems may present with psychiatric manifestations symptoms, while some psychiatric problems may present with physical manifestations. 01.01.03 Impact of Chronic Illness on Daily Living
Prevalence of Disability:
• Increases with age
Types of Disability:
• Activity limitation • Functional limitation
Morbidity: Multiple conditions produce greater disability
Disability is the practical impact of a disease or disorder on daily living. It is manifested as limitations in activity, limitations in function, or both. Multiple conditions typically produce a greater degree of disability.
01.01.04 Disability and Activity Limitations • Restricted Activity Days: Definition: staying in bed or decrease in usual
activities
Epidemiology: Incidence increases with age
Severe Limitations:
• Definition: being unable to carry out basic activities
• Epidemiology:
o Moderate limitations increase with age o Severe limitations decrease with age o 11% of the elderly have severe limitations
Older adults with disabilities that limit their activities fall into one of two principal groups: those with restricted activity days and those with more severe limitations. A restricted activity day is one in which the older adult stays in bed or decreases his or her participation in usual activities. The number of restricted activity days tend to increase with age. Older adults with severe limitations may be unable to carry out many basic activities. While moderate limitations increase with age, severe limitations usually decline with age due to mortality or transfer to a long-term care facility. Severe limitations affect as many as 11% of the elderly. Activities of Daily Living
(ADLs) ( Instrumental Activities of Daily Living (IADLs)
Personal hygiene / grooming
Dressing / undressing Self-feeding Functional transfers Toileting Ambulation Housework
Managing finances
Grocery and clothes shopping
Transportation Finance management Basic Activities of Daily Living (ADLs) consist of self-care tasks necessary for fundamental functioning. Functional transfer examples include getting from the bed to the wheelchair, or getting on or off the toilet. Ambulation is measured by walking without the use of any assistive device – including a walker, cane, or crutches, and without the use of a wheelchair. Instrumental Activities of Daily Living (IADLs) are not necessary for fundamental functioning; however, they do let an individual live independently in a community. 01.01.05 Disability and Functional Limitations
Types of Functional Activities:
ADLs
IADLs
dressing
shopping
eating
house cleaning
transferring
accounting (banking)
toileting
food preparation (cooking)
bathing
transportation
Epidemiology of Functional Limitations:
• 30% of community dwelling elderly report ADL or IADL performance problems • Greatest problems with ambulation and hygiene (ADLs) and with shopping
and transportation (IADLs) • Nursing Facilities and Assisted Living Facilities report the most common ADL
problems are with bathing and dressing
• Risk of functional limitations increases with age, which can lead to an increased risk of institutionalization and death
• May compromise the quality of life or indicate need for long term care For more information: Lawton Instrumental Activities of Daily Living Scale: http://www.abramsoncenter.org/PRI/documents/IADL.pdf
Like activity limitations, the risk of functional limitations also increases with age. Functional activities include personal management tasks, known as activities of daily living (ADLs), and home management tasks, referred to as instrumental activities of daily living (IADLs).
Of the ADLs listed, the most common problems experienced by the older adult are bathing and walking. In nursing facilities and assisted living facilities the most common ADL problems are with bathing and dressing.
Of the IADLs, the most common problems are shopping and transportation. While only 30% of community dwelling older adults report problems with performing such activities, functional limitations may compromise the quality of life of an older adult and indicate a need for a higher level of care or institutionalization. They are also associated with increased mortality.
01.01.06 Loss of Independence in the Elderly
Contributing Factors:
• Physical disability • Cognitive disability • Limitations of activity and function • Loss of spouse • Financial limitations
Options:
• In-home caregivers • Moving to live with another family member • Retirement communities • Assisted living • Nursing homes
Loss of independence can be a traumatic experience for the older adult. Many factors can cause the loss of this independence, including physical or cognitive disabilities, the loss of a spouse, or financial limitations.
Any of these problems may limit the activities and functions the person can perform, forcing them to depend on someone else for their care.
This dependency may be harder for women who have been in a care giving role for much of their lives. For many older adults, the loss of independence is synonymous with placement in a nursing home. This fear prompts many elderly to try to compensate for the loss until additional service and assistance is absolutely necessary. Unfortunately, this behavior puts many older adults in the position of doing harm to themselves or others.
Continuing care retirement communities (CCRC’s) may provide an attractive alternative for such people because they provide various levels of care ranging from independent living to nursing facility in a campus-like environment. This can help the aging adult transition gradually to a more dependent lifestyle by providing additional services when the resident needs them.
01.01.07 Patterns of Drug Use in the Elderly • Older adults take an average of 4-6 prescription medications • 20 medications or more may be taken for multiple chronic illnesses • Polypharmacy leads to increased risk of:
o Toxicity and adverse reactions
o Improper drug administration
o Non-compliance with regimen, including missed doses
o Drug-drug interactions, both pharmacokinetic and pharmacodynamic
o Drug-disease interactions
The elderly consume a disproportionate amount of both prescription and nonprescription drugs. While making up approximately 13% of the US population, they purchase approximately one-third of the medications.
The average elderly individual takes between four and six prescriptions; however, this is highly dependent on health care environment and the individual’s health status. Some elderly with multiple health care conditions may take 20 medications or more a day.
While medications may control disease and reduce suffering, increased medication use also places the individual at risk of potentially serious medication-
related problems including, adverse drug reactions, improper drug administration, and noncompliance with the therapeutic regimen. There is also an increased risk of drug-drug or drug-disease interactions among this population.
01.01.08 Trends in Elderly Mortality
Trends in Death Rates:
• Overall, older adults are living longer, with declines in death rate noted in specific age groups Greatest declines are in the following groups:
o individuals age 65-84 yo o older women o older whites
• 85+ years is fastest growing segment of the population
Trends in Life Expectancy:
• Life expectancy for those Americans born in 2003 reached an all-time high of 77.5 years
Major Causes of Mortality age 85 and older:
1. Heart Disease
2. Malignant neoplasms
3. Cerebrovascular disease
4. Chronic lower respiratory diseases
5. Accidents of unintentional injury
6. Alzheimer’s dementia
7. Diabetes mellitus
8. Influenza and Pneumonia
9. Nephritis, nephritic syndrome, and nephrosis
10. Septicemia
Per: CDC: http://www.cdc.gov/nchs/fastats/lcod.htm
Death rates for the elderly have steadily decreased over the last fifty years. The greatest declines have been for those individuals between the ages of 65 and 84,
especially white women. Americans born in 2003 can expect to live an average of 77.5 years, up from 49.2 years at the turn of the 20th century. Additionally, record-high life expectances were identified for white women (80.5 years) and black women (76.1 years), as well as for white men (75.3 years) and black men (69.0). Life expectancy gaps continue to persist between gender and race.
With the fastest growing population consisting of those individuals over the age of 85, extended life expectancy will place a greater burden on the healthcare system in the coming years. Furthermore, the onslaught of baby boomers turning 65 – nearly 10,000 a day from Jan. 1, 2011 for the next 18 years – puts dramatic pressure on a healthcare system that is poorly situated to handle the ‘bump’ of 78 million additional persons.
01.01.09 Resources
For additional information, see:
Andreopoulos, S. & Hogness, J. R.(1991).Health care for an aging society. New York:Churchill Livingstone
Bootman, J. L., Harrison, D. L. & Cox, E.(1997).The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med; 157: 2089-96.
Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA2005;294:716-724. [PubMed: 16091574]
Furner, S. E., Brody, J. A., & Jankowski, L. M. (1997). Epidemiology and aging. In Cassel, C. K., Cohen, H. J., Larson, E.B., et al, (Eds.). Geriatric Medicine, 3rd ed. New York: Spring-Verlag,. 37-41.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186.
Leroi I, Samus QM, Rosenblatt A, et al. A comparison of small and large assisted living facilities for the diagnosis and care of dementia: The maryland assisted living study. Int J Geriatr Psychiatry 2007;22:224–232. [PubMed: 17044133]
Mantonn, K. G. & Soldo, B. J. (1992). Disability and mortality among the oldest old:Implications for current and future health and long-term care service needs.
In Suzman, R. M., Willis, D. P. & Manton, K. G. (Eds.). The Oldest Old. New York:Oxford University Press.
McNabney MK, Samus QH, Lyketsos CG, et al. The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland. J Am Med Dir Assoc. 2008 Oct;9(8):558-564. [PubMed: 19083289]
Mourey, R. L. (1994). Promoting health and function among older adults. In: Hazzard WR, Bierman EL, Blass JP et al, (Eds). Principles of Geriatric Medicine and Gerontology, 3rd ed. New York: McGraw Hill, 213-20.
Pifer, A. & Bronte, L. (Eds.). Our aging society.New York: W. W. Norton.
Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfialls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004;351:2870-2874. [PubMed: 15625341]
Wolff JL, Starfield, B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Int Med 2002;162:2269-2276. [PubMed: 12418941
Websites:
American Association on Intellectual and Developmental Disabilities (AIDD). Aging: Older Adults and Their Aging Caregivers. www.aidd.org Accessed: September 6, 2011.
Centers for Disease Control and Prevention: www.cdc.gov
Morbitity and Mortality Weekly Report
www.cdc.gov/mmwr
Lawton Instrumental Activities of Daily Living Scale: http://www.abramsoncenter.org/PRI/documents/IADL.pdf
01.02 Wellness and Geriatric Health Promotion 01.02.01 Factors Affecting Geriatric Wellness • Blood pressure
• Driving safety
• Emotional health
• Environmental safety/prevention of falls
• Exercise and activity
• Immunization
• Nutrition
• Oral health
• Osteoporosis prevention
• Cancer screening
• Social networks
• Smoking cessation
• Therapeutic drug safety
Health screening, disease prevention and health promotion opportunities for geriatric patients are essential to ensure wellness in this population. As a senior care pharmacist, you can help your elderly patients improve their overall health by educating them on the impact of each of the factors listed here.
It is important to note that the aging “baby boomers” are a sophisticated and educated group of health care consumers who are accustomed to having things their way. They are not afraid to ask informed questions of health professionals and are generally quite interested in interventions that can help them maintain their health and independence. 01.02.02 Blood Pressure and Geriatric Wellness
Cardiovascular Causes of Morbidity and Mortality:
• isolated systolic hypertension • mixed hypertension • isolated diastolic hypertension
Strategies to Control Blood Pressure:
• Recommend non-pharmacological strategies first:
o Limit salt intake o Weight control o Exercise o Stress management
• Consider pharmacological strategies if needed:
o Diuretics o Beta blockers o ACE inhibitors o Angiotensin receptor blockers o Calcium channel blockers
Isolated systolic hypertension, mixed hypertension, and isolated diastolic hypertension must be treated in the elderly to reduce morbidity and mortality from cardiovascular disease.
As an initial measure, non-pharmacological strategies should be used first, including: limitation of salt intake, weight control, exercise, and stress management. Compliance with these strategies is often difficult, but must still be applied even if the patient is placed on pharmacological therapy.
The Joint National Committee, JNC VII, provides guidelines for appropriate lifestyle modification or pharmacotherapy. Effective medications include thiazide diuretics, beta blockers, ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers. Doses of these medications are typically lower to achieve comparable blood pressure reductions to middle-aged and younger adults. Also, recent studies have suggested that strict blood pressure control is no more effective in the elderly than mild blood control in preventing cardiovascular-related morbidity and mortality (Rakugi).
01.02.03 Driving Safety and Geriatric Wellness
Impairments that Can Cause Accidents:
• Cognitive • Hearing • Vision • Lower extremity weakness
Strategies to Ensure Driving Safety:
• Health screenings to identify possible impairments • Driver re-education programs • Periodic driver testing
For many older adults, driving a car is not only essential for mobility it is a symbol of continued freedom and independence. For these reasons, elderly adults are often driving despite increasing disability and perhaps to the point where their presence behind the wheel represents a significant risk to themselves and others.
Elderly drivers should be screened for cognitive and sensory impairments, and for lower extremity weakness that could lead to accidents and cause injury to the senior and innocent bystanders. For patients who present a potential safety risk, recommend re-education programs and periodic testing to ensure driving safety.
01.02.04 Emotional Health and Geriatric Wellness
Selected Causes of Depression and Anxiety:
• Psychosocial - loss of a loved one, negative self-image, isolation, lack of social support
• Medical:
o Depression: hypothyroidism; stroke; Alzheimer’s and Parkinson’s disease; arthritis; pulmonary, metabolic, and cardiovascular disorders; alcoholism
o Anxiety: delirium, dementia, schizophrenia; tumors; cardiovascular, pulmonary and endocrine disorders; drug withdrawal
• Pharmacological:
o Depression: H2 antagonists, anti-inflammatory drugs, steroids, sedative-hynotics, antiparkinsonian and cardiovascular agents
o Anxiety: sympathomimetics, thyroid hormone replacement, corticosteroids, antidepressants, anticholinergics, antihypertensives
• Identification and Treatment of Emotional Disturbances: o Look for signs and symptoms of emotional disturbance o Use scales to gather additional assessment data
• Geriatric Depression Scale (GDS)
• Score of >5 suggests depression
• http://www.chcr.brown.edu/GDS_SHORT_FORM.PD
F
• Hamilton Depression Scale (HAM-D)
• Although based on 21 items, typically the first 17 are
used to score:
HAM-D Scoring
After summing the first 17 items,
0-7 Normal
8-13 Mild depression
14-18 Moderate depression
19-22 Severe depression
>23 Very severe depression
• http://healthnet.umassmed.edu/mhealth/HAMD.pdf
• Hamilton Anxiety Scale (HAM-D)
o http://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdfRecommend non-pharmacological strategies first
o Consider pharmacological therapy if needed
Emotional disturbances such as depression and anxiety affect approximately 25% of older adults, with a higher incidence in nursing facilities.
These conditions can be caused by a variety of psychological, psychosocial, medical and pharmacological factors and are often under-diagnosed and untreated because health professionals and family members may interpret the symptoms as a “normal” consequence of aging. Misdiagnosis can result in a
worsening of comorbid conditions and increased mortality due to illness or suicide.
To ensure the emotional wellness of the geriatric patient, check for stress and signs of depression or agitation. If the patient seems to be depressed or anxious, consider recommending one of the assessment scales listed.
Non-pharmacological strategies to improve emotional health, such as participation in a social support group, visiting a friend, or adopting a pet may be feasible, depending on the individual’s living arrangement. Non-pharmacological strategies may have some benefit and can be considered either before pharmacotherapy is initiated or concurrently; however, excessive attempts to treat with non-drug measures should not be a reason for depriving the patient from potentially effective medications.
01.02.05 Environment Safety and Geriatric Wellness
Problems that Can Compromise Geriatric Safety:
• Floor structures and obstacles that lead to tripping and falls
• Loose hand rails
• Poor lighting
• Slippery surfaces
• Pollutants and toxins
• Absence of alarms, emergency equipment
Recommendations for Improving Environmental Safety:
• Repairs or modifications of the physical environment
• Proper use of fire, smoke and carbon monoxide detectors
• Planning of fire escape routes
• Inspection of bathroom, kitchen, garage, etc. for toxins
For more information , see: 2010 AGS/BGS Clinical Practice Guideline for Falls http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/
Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force Ann Intern Med. 2010;153:815-825. (http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/fallsprevart.htm
The home must be a safe environment to promote geriatric health. Loose carpets and hand rails, poor lighting, and slippery or uneven surfaces can lead to accidents and serious injury. Water, air, and ground pollution pose a particular health risk to the older adult. In 2002, more than 33,000 elderly in the US died due to unintentional injuries, including falls.
