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
individuals 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%)
Parkinsons Disease (5%)
Cancer (4%)

Mental Health Conditions Among Assisted Living Residents
Dementia (mild) (25%)
Depression (24%)
Alzheimers 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 Parkinsons disease
or Alzheimers 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 (CCRCs) 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 individuals
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. Alzheimers 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 20
th
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, 3
rd

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;22:224232. [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; Alzheimers and Parkinsons
disease; arthritis; pulmonary, metabolic, and cardiovascular
disorders; alcoholism
o Anxiety: delirium, dementia, schizophrenia; tumors; cardiovascular,
pulmonary and endocrine disorders; drug withdrawal

Pharmacological:

o Depression: H
2
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 individuals 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_g
uidelines_recommendations/2010/

Primary CareRelevant 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 Marys 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, 3
rd
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: Physicians Guide to Assessing and Counseling
Older Drivers, 2
nd
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_g
uidelines_recommendations/2010/

Primary CareRelevant 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 residents 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 doesnt 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 hasnt 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 doesnt 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 doesnt 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 patients 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.

Dont 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. Dont speak down to the patient, either literally or
figuratively. Just because an individual may have hearing loss it doesnt 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 medications
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 Im 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, dont 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

Dont 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 patients 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. Dont 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
patients time to attend to one thing at a timefirst, the verbal information point
by point, then the written information point by point.
Assess patients 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 patients, 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 patients 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 patients
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, 3
rd
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 patients 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 patients 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 patients behalf

Role of the Proxy:
Decided before the patient becomes incapacitated
Decisions of the proxy are based on:
specific knowledge of patients prior interests, opinion, beliefs
reasonable perspective in the patients 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 Alzheimers 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 patients 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 patients 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 patients
behalf. A substitute decision-maker or proxy can fill this role. Being a proxy
requires an understanding of patients 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 patients interest, for example, looking
at what the patients 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 patients interests.

Putting aside differences
and focusing on patients
interest
Self-effacement
Risking their relationship,
health, life by caring for
patients 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 patients interest. Self-sacrifice involves risking
ones relationship, health, and even ones life when threatened by the care of
patients 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 patients interest (self-effacement)
Risking their relationship, health, life by caring for patients 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. Patients Understanding: ask what patient believes about condition, diagnosis,
alternatives for managing, and prognosis of each alternative
2. Patients Accuracy of Understanding: correct factual error or incompleteness in
patients knowledge
3. Physicians 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. Patients Values: identify patients 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 patients preferences in step 7
9. Management Plan: reach a mutual decision about managing patients
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, 4
th
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 patients condition, management
alternatives
Discuss benefits/risks of each strategy
Identify and correct mistaken beliefs
Gather information on patients 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). Patients advance directives for health care in case of
incapacity. In Cassel, C. K., et al (Eds). Geriatric Medicine, 3
rd
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, 4
th
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, 4
th
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. 2
nd
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 ones 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 ones 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 ones 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, 3
rd

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 bodys 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 persons 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 patients 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 drugs
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):
Clcr
male
= (140-age)(Wt)
72 (Scr)
Clcr
female
= Clcr
male
(.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 patients 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
Alzheimers disease, Parkinsons 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 patients 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, 3
rd
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,
3
rd
ed. New York:McGraw-Hill.

Sharget, L. & Yu, A. B. C. (1992). Applied biopharmaceutics and
pharmacokinetics, 3
rd
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.authch
eckdam.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 patients
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 appointees 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 patients 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 patients chart.

01.09.05 Treatment Issues Related to End-of-Life

Ordinary and extraordinary treatment
Withdrawing and withholding treatment
Refusal of specific treatments
patients 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). Patients advance directives for health care in case of
incapacity. In Cassel, C.K., et al (Eds.). Geriatric Medicine, 3
rd
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, 4
th
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, 4
th
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. 2
nd
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/