Geriatrics Test #2 Kuma

Front 1

SBP Throughout Life.......

Back 1

increases throughout life (lead pipe to decline)

DBP tends to decline

Front 2

ISH: Recent Guidelines

Back 2

JNCVI

Front 3

ISH

Back 3

isolated systolic HTN

Front 4

what should be your primary goal with ISH

Back 4

reducing SBP

Front 5

JNC 7: Hypertension in Older
Individuals

Front 6

do you start with 2 drugs in the elderly for ISH

Back 6

NO, because of tolerability

Front 7

Lowering SBP In Older Patients trials

Front 8

SHEP trial (1999): meds, inclusion BP, goal BP, primary outcome, mean age

Back 8

BP inclusion: 160-219/<90
goal SBP: <160
meds: diuretic, add BB
primary outcome: total stroke
mean age: 72

Front 9

Syst-Eur trial (1997): meds, inclusion BP, goal BP, primary outcome, mean age

Back 9

BP inclusion: 160-219/<95
goal SBP: <150
meds: DHP-CCB, add ACE/diuretic
mean age: 70
primary outcome: total stroke

Front 10

HYVET trial (2008): meds, inclusion BP, goal BP, primary outcome, mean age

Back 10

BP inclusion: 160-219/<95
goal SBP: >160/>110
meds: diuretic, add ACE
primary outcome: total stroke
mean age: 84

Front 11

results of SHEP vs. Syst-Eur vs. HYVET

Back 11

Relative Risk Reduction
Primary total stroke:
SHEP 36%
Syst-Eur 42%
Hyvet 30% (not significant because stopped early because showed decreased mortality and unethical to continue placebo treatment)

secondary total CV events
SHEP 32%
Syst-Eur 31%
Hyvet 34%

secondary Total mortality
SHEP 13%
Syst-Eur 14%
Hyvet 21% (why stopped early)
all results were significant except mortality decrease in SHEP, and syst-eur, and decrease in stroke in HYvet

Front 12

did the HYET just include ISH

Back 12

nope

Front 13

ANBP2 ISH

Back 13

Meds: ACE-I (enalapril) vs diuretic (HCTZ)

Front 14

ANBP2 ISH results

Front 15

LIFE ISH Substudy

Back 15

JUST ISH

every outcome was better with an ARB

Front 16

LIFE ISH Substudy outcomes

Front 17

SCOPE ISH Substudy

Front 18

SCOPE ISH Substudy outcomes

Front 19

is a BB first line for ISH

Back 19

nope

Front 20

Treatment Results for ISH/HTN in Elderly

Front 21

do you get benefits even if you do not reach SBP goals

Back 21

yep

Front 22

JNC-VI Treatment of ISH:
preferred drugs

Back 23

ACE: 1st of 2nd line
ARB: 1st of 2nd line
BB: 3rd line unless compellling indication

Front 24

diuretics may cause SE such as......

Back 24

Hypokalemia, gout, ↑ DM risk, urinary incontinence

Front 25

CCB (DH) may cause SE such as.....

Back 25

Peripheral edema, constipation

Front 26

ACE may cause SE such as.....

Back 26

Cough, hyperkalemia, ↑ SCr

Front 27

ARB may cause SE such as....

Back 27

Hyperkalemia, ↑ SCr, $$

Front 28

BB may cause SE such as....

Back 28

Use in caution with CHF/COPD, fatigu, decrease exercise intolerance

Front 29

ISH/HTN in Elderly Conclusions

Front 30

PATIENT CASE: SM is a 80 y/o WM with a history of
dyslipidemia, HTN, CKD and BPH. His BP is 156/79,
HR 78. His CrCl is 45 ml/min. His other medications
include: aspirin 81mg/d, terazosin 4mg/d, simvastatin
20mg/d and lisinopril 40mg/d. Which medication is
most appropriate for him at this time for the treatment
of his HTN?

A. Metoprolol
B. Amlodipine
C. HCTZ
D. Losartan
E. No treatment indicated

Back 30

B. Amlodipine

HCTZ not in this patient because of BPH

CKD goal <130/80

Front 31

DL background

Front 32

when do you see benefits when lipids are lowered

Back 32

at least 5 years

Front 33

treatment guidelines for older adults and DL are....