When possible, encourage the patient to make any repairs or modifications to reduce the risk of accidents in the home. For example, the use of traction strips in the bathroom and on staircases can reduce the risk of falls. Handrails and shower bars are helpful for stability when getting in and out. A shower chair can also provide a brief reprieve for a weaker geriatric patient. Raised toilet seats also assist by reducing the distance necessary to bend when getting on and off the commode.
Provide counseling on the use of fire, smoke and carbon monoxide detectors, as well as how to plan fire escape routes. Advise the patient to check the bathroom, kitchen and garage for toxins.
01.02.06 Exercise and Geriatric Wellness
Problems Exacerbated by Lack of Exercise:
• Risk of coronary heart disease
• Progressive loss of bone density
• Lack of emotional reserve
• Risk of falls
• Metabolic abnormalities (e.g. obesity, dislipedimia, diabetes, metabolic
syndrome)
Recommendations:
• Light exercise and activity provides benefits in elderly 75+, especially obese elderly
• Required in adults age 40-70 for maximum cardiovascular function and other organ benefits
• Minimum 30 minutes/day, not necessarily all at once • Weight bearing exercise preferred for bone health; aerobic exercise provides
the best cardiovascular benefit • If pain is severe, exercise in water • Consult a physical therapist or personal trainer to avoid injury
Fewer than 60% of persons over the age of 65 engage in leisure-time physical activity. Lack of physical activity predisposes the older adult to increased risk coronary heart disease, accelerated bone degeneration, and mood disorders. Light exercise and activity can provide benefits for the elderly, especially those with a tendency toward obesity. Those between 40 and 70 years of age need exercise for maximum cardiovascular and other organ benefits.
The minimum amount of exercise required keeping older bones, muscles and hearts healthy is thirty minutes a day, but not necessarily all at once. Weight bearing exercise is good for bone health, unless musculoskeletal disease is present. If the patient experiences severe pain with land exercise, recommend exercise in water. An evaluation by a physical therapist or personal trainer should be advised to prevent injuries.
Learning Exercise: Mary is 68. Recently, she had a scan to check her bone mineral density (BMD). The results showed she had a T-score of -2.7, suggesting she was at risk for wrist, hip, or spinal fracture because she has osteoporosis. In addition to considering pharmacological treatment for osteoporosis Mary’s physician would like to see her start doing weight-bearing activities to increase the density of her bones and balance exercises to help her avoid falls.
Is Mary too old to exercise?
No, Mary is not too old to exercise. She does, however, need to start gradually and work her way up to 30 minutes a day. She should consider having an exercise ‘buddy’ – either a spouse, or a friend – to keep her committed and motivated. Her doctor may want to refer her to a physical trainer or therapist to initiate her exercise routine safely so that she does not get injured.
01.02.07 Immunization and Geriatric Wellness
Diseases Prevented by Immunization:
• Pneumococcus • Influenza
• Tetanus
CDC Immunization Guidelines:
• Pneumococcal vaccine o give once if over 65 o revaccination not recommended
• Influenza vaccine
o give yearly o administer 6-8 weeks prior to flu season
• Tetanus booster
o if no primary immunization of tetanus o give series of tetanus toxoid to reduce risk
Appropriate immunizations can improve health and prevent illness. The pneumococcal vaccination may be given once if the patient has not been vaccinated since turning the age of 65. Guidelines developed by the Centers for Disease Control recommend that the vaccine be given once for those over 65. If immunization records are unavailable for those patients over 65, they should be immunized, with the immunization properly documented in their permanent medical record. At this time, revaccination for those over 65 is not recommended.
Elderly individuals should be vaccinated yearly for influenza. It is recommended to vaccinate a minimum of 6-8 weeks prior to the start of Flu season, which in the U.S. is usually late November through February. Tetanus booster is recommended for all ages. If there is no primary immunization of tetanus, a series of tetanus toxoid injections may be given to reduce the risk.
01.02.08 Nutrition and Geriatric Wellness
Causes of Malnutrition
• Medical: acute infections, pressure ulcers, traumatic injuries such as hip fractures, cancer
• Dietary: inadequate intake due to insufficient funds, isolation, poorly fitting
dentures, and depression • Pharmacological: medications that interfere with the absorption of nutrients
Recommendations for Improving Nutrition:
• Healthy eating • Regular assessment of nutritional status using weight measurement, diet
history • Dietary changes
o Reduce fat to < 30% o Increase complex carbohydrates o Decrease simple sugars
Malnutrition affects as much as 1% of healthy older adults, with estimates as high as 27% for long-term care residents and 58% of acute care patients. Malnutrition may be caused by acute infections, pressure ulcers, and traumatic injuries, such as hip fractures. Malnutrition may also be the result of inadequate dietary intake. This sometimes happens in obese elderly who are on aggressive weight reduction diets.
In the community, some older adults may not be able to afford high-nutrient foods or vitamin supplements; others may simply forget to take them. Psychosocial factors such as isolation and depression can suppress appetite. Individuals taking medications which cause malabsorbtion of various nutrients, such as fat soluble vitamins, may be at higher risk for malnutrition.
To ensure adequate nutrition, encourage healthy eating in all patients. Assess the nutritional status of the elderly by assessing weight and diet history. Recommend a diet that is less than 30% fat, high in complex carbohydrates, and low in simple sugars.
01.02.09 Oral Health and Geriatric Wellness
Types of Oral Health Problems:
• Caries and periodontal disease caused by chronic bacterial and yeast infections
• Oral cancer resulting from chronic tobacco or alcohol use • Oral ulcerations associated with trauma or use of dentures • Decreased oral hygiene due to arthritis, stroke, dementia • Oral complications of drug therapy (e.g., bleeding, inflammation) • Dry mouth (e.g. anticholinergic use)
Recommendations for Improving Oral Health:
• Inspect and palpate the oral tissues • Re-educate the patient on brushing, flossing, topical fluorides, and denture
care • Advise minimizing tobacco and alcohol use • Ensure proper fitting of dentures / orthodontics
Oral health is essential to geriatric nutrition, health and well-being. Oral health problems may be caused by bacterial and yeast infections, by friction caused by loose dentures or other trauma, and by drug therapy such as phenytoin or chemotherapy. To improve oral health, the clinician should inspect and palpate the oral tissues.
Patients may need to be re-educated on brushing, flossing, and topical fluoride. Tobacco and alcohol use should be minimized for oral health promotion. Dentures should be checked routinely, especially if there has been a significant weight change. Because loose or sliding dentures can cause gum sores, it is important to ensure proper fitting.
01.02.10 Osteoporosis Prevention and Geriatric Wellness
Problems Associated with Osteoporosis:
• High risk of fractures • Impairment of ADLs • Chronic musculoskeletal complications • Institutionalization and death
Strategies for Preventing Osteoporosis:
• Recognize that prevention of osteoporosis starts early in life, through diet and exercise
• Diet supplements of Calcium and Vitamin D for o Men > 60 o Women > 50
• Slow the loss of bone loss through: o smoking cessation o moderate alcohol consumption o avoidance of corticosteroids
• Prescription medications (e.g., bisphosphonates, calcitonin)
Osteoporosis affects more than 25 million people in the United States and costs more than 10 billion dollars in health care expenditures annually. These expenditures are related primarily to injuries that occur as the bones become more fragile and susceptible to fracture.
As women age, they are especially susceptible to osteoporotic fractures. These fractures can not only impair the activities of daily living, they can lead to chronic complications, institutionalization, dramatically decreased quality of life and even death.
Osteoporosis prevention can contribute greatly to overall geriatric wellness. Calcium and Vitamin D supplements should be recommended in women over 50 and men over 60 years of age. Additionally, bone loss can be reduced by smoking cessation, moderation of alcohol use, and the avoidance of systemic corticosteriods when possible. A number of medications including the bisphosphonates, denosumab, selective estrogen receptor modifiers such as raloxifene, calcitonin, and teriparatide are available for the treatment of osteoporosis.
01.02.11 Cancer Screening and Geriatric Wellness
Goal: early detection and treatment
Strategies:
• Patient self-exams o Skin o Breasts o Mouth
• Annual physician screenings o Skin o Breasts o Mouth o Rectum o Prostate
• Flexible sigmoidoscopy at age 50, and every 5 years thereafter • Fecal occult blood screen • PSA assay in men • Mammograms in women
Because age is a significant risk factor for cancer, screening is especially important in the elderly. The goal of cancer screening is the prevention or early detection while the disease is in a state where it is treatable. To accomplish this, elderly patients must be educated on self-exams, and regularly examine their skin, breasts and mouth.
Patients should be screened by their physician annually, and flexible sigmoidoscopy or colonoscopy should be performed at age 50 and every 5 years thereafter. In addition, fecal occult blood screens in both genders, and PSA assays in men and mammograms in women can be used to detect potential malignancies in their early states.
01.02.12 Smoking Cessation and Geriatric Wellness
The Chain of Events:
Smoking Lung Cancer Death
Strategies for Smoking Cessation:
• Nicotine patch or gum
• Medication
• Social support
In the United States, lung cancer is the leading cause of cancer death in men and women. The primary risk factor for lung cancer is smoking, and studies have shown that major benefits can be achieved by patients who stop smoking at any age. Major pulmonary and cardiovascular benefits can help reduce morbidity and mortality, after even the first year of quitting.
There are several products on the market to help the patient to quit smoking. Nicotine products are available in the form of a patch or gum that allows the patient to taper the amount of nicotine in his or her system. Medications such as bupropion and varenicline may decrease the cravings for nicotine. It is important that the patient have a good support system to help them succeed with their cessation plan.
01.02.13 Social Networks and Geriatric Wellness
Problems Associated with Inadequate Social Networks:
• Loneliness and depression • Sense of isolation • Fear and anxiety about surroundings • Preoccupation with health concerns • Inadequate medical care
Options for Social Contact:
• Companions • Family • Volunteers • Ex co-workers • Room mate • Organizational membership
Social interaction is a strong predictor of health, and the absence of these interactions can predict disease and early death. While studies show that most elderly Americans enjoy active family ties, close friends, and organizational involvement, a significant number experience loneliness and isolation, fueled by loss of loved ones, financial limitations, or fear of crime.
Positive social networks are an important component of geriatric wellness. Social contacts with companions, family members, volunteers, and roommates should be encouraged. Opportunities for social contact through community centers, churches, schools, and clubs should also be explored.
01.02.14 Therapeutic Drug Safety
Types of Medication-Related Problems Drug Problems:
• Adverse drug reactions
• Drug dosage is too high or too low
• Improper administration of drug
• Patient is taking the wrong drug
• Patient does not comply with therapeutic regimen
Strategies for Improving Therapeutic Drug Safety:
• Simply therapeutic regimen
• Evaluate drugs currently taken
• Educate patient on prescription and non-prescription drug hazards
Medication-related problems may affect as many as one-third of the older adult population including adverse drug reactions and interactions, improper dosage or drug administration, and noncompliance. Medication-related morbidity and mortality represents not only a serious health concern, but a major economic problem as well.
To ensure optimal drug therapy, senior care pharmacists should work with other members of the interdisciplinary health care team to eliminate the use of unnecessary medications and optimize the use of needed medications.
Often this involves a reduction in the number and types of medications taken; however, in some instances pharmacists can recommend the addition of medications that will likely benefit the patient, such as antidepressants or medications for osteoporosis.
In the outpatient environment, it may be helpful to evaluate the current drugs being taken using a “brown bag” medication regimen review approach by identifying the drugs and the frequency with which they are being taken. It can also be beneficial to educate the patient and/or their family members on the hazards associated with both prescription and nonprescription drugs. Numerous technologies exist to develop medication lists and reminders to increase adherence.
01.02.15 Resources
For additional information, see:
Andreopoulos, S. & Hogness, J. R.(1991).Health care for an aging society.New York:Churchill Livingstone
Applegate, W. B., Blass, J. P., & Williams,T. F. (1990). Instruments for the functional assessment of older patients. N Engl J Med; 322: 1207-1213.
Besdine, R. W. (1997). Clinical approach: An overview. In Cassel, et al (Eds). Geriatric Medicine, 3rd ed.). Springer-Verlag, New York, NY: 155-168.
Cipole, R. J., Strand, L. M. & Morley, P. C. (1998).Pharmaceutical care practice.New York: McGraw Hill.
Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4.
Hanlon JT, Gray SL, Schmader KE. Adverse Drug Reactions Chapter 11 IN Therapeutics and the Elderly. Delafuente J and Stewart R eds. Harvey Whitney Books Company, Cincinnatti pp 289-314.
Mourey, R. L. (1994). Promoting health and function among older adults. In: Hazzard WR, Bierman EL, Blass JP et al, (Eds). Principles of Geriatric Medicine and Gerontology, 3rd ed. New York: McGraw Hill, 213-20.
Pifer, A. & Bronte, L. (Eds.). Our aging society.New York: W. W. Norton.
Rakugi H, Ogihara T, Goto T, Ishii M. Comparison of strict- and mild-blood pressure control in elderly hypertensive patients: a per-protocol analysis of JATOS. Hypertension Research 2010;33:1124-1128. [PubMed: 20686490]
US Administration on Aging, Wellness, Nutrition, & Exercise
Websites:
US Administration on Aging: www.aoa.gov
American Medical Association: Physician’s Guide to Assessing and Counseling Older Drivers, 2nd ed. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-guide.pdf
Buerger, David K., Wellness Programs: Assisted Living & Pharmacy Team Up, ASCP Clinical Consult (January 1999)
http://www.ascp.com/public/pubs/tcp/1999/jan/wellness. html
2010 AGS/BGS Clinical Practice Guideline for Falls http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/ Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force Ann Intern Med. 2010;153:815-825. (http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/fallsprevart.htm
01.03 Continuum of Care
01.03.01 Options for Care of the Elderly Selected Senior Living Environments:
• home (with or without assistance) • day care • assisted living • group homes • continuous care retirement communities • hospice • long term care/nursing facility
Primary Payment Options for Seniors:
• Medicare • Medicaid • private insurance • private pay
In the United States, the elderly have access to an entire continuum of geriatric care that includes such varied living environments including living at home (with or without assistance) home health care, day care, assisted living, group homes, continuous care retirement communities, and “traditional” long-term care offered by nursing facilities. Nursing facilities are subject to federal regulations; however, the less formal living environments such as assisted living and other types of community or home-based care are subject to state regulations. Most state regulations are minimal so the type and quality of living environments other than nursing facilities may differ dramatically between states. Some elderly individuals may live in a variety of these care environments over a course of twenty or more years. Each living environment has unique characteristics, and is selected based on factors such as availability, feasibility, costs, acceptability, and health care needs of the resident.. The health care reimbursement system, with its current payment programs such as Medicare, Medicaid, private insurance and private pay, plays a major role in determining which of these options are accessible to the older adult.
