Aging America: Caring for our Elders

MOAPA CONFERENCE JUNE 26, 2017

JOANN FRANKLIN, DNP, GNP-BC, FNP-BC, MHNP, FAANP MOQI ADVANCED PRACTICE RN

FRANKLINJB@MISSOURI.EDU

What is MOQI?

!CMS’ Initiative to Reduce Avoidable Hospitalization Among Nursing Home Residents, was awarded in 2012 to the Sinclair School of Nursing at the University of Missouri

!One of seven grants awarded across the country to reduce unnecessary transfers from LTC to hospitals

!Missouri leads all grants and NHC Desloge leads all Missouri homes

MOQICMS awarded an Initiative Grant of 14.8 million dollars to University of Missouri, Columbia who partnered with National Health Care (NHC) in Desloge and T&C, Missouri and 15 other Missouri Nursing Homes with goals of: 1. Reducing avoidable hospitalizations by recognizing illness early 2. Reducing antipsychotics in Dementia 3. Reducing polypharmacy 4. Increasing Advance Directive discussions PHASE 2 is 21 million 6 illnesses reimbursed in NH and compared with homes without NPs

Question: How many “Baby Boomers” turn 65 TODAY?

A. 1000 B. 3000 C. 5000 D. 10000 E. 15000

May 2016 Pew Research Center Global Attitudes Project Survey

! The 79 million Baby Boomers account for 26% of the total U.S. population. ! By numbers alone, they will redefine old age in America ! 20% Of Our Population Will Be 65 Or Older By 2030 ! By 2052 will we serve 40 Million Additional Medicare Patients

Silver Tsunami

Advances in healthcare allow people to live longer Aging makes us more venerable to chronic conditions which can accumulate Everyone wants to live a long time BUT no one wants to be OLD Western Medicine focuses on disease so we need to recognize the importance of disability prevention

Providing Aging Care

! Must be able to treat multiple chronic conditions rather than single illness ! Attaining an individuals goals of patients ! Look for modifiable factors as a broader approach ! Dementia prevalence doubles every five years after age 60 ! Rather than increasing longevity we should focus on increasing independent function to

reduce hands on care as long as possible

Question: What is the fastest growing age group in America?

A. Generation Z or Centennials: Born 1996 & later B. Generation Y or Millennials: Born 1977to 1995 C. Generation X: Born 1965 to 1976 D. Baby Boomers : Born1946-1964 E. Traditionalists or Silent Generation : Born 1945 and

before

1. Septicemia accounted for $23.7 billion (6.2%), 2. Followed by osteoarthritis, at $16.5 billion (4.3%), 3. Newborn infant care, at $13.3 billion (3.5%), 4. Complication of device, implant or graft, at a cost of $12.4 billion (3.3%), 5. Acute MI, at $12.1 billion (3.2%).

Total costs for all hospitalizations in 2013

In 2013, a total of 2,596,993 resident deaths were registered in the United States.

Life expectancy at birth was 78.8 years.

The 15 leading causes of death in 2013 were: 1. Diseases of heart (heart disease) 2. Malignant neoplasms (cancer) 3. Chronic lower respiratory diseases 4. Accidents (unintentional injuries) 5. Cerebrovascular diseases (stroke) 6. Alzheimer’s disease 7. Diabetes mellitus (diabetes) 8. Influenza and pneumonia 9. Nephritis, nephrotic syndrome and nephrosis (kidney disease) 10. Intentional self-harm (suicide) 11. Septicemia 12. Chronic liver disease and cirrhosis 13. Essential hypertension and hypertensive renal disease (hypertension) 14. Parkinson’s disease 15. Pneumonitis due to solids and liquids

1. congestive heart failure;

2. Spondylosis

3. intervertebral disc disorders and other back problems;

4. pneumonia;

5. coronary atherosclerosis;

6. acute cerebrovascular disease;

7. cardiac dysrhythmias;

8. respiratory failure, insufficiency, arrest (adult);

9. complications of surgery or medical care;

10. rehabilitation care, fitting and adjustment of prostheses;

11. mood disorders;

12. chronic obstructive pulmonary disease and bronchiectasis; 13. heart valve disorders;

14. diabetes with complications;

15. fracture of neck or femur;

16. biliary track disease.