Back 33

AHA

section just for the elderly

Front 34

2001 NCEP III Guidelines

Front 35

what is the upper age limit of the framingham

Back 35

79

Front 36

minimum risk for females age 75-79

Back 36

4%

Front 37

minimum risk of males 75-79 (framingham)

Back 37

12%

Front 38

2002 AHA Scientific Statement (DL)

Front 39

2004 NCEP Report (DL)

Front 40

2008 ACC/AHA AVD Guidelines (DL)

Front 41

Major Clinical Trials:
Elderly Subgroups (DL)

Front 42

what was the percent of elderly, and lenght of trial for AFCAPS, CARE, 4S, LIPID

Back 42

AFCAPS
21% elderly
5.2 years follow up
CARE
31% elderly
5 years
4S
23% elderly
5.4 years
LIPID
39% elderly
6.1 years

illustrates need at least 5 years to see benfits with lipid lowering

Front 43

what results were significant in the AFCAPS, CARE, 4S, LIPID

Back 43

CARE
CHD death
Major CHD events (primary endpoint)
CHD death/nonfatel MI

4S
all cause mortality
CHD death
major CHD events (primary endpoints)
nonfatal MI
revascularization

4S
all cause mortality (primary mortality)
CHD death
major CHD events
nonfatal MI
revascularization

LIPID
all cause mortality
CHD death
CHD death/nonfatal MI (primary endpoint)

AFCAPS
nothing significant

subgroup anaylsis shouwed there was benfit in the elderly

Front 44

HPS and PROSPER (DL) lenght of studies

Back 44

5.5 years

3.2 years

Front 45

HPS and PROSPER results

Back 45

prosper showed no decrease in stroke and HPS did

not as effective to prevent stroke, treating CV events

Front 46

primary endpoint of Prosper

Back 46

CHD death/nonfatal MI/stroke

Front 47

What did the secondary endpoint of the prosper study show (DL)

Back 47

no difference in total stroke

Front 48

Prosper subgroup analysis showed (DL)

Back 48

use for secondary prevention
low HDL
men

these groups benefited the most from lipid lowering

Front 49

Prosper: drug, age, treatment lenght, N

Back 49

simvastatin 40 mg
age 40-80yrs
treatment lenght 5.5yrs
N=20,538 (28% 70-80)

Front 50

HPS: drug, age, treatment lenght, N

Back 50

pravastatin 40 mg
age 70-82
treatment lenght 3.2 yrs
N=5804

Front 51

TNT Elderly Subgroup (DL)

Front 52

TNT stroke reduction

Back 52

Stroke reduction

Front 53

was the jupiter study primary or secondary prevention

Back 53

primary prevention

Front 54

JUPITER Elderly Subgroup

Front 55

jupiter outcomes

Front 56

JUPITER Elderly Subgroup:
Baseline Characteristics

Back 56

51% women
69% HTN
66 %FH risk score >10%
9 % smoker
42% hsCRP ≥ 5.0 mg/L
66% LDL >100 mg/dL
40% metabolic syndrome
30% low HDL
30% pre-diabetic

Front 57

JUPITER Elderly Subgroup results

Front 58

Juptier CV reduction

Back 58

Major CV event reduction

Front 59

jupiter stroke reduction

Back 59

Major CV event reduction

Front 60

jupiter adverse events

Front 61

Safety Considerations:
Meta-analysis of Statins in Older Adults

Back 61

GI (N/V/D, constipation)
musculoskeletal

Front 62

Beyond Statins:
Other Drug Considerations

Front 63

Dyslipidemia Conclusions

Back 63

TLC for all with dyslipidemia
Statins

Front 64

do statins reduce stroke risk in the elderly

Back 64

nope

Front 65

PATIENT CASE: SM is a 80 y/o WM with a history of
dyslipidemia, HTN, CKD and BPH. He doesn’t
smoke. His TC, LDL, HDL, and TG are: 153, 78, 49,
and 132 mg/dl. His TC, LDL, HDL, and TG prior to
starting simvastatin were 188, 115, 47, and 132. Is
simvastatin appropriate for this patient and is the
dose appropriate?