01.03.02: Home Health Care
• arrangement chosen by most elderly • provides familiar setting and continued independence • can be supplemented with home health agency resources
The majority of older adults choose to live at home. Residing at home, either alone, or with assistance provided by family members or health assistants provides a familiar setting and sense of independence that would be difficult to find in another type of care facility. Some degree of assistance can be provided by locally offered programs such as visitor programs or meals on wheels. Home Health agencies can provide nursing assistance to help with daily personal care and household duties. Geriatric care management organizations can provide in-home support and oversight to help the older adult remain safely independent. 01.03.03: Assisted Living
• usually small apartments with amenities • may be customized to special populations such as dementia • offers a variety of programs and services including meals and health
services • staff assists with Activities of Daily Living (ADLs), medications • preferred for demented patients and elderly in need of socialization
Assisted living is a more recent concept that usually involves small, comfortable living units equipped with all amenities. Typically these units are grouped in a facility that contains 50 or more units with common spaces for activities and meals. In some cases the assisted living environment is customized to meet the needs of a particular patient population such as those with dementia. A staff member is provided to assist with daily living activities. These are not licensed as health care facilities like a nursing home; medical staff support varies by facility. Depending on state regulations, staff may also help with medication reminders or assistance with medication administration to improve compliance and safety. This living arrangement is generally considered to be a better alternative than home health care for the demented patient in that it offers supervision, safety, security and nutrition. It may also be a good option for an older adult who has lost a spouse and is in need of socialization. 01.03.04 Group Home
• small group of elderly living in a house • maintenance responsibilities are shared • socialization opportunities are provided • staff may be hired to assist with activities and medications
A group home is a small group of older adults living in a house in a community environment. Together, they share the responsibilities of maintaining the house, providing socialization opportunities, and monitoring routine health needs. Additional staff may be hired to assist with activities or provide help with medications. This is not a common living environment at this time but could grow in importance as the aging baby-boomer population looks for more attractive housing options in the future. 01.03.05: Continuous Care Retirement Community
• campus setting with independent apartments, assisted living, daycare, and skilled nursing facility
• may include a wellness center • provides for the needs patients of all ages, levels of health and functional
abilities A relatively new concept in the continuum of care includes continuous care retirement communities. These communities resemble a college campus that contains living units (typically apartments but sometimes homes or cottages are available) as well as, supervised day care, assisted living and skilled nursing facilities. Continuous care retirement communities provide for all needs as the patient ages and health declines, including health care and medication management. They provide the flexibility to provide the resident’s individual care needs. Typically residents can be moved into a more intense care environment, such as the nursing facility unit, and then move back to independent or assisted living when appropriate for their condition. A range of activities are offered for all levels of residents, including those with multiple functional limitations. Some continuous care retirement communities also have a wellness center to promote geriatric health. While this environment is growing in popularity, it tends to be very expensive and is not covered by Medicare, Medicaid, or private insurance so costs are generally the responsibility of the resident. 01.03.06: Day Care/Senior Center
• day programs where custodial, maintenance and supervisory needs are
met • appropriate for patients who do not require 24 hour medical supervision • socialization is encouraged through activities • may provide respite for primary care giver
Day care is an arrangement where the older adult meet at a facility for the day during which custodial, maintenance and supervisory needs are met. Day care provides care for patients who do not require 24-hour medical supervision, but do require assistance with some aspect of their daily living activities. Socialization is encouraged at day care facilities where activities are planned and the older adults are encouraged to participate. This type of setting may also provide respite for the primary care giver as well. Senior centers that have traditionally served the needs for socialization are beginning to offer some health services such as health screening and medication management. 01.03.07 Hospice
• provides palliative care for the terminally ill with less than 6 months to live • emphasizes pain control and comfort measures • hospice care may be provided in other care settings such as home,
continuous care retirement community, long term care • Medicare waived
A hospice provides services for the terminally ill or those with presumably less than six months to live. The palliative-based care emphasizes pain control and comfort measures only. The actual hospice program may be provided throughout other care settings such as home, continuous care retirement communities or long term care facilities. Hospice care is waived by Medicare. 01.03.08 Nursing Facilities
• provide 24 hour medical supervision • providefor all levels of healthcare need • provide socialization opportunities • patients often admitted due to level of care needed and associated costs
Nursing facilities provide services for patients that require medical supervision and 24 hour nursing care. Such facilities provide for all the health care needs of
patients, and provide opportunities for socialization with other patients and volunteers. Patients are often admitted to long-term care facilities when home care or assisted living care becomes too costly based on the patients’ health care needs.
Chosen by most elderly Home health care Small, comfortable living units with most amenities Assisted Living Facilities (ALFs)
Provide services for patients that require medical supervision and 24 hour nursing care
Nursing facilities
Resemble a college campus that contains living units Continuous care retirement community
Small group of elderly living in a house in a community environment Group home
01.03.09 Healthcare Reimbursement Options
• Medicare • Medicaid • Private Long-Term Care Insurance • Private Pay
Many different options for health care reimbursement are available to the older adult. The government sponsors some of these options, such as Medicare and Medicaid. Other options, such as private insurance and private pay, require the patient to rely on his or her own financial resources. 01.03.10 Medicare Part A • Medicare Part A: “Hospital Insurance”
• Helps cover inpatient care in hospitals as well as in a skilled nursing facility (SNF), hospice, and home health care
• No premium costs for Medicare-eligible individuals; Individuals who did not pay enough into Social Security to qualify for Medicare can purchase Part A coverage
• Covered services and patient costs: o Hospital:
Deductible, but no co-insurance for the first 60 days of each benefit period*
Daily coinsurance fee for days 61-90 of each benefit period*
60 “lifetime reserve days” are allotted to a patient over their lifetime and can be used after day 90 in each benefit period*; Lifetime reserve days cost the patient a per day co-insurance fee that is higher than the previous co-insurance rate but less than the total hospital charge
Patient pays all hospital costs that are incurred after 90 days if all lifetime reserve days have been used
o Home Heath Care: $0 for home health care services 20% of Medicare-approved amount for durable medical
equipment o Hospice:
$0 for hospice care Copayments for hospice-related medications 5% for inpatient respite care Medicare doesn’t cover room and board when a patient
receives hospice care in their own home or in another facility (e.g., nursing facility)
o Skilled Nursing Facility: $0 for the first 20 days of each benefit period* Daily coinsurance fee for days 21-100 of each benefit
period* Patient pays all costs incurred after 100 days in a benefit
period* – or other coverage is sought * A benefit period begins the day an individual goes to a hospital or skilled nursing facility. The benefit period ends when inpatient hospital care or skilled care in a SNF hasn’t been needed or used for 60 days in a row. If the individual goes into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins.
Medicare was enacted by Congress in 1965 to provide universal health care coverage to Americans sixty-five years and older. It is comprised of four distinct parts – Part A, B, C, and D – that specify the eligibility, types of health care services or supplies covered, and reimbursement limits. Services that are provided under Medicare Part A include hospitalization, home health care and hospice care. The first 100 days at a skilled nursing facility are also covered under Part A after a qualifying hospitalization. Medicare Part A pays for the care of approximately 13% of nursing facility residents nationwide. Under Part A, Medicare pays hospitals, home health agencies, hospices, skilled nursing facilities and other health care entities a per diem amount according to their Prospective Payment System (PPS). PPS is a method of reimbursement based on a predetermined, fixed amount. The payment amount for a particular
service is derived based on the classification system of that service. Examples include diagnosis-related groups or DRGs for inpatient hospital services and resource utilization groups or RUGs for nursing facility services. People with Medicare who are inpatients of hospitals or skilled nursing facilities during covered stays may receive drugs as part of their treatment. Medicare Part A per diem payments made to hospitals and skilled nursing facilities generally cover all drugs provided during a stay. Under the Medicare hospice benefit, people receive drugs that are medically necessary for symptom control or pain relief. 01.03.11 Medicare Part B • Medicare Part B: “Medical Insurance”
• Optional program to supplement Part A benefits • Patients are charged monthly premiums, plus a yearly deductible • Helps cover physician services, outpatient services, preventive
services, and medical supplies • Covered services and patient costs, in addition to monthly
premium: o Lab services
$0 for Medicare-approved services o Home health services
$0 for Medicare-approved services 20% of Medicare-approved amount for durable
medical equipment o Physician services
One physical exam within the first six months of initial enrollment in Medicare Part B
20% of most Medicare-approved physician services o Mental health services
50% for outpatient mental health care
• Medigap policies help fill the “gaps” in original Medicare coverage (Parts A & B)
Medicare Part B is an optional program and a supplement to Medicare Part A benefits. Part B requires the beneficiary to pay a monthly premium. Services covered under Part B include physician services, outpatient hospital services, and medical supplies such as durable medical equipment. Medicare Part B covers a limited set of drugs. Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished and administered as part of a physician service. Medicare Part B also covers a limited number of other types of drugs, such as oral chemotherapy drugs.
Medicare B is often used alongside other insurance programs such as Medicaid and private insurance to extend coverage. A “Medigap” policy is health insurance sold by private insurance companies to fill the “gaps” in original Medicare coverage. Medigap policies help pay some of the health care costs that the original Medicare plan doesn’t cover. Generally with Medigap policies, the individual must have Medicare Part A and Part B. In addition to the Part B premium, the individual will have to pay a premium to the Medigap insurance company. There are up to 12 different standardized Medigap policies (Medigap Plans A through L) available. 01.03.12 Medicare Part C • Medicare Part C: “Medicare Advantage Plans”
• Started in 1997 • Health coverage choice run by private companies approved by
Medicare • Includes Part A, Part B, and usually other coverage including
prescription drugs • Medigap policies are unnecessary for individuals who choose a
Medicare Advantage Plan • Costs and services vary by plan • Individual usually pays full cost when providers outside of local
network are used • Does not typically cover additional SNF services beyond those paid
for under Medicare Part A Beginning in 1997, Medicare Part C was designed to transfer Medicare eligible patients to managed care. Medicare Part C provides broad health coverage from private, Medicare-approved insurance companies called Medicare Advantage Plans. In this situation, Medigap policies are unnecessary because the Medicare Advantage Plan is providing not only Part A, Part B, and typically Part D services but is also providing coverage for additional products and services often covered by Medigap policies. The advantages of Medicare Advantage Plans typically include better preventative health coverage and having only one insurance company rather than multiple insurance companies. Medicare Advantage Plans are not frequently used by nursing facility residents because the Medicare Advantage Plan doesn’t necessarily cover additional long-term care services beyond those typically covered by Part A. 01.03.13 Medicare Part D
• Medicare Part D: “Prescription Drug Coverage” • Started in 2006 • Run by private companies approved by Medicare, either stand-
alone prescription drug plans (PDPs) or as part of Medicare Advantage Plans (MA-PDs)
• Provides coverage for FDA-approved prescription drugs, some vaccines, and medical supplies associated with the injection of insulin
• Costs, formularies, and utilization management requirements vary by plan
• Most nursing facility residents are covered by Medicare Part D plans for their prescription medications
• Links to more information: o http://www.cms.hhs.gov/partnerships/downloads/determine.p
df o http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloa
ds/PartBandPartDdoc_07.27.05.pdf o http://www.ascp.com/medicarerx o www.medicare.gov
Medicare Part D began in 2006, as mandated by the Medicare Modernization Act of 2003. Part D is an optional benefit to all Medicare-eligible beneficiaries, although there is a late-enrollment penalty incurred every month the individual delays enrolling in Part D after they become eligible. Medicare Part D is run by private companies approved by Medicare and consists of stand-alone prescription drug plans (PDPs) and prescription plans within Medicare Advantage Plans (MA-PDs). Costs, formularies, and utilization management requirements vary by plan. As of 2006, prescription medications used by ‘dual eligibles’ - those who qualify for both Medicare and Medicaid, are covered primarily by Medicare Part D, although Medicaid may cover certain medications that are not covered by the Part D plan. Since many nursing facility residents are dual eligibles, Medicare Part D has become the primary payer for prescription medications in nursing facilities. Between two-thirds and three-fourths of nursing facility residents nationwide are covered by various Medicare Part D plans. Part D-covered drugs are defined as drugs and biologicals available only by prescription, used and sold in the United States, and used for a medically accepted indication. Part D covers FDA-approved drugs; insulin; some vaccines; and medical supplies associated with the injection of insulin, such as syringes, needles, alcohol swabs, and gauze. Certain drugs or drug classes, or certain medical uses for drugs, are excluded by law from Part D coverage. Benzodiazepines, barbiturates, and over-the-counter medications are among the drug classes NOT covered by Part D. Some state Medicaid programs do cover
these classes of medications for dual eligible individuals. Providers are encouraged by the Centers for Medicare & Medicaid Services (CMS) to assist individuals in an objective assessment of their needs and potential Medicare Part D plan options. CMS has stated that providers, including pharmacists, may certainly engage in discussions with individuals when they seek information or advice regarding their Medicare options. However, CMS also recognizes that some providers may have a financial interest in certain choices. CMS guidelines specifically prohibit pharmacists and other health care providers from steering beneficiaries into plans based upon financial self-interest. Such steering could be considered a violation of the law. 01.03.14 2010 Affordable Care Act
• Removed cost-sharing requirement for many preventive services • Added preventive service benefits • No cost sharing:
o Influenza, pneumococcal, Hepatitis B vaccinations o Cardiovascular screening – every 5 years o Mammograms annually over age 40 o Cervical, vaginal cancer screening
Varies with risk o Colorectal screening (also not subject to deductible)
Frequency varies by type of screening o Diabetes screening: up to twice annually, depending upon
results o Bone mass measurement: every 24 months o Prostate cancer screening: annually beginning at age 50 o Tobacco cessation counseling: 8 sessions/year
• “Welcome to Medicare” Physical Exam
o New benefit under Affordable Care Act o No cost-sharing applies o Must be stand-alone visit, un-related to an otherwise noted
incident visit o Included:
Record medical history Check height, weight, blood pressure Calculate body mass index (BMI) Give vision test Screen for depression and cognitive impairment
• Changes to Medicare Advantage Plans
o Gradually reduces the surplus payment Medicare Advantage plans receive compared to traditional Medicare insurance
• Changes to Medicare Part D
o Doughnut hole reduction phased in The 2010 Affordable Care Act removed the cost sharing requirement for many preventive services, and added preventive service benefits. Until the end of 2010, Medicare beneficiaries were responsible for cost sharing when they received health promotion and/or disease prevention services. Clinical preventive services that are now covered under Medicare with no cost sharing are listed above. The “Welcome to Medicare” physical exam is not subject to the cost-sharing, nor are the annual wellness visits that can begin 12 months after the welcome exam. It is noted, however, that these exams must be differentiated from and unrelated to other ‘incident’ related visits. The 2010 Affordable Care Act also implemented changes to Medicare Advantage (MA) plans that will be phased in. Fewer enrollees and fewer beneficiaries are projected, and fewer MA plans will likely remain in business over the coming decade. Medicare Part D saw much welcomed changes by its beneficiaries as a result of the 2010 Affordable Care Act as it resulted in a reduced amount that Medicare Part D enrollees are required to pay for their prescriptions when they reach the coverage gap (aka: doughnut hole). In 2010, Part D enrollees with spending in the coverage gap received a $250 rebate. In 2011, Part D enrollees meeting the coverage gap received a 50% discount on the total cost of their brand-name drugs in the gap, as agreed to by pharmaceutical manufacturers. Over time, Medicare will gradually phase in additional subsidies in the coverage gap for brand drugs (beginning in 2013) and generic drugs (beginning in 2011), reducing the beneficiary coinsurance rate in the gap from 100% to 25% by 2020. By 2020, for brand drugs, Part D enrollees will receive the 50% discount from pharmaceutical manufacturers, plus a 25% federal subsidiary (phased in beginning in 2013). In addition, between 2014 and 2019, the law will reduce the out-of-pocket amount that qualifies an enrollee for catastrophic coverage, further reducing out-of-pocket costs for those with relatively high prescription drug expenses. In 2020, the level will revert to that which it would have been absent the reductions in the intervening years. 01.03.15 Medicaid
• Generally provides health insurance to low-income individuals, including many seniors
• Federal government establishes general guidelines for the Medicaid program, but program requirements are actually established and managed by each State
• Medicaid is the primary payer of nursing facility care nationwide • Some states have Medicaid waiver programs that pay for
community-based services, including room, board, and services provided in assisted living communities, as well as other community-based care management programs.