TOP 16 Most Expensive Conditions 2015

Together, the 20 most expensive conditions accounted for nearly half (47.7%) of aggregate hospital costs.

They accounted for 43.7% of all hospital stays.

Leading Causes of Death 2015

• Heart disease: 614,348 • Cancer: 591,699 • Chronic lower respiratory diseases: 147,101 • Accidents (unintentional injuries): 136,053 • Stroke (cerebrovascular diseases): 133,103 • Alzheimer's disease: 93,541 • Diabetes: 76,488 • Influenza and pneumonia: 55,227 • Nephritis, nephrotic syndrome, and nephrosis: 48,146 • Intentional self-harm (suicide): 42,773

Huge Challenge to current Healthcare System

! Currently organ based care ie. Heart or lung specialist ! Need Holistic care ! Team based multidiscipline ! Performance and high quality care will be the focus ! Most older people want to stay at home ! Home care has expanded cheaper than Nursing Home ! Average NH cost $6000-8000/month 2016 ! Penalized for hospitalizations

Leading Geriatric syndromes

!Falls !Confusion ! Incontinence !Polypharmacy !Disability

Answers to independent function! Physical activity ! Walking 30 minutes -5 days a week ! Obesity problems lead to multiple chronic conditions ! Look at each individual and consider goals, values & preferences ! Consider prognosis so if limited less aggressive ! Direct your healthcare at each visit ! Consider hearing and sight impairments ! Patient centered goal oriented care

Question: Polypharmacy is defined by CMS as ??

A. Taking six medications B. Taking nine medications C. Taking twelve medications D. Taking multiple medications in the same class E. Taking multiple medications for coexisting conditions

increasing the risk of adverse drug interactions

Medication Safety IssuesCMS reports in 2011 almost ½ of NH residents had nine or more drugs = POLYPHARMACY

These conditions listed place older residents at risk: ! 1. Decreased renal function ! 2. Impaired vision & hearing ! 3. Cognitive & functional limitations

POLYPHARMACY

!Risky due to side effects and interactions !Expensive

!Can cause sedation !Can cause falls !Decrease interaction !Cause apathy

Multiple Medications often:

! Are often from the same class ! May not be at maximum dose ! Can be unnecessary ! Can be duplicates ! Can have interactions ! Can cause side effects ! Increase costs

Medication ReviewWhat is it treating?

Is it effective?

Does it require labs?

Are there current labs and are they normal? Is it routine and how often dispensed? Does it have stop date? Example PRN nystatin IF PRN has it been used in last 30 days? If PRN & used frequently MAKE ROUTINE

What is the drug treating?

!Example: multiple Antihypertensive meds !Check Epocrates for maximum dose !Try to use one medication per class to treat dx !Check VS & B/P to see if effective !Elders recommended B/P 150/90

DRUG LEVELSCheck Any blood levels of drugs in chart if Sub-therapeutic take action

Digoxin (not exceed >.125mg/day except in atrial arrhythmias)

Tegretol Dilantin

Lithium

Coumadin/ Warfarin (PT/INR) Levothyroxine (TSH)

Vitamin B12 Vitamin D

Unnecessary Drugs Are:

• Given excessive dose • Duplicate therapy • For excessive duration • Without adequate monitoring • Without adequate indications for use or • In presence of significant adverse side effects

Medications to assess! Elders on high risk medications (e.g., antipsychotics, diabetic

agents, anticoagulants) ! Elders with duplicate medications (e.g., multiple antihypertensives) ! Elders on medications requiring lab monitoring (e.g., Coumadin) ! Elders who have fallen ! Elders who have a change in condition ! Elders when returning from hospital

Question: At what age do you have a one in three chance of Dementia?