A. Yes, Yes
B. No, --
C. Yes, No
D. Not sure

Back 65

need to get answer, ha
C. Yes, No

Front 66

HF in the Elderly

Front 67

Systolic (LVD)

Back 67

impaired LV contractility
increased preload= decreased SV
increased afterload=decreased in SV
ventricular remodeling and hypertrophy

Front 68

Diastolic HF

Back 68

normal or enhanced LV contractility
increased ventricular stiffness (decreased compliance-->problems with filling)
increased left atial and pulmonary pressures

preserved EF

Front 69

Heart Failure:
Preserved LV Function

Back 69

PLVEF

Front 70

Diagnosis of PLVEF

Front 71

Common Causes of PLVEF

Front 72

treatment Systolic HF

Back 72

Systolic

Front 73

treatment PLVEF

Back 73

not evidence based

no guidelines

Front 74

PLVEF Guidelines

Front 75

is rate or rhythm control safer in afib

Back 75

rate

if rate is controlled and rhythm is causing symptoms then treat

Front 76

Diastolic/PLVEF: Clinical Trials

Front 77

when do you use diuretics in HF

Back 77

to control fluid overload

dont use if volume delpeted

Front 78

what is digoxins role in HF

Back 78

last line to prevent hospitalizations

Front 79

do you ever use a CCB in systolic HF

Back 79

no

Front 80

can you use CCB in diastolic HF

Back 80

yep NDHCCB or DHP

(can control rate)

Front 81

PEP-CHF

Front 82

PEP-CHF results and conclusions

Front 83

CHARM-Preserved

Front 84

CHARM-preserved drugs

Back 84

ARB
BB
spironolactone

Front 85

CHARM-Preserved results and conclusions

Front 86

I-PRESERVE

Front 87

I-PRESERVE results and conclusions

Front 88

SENIORS trial

Front 89

SENIORS results and conclusions

Front 90

what type of HF did the seniors trial include

Back 90

both systolic and diastolic

therefore showed more benefit because systolic HF is more likely to benefit form a BB

Front 91

TOPCAT

Back 91

diastolic patients
spironolactone

Front 92

PLVEF Conclusions

Front 93

PATIENT CASE: SM is a 80 y/o WM with a history of
CAD, HTN, CKD and BPH and newly diagnosed
diastolic HF. His BP is 142/77, HR 76. His CrCl is 45
ml/min. His other medications include: aspirin 81mg/d,
terazosin 4mg/d, simvastatin 20mg/d, lisinopril
40mg/d, and HCTZ 25mg/d. Which of the following
treatments is most appropriate?
A. add BB
B. Change ACE-I to ARB
C. Add furosemide
D. Do nothing

Back 93

A. add BB

Front 94

Conclusions: CV in the Elderly

Front 95

Consultant Pharmacy and where they work

Back 95

Potential for assisted living facilities

Community residents (ASCP)

Large corporations

MMA PDP’s: Med D MTM

primarily in nursing homes

Front 96

Regulatory Issues with CP

Back 96

Help facilities comply with Federal and State Regulations (must know federal regualtions)

Facility Management Focus
survey process

Front 97

CP

Back 97

conslutant pharmacist

Front 98

Clinical issues and CP

Back 98

Health Management
DM, CHF, CKD, Fracture Prevention, Pain, Depression, Urinary Health, Dementia, etc
Drug related problems
Medication Monitoring
Polypharmacy
IDT’s (psychotropic , utilization review)

Front 99

what makes a good CP

Back 99

Communication
(80% of problems)
Communication

Documentation (so everyone else understands what was communimcates)

Communication (Perception) (show what you know)

Front 100

What Makes a Good CP continued

Back 100

Life Long Learning
Embrace the rules and regulations
Mentor relationship
Use care in answering questions
Julia Child vs. Sherlock HOlmes(critical thinkink is more important to figure out the problems)
BIG PICTURE

Front 101

BIG TAKE HOME POINT WITH CP

Back 101

use care in answering questions

ask clarifying questions

Front 102

Medication Regimen Review (CP)

Back 102

Document Visit (Sign Consultant Sheet)
Review:
Physician Orders
Telephone Orders
Physician Progress Notes
Vitals (who took, when and how
Medication Administration Record (d/d, timing of rugs if they are given together when not suppose to
Labs (monitoring)
Storage , Medication Pass, E - Kits