• Dual eligibles who qualify for both Medicaid and Medicare receive prescription benefits through Medicare Part D; other Medicaid-eligible individuals typically receive prescription benefits through their state Medicaid program
• Links to more information: o http://www.cms.hhs.gov/home/medicaid.asp o http://www.kff.org/medicaid/rxdrugs.cfm
Summary of 2010 Affordable Care Act Effects on Medicaid Long-Term Care:
• CLASS Act o Effective Jan 1, 2011: national, voluntary insurance program to
purchase community living assistance services and supports (CLASS)
o After 5 year vesting period, operates like daily cash payment LTC insurance programs, triggered by functional limitations
• Extends Money Follows the Person (MFP) demonstration programs through September 2016
• Offers states new options and incentives to provide home- and community-based services to include LTC rebalancing efforts
The Medicaid Program provides medical benefits to 59 million low-income people, including children and families, people with disabilities, and elderly who are also covered by Medicare. In fact, seniors constitute over 10% of Medicaid beneficiaries. Although the Federal government establishes general guidelines for the program, the Medicaid program requirements are actually established by each State. Whether or not a person is eligible for Medicaid will depend on the State where he or she lives. All states provide long-term care services for individuals who are Medicaid eligible and qualify for institutional care. In fact, Medicaid is the primary insurance mechanism for nursing facility care. Medicaid pays for the care of approximately two-thirds of nursing facility residents nationwide. Many nursing facility residents become eligible for Medicaid benefits after depleting their Part A nursing facility benefits and “spending down” their assets. The Social Security Act allows states the flexibility to utilize waiver and demonstration projects in their Medicaid programs. Home and community-based
waivers allow states to pay for long-term care services delivered in community settings, such as assisted living communities This program is the Medicaid alternative to providing comprehensive long-term services in institutional settings. Today, 41 states reimburse assisted living services through Medicaid. Still, Medicaid covers only about 8 percent of assisted living residents, and the majority of beneficiaries are concentrated in a few states. With implementation of Medicare Part D on January 1, 2006, Medicare Part D covers prescription drugs for dual eligibles that qualify for both Medicare and Medicaid. For those Medicaid-eligible individuals without Medicare benefits, prescription drugs are typically paid for by the state Medicaid program. The 2010 Affordable Care Act also provided changes to Medicaid Long-Term Care. In addition to what is outlined above, the Affordable Care Act had a new LTC initiative to provide home- and community-based services to dual eligibles. The objective of this initiative was to improve care coordination and control costs for dual eligibles through an integrated care model developed by service provider partners. Fifteen different states were awarded competitive one-year planning grants to design and propose an integrated model for implementation in late 2012. Another example of new Medicaid initiatives in the 2010 Affordable Care Act is Health Homes. These are offered as an optional State Plan Amendment, and states must initiate and work with CMS to develop these health homes. The targeted population is beneficiaries of all ages with 2 or more chronic conditions, including mental health, substance abuse, asthma, diabetes, heart disease, and obesity. Services can include care management, health promotion, transitional care, and family support. 01.03.16 Private Long-Term Care Insurance
• Provides coverage beyond Medicare • Policies vary widely between insurance companies • Usually provides reimbursement at per diem rate • Link to more information:
o http://www.longtermcare.gov Many private insurance carriers offer long-term care insurance, which provides coverage of long-term care services beyond the typical Medicare benefits. Policies differ significantly from one company to another; however, benefits usually include reimbursement for services on a per diem basis.
01.03.17 Private Pay
• Generally means individuals paying out-of-pocket for services not covered by other means
• Examples of services typically paid for on a private pay basis include: eye care, herbal/alternative medicines, pharmacists’ services
• Individuals may be required to use private funds and "spend down” to qualify for Medicaid
The individual pays out-of-pocket, or on a private pay basis, for those services and products that are not covered by Medicare or by other means. Examples of services and products paid for on a private pay basis include eye care, herbal or alternative medicines, and pharmacists’ services. Medicare does generally not cover pharmacists’ services, although some Part D plans are beginning to utilize pharmacists for medication therapy management (MTM) services. Part D plans are required to have an MTM program, but they are not required to use pharmacists in the provision of those services. Many pharmacists, however, still provide MTM and other related services to individuals – including Medicare beneficiaries - on a private pay basis. Often, the patient must use private funds or “spend down” to the point where their assets are depleted in order to quality for Medicaid. “Spending down” can be a difficult process for a sick patient with a healthy spouse. If the healthy spouse outlives the patient, he or she may end up with limited financial resources and will be placed on Medicaid as well. 01.03.18 RESOURCES For additional information, see: Center for Medicare Advocacy, Inc.: www.medicareadvocacy.org Centers for Medicare and Medicaid Services: www.cms.gov Accessed: September 6, 2011 Explaining Health Care Reform: Key changes to the Medicare Part D Drug Benefit Coverage Gap (2010 Mar). The Henry J. Kaiser Family Foundation. http://www.kff.org/healthreform/upload/8059.pdf Kaiser Family Foundation: www.kff.org Accessed: September 6, 2011
Medicare: www.cms.gov/Medicare Medicaid: www.cms.gov/Medicaid US Administration on Aging: www.aoa.gov
01.04 Communicating with the Elderly 01.04.01 Barriers to Communicating with the Elderly
Age-related Impairments:
• visual • auditory • cognitive • physical
Cultural/Social Barriers:
• literacy • language
Stereotypes by Health Professionals
• Unfair stereotypes of elderly may exist
The ability to communicate effectively with patients is vital to pharmacists and other health care professionals. Communication with the elderly can break down and become ineffective due to both obvious and subtler barriers.
For example, many of older adults suffer from age-related visual and auditory impairments that affect the quality of communication between them and others. Impaired cognition is another factor that greatly influences communication with the aging adult. Chronic medical conditions such as diabetes, dementia, and cardiovascular disease can cause or worsen these impairments. Other conditions, including stroke or fracture, can create physical barriers to communication by reducing mobility.
Illiteracy and language incongurence can also contribute to communication difficulties between two people. The clinician must keep in mind that there is great diversity within the older adult population, and assumptions about the individual patient’s ability to communicate must be made with caution. Barriers may also be the result of health professionals who have unfair stereotypes of the aging individual, such as assuming older adults are less intelligent or less likely to comply with prescribed therapy.
01.04.02 Communication Barriers: Vision Impairment
Sources of Vision Impairments:
• heredity • medical conditions (e.g., accidents, diabetes, glaucoma, cataracts) • aging-related conditions (e.g. macular degeneration)
Problems Encountered by Elderly with Vision Impairments:
• reading prescription labels: • fine small print • glare-producing paper
• low contrast between background and print • other documentation (e.g., patient handouts, brochures)
Age and certain medical conditions, such as diabetes, glaucoma, and cataracts, can have a significant effect on vision as do certain aging-related conditions such as macular degeneration. Most elderly people wear glasses to compensate for such effects; however, glasses may not be enough to help the elderly read the fine print on glossy prescription paper, especially if the background and print have a low contrast.
The clinician can help compensate for vision impairments by following a few strategies aimed at enhancing written communication with the patient.
01.04.03 Strategies for Overcoming Vision Impairment
Improve Prescription Label Readability:
• Use large, upper case type • Use high contrast background for print to stand out • Use non-glare finish paper • Use ink colors that can be read by colorblind individuals
Provide Verbal Reinforcement:
• Read audibly key instructions on prescription label or OTC products
Improve the Reading Environment:
• Use bright lighting in consulting area
Use Visual Cues to Package Medications:
• Color code containers with tape – use yellow, orange and red instead of violet, blue or green
• Code containers for different medications using different size or shapes • Suggest using divided pill containers
Strategies for overcoming vision impairments are listed above. Prescription labels can be made more legible by using larger, uppercase type, on a high contrast background paper that has a non-glare finish. Verbal reinforcement of written instructions is also important. Help the patient understand his or her prescription with visual cues such as color-coded containers. Remember, many elderly are taking more than one drug at a time for concurrent conditions. Use yellow, orange or red tape to cue the patient rather than violet, blue or green which the elderly find harder to read. Code the containers by using different sizes to help patients avoid taking the wrong drug at the wrong time. Divided pill containers can also help, separating pills by time of day and/or day of the week. Such containers are also available with Braille labeling, although Braille is not typically learned by individuals who experience age-related blindness.
Aging is associated with decline in color discrimination ability and contrast sensitivity. According to the University of Maryland, elderly have reduction in the transmission of blue light, have more trouble sorting or matching colors, and make more errors in the short wavelength and blue-green regions than in the other color regions.
Additionally, colors that are exceptionally bright, fluorescent, or vibrant can have edges that appear to blur and create after-images, which tire the eyes. For example, yellow text is very difficult to read.
The weblink below also suggests to maximize contrast, always use dark types on light or white backgrounds, exaggerate lightness differences between foreground and background colors, and avoid using colors of similar lightness adjacent to one another. Be aware that people with color deficits will see less contrast between colors. So it helps to even lighten light colors and darken dark colors.
REF: Universal Usability Web Design Guidelines for the Elderly – University of Maryland
http://otal.umd.edu/uupractice/elderly/
For additional information: Guidelines for Prescription Labeling and Consumer Medication Information for People with Vision Loss http://www.ascpfoundation.org/downloads/Rx-CMI%20Guidelines%20vision%20loss-FINAL2.pdf 01.04.04 Communication Barriers: Symptoms of Hearing Impairment • irritable • depressed • fatigued • negativism • inattentive • turns one ear to listen • requests repetition of words heard • speaks loudly • states irrelevant comments • withdrawn • paranoid reactions Hearing loss in the aging adult may go undiagnosed and therefore untreated due to psychological factors, such as denial, or economical factors. Elderly patients with a hearing loss may be more irritable, depressed, and fatigued, and show greater negativism than seniors without such impairment. Paranoid reactions are common. Other symptoms of hearing loss are listed above. Don’t automatically assume that an unresponsive patient has a hearing impairment; patients may not respond for a variety of reasons that can include stroke or dementia. 01.04.05 Interpersonal Strategies for Overcoming Hearing • Use an introductory statement to gain attention
• Face patient, make eye contact • Be on same level and look directly at the patient • Speak distinctly • Lower pitch of voice • Speak slowly with long pauses • Keep hands away from face
For those that are hearing impaired, there are interpersonal, environmental, and supplemental strategies that can enhance communication.
With respect to interpersonal strategies, begin your interaction with an introductory statement, such as “Do you have time to talk?” This helps you gain the attention of the patient and assures that he or she can hear you before you continue.
Face the patient when you speak; do not walk up to a patient and begin speaking from behind, but instead wait until you have established eye contact and are in front of them.
Be on same level as patient. Don’t “speak down” to the patient, either literally or figuratively. Just because an individual may have hearing loss it doesn’t mean that they are unintelligent. See yourself more as an educator rather than an authority figure.
Speak distinctly, but without shouting. In fact, you may need to lower the pitch of your voice as most hearing loss is at the higher frequencies.
Speak slowly with long pauses between sentences, and look for feedback between the pauses. Keep your hands away from your face while speaking to help those who rely on lip reading.
01.04.06 Other Strategies for Overcoming Hearing Impairment
Environmental Strategies:
• good lighting • minimal noise
Supplemental Strategies:
• Use written material to augment verbal information • Use nonverbal cues, gestures • Use pictures or other visual aids.
• Encourage patients to have hearing evaluated
To optimize communication with patients, make sure your consultation area is well lit and noise free to minimize distractions. Supplement verbal information with written material that is concise and easy to read. Non-verbal cues and gestures can be used to demonstrate procedures, such as drug administration. Pictures or other visual aids can also be used to reinforce the verbal information and act as a resource later.
Finally, encourage patients to have their hearing evaluated. Some community organizations may be able to provide hearing tests and hearing aids at a nominal fee.
01.04.07 Communication Barriers: Cognitive Impairment
Sources of Cognitive Impairment:
• heredity • medical conditions • medications • aging
Problems Encountered by Elderly with Cognitive Impairment:
• processing new information • responding to questions • remembering information
Cognitive impairment makes it difficult for the older adult to learn and remember new information. The elderly are at an increased risk for cognitive impairment due to aging-related physiologic changes, medical conditions, and the medications they take for these conditions. Patients with such impairment need more time to process information and respond to questions.
Cognitive impairment may also go hand in hand with loss of hearing and vision. Hence it is important to recognize opportunities to apply all the strategies that can help improve communication.
01.04.08 Strategies for Overcoming Cognitive Impairment: Make the Information Understandable Make the Information Understandable: • Categorize points • Use concrete terms over general terms • Use simple words and short sentences • Avoid medical jargon • Communicate logically • Emphasize important points • Back up important points with reasons • Do not overload • Do one thing at a time
Cognitive barriers to communication can be overcome by paying attention to two basic principles:
• First, make the information easy to understand; second, put the patient
first.
• To make the information easier to understand, it should be categorized.
For example, tell the patient you want to talk about the medication’s
dosing first and then the potential side effects.
• Use specific and concrete terms instead of general statements. Instead of
saying, “drink a lot of water.” Be specific, for example by telling the patient
to “drink 6 large glasses of water a day”. Patients perceive specific advice
to be more important than general advice.
• Use simple words in short sentences, and avoid medical jargon.
• Communicate logically, being careful not to jump around from topic to
topic.
• Emphasize important points by cueing the patient with statements such
as, “What I’m about to tell you next is really important.”
• Back up important advice with reasons, such as why it is important to take
an antibiotic for the full duration of prescribed therapy. Rather than
overload the patient with information, highlight essential points.
• To avoid distraction, don’t give written material to the patient at the same
time you are providing information verbally, but do provide this at the end
of your counseling for them to refer back to after they depart.
01.04.09 Strategies for Overcoming Cognitive Impairment: Put the Patient First Put the Patient First • Don’t scare or scold • Be friendly and concerned, not overly businesslike • Help identify routine events for medication administration • Allow patient to attend to one thing at a time • Assess patient’s understanding or misunderstandings by having the patient
repeat instructions • Suggest reminder systems
The second main principle for overcoming cognitive barriers to communication is to put the patient first. Don’t scare or scold the patient for past behaviors that affected their condition. This will only increase their anxiety level. Instead, put the patient at ease, being friendly and concerned, not overly businesslike.
Help the patient identify routine events around which medication can be administered, such as after dinner or during the eleven o-clock news. Allow patient’s time to attend to one thing at a time—first, the verbal information point by point, then the written information point by point.
Assess patient’s understanding of information covered by having him repeat the instructions back to you. The patient may have difficulty choosing the appropriate words, so be sure to give them adequate time to respond. Offer suggestions to cue his or her memory.
Finally, suggest reminder systems such as an alarm, a wristwatch or phone call from a friend or family member to help the patient improve compliance with the therapeutic regimen.
As our older population becomes more tech savvy, there are many text message reminder services and web-based automated phone calls that can assist with memory cues like when to take the next dose of a medication or order a refill.