A. 65 years B. 68 years C. 72 years D. 85 years E. 90 years

Don’t Prescribe Describe! Eliminate drugs without indication, not efficacious, do not help with patient

goals, have more risk than benefit ! Guidelines recommend pills for each condition but does not take into account

multiple conditions and multiple guidelines also patients can have memory problems, mobility problems, incontinence , osteoporosis, frailty with slower physically & mentally

! Think about prognosis and life expectancy ! Any drug must be evaluated for indication, side effects, toxicity, possible allergy

or know as high risk to elderly ! Is there benefit? ! Most drugs do not prolong life ! Conversely cessation of drug does not mean it will shorten life ! Describe can take months set priorities and make plan

AVOID TOO MUCH ! Alternatives (warm milk not sleeping pill) ! Vague history or symptoms (GI upset with H2 blocker)

! OTC

! Interactions (drug-drug, drug disease)

! Duration (decide on trial if not effective STOP before adding another drug

! Therapeutic vs. preventative

! Once a day vs. BID, TID, QID (Once improves compliance >$$)

! Other MDs

! Money issues

! Adverse drug effects of other drugs (Do not treat adverse event with another drug)

! Need

! Yes/No ( Are they taking it?)

Eliminate Polypharmacy

! Reducing sedating medications results in increased alertness and activity

! Medication effect elders differently ! PRN medications should not be used it can cause confusion ! If PRN meds are used have stop dates like cough syrup ! Assess medications that can cause hypotension ! Less cost

Polypharmacy Reduction

!Medication is “a poison with a desired side effect” !Elders are on too many meds

!Polypharmacy is number one risk factor for hospitalizations

!Polypharmacy increases risk for falls !Polypharmacy increases adverse events and

interactions of medicationsadveevents

BEERS Criteria! 2012 American Geriatric Society updated Beers

Criteria for potentially Inappropriate Medication use in older Adults -34 medications and types of medications due to side effects

! (e.g.. Sliding Scale Insulin)

! Drug to drug interactions ! Doses adjusted with CrCl in mind and reassess ! Beware of BMI some drugs require lean BM ! Cascading drugs

Would you give these drugs to your mother if: ???

! Caused aspiration ! Made her drink less well ! Could make her more agitated ! Increase falling and hip fractures

! Increased aspiration pneumonia

! Increased chances of dying by 10%

! Didn’t work

! THESE ARE ANTIPSYCHOTIC DRUG EFFECTS

Hazards of Antipsychotics! Associated with increased risk of stroke, falls, dysphagia and

other neurologic risk

! NO Value of antipsychotics in treatment of behavioral and psychological symptoms of dementia

! CMS’s QM/QI report (July - September 2010) showed 39.4% of nursing home residents nationwide who had cognitive impairment & behavioral problems but no diagnosis of psychosis or related conditions received antipsychotic drugs

Antipsychotics

! Antipsychotics are off-label in Dementia with a “black box” warning

! Antipsychotic use in elders, increases mortality risk

estimated at 1.6-1.7 times higher than those not taking antipsychotics

! Elderly NH residents account for 20% or $1.7 million atypical antipsychotics

Which drug is in antipsychotic class?

A. Lamictal B. Nardil C. Pristiq D. Abilify E. Cymbalta

Advanced Directives

! Conversation Project ! April 16 National Healthcare Decisions Day ! Any age ! Wishes known if cant speak for self ! Who will speak for them ! Free forms Attorney General

Use Epocrates! Its free and easy

! List each drug

! Hit interaction

! Will give number behind each drug listed ! That tells which drugs are affected

Questions??????????

References

1. www.pewglobal.org 2017/04/9

2. NPR- 2014/05/19 Silver Tsunami and other Terms that can Irk the Over 65 Set

3. Reenita, Das Forbes A Silver Tsunami Invades the Health of Nations 4. https://www.senioradvosor.com The Silver Tsunami: What Senior Population Growth

Means to You 5. https://innovation.cms.gov Initiative to reduce Avoidable Hospitalization among Nursing

Facility Residents

6. Rantz, MJ, Flesner, MK, Franklin JA (2015). Better care, better quality: Reducing avoidable hospitalizations of nursing home residents

7. Power, Allen G., (2010). Dementia Beyond Drugs Changing the Culture of Care

8. https://psychnews.psychiatryonline.org/doi/10.1176/pn.43.14.0001 FDA Extends Black-Box Warning to all Antipsychotics

References Continued

9. Nursing Home Data Compendium 2012 available CMS

10. J Gen Internal Med 2009: 24(5) : 630-5 11. Paul G Perniciaro BS Pharm, R PH, CGP, FASCP

12. SLU GERIATRIC EVALUATION Mnemonic Screening tools