Front 103

Medication Appropriateness

Back 103

Indication for use
Medication known to be effective for indication
Dose correct (age, renal function, liver function, etc)
Directions for use correct
Assess for Drug-Drug Drug-Food interactions
Assess for Drug Disease interactions
Assess for Duplicate Therapy
Assess Duration of Therapy
Medication is NOT being used to treat the adverse effect of another drug
Medication is NOT causing a significant adverse effect
Medication is being monitored (vital signs, labs, etc)
Medication is cost effective

Front 104

Advantages of CP

Back 104

Flexibility in work schedule
You get to ski, hike, climb, fish, bike, etc
during the week
Diversity in daily activities
Use your clinical skills
Affect the lives of our Senior Citizens

get to see the end results and the changes you can make in someones life

Front 105

disadvantages of CP

Back 105

Travel (daily)
Work alone
No set schedule
No place to hide
Early Morning Meetings, Long Days
You can’t fix everything

Front 106

Student Consultant Pharmacist

Back 106

MRR reviews
Focus on F-329 table 1
HM reviews – fracture prevention, HF, DM, dementia, depression, pain, polypharmacy, VTE, CKD, etc
Audits: warfarin, insulin, crush meds, med pass, med storage, control substances, fentanyl and patches, meds with hold parameters, prn meds, etc

Front 107

Links for CP (like we need more links)

Back 107

The American Society of Consultant Pharmacy ascp.com
SeniorCarePharmacist.com
Commission for Certification in Geriatric Pharmacy ccgp.org
Colorado Foundation for Medical Care www.cfmc.org

Front 108

Geriatric Principals

Back 108

Rule out medications as the cause of any change in condition
Consider all medications even those being taken for years
Hospitalization is a change in condition

lookat all meds (may be cause of the problem)

Front 109

Cockcroft-Gault Equation

Back 109

CrCl (ml/min) = (140-Age) x Weight (kg) x (0.85 if female)
/72 x SCr

Front 110

when you have a Scr <1 what do you use for the cockcroft gault equation

Back 110

1

Front 111

what do you do if the mdrd and cockcroft gault equation are way different

Back 111

you have no idea of the renal function

Front 112

what if the cockcraft gault equation and mdrd give you similar results

Back 112

you have a good idea of the patients renal funciton

Front 113

what happens to half life of renally cleared drugs with a decline in renal function (this has been beat into our head)

Back 113

Half Life = T ½ of many medication increase with decline in renal function
Coumadin / Warfarin can be one of these
(T ½ 20-60 hr, up to 12.5days to steady state)
Time to steady state increases
Serum Levels may increase

Front 114

reserve capactiy and age

Back 114

as we age the body has a harder time responding to stress (less reserve capactiy)

less ability to respond to stress

Front 115

as we age what happens to muscle mass

Back 115

it declines (get fat)

Hydrophilic vs. Lipophilic

consider not using lipophilic becaue there half life will increae (diazepam)

Front 116

what happens to albumin levels as we age

Back 116

decline

so for portein bound drugs there will be more free/active drug

Front 117

achlorhydia

Back 117

decreased acid in the stomach

happens when we age

Front 118

PPI use in the the elderly

Back 118

Pervasive use of PPI medications
Omeprazole, Prilosec, Nexium, Prevacid, Protonix, Aciphex
Acid: part of immune system
C-Diff
Acid needed for absorption of vitamins and minerals

increase risk of fractures

Front 119

narrow therapeutic ranges drugs and elderly

Back 119

Medications with narrow therapeutic index
Therapeutic dose close to toxic dose
Warfarin, Digoxin, Theophylline, Lithium, Dilantin (phenytoin), methotrexate, etc

Front 120

polypharmacy

Back 120

When one medication is given to treat a side effect or adverse effect of another medication

bad bad bad

Front 121

Anticholinergic Medications and the old

Back 121

Dry Mouth (eating /nutrition problems)
Blurred Vision (falls)
Constipation (behaviors)
Urinary Retention
BP increase, clumsiness, unsteadiness, N/V, Delirium, Drowsiness, Lethargy, muscle weakness, flushing, nervousness, attention impaired, cognitive decline, confusion, disorientation, hallucinations, dizziness, memory loss, restlessness, irritability, etc