01.04.10 Strategies for Overcoming Communication Barriers Due to Illiteracy
Interpersonal Strategies:
• Use an introductory statement to gain attention • Face patient, make eye contact • Be on same level and look directly at the patient • Speak distinctly • Lower pitch of voice • Speak slowly with long pauses • Keep hands away from face
Environmental Strategies:
• good lighting • minimal noise
Supplemental Strategies:
• Use nonverbal cues, gestures • Use pictures or other visual aids • Use instructional videotapes • Record the counseling session and give a copy of the tape to the patient • Encourage patients to have hearing evaluated
Illiteracy can be an important communication barrier with elderly patients. Patients may not be forthcoming about their ability to read and may have developed ‘faking’ strategies over years of time to hide this problem.
It is estimated that 61% of persons over the age of 65, read at only basic or below basic level. You may decide to screen for literacy in your patients, using a tool such as the REALM-R (see below).
With a few modifications, the strategies for overcoming hearing impairment can be applied to the illiterate. These strategies are reviewed above. These modifications include the use of video or audiotapes instead of written material. If the patient is both hearing impaired and illiterate, rely on pictures and gestures or demonstrations.
For more information, see:
http://www.health.gov/communication/literacy/quickguide/quickguide.pdf
For the REALM-R, see:
http://www.ahrq.gov/pharmhealthlit/documents/REALM-R.pdf
01.04.11 Strategies for Overcoming Communication Barriers Due to Language Differences • Offer instructions in more than one language • Use an interpreter
• Family member • Staff
• Use visual aids
For patients who rely on their native language and do not understand English, think about providing instruction or directions in his or her language. Educational literature on drug products and medical conditions is frequently available in multiple languages.
If possible, arrange for an interpreter to be at the consultation, either a family member who can understand your language and the patient’s, or someone on your staff who has experience with both. Ensure that the interpreter understands the instructions before beginning the consultation. If necessary, have the interpreter repeat back the instructions in English.
01.04.12 Assessing Patient Understanding • What did the doctor tell you about this medication? • How were you told to take this medication? • What side effects have we discussed about this medication
Whichever barriers you encounter or strategies you utilize make sure you assess the patient’s understanding of the information at the end of the consultation. Use questions such as those listed above. Provide opportunities for open-ended questions instead of close-ended questions to gain a clear picture of the patient’s understanding.
USP Pictograms are helpful in communicating when language or literacy may be barriers.They can be downloaded at no charge.
Samples include:
For more information on the USP Pictograms, see:
http://www.usp.org/usp-healthcare-professionals/related-topics-resources/usp-pictograms
01.04.13 Resources
For additional information, see:
Barrett, D. (1994). Older people. Watching your language. Health Visit; 67(8): 269.
Douglas, K. C. & Fujimoto, D. (1995). Asian Pacific elders; implications for health care providers. Clin Geriatr Med; 11(1): 69-82.
Erbger, N. P. (1994). Communicating with elders. Effects of amplification. J Gerontol Nurs; 20(10):6-10.
Evans, C. A. & Cunningham, B. A. (1996). Caring for the ethnic elder. Even when language is not a barrier, patients may be reluctant to discuss their beliefs and practices for fear of criticism or ridicule. Geriatr Nurs; 17(3):105-10.
Hanson, L. (1995). Breaking through barriers. Nurs; 25(9):31.
Hepburn, K. & Reed R. (1995). Ethical and clinical issues with Native-American elders. End-of-life decision making. Clin Geriatr Med; 11(1):97-111.
Kato, J., Hickson, L., & Worrall, L. (1996). Communication difficulties of nursing home residents. How can staff help. J Gerontol Nurs; 22(5): 26-31.
Kimberlin CL. Communicating with the Elderly. Chapter 3 IN Therapeutics in the Elderly, 3rd ed. Delafuente J, Stewart R, eds. Harvey Whitney Press, Cincinnatti, pp63-85
Le Dorze, G., Julien M., Brassard, C., Durocher, J. & Boivin, G. (1994). An analysis of the communication of adult residents of a long-term care hospital as perceived by their caregivers. Euro J Disord Commun; 29(3): 241-68.
Lindblade, D. D. & McDonald, M. (1995). Removing communication barriers for the hearing-impaired elderly. Med Surg Nurs; 4(5): 379-85.
Mallet, L. (1992). Counseling in special population: the elderly patient. Am Pharm; NS32:71-79.
Mayeaux, E J. Jr, et al. (1996). Improving patient education for patients with low literacy skills. Am Fam Physician; 53(1): 205-11.
Mazur, D. J. & Merz, J. F. (1993). How the manner of presentation of data influences older patients in determining their treatment preferences. J Am Geriatr Soc; 41: 223-228.
Morrison, R .S., Morrison, E. W. & Glickman, D. F. (1994). Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med; 154(20): 2311-8.
Ryabn, E. B., Meredith, S. D., MacLean, M. J. & Orange, J. B. (1995). Changing the way we talk with elders: promoting health using the communication enhancement model. Internat J Aging Human Devel; 41(2): 89-107.
Vance, D. (1995). Barriers and aids in conducting research with older homeless individuals. Psychol Rep; 76(Pt 11): 783-6.
Websites:
AARP
http://www.aarp.org/
ASCP: Publications
http://www.ascp.com/public/pubs/
Universal Usability Web Design Guidelines for the Elderly. University of Maryland Department of Computer Science. http://otal.umd.edu/uupractice/elderly/ Accessed: September 8, 2011.
01.05 Ethical Issues in Geriatrics 01.05.01 Introduction to the Ethics of Geriatric Care
Why the Ethics of Geriatric Care are Complex:
• Many elderly have chronic illnesses for which treatment is costly and risky, and the outcomes uncertain
• Many elderly are impaired cognitively and cannot make their own decisions
Typical Ethical Issues:
• Confidentiality • Euthanasia • Cognitive Impairment • Decisions by patient/family or health care provider • Informed consent • Right to refuse medical treatment
Key Questions:
• Who should make the medical decisions? • What are the “right” medical decisions?
Ethical issues within the field of geriatrics are, by nature, quite complex. Many elderly patients have one or more chronic illnesses. Treatment for these illnesses is often costly and risky, and outcomes are uncertain.
In addition, many elderly have conditions that impair their cognitive abilities. Some of the areas that present ethical dilemmas in geriatric care are listed on your screen. For each of these areas, one must ask, “Who should make medical decisions for the patient?”, and “What decisions are the ‘right’ decisions?”
01.05.02 Confidentiality of Patient Information: Key Issues
Clinician must keep all personal patient information in confidence.
Violating confidentially is grounds for revoking, denying or suspending license and substantial monetary fines.
Exceptions include:
• when the patient voluntarily waives right to confidentiality (patient must be competent and informed)
• cases in which rights of innocent third parties are jeopardized • legal requirements to report certain conditions
Medical professionals have an obligation to hold all patient information in confidence. Violating this confidentially may be grounds for revoking, denying, or suspending a license.
However, there are exceptions to when patient information may be shared and the confidentiality agreement broken. A patient may waive his or her right to waive confidentiality. This waiver must be voluntary, the patient must be cognitively competent, and the patient must be informed of his or her actions and their consequences. Documenting the waiver to confidentiality is essential.
When the rights of innocent third parties are jeopardized, the medical professional has an obligation to break the agreement of confidentiality, for the safety of all concerned. Certain laws require the clinician to report specific conditions to determined public health authorities, such as in the case of communicable diseases. The clinician is also required to report information regarding the patient if legally mandated by a judge.
In 2003, The U.S. Department of Health and Human Services (HHS) issued the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Privacy Rule standards address the use and disclosure of individuals’ health information — called “protected health information” (PHI) by organizations subject to the Privacy Rule — called “covered entities,” as well as standards for individuals' privacy rights to understand and control how their health information is used.
Within HHS, the Office for Civil Rights (OCR) has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil monetary penalties.
A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected, while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being.
The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.
01.05.03 Euthanasia: Key Issues
Save or maintain life, or stop prolonging pain and suffering?
Respect patient autonomy, or establish limits on patient’s rights?
Is taking action the same as refraining from action (e.g.do nothing)?
Euthanasia, also known as assisted suicide, or physician-assisted suicide, is the act of permitting, assisting with or causing a patient’s death as requested by the patient. Euthanasia is an extremely controversial topic because it introduces a conflict between patient autonomy and socio-legal restrictions on suicide. Is it better to allow the patient to die with dignity, or should every effort be made to preserve life, even if it prolongs pain and suffering?
Religious beliefs play a significant role in this controversy, and vary from enthusiastic support to adamant protest. The issue raises another important question: Is there is a difference between taking action and refraining from action? A few states have considered legislation on euthanasia and physician-assisted suicide. Currently, Oregon, Montana, and Washington are the only states in which physician-assisted suicide is permitted by law for terminally ill individuals. Many states and the federal government are struggling currently with the issue of euthanasia.
This issue has profound implications for pharmacists, who may someday be faced with a prescription for pharmacotherapy to aid in such patient requests or even requests from a physician.
01.05.04 Mental Incompetence and Decision Making: Key Issues
Medical conditions may render a patient incapable of making his/her own decisions.
If the patient is incompetent, who will decide his or her care?
• Patient: using advanced directives, living will • Proxy: makes decisions on patient’s behalf
Role of the Proxy:
• Decided before the patient becomes incapacitated • Decisions of the proxy are based on:
• specific knowledge of patient’s prior interests, opinion, beliefs • reasonable perspective in the patient’s interest
Making Medical Decisions for Someone Else: A Maryland Handbook - http://www.oag.state.md.us/Healthpol/proxyHandbook.pdf
Many conditions, such as dementia of Alzheimer’s type, can contribute to cognitive impairment. When these conditions render the patient incompetent to make his or her own decisions, the crucial question is: “who will decide what route to take for the patient’s care?”
The patient can decide this beforehand by creating an advanced directive that states what kind of care the patient wants. A living will may also be used to voice the patient’s wishes regarding what to do in a specific situation.
However, keep in mind that living wills may not cover all anticipated situations; there may still be a need for someone else to make decisions on the patient’s behalf. A substitute decision-maker or proxy can fill this role. Being a proxy requires an understanding of patient’s known opinions on similar matters, religious and ideological views, and feelings about life in general.
If this information is not known about the patient, proxies may make decisions based on a reasonable perspective in the patient’s interest, for example, looking at what the patient’s cohorts have done in this type of situation. Both the patient and proxy should understand the proxy's role before the decision for a proxy is made.
01.05.05 Patient/Family Decisions vs. Provider Decisions; Key Issues
Decisions of patient or family and providers may differ.
Clinicians are obligated to promote and protect patient’s interests.
Putting aside differences and focusing on patient’s interest
Self-effacement
Risking their relationship, health, life by caring for patient’s interests
Self-sacrifice
Acknowledging and relieving suffering and distress of others
Compassion
Forming well-made clinical ethical judgments to protect and promote others’ interests
Integrity
Differences over treatment decisions can be avoided or alleviated if the clinicians agree to promote and protect their patients’ interests by following the four principles of self-effacement, self-sacrifice, compassion, and integrity.
Self-effacement involves putting aside differences between patient and medical professional, and focusing on patient’s interest. Self-sacrifice involves risking one’s relationship, health, and even one’s life when threatened by the care of patient’s needs. Compassion involves acknowledging and relieving the suffering and distress of others. Integrity involves forming well-made clinical ethical judgments regarding how to protect and promote the interests of others.
Clinicians can alleviate conflicts by:
• Putting aside differences and focusing on patient’s interest (self-effacement) • Risking their relationship, health, life by caring for patient’s interests (self-
sacrifice) • Acknowledging and relieving suffering and distress of others (compassion) • Forming well-made clinical ethical judgments to protect and promote others’
interests (integrity)
Decisions of the patient or family and the health care providers managing the patient may differ. Sometimes family members have their own interests in mind, or feel they know what the patient would want in the situation they are in. 01.05.06 Informed Consent: Key Issues
Informed consent insures that the patient:
• Understand his or her medical conditions
• Is aware of the treatment options available • Consents to the treatment selected
Use the following process to prevent ethical conflicts:
1. Patient’s Understanding: ask what patient believes about condition, diagnosis, alternatives for managing, and prognosis of each alternative
2. Patient’s Accuracy of Understanding: correct factual error or incompleteness in patient’s knowledge
3. Physician’s Judgment: explain the clinical judgment at the condition and available management strategies
4. Cognitive Understanding: work with patient to help develop a complete picture of the condition and available management strategies
5. Patient’s Values: identify patient’s relevant values and beliefs
6. Evaluative Understanding: help patient evaluate alternative management strategies in terms of values and beliefs
7. Value-Based Preferences: patients identify which alternatives are consistent with their values and beliefs… expressing valued-based preferences
8. Physicians Recommendation: make recommendation based on clinical judgment in step 3 and patient’s preferences in step 7
9. Management Plan: reach a mutual decision about managing patient’s condition
Adapted from:
McCullough, L. B., Doukas, D. J., Holleman, W. L., & Reilly, R. B. (1995). Advance Directives. In Reichel, W. (Ed). Care of the Elderly: Clinical Aspects of Aging, 4th ed. Williams & Wilkins; Baltimore, MD. 597-608.
Informed consent ensures that patients understand as completely as possible their condition, that they are aware of the treatment options available to manage the condition, and that they consent to the treatment selected.
To exercise their right to informed consent, the patient must attend to what the clinician has to say, and must negotiate with the clinician to reach agreement on therapeutic recommendations based on his or her personal beliefs and preferences. Use the nine steps of the informed consent process outlined here
to prevent ethical conflict during negotiations and reach mutually agreed upon decisions.
01.05.07 Physical and Chemical Restraints
Types of Restraints:
• Physical restraints: used to restrict freedom or movement • Chemical restraint: used to restrict movement or control behavior
Use of physical and chemical restraints has been strictly controlled in nursing homes.
They cannot be used simply for behavior control.
Physicians must document the need for restraints, must order them and continuously review their need, and a responsible party must approve their use.
Physical restraint is any device that restricts a patient from freedom and movement. A chemical restraint is any mind-altering substance that is used to keep a patient immobile or control their behavior. The use of both physical and chemical restraints has been controversial in nursing facilities, and was a primary reason for the enactment of the Omnibus Budget Reconciliation Act of 1987.
Obviously, being physically restrained limits personal dignity and autonomy. In addition, prolonged use of physical restraints can result in incontinence, pressure sores, and loss of function. Federal law now prohibits use of physical restraints unless they are medically necessary and ordered specifically by a physician. When a physical restraint is ordered the responsible party must sign a consent form before the restraints can be used.
The use of medications as “chemical restraints” to control behavior is inappropriate and is not allowed. If antipsychotic medications are to be used their use must be supported by an appropriate indication and a specific target behavior must be identified. These medications cannot be used simply for behaviors that staff find annoying, such as calling out, but are reserved for behaviors that represent potential harm to staff, other patients, or the patient being treated.
01.05.08 Right to Refuse Medical Treatment: Key Issues
Common law states that competent patients have the right to accept or refuse medical treatment. Refusal should be documented if possible.
Steps to help accept medical treatment include:
• Provide enough information about patient’s condition, management alternatives
• Discuss benefits/risks of each strategy • Identify and correct mistaken beliefs • Gather information on patient’s values and beliefs relevant to condition and
management options
It is common law that all competent patients have the right to accept or refuse medical treatment. If the patient refuses treatment, document the refusal if possible. There are steps the clinician can take to help the patient accept medical treatment.
For example, the clinician can make sure the patient has enough information about his or her condition and that the patient is aware of alternatives for management. The patient should be told about the relative benefits and risks of each option.
The clinician can help the patient feel assured by identifying and correcting mistaken beliefs, and gathering information from the patient on his or her values and preferences as they relate to the condition and its treatment.
01.05.09 Resources
For additional information, see:
Bandman, E. L. (1994). Tough calls: making ethical decisions in the care of older patients. Geriatrics; 49(12): 46-51.
Cattorini, P. & Marchionni, N. (1994). Clinical decision-making and the "treat or not to treat" dilemma in geriatrics: ethical implications. Aging; 6(6): 391-8.
Emanuel. L. (1997). Patient’s advance directives for health care in case of incapacity. In Cassel, C. K., et al (Eds). Geriatric Medicine, 3rd ed.New York: Springer. .993- 1002.
Feinberg, J. L. (1992). The patient self-determination act: an education and information mandate on the use of advance directives. Consult Pharm; 7(8): 797-803.
Friedlob, A.(1993). The use of physical restraints in nursing homes and the allocation of nursing resources.University of Minnesota., HSRA.
Gore, M. J. (1993). Ethics: most people favor right to die. Consult Pharm; 8(11): 1289-1290.
Hayley, D. C., Cassel, C. K., Snyder, L., & Rudberg, M. A. (1996). Ethical and legal issues in nursing home care. Arch Intern Med; 156(3): 249-56.
Iris, M. A. (1995). The ethics of decision making for the critically ill elderly. Cambridge Quart Healthc Eth; 4(2): 135-41.
Kane, R. A.. (1994). Ethics and long-term care. everyday considerations. Clin Geriatr Med; 10(3): 489-99.
Knight,J. A. (1994). Ethics of care in caring for the elderly. South Med J; 87(9): 909-17.
Mahowald, M. B. (1994). So many ways to think. an overview of approaches to ethical issues in geriatrics. Clin Geriatr Med; 10(3): 403-18.
Manolakis, M. L. (1988). Ethical principles and the consultant pharmacist. Consult Pharm; May/June: 205, 207.
McCullough, L. B., Doukas, D. J., Holleman, W. L., & Reilly, R. B. (1995). Advance Directives. In Reichel, W. (Ed). Care of the Elderly: Clinical Aspects of Aging, 4th ed. Baltimore: Williams & Wilkins. 597-608.
McCullough, L. B., Rhymes, J. A., Teasdale, T. A., & Wilson, N. L. (1995). Preventive ethics in geriatric practice. In Reichel, W. (Ed). Care of the Elderly: Clinical Aspects of Aging, 4th ed. Baltimore: Williams & Wilkins. 573-786.
Morgan, D. (1996). Respect for autonomy: is it always paramount. Nurs Ethics; 3(2): 118-25.
Peters,N. L. (1989). Snipping the thread of life. Arch Intern Med; 149: 2414-2420.
Schommer, J. C. (1991). Long-term care facility resident rights:an elderly population's perspective. Consult Pharm; 6(5): 406-410.
Sloan, J. P. (1996). Protocols in primary care geriatrics. 2nd ed. New York: Springer. 113.
Taniguchi, G. (1992). Ethical considerations in drug-regimen review. Consult Pharm; 7(10): 1100-1102.
Websites:
ASCP Publications
http://www.ascp.com/public/pubs/
Factors Affecting Opinions on Life Support Issues in the Elderly
http://geriatricspt.org/pubs/ioa/V18n2/V18n2p19.html
Making Medical Decisions for Someone Else: A Maryland Handbook http://www.oag.state.md.us/Healthpol/proxyHandbook.pdf
The Merck Manual of Geriatrics: Ethical Issues
http://www.merck.com/pubs/mm_geriatrics/109x.htm
US Department of Health and Human Services
Summary of the HIPAA Privacy Rule
http://www.hhs.gov/ocr/privacysummary.pdf
01.06 Social and Psychological Issues in Geriatrics 01.06.01 Sources of Variability Among Older Adults
Economic and Social Health:
• economic indicators • social indicators • social networks
Coping and Adaptation to
• normal life events • crisis events
Life Cycle Issues:
• young adulthood • middle age • old age
While it is often convenient to refer to the elderly as a single, homogenous group, it is important to remember that a great deal of heterogeneity exists in the older adult population.
The individuals that comprise this group have varying lifestyles, preferences, health histories, genders, ethnicities, socioeconomic status, and psychosocial characteristics. These differences did not appear overnight; they are the result of changes that occur over the course of one’s entire lifespan.
Nor are they synchronous; physical, psychological, and social changes occur at different rates in different people.
To explore these differences, we must understand the influence of economic and social health, social networks, coping and adaptive mechanisms, and life cycle issues affecting young adulthood, middle age, and old age.
01.06.02 Elderly Quality of Life
Factors that Affect Elderly Quality of Life:
• economic health of society • social health of society
Quality of Life Trends:
• improvement in economical status since 1960s • people supported 30+ years after retirement • elderly retiring earlier and living longer
Quality of life for the older adult is related to the economic and social health of society at large. Since the 1960s, the economical status of the elderly has improved greatly. The multi-tiered system used in America now supports people thirty or more years after retirement. With people retiring earlier and living longer, more changes will occur in the future that will affect the economic and social health of the elderly.
01.06.03 Economic Health Indicators
Economic Status of Elderly:
• Older adults often have more wealth than younger adults due to special income tax benefits, home ownership
• The percentage of men with highest income is roughly equal to the percentage of men with lowest income (10%)
Factors that Affect Elderly Economic Status:
• Gender: women are more likely to live in poverty due to being widowed, less work time, fewer income benefits
• Race: 33% of older minorities live in poverty due to accumulated life disadvantages
Most of the elderly in America are not poor. In general, older people in this country tend to have more wealth than younger people due to special income tax benefits and ownership of homes that have greatly appreciated in value. There are as many elderly men with higher incomes as there are at the poverty level.
However, economic status is affected by gender and race. Women are more likely to live in poverty then men. This may be due to the fact that they are widowed, have spent less time in the workforce, or have earned less social security benefits and pensions.
In addition, 33% of older minorities live below the poverty line, which can be attributed to accumulated life disadvantages in education, occupational opportunities, health care and pensions.
01.06.04 Social Health Indicators
Retirement:
• Majority of elderly retire before age 65 • Small minority work part time after age 65
Marriage:
• Most men age 65 or older live with spouse • Most women age 75 or older are widowed, living alone
Living Arrangements: Most elderly want to grow old in the same house and community as during younger years
The majority of older adults retire before they are 65 years old, drawing social security benefits earlier and living longer than in the past. Small percentages of older adults remain in the labor force beyond age 65, but are likely to work only part time.
With respect to social relationships, most men older than 65 years of age are married and live with their spouse. In contrast, most women are widowed by the age of 75 and live alone. Elderly widowers are more likely to re-marry than elderly widows, who typically do not remarry.
Regardless of gender or race, most elderly prefer to grow old in a familiar place, usually in the same house and communities they lived in during their younger years.
01.06.05 Geriatric Trends in Social Networks • Majority of older adults have active ties to family and friends • Most attend other social functions regularly • Many volunteer in their community • Small percentage are lonely and socially isolated
Social networks are strong predictors of health. The majority of seniors have active ties to family and friends, and regularly participate in social functions in the community, including, attending church or volunteering in a community
organization. A small percent of older adults report loneliness due to loss of a loved one and social isolation.
01.06.06 Variations in Coping and Adaptation
Types of Life Changes Confronting the Elderly:
• Gradual – e.g., loss of physical and cognitive ability • Abrupt – e.g., forced retirement, loss of a spouse
Coping Strategies:
• Most older adults think they can cope with new transitions • Nature of expectation is significant factor in adapting to change • Some seniors can sense whether the timing of life events is “normal”;
unanticipated events may trigger a crisis
Older adults are confronted with a variety of life changes as they age, many of which are traumatic. Some of these changes, such as the gradual deterioration of physical ability and health, require some time for adjustment. That is one reason why older adults tend to become more preoccupied with health than younger adults.
Abrupt changes, such as the death of a spouse, require more rapid and dramatic adjustment. With respect to coping and adaptation skills, most elderly feel that they can cope with new transitions given reasonable support. The nature of this expectation is a significant factor in adapting to change.
For example, some older adults have an internal social clock that helps them determine if they are on track in accepting normal life events. For these people, the sense of being “off track” usually prompts a self-assessment and may trigger a life crisis.
01.06.07 Life Events Variably Experienced by the Elderly
Defining Characteristics of Normal Life Events:
• contribute to self-concept and identity • timing of the event determines if it is a crisis • losses may be traumatic, causing anxiety, grief, depression
Examples:
• marriage • parenthood, grand-parenthood • climacteric • retirement • onset of chronic illness • death of a parent or spouse
Normal life events, such as those listed here, are anticipated events that bring about changes in self-concept and identity. The timing of the event usually determines if it is a crisis or not. Some of these events involve traumatic losses that cause a great deal of anxiety, grief, and depression in the elderly.
01.06.08 Issues in Young Adulthood that Contribute to Geriatric Diversity • Identity formation • Intimacy • Investing in lives of few others • Buying a home • Having a family • Mastering work
Life cycle issues that are relevant to understanding geriatric diversity occur in young adulthood, middle age and old age. Issues of young adulthood involve identity formation, intimacy, and investing in lives of few others, as well as buying a home, having a family, and mastering one’s work.
01.06.09 Issues in Middle Adulthood that Contribute to Geriatric Diversity • Introspection • Increasing concerns about health and performance • New perspectives about life and death • Changing family roles
• spousal relations • parent-child relations • grandparenting • parent-caring
Introspection and reflection on one’s life “so far” characterize the middle years of the life cycle. People in this stage of their life spend more time thinking about their health, and are concerned about maintaining performance while monitoring
changes in their bodies. During this period, perspectives about time also seem to change.
Middle-aged people tend to revise their thinking about life in terms of time left to live, realizing that the number of years left to them is finite. During the later middle years, death becomes a new reality that is likely to occur sooner rather than later.
Other issues that people face during middle-age include adapting to changing family roles, the introduction to grand-parenthood, or possible divorce of a child. Parent-caring becomes another concern as middle-aged adult children face decisions about the best care for an aging parent, especially when chronic illness is involved.
01.06.10 Issues in Old Adulthood that Contribute to Geriatric Diversity • Renunciation • Adapting to loss • Grief • Survivorship • Concerns about health • Sensitivity to physical and psychological care • Concerns about dependency and deterioration • Willingness to consider death with dignity
When we reach old age, the primary issues that we must deal with include renunciation of our past life, adapting to loss of loved one or home, grief and survivorship, and sensitivity to physical and psychological care.
These ongoing concerns regarding health and health care are exacerbated with increasingly higher expectations for treatment and quality of life. Concerns regarding dependency and deterioration are also on the minds of the elderly. The prospect of dying with dignity may be considered as well.
01.06.11 Resources
For additional information, see:
Andreopoulos, S. & Hogness, J. R.(1991). Health care for an aging society. New York: Churchill Livingstone
Berardo DH. Social and Psychological Issues in Aging and Health Chapter 2 IN, Therapeutics in the elderly. Harvey Whitney Press, Cincinnatti, 2000 pp 41-61
Fortinsky RH. Social Networks and Human Services. Chapter 5 In: Therapeutics in the elderly. Harvey Whitney Press, Cincinnatti, 2000 pp 109-134.
Neugarten, B.L. & Reed, S. C. (1997). Social and Psychological characteristics. In Cassel, C. K., Cohen, H. J., Larson, E.B., et al, (Eds.). Geriatric Medicine, 3rd ed. Spring-Verlag, New York, Inc. 37-41.
Pifer, A. & Bronte, L. (Eds.). Our aging society.New York: W. W. Norton.
Websites:
The Merck Manual of Geriatrics: Social Issueshttp://www.merck.com/pubs/mm_geriatrics/110x.htm
The Merck Manual of Geriatrics: Establishing Therapeutic Objective: Quality of Life Issueshttp://www.merck.com/pubs/mm_geriatrics/18x.htm
01.07 Physiological Aspects of Aging 01.07.01 Age-Related Physiological Changes and Functional Decline
Types of Changes Expected with Age:
• overall decline in body systems function • variable decline in specific organs and systems • different presentations of diseases and symptoms
Factors Contributing to Variations in Functional Decline:
• aging process • disease • adverse environmental factors • adverse lifestyles
Systems and Organs Most Affected by Aging:
• Cardiovascular system • Pulmonary system • Central nervous system and brain • Renal system and kidneys • Liver • Immune system • Gastrointestinal system • Endocrine system
As people age, it is inevitable that their body systems will change, typically functioning less efficiently than in their younger years. However, the specific declines in the different organ systems vary among individuals, and this variability increases with age.
Factors that contribute to this variability in functional decline include genetic predisposition, disease, environmental factors, and lifestyle. Organs and systems that change the most with age include the cardiovascular system, pulmonary system, central nervous system, renal system, immune system, gastrointestinal tract, and endocrine system.
01.07.02 Effects of Aging on the Cardiovascular System
Overall System Function
• generally sufficient for needs of aging adult
Heart:
• size of heart stays the same • heart wall thickens with age • diastolic filling rate decreases, with atrial contribution to ventricular filling
normal • systolic blood pressure at rest increases, with end systolic volume and
ejection fraction normal
Peripheral Circulation:
• maximal oxygen consumption decreases • beta-adrenergic modulation decreases, alpha-adrenergic response normal • stroke volume increases, counteracting decreased heart rate
Despite changes to the heart and blood vessels due to aging, cardiovascular function is usually sufficient to meet the body’s needs in old age. Although the heart wall thickens, heart size is relatively unchanged. Diastolic filling rate is reduced, though atrial contribution to ventricular filling maintains filling at a normal volume.
Systolic blood pressure at rest increases, but due to increased left ventricular thickness, the end systolic volume and ejection fraction is not significantly altered.
A decline in maximal oxygen consumption is observed due to peripheral vascularity more than central circulatory factors. Although beta-adrenergic modulation diminishes, the alpha-adrenergic response stays intact. An increase in stroke volume is noted due to cardiac dilation, which counteracts the decrease in exercise heart rate.
01.07.03 Effects of Aging on the Pulmonary System
Trachea and Central Airways increase, leading to:
• more anatomic dead space • decreased lung weight
Chest Wall thickens, leading to:
• loss of elastic recoil in the lung • increased closing volume • decreased maximum expiratory flow • increased risk for respiratory failure
In the pulmonary system, the trachea and central airways increase in size, creating more anatomic dead space. The weight of the lungs decreases and the chest wall thickens. The loss of elastic recoil in the lung increases closing volume and decreases maximum expiratory flow. All these factors make the elderly at greater risk for respiratory failure.
01.07.04 Effects of Aging on the Central Nervous System and Brain
Brain mass and cerebral blood flow decreases, leading to:
• decreased coordination • prolonged reaction time • impairment of short- term memory • decreased sensory conduction time • more permeable blood-brain barrier
Serotonin System changes affect neuronal functions such as:
• pain • feeding • sleep • sexual behavior • cardiac regulation • cognition
With age, cellular brain mass and cerebral blood flow decrease. As a result, coordination is decreased, reaction time is prolonged, and short-term memory is impaired, sometimes quite noticeably. Long-term memory tends to be maintained. More time is needed for sensory conduction, and the blood- brain barrier tends to be more permeable. As the brain shrinks and loses nerve cells,
a decrease in the amount of brain tissue results. Advancing age may also bring a change in cognitive performance, which is affected by the physical and mental health of the individual.
Changes in the serotonin system may affect neuronal functions such as pain, feeding, sleep, sexual behavior, cardiac regulation and cognition. All of these age-related changes tend to leave the brain and central nervous system very vulnerable to disease and impairment.
01.07.05 Effects of Aging on the Kidneys and Renal System
Anatomic Changes:
• kidney size decreases • number of glomeruli decreases • renal tubules changes • renal vasculature changes
Functional Changes:
• GFR decreases • mean CLcr rate decreases • renal blood flow declines • conservation of sodium is reduced due to:
• lower plasma renin activity • urinary aldosterone excretion
Age-related changes in the kidneys and renal system can be categorized in terms of anatomic and functional changes. Anatomic changes include the loss of glomeruli, decreased kidney size, and associated renal tubular and vascular changes.
Functional changes include reduced glomerular filtration rate and mean creatinine clearance. Decreasing creatinine excretion in the face of decreased muscle mass results in serum creatinine concentrations that remain relatively constant.
Thus, standard equations for estimations of creatinine clearance, such as Cockcroft-Gault, tend to over-estimate actual renal function. The renal blood flow and plasma flow decrease and conservation of sodium are seen less due to lower plasma renin activity and urinary aldosterone excretion.
01.07.06 Effects of Aging on the Liver • overall function less affected by age than other organs • liver size decreases • hepatic blood flow decreases, leading to altered metabolic clearance of
certain drugs
The liver is one of the organs least affected by age. A decrease in the size of the liver occurs, with a corresponding decrease in hepatic blood flow. This reduced hepatic blood flow may affect the metabolic clearance of certain drugs. These factors are most likely to affect high first pass extraction ratio drugs.
01.07.07 Effects of Aging on the Immune System • cell-mediated responses decrease • humoral responses decrease • thymus size decreases • T-cell function is altered • B cells produce less antibodies
The immune system is affected more profoundly by the aging process. As a result of aging, cell-mediated and humoral immune responses decline.
The thymus decreases in size, and T cell function is altered. The B Cells also produce fewer antibodies, thus leaving the aging body more vulnerable to infection than a younger counterpart.
01.07.08 Effects of Aging on the Gastrointestinal System
Oral Cavity:
• traumatic oral lesions • xerostomia
Stomach:
• gastric muscular atrophies • gastric mucosa thins • submucosa is infiltrated with elastic fibers • gastric secretion decreases
• pH increases (once thought to be a consequence of aging, is now thought related to latent H. pylori infections which result in gastric mucosal atrophy and loss of acid producing parietal cells)
• gastric emptying slows
Small Intestine and Colon:
• nutrition absorption decreases (e.g., vitamin D, calcium) • motility remains intact • constipation and fecal incontinence is common
Age-related changes in the gastrointestinal system due to age begin with the oral cavity. Many elderly experience traumatic oral lesions, making them more susceptible to disease. Medications may exacerbate these lesions, making treatment difficult. Xerostomia, or dry mouth, is another common condition in the elderly that may be caused by drugs or disease.
Changes in the stomach that are associated with age include gastric muscular atrophy, thinning of the gastric mucosa, and infiltration of the submucosa with elastic fibers. As gastric secretion declines with age, pH increases, resulting in prolonged gastric emptying and altered drug absorption.
Changes experienced in the small intestine with age include a decrease in nutrition absorption, especially in the absorption of vitamin D and calcium. However, motility remains intact.
As for the colon, constipation is common in the elderly, but so is fecal incontinence. Many of these changes can reduce the elderly person’s ability to fight disease.
01.07.09 Effects of Aging on the Endocrine System • regulatory and feedback mechanisms deteriorate • binding affinities and receptors decrease • glucose tolerance decreases • production of sex hormones decreases
The endocrine system changes with age as well, with diminished endocrine regulatory mechanisms and deficiencies in hormonal feedback mechanisms. A decrease in binding affinities and receptors is experienced, as well as a decrease in both glucose tolerance and the production of sex hormones.
01.07.10 Resources
For additional information, see:
Arking, R.(1998). Biology of aging : Observations and principles. Sinauer Association.
Booth, F. W., Weeden, S. H., Tseng, B. S. (1994). Effect of aging on human skeletal muscle and motor function. Med Sci Sports Exerc; 26(5): 556-60.
Erwin,W. G. Geriatrics. (1992). In: Dipiro J. T. et al, (Eds.). Pharmacotherapy: A Pathophysiologic Approach, 2nd ed. Norwalk, CT: Appleton & Lange, 64-70.
Frolkis, V. V., Bezrukov, V. V., & Kulchitsky, O. K. (1996). The aging cardiovascular system : Physiology and pathology. New York: Springer.
Geokaz,M. C, Lakotta, E. G., Makinodan, T., & Timiraz, P. S. (1990). The aging process. Ann Intern Med; 113: 455-466.
Gurwitz, J. H. & Avorn, J. (1991). The ambiguous relation between aging and adverse drug reactions. Ann Intern Med; 114: 956-965.
Lamy, P. P. (1991). Physiological changes due to age. pharmacodynamic changes of drug action and implications for therapy. Drugs Aging; 1(5) : 385-404.
Rapp,P. R. & Heindel,W. C. (1994). Memory systems in normal and pathological aging. Curr Op Neurol; 7(4): 294-8.
Silver,A. J., Guillen, C. P., Kahl,M. J., & Morley, J. E. (1993). Effect of aging on body fat. J Am Geriatr Soc; 41: 211-213.
Simonson, W. Introduction to the Aging Process, In: Therapeutics in the Elderly, Delafuente j (ed). Cincinnatti, Harvey Whitney Books, 2000 pp 1-39.
Spence, A. P.(1995). Biology of human aging. New York: Prentice-Hall.
Stolarek, I., Scott,P. J. , & Caird,F. I. (1991). Physiological changes due to age: implications for cardiovascular drug therapy. Drugs Aging; 1(6) : 467-76.
Vijg, J. & Wei, J. Y. (1995). Understanding the biology of aging: the key to prevention and therapy. J Am Geriatr Soc; 43: 426-434.
Wei ,J. Y. (1992). Age and the cardiovascular system. N Engl J Med; 327: 1735-1739.
Woodhouse,K. W. & James, O. F. W. (1990). Hepatic drug metabolism and aging. Brit Med Bull; 46: 22-35.
Websites:
The Merck Manual of Geriatrics: (TOC) Ch 3. Organ Systems
http://www.merck.com/pubs/mm_geriatrics/toc.htm
01.08 Pharmacokinetic and Pharmacodynamic Interactions 01.08.01 Two Basic Concepts
Pharmacokinetic Interactions:
• Absorption: rate and extent drugs are absorbed • Distribution: speed and extent drugs are distributed • Metabolism: speed and extent drugs are broken down • Renal Elimination: efficiency of drug removal process
Pharmacodynamic Interactions:
• Effects of drug on biochemical, physiological processes • How the drug mediates or controls varies bodily functions • Adverse reactions that may result from drug use • How drugs affects functional status
Two basic concepts that are integral to the successful application of pharmacotherapy are the concepts of pharmacokinetic and pharmacodynamic interactions. Pharmacokinetics describes how medications are absorbed, distributed, metabolized, and eliminated from the body. Pharmacodynamics is the study of the biochemical and physiologic effects of drugs on the body and their mechanisms of action, including therapeutic and adverse effects. Ultimately, this translates into the impact of drug therapy on a patient’s functional status.
01.08.02 Pharmacokinetic Interactions: Drug Absorption through Oral Route
Site of absorption: Small intestine, GI tract
Factors that Influence Absorption:
• Comorbid disease • Concurrent medications • Specific physiochemical properties of the drug • Age-related physiologic changes
• increased gastric pH • decreased gastric emptying • decreased intestinal motility • reduced splanchnic blood flow
The body absorbs a drug through one of three mechanisms: oral absorption, presystemic clearance, or transdermal absorption. Drugs that are administered orally are absorbed in the gastrointestinal tract, primarily by the small intestine. There, absorption is influenced by comorbid diseases such as congestive heart failure, concurrent medications, and specific physiochemical properties of the drug, such as the need for an acidic environment. The rate of absorption is highly dependent on the delivery of the drug to the small intestine. Age-related physiologic changes also influence absorption.
These changes include an increased gastric pH, decreased gastric emptying, decreased intestinal motility, and reduced splanchnic blood flow. Of the four pharmacokinetic properties, absorption is the least effected by age.
01.08.03 Pharmacokinetic Interactions: Drug Absorption with Presystemic Clearance (First-Pass effect)
Site of absorption: GI tract, with rapid extraction by liver
Factors that Influence Clearance:
• Age-related physiologic changes • decrease portal blood flow • increase systemic bioavailability and toxicity
• Medications • decrease hepatic blood flow and presystemic clearance • increase systemic bioavailability and toxicity
Presystemic clearance results when drugs are absorbed well by the GI tract and extracted by the liver at a rapid rate, also known as the “first-pass” effect. As a result, systemic concentrations are low. When there is a decrease in portal blood flow – as seen with aging – there may be a decrease in the first-pass effect and therefore, an increase in systemic bioavailability.
In addition to age-related changes, certain medications, such as histamine 2 blockers, may reduce hepatic blood flow resulting in a further decrease in presystemic clearance and an increase in bioavailability. The clinical impact of this could be an increase in the therapeutic or toxic effect of a medication, necessitating a decrease in dosage in elderly individuals.
01.08.04 Pharmacokinetic Interactions: Drug Absorption through Transdermal Route
Advantages Over Other Routes:
• First pass effect avoided • Duration of activity prolonged • Compliance improved Age related Factors that Affects Absorption: insufficient data
Transdermal absorption has advantages over other routes in that the first pass effect is avoided and the duration of activity of the drug may be prolonged. With transdermal application, patient compliance is also improved. As for age related changes of absorption via the transdermal route, studies are inconclusive; however, clinical experience with products such as transdermal fentanyl indicate that transdermal drug delivery is an effective route of administration in the elderly. Thinner skin and altered fat tissue can, however, influence the predictability of drug absorption across the skin.
01.08.05 Pharmacokinetic Interactions: Body Composition and Drug Distribution
Age-related Changes in Body Composition:
• decrease in total body water • decrease in lean muscle mass • increase in adipose tissue
Impact of Body Composition Changes on Drug Distribution:
• depends on physiochemical properties of drug • lower bioavailability with fat soluble drugs • higher bioavailability with water soluble drugs, potentiating adverse reactions
How the body distributes a drug depends on a variety of factors including body composition, plasma protein binding, and organ blood flow. The first factor, body composition, significantly changes with age. The elderly have reduced total body water and lean muscle mass, with an increased percentage of fat tissue. The importance of these changes on distribution depends on the drug’s
physiochemical properties. For example, a fat-soluble drug taken by an elderly patient will be distributed to the adipose tissue, reducing the amount of the drug available to circulation. In contrast, a water-soluble drug taken by the same elderly patient will be more available in circulation due to decreased water composition, possibly accentuating the adverse or therapeutic effects of a medication.
01.08.06 Pharmacokinetic Interactions: Plasma Binding and Drug Distribution
Binding Patterns:
• Many drugs bound to circulating plasma proteins • Acidic drugs bind primarily to albumin
Factors that Influence Binding:
• Protein concentration • Comorbid disease • Concurrent drugs • Nutritional status • Age-related physiologic changes (e.g., decrease in serum albumin)
Body composition is not the only factor that influences distribution of a drug in the body. Many drugs bind to plasma proteins circulating in the bloodstream. Acidic drugs bind primarily to albumin - which may be decreased in the elderly - especially if malnutrition or serious illness is present. Factors that influence binding and therefore drug distribution include the protein concentration, the presence of comorbid diseases and concurrent drugs, and the nutritional status of the patient.
01.08.07 Pharmacokinetic Interactions: Organ Blood Flow and Drug Distribution
Age-related Changes in Organ Blood Flow:
• Diminished cardiac output and circulation • Decreased blood flow to organs such as the liver
Impact of Reduced Organ Blood Flow on Drug Distribution:
• drug metabolism is delayed in liver • unmetabolized drug remains in the system longer • increased risks of adverse reactions or toxicity
Organ blood flow changes with age and these changes may affect the distribution of a drug. Diminished cardiac output decreases the circulation, which in turn slows the distribution of the drug throughout the blood and to the organs. This includes a decrease in blood flow to the liver, which is a site for drug metabolism. The decline in blood flow to the liver increases the time the drug is in the body before it is metabolized, increasing the likelihood of adverse reactions, toxicity or increased therapeutic effect of the medication.
01.08.08 Pharmacokinetic Interactions: Age-related Changes and Drug Metabolism
Factors that Affect Drug Metabolism/Clearance:
• Activity of different enzyme systems • Hepatic blood flow
Age-related Changes that Affect Metabolism/Clearance:
• Enzyme systems: • CYP3A4 may display reduced activity with aging and lead to slower
clearance • P-glycoprotein transporters likely are maintained as persons age
• Hepatic blood flow: 40-45% reduction in elderly > 65
• Leads to decreased metabolism and increased drug bioavailability (affects high hepatic extraction ratio drugs to a greater extent)
The way the body metabolizes a drug has a great impact on how the drug in turn affects the body. Drug clearance through the liver is dependent on the biotransformation through enzyme systems and hepatic blood flow.
Some of these enzyme systems are considerably reduced in the elderly, while others are not appreciably altered. The liver itself decreases in total mass with age, but is not significantly impaired in terms of function.
More significant is the decrease in hepatic blood flow with advancing age. It is estimated that blood flow is diminished to the liver by as much as 45% in persons over the age of 65. This decrease in blood flow may increase bioavailability of drugs that have a high extraction rate by the liver.
01.08.09 Pharmacokinetic Interactions: Biotransformation and Drug Metabolism Phase I (preparative) - Affected by Age: • Oxidation • Hydrolysis • Reduction • Results in:
• slower drug clearance • higher extraction rate • greater bioavailability
Phase II (synthetic) - Less Affected by Age: • Glucuronidation • Acetylation • Sulfation
The enzyme pathways of metabolism can be described in two phases. The phase I pathways, which include oxidation, reduction and hydrolysis, are most
affected by age. Impairment of the Phase I pathways result in slower clearance, a higher extraction rate and higher bioavailability of the drug.
The conjugation pathways in Phase II, which include glucuronidation, acetylation and sulfation, are less affected by age-related changes. It is important to know how a drug is metabolized through these pathways and how the aging process will affect their clearance and bioavailability.
Pictured above is an example of how certain variabilities exist within drugs of the same class. Benzodiazepines – a class typically avoided in the declining elderly – can go through either Phase I or Phase II metabolism based on which specific drug.
Think OTL – outside the liver – for benzodiazepines that are handled through glucuronidation metabolism (oxazepam, temazepam, lorazepam), as compared to DTA – drugs to avoid – for ones that are handled via oxidative metabolism (diazepam, triazolam, alprazolam). Even still, clinical judgment should overrule therapeutic decision making and the use of any benzodiazepine in an elderly patient.
01.08.10 Pharmacokinetic Interactions: Other Factors Affecting Drug Metabolism • Concurrent drugs • Comorbid diseases • Nutrition (e.g., vitamin supplements) • Gender • Genetics • Environmental factors (e.g., smoking)
Drugs with a slower rate of metabolism have a reduced clearance rate in the elderly. In addition to the age-related changes discussed earlier, the rate of drug metabolism is often slowed by concurrent drugs, comorbid disease, nutritional status, gender, and hereditary factors. Environmental factors such as smoking can also affect drug clearance. These factors must be considered when dosing medication in the elderly.
01.08.11 Pharmacokinetic Interactions: Changes in the Kidney and Renal Elimination
Age-related Changes in the Kidney:
• Decrease in kidney size • Loss of glomeruli, causing reduced GFR • Tubular changes, causing decreased tubular secretion • Vascular changes, causing decreased renal plasma flow • Decreased creatinine clearance Impact of Changes: Renal elimination reduced by up to 50%
Anatomical and functional changes in the kidneys are associated with aging. The kidney decreases in size, with renal tubular and vascular changes. The number of glomeruli decreases as well. Functional changes include a decrease in the glomerular filtration rate and the mean creatinine clearance rate.
The serum creatinine concentration remains constant due to the decrease in body muscle with age. The decrease in glomerular filtration rate, or GFR, renal plasma flow and tubular secretion contribute to a significant decrease in elimination of renally excreted drugs, in some cases, by a factor of at least 50%.
How does the glomerular filtration rate (GFR) change after the age of 40? a) Increase 1% each year b) Increases 2% each year c) Decreases 1% each year – CORRECT ANSWER d) Decreases 2% each year e) Does not depend on age
As noted before, GFR can significantly decrease as we age. This equates to about 50% of renal function at 80 years old as compared to a 40 year old renal system. There is roughly a 1% decrease in GFR each year after the age of 40.
01.08.12 Pharmacokinetic Interactions: Creatinine Clearance and Renal Elimination
Importance of Creatinine Clearance:
• Indicator of renal filtration and elimination • Used to monitor drug elimination
• Drugs may accumulate in circulation • Active metabolites may accumulate
• Guides dosing adjustments in patients with renal insufficiency
Formula for Estimation (Cockcroft-Gault):
Clcrmale = (140-age)(Wt)
72 (Scr)
Clcrfemale = Clcrmale (.85)
01.08.13 Pharmacodynamic Interactions
Types of Pharmacodynamic Effects:
• Positive: therapeutic benefit • Negative: adverse reaction, toxicity, reduced therapeutic benefit
Changes that Influence Pharmacodynamic Interactions:
• Changes in receptor binding • Changes in number of receptors • Changes in events that occur after binding
Consequences of Pharmacodynamic Changes:
• Increased sensitivity to a drug, leading to toxicity • Decreased response from other drugs
Pharmacodynamic interactions involve the effect of drugs on the body. These effects may be positive or negative, depending on how they affect the functional status of the patient.
Pharmacodynamic interactions are influenced by changes in receptor binding or the number of receptors, or events that occur after binding. The consequences of these changes include an increased sensitivity to a drug or a decreased response from other drugs. Receptor binding is a major factor in the occurrence of adverse reactions.
01.08.14 Pharmacodynamic Parameters and their Effect on Functional Status
Negative Effects on Functional Status:
• Falls and Fractures • Anticholinergic effects (e.g., urinary retention, constipation, confusion,
sedation) • Depression • Cognitive decline
Positive Effects on Functional Status:
• Improved cognition • Improved gait
The pharmacodynamic parameters of medications must be considered when assessing a patient’s status and outcome. For example, the anticholinergic effects associated with medications such as tricyclic antidepressants, antihistamines, and other medications can have a significant impact on the functional status of an elderly person. These effects include urinary retention, constipation, confusion, and sedation.
Medications such as long half-life benzodiazepines, vasodilators and non-steroidal anti-inflammatory agents can put a patient at increased risk for falls and fractures, GI bleeds, and more. Other drugs may contribute to depression or cognitive decline. In contrast, many medications used to treat conditions such as Alzheimer’s disease, Parkinson’s disease, and osteoporosis may help to improve the functional status of the patient, but are not without their own untoward effects.
It is important to examine the drug regimen and identify those agents that may have a negative effect on the patient’s functional status and try to remove them from the regimen, possibly substituting with a more appropriate agent.
01.08.15 Resources
For additional information, see:
Avorn, J. & Gurwitz, J.H. (1997). Principles of Pharmacology. In Cassel, C. K., et al (Eds.). Geriatric Medicine, 3rd ed. New York: Springer-Verlag. 55-67.
Crome, P. & Flanagan, R. J. (1994). Pharmacokinetic studies in elderly people. Are they necessary. Clin Pharmacokin; 26(4): 243-7.
Dawling S, Crome P. (1989). Clinical pharmacokinetic considerations in the elderly.an update. Clin Pharmacokin; 17(4) : 236-63.
Feely, J. & Coakly, D. (1990). Altered pharmacodynamics in the elderly. Clin Geriatr Med; 6: 269-283.
Gurwitz,J. H. & Avorn, J. (1991). The ambiguous relation between aging and adverse drug reactions. Ann Intern Med; 114: 956-965.
Jackson,S. H. (1994). Pharmacodynamics in the elderly. J Royal Soc Med; 87(Suppl 23): 5-7.
Lamy,P. P. (1991). Physiological changes due to age. pharmacodynamic changes of drug action and implications for therapy. Drugs Aging; 1(5) : 385-404.
Mayersohn, M. (1994). Pharmacokinetics in the elderly. Environ Health Perspect; 102(Suppl 11): 119-24.
Parker,B. M, Cusack, B. J., & Vestal, R. E. (1995). Pharmacokinetic optimization of drug therapy in elderly patients. Drugs Aging; 7: 10-18.
Ritschel,W. A. (1992). Drug disposition in the elderly: gerontokinetics. Meth Find Experiment Clin Pharmacol; 14(7): 555-72.
Schenker, S. & Bay, M. (1994). Drug disposition and hepatotoxicity in the elderly. J Clin Gastroenterol; 18(3): 232-7.
Schwartz, J. B. (1994). Clinical pharmacology. In Hazzard, W. R., Bierman, E. L., Blass, J. P. , et al, (Eds.). Principles of Geriatric Medicine and Gerontology, 3rd ed. New York:McGraw-Hill.
Sharget, L. & Yu, A. B. C. (1992). Applied biopharmaceutics and pharmacokinetics, 3rd ed. Norwalk, CT: Appleton & Lange.
Simonson, W, et al. (1990). Basic pharmacokinetic principles for consultant pharmacists. Consult Pharm; 5(11): 741-746.
Simonson, W. Introduction to the Aging Process, In: Therapeutics in the Elderly, Delafuente j (ed). Cincinnatti, Harvey Whitney Books, 2000 pp 1-39.
Smith, C. L. & Hampton, E. M. (1990). Using estimated creatinine clearance for individualizing drug therapy: a reassessment. Ann Pharmacother; 24: 1185.
Swift, C. T. (1990). Pharmacodynamics: changes in homeostatic mechanisms, receptors and target organ sensitivity in the elderly. Br Med Bul; 46: 36-52.
Woodhouse KW. Pharmacokinetics of drugs in the elderly. J Royal Soc Med 1994; 87(Suppl 23): 2-4.
Yuen, G. J. (1990). Altered pharmacokinetics in the elderly. Clin Geriatr Med; 6(2): 257-268.
Websites:
The Merck Manual of Geriatrics: (TOC) Ch 3. Organ Systems
http://www.merck.com/pubs/mm_geriatrics/toc.htm
01.09 End-of-Life Issues 01.09.01 Concepts and Issues Related to End-of-Life
Advanced Directives:
• Living will • Power of attorney • Durable power of attorney • Do-not-resuscitate orders
Treatment Issues:
• Ordinary and extraordinary treatment • Withdrawing and withholding treatment • Refusal of specific treatments • Request for specific treatment • Euthanasia For more information: American Bar Association – Commission on Law and Aging: http://www.americanbar.org/content/dam/aba/migrated/aging/toolkit/tool7.authcheckdam.pdf
When working with geriatric patients, clinicians must often confront issues surrounding care and treatment of the dying. For this reason, it is important for the clinician to understand concepts such as advanced directives, living wills, power of attorney, and do-not-resuscitate orders.
The clinician must also be prepared to wrestle with the kinds of ethical dilemmas associated with euthanasia, withdrawing and withholding treatment, and the patient refusal to accept treatment.
Although everyone is faced with these decisions at some time in their lives, it is especially important for clinicians to have the proper information and documentation at their fingertips when confronting these decisions.
Often times, family and friends are not in line with the wishes and wants of the patient. Simple tools such as the one from the American Bar Association Commission on Law and Aging can assist in patients communicating their end-of-life desires to their loved ones.
01.09.02 Advanced Directives: Living Wills • Explains type of care the patient would want to accept or reject in the future • Most often directs to withhold or withdraw life sustaining measures, but may
outline requests for care • Each state has different living will requirements and documents • Be aware of these documents before treatment
Advanced directives are specific written documents of empowerment executed when the patient is capable of choosing and intending to direct his or her future care. One example of such an advanced directive is a living will. Living wills are documents that specify the type of care the patient would want to accept or reject in the future should they be unable to make health care decisions.
Most often these documents direct physicians to withhold or withdraw life-sustaining measures, but they may also outline requests of care as well. Different states have specific requirements and documents for living wills; all healthcare providers should be aware of these documents and the patient’s wishes before treating a patient.
01.09.03 Advanced Directives: Power of Attorney
Power of Attorney:
• Allows competent person to delegate his rights • Invalid if patient becomes incompetent
Durable Power of Attorney:
• Allows competent person to delegate his rights • Valid if patient becomes incompetent
Durable Power of Attorney for Health Care Decision Making:
• Permits patient to delegate health care decisions • Valid when patient becomes incapacitated
Power of attorney and durable power of attorney are also considered advanced directives. A power of attorney is a document that allows a competent person to delegate some of his or her rights to someone else. This document usually becomes invalid if the person delegating the rights becomes incompetent.
A durable power of attorney is different from power of attorney in that it specifies that the appointee’s power begins or continues with the onset of incompetence.
An alternative document is the durable power of attorney for health care decision making that permits individuals to delegate health care decisions in case they become incapacitated.
01.09.04 Advanced Directives: Do-Not-Resuscitate (DNR) Orders • Used in hospitals and long term care facilities • Guides decisions about resuscitation • Decision made by
• Patient while competent • Family and practitioner
• Decision should be noted in patient’s chart
Do-not-resuscitate (DNR) orders are used in hospitals and long term care facilities to guide decisions about resuscitation. Such decisions should be made and documented while the patient is competent and still able to make the decision. The family and practitioners may also make the decision. Both parties should be aware of the decision and it should be noted in the patient’s chart.
01.09.05 Treatment Issues Related to End-of-Life • Ordinary and extraordinary treatment • Withdrawing and withholding treatment • Refusal of specific treatments
• patient’s rights should be respected • provide supportive palliative care
• Request for specific treatment • explain all options and consequences • respect wishes of patient
Issues regarding choice of therapy are frequently intertwined with end-of-life issues. The use of ordinary and extraordinary treatments is one such issue; withdrawing and/or withholding treatment is another. Physicians may find it difficult to deal with withdrawing treatment.
Before such a decision is made, the patient must be assessed thoroughly and carefully. Refusal of specific treatments by a patient may create dilemmas with healthcare providers, especially when the treatment is likely to prolong life. Providers should respect the rights of the patient and continue to provide supportive palliative care as best they can.
At the other end of the spectrum are patients who request specific treatments to prolong life. As in the case of refusal of treatment, request for treatment should be respected. The clinician should explain all options and consequences to the patient before treatment begins. Ultimately, patients are most worried about being a burden to their spouse and/or family. Their second greatest fear associated with dying is pain.
The primary goal of palliative sedation, also known as "terminal" or "total" sedation, in the patient with a terminal illness is:
A. Relief of intractable pain or suffering – CORRECT ANSWER B. Hastening of death C. Improved oxygenation D. Reduction in opioid medication doses Answer A. The essence of palliative care involves the relief of pain and suffering in the terminally ill patient. Palliative (or terminal) sedation describes the use of sedative agents (e.g., benzodiazepines, barbiturates) to treat pain or suffering in the dying patient when other treatment measures are ineffective. Palliative sedation is employed to relieve intractable symptoms in the dying patient, not to expedite the dying process. Palliative sedation is somewhat controversial as some argue that it is the ethical equivalent to euthanizing a dying patient given that death may be hastened with the use of sedative medications. Palliative sedation is more often administered for relief of intractable physical symptoms, such as dyspnea, pain, or agitation, than for so-called "psychic" suffering. As with other decisions made in palliative care, honest discussion between providers and the patient and family members about the use of palliative sedation should occur. 01.09.06 Euthanasia • Treatment and care must result in a peaceful, dignified, humane death with
minimal suffering • For patients with untreatable, progressive illness and unrelenting symptoms,
euthanasia may seem preferable • Sustained symptom relief combined with emotional and spiritual support may
provide an alternative to euthanasia • Several States have considered legislation on euthanasia and physician-
assisted suicide
Physicians are obliged to provide treatment and care that result in a peaceful, dignified, and humane death with minimal physical suffering. Sometimes when disease is progressive, treatment is futile, and symptoms such as pain cannot be easily alleviated, the patient may request to end his or her life. Although sustained, comprehensive symptom relief, combined with emotional and spiritual
support may provide an alternative to euthanasia for many dying patients, there are those who will continue to fight for their right to a dignified death.
Over the past two decades, several states have considered legislation regarding euthanasia and physician assisted suicide, making this issue even more controversial. At present, physician-assisted suicide is legal in the states of Oregon, Montana, and Washington, but only within very narrowly prescribed circumstances, i.e., for a terminally ill patient. As technology advances and we are able to keep patients alive a longer, the issue of quality of life becomes a major topic of discussion among the public and healthcare professionals.
01.09.07 Resources
For additional information, see:
Becker ES. Ethical issues in aging. Chapter 6 IN, Therapeutics in the elderly. Harvey Whitney Press, Cincinnatti, 2000 pp 135-156.
Emanuel LL, Barry MJ, Stoeckle J D, Ettelson LM & Emanuel EJ (1991). Advance care directives: A case for greater use. N. Eng J Med. 324: 889-895.
Emanuel LL, Barry MJ, Stoeckle J D, Ettelson LM & Emanuel EJ (1994). Advance directives: Stability of patients treatment choices. Arch Int Med. 154: 209-217.
Emanuel. L. (1997). Patient’s advance directives for health care in case of incapacity. In Cassel, C.K., et al (Eds.). Geriatric Medicine, 3rd ed. Springer; New York, NY.993- 1002.
Gore, M. J. (1993). Ethics: most people favor right to die. Consult Pharm; 8(11): 1289-1290.
McCullough, L. B., Doukas, D. J., Holleman, W. L., & Reilly, R. B. (1995). Advance Directives. In Reichel, W. (ed). Care of the Elderly: Clinical Aspects of Aging, 4th ed. Williams & Wilkins; Baltimore, MD. 597-608.
McCullough, L. B., Rhymes, J. A., Teasdale, T. A., & Wilson, N. L. (1995). Preventive ethics in geriatric practice. In Reichel, W. (Ed). Care of the Elderly: Clinical Aspects of Aging, 4th ed. Williams & Wilkins; Baltimore, MD. 573-786.
Meisel, A.(1989). The right to die. New York: John Wiley.
Singer, P. A. (1994). Disease-specific advance directives. Lancet; 344: 594-596.
Sloan, J. P. (1996). Protocols in primary care geriatrics. 2nd ed. Springer; New York, NY. 113.
Websites:
American Bar Association: Commission on Law and Aging
http://www.americanbar.org
Growth House Topi Incex
http://www.growthhouse.org/pages.html
Choice in Dying
http://www.choices.org/
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