Front 122

Anticholinergic Medications
list

Back 122

Antihistamines (older sedating, Diphenhydramine)
Antidepressants (Elavil/amitriptyline)
Anti- emetics (Compazine, Phenergan)
Anti-Parkinson (Amantadine, Benztropine, etc)
Antipsychotic (Clozaril, Zyprexa) (Quetiapine Dry Mouth)
Cardio-vascular (lasix, digoxin, nifedapine, etc)
Gastrointestinal
Anti-spasmodic: (atropine, lomotil, hyoscyamine)
H-2 blockers (cimetadine)
Muscle Relaxants (Flexeril, Norflex, Dantrium)
Vertigo Meds (meclizine , scopolamine)

Front 123

beers list

Back 123

Potentially Inappropriate Medication Use in Older Adults

Front 124

how do we dose meds in the old

Back 124

Start Low
Go Slow (attempt to change one medication at a time)
GO to therapeutic doses

Difference between diagnosis of a disease and treatment of a syndrome

Front 125

Atypical Presentation of symptoms in the old

Back 125

rule out acute problem and medications

Inability to verbalize complaints and problems
Choose medications based on side effect profile

Front 126

what should aid in selection of meds for the elderly

Back 126

Choose medications based on side effect profile

Front 127

Adverse Drug Events in nursing homes example

Back 127

18 community nursing homes over 12 months
546 Adverse Drug Events
17% Identified by nursing home staff
50% characterized as preventable
72% of serious events characterized as preventable (inadequate monitoring, lack of response to signs of toxicity)
Antibiotics associated with non preventable
Anticoagulants, Diuretics, Psychoactives, Anti-Infectives, and Anticonvulsants associated with preventable events

Front 128

Take Home Message #2

Back 128

Identify the Underlying Cause
“Recognize and evaluate the onset of worsening of signs or symptoms, or a change in condition to determine whether these potentially may be related to the medication regimen; and follow up as necessary upon identifying adverse consequences”

Front 129

dont to forget to lokk at the cases for

Back 129

4/11

Front 130

What is Social Work?

Back 130

Commitment to Self-Determination
Quality of Life
Bio-psycho-social
Employed by governments, schools, mental health centers, hospitals, nursing homes, and private agencies such as home health services facilitate avaivable resourses in the community

fill out the paper work that coes with the resources

Front 131

Social Work & Older Adults

Back 131

Community Resources
Family and Social Support Networks
Transportation
Legal forms
Insurance & Health Delivery
Housing
Home Health Services
End-of-Life Care

Front 132

Pharmacy + Social Work = ?

Back 132

Barriers to compliance
Medication administration
Transportation
Insurance coverage
Financial resources
Cognitive impairment
Lack of family or social support
Pharmacists may be one of the most regular care providers a patient has contact with
Important to work as a “team” in the community

Front 133

social factors can be a cause of.....

Back 133

non-compliance

Front 134

Meals on Wheels

Back 134

Volunteers of America [phone]
For homebound elderly
Contribution of $2.50 per meal requested (don't have to pay)
Services include hot meal delivery, box of staples, and nutrition education
Waiting list for program (sometimes a year long)

if cannot get to grocery store

Front 135

Senior Centers
community resource

Back 135

Best resource = Senior Blue Book www.SeniorsResourceGuide.Com
www.SRCAging.org non-profit Senior’s Resource Center
Recreational Centers – some have annual membership requirements ($30 for Jewish Community Center)
Activities and Groups
Social Gatherings
Lunches
Some provide transportation ($5 round trip)

community type of program that is good for those that typically don't get out

Front 136

best senior center resource

Back 136

senior blue book

Front 137

Seniors Inc. community resource

Back 137

[phone]
Financial Management – free – income limits
Companionship Services – $12/hour and up (paying someone to do an activity with)
Energy Assistance – must have applied for LEAP
Caregiver Respite – free (grant funded) – 4 hrs/biweekly (when the family is burnt out)
Foster Grandparent – volunteer program

Front 138

Adult Protective Services (APS) community resource

Back 138

when feel some kind of abuse or self neglect, explotation is taking place (or any situation that makes you worry)

http://www.cdhs.state.co.us/aas/adultprotection_reporting.htm
Each county has an APS department through DHS
Colorado is one of only six states to rely on voluntary reports (McInnis-Dittrich, 2009)
Exploitation, abuse, and neglect including self-neglect
Neglect is the most common form of maltreatment (McInnis-Dittrich, 2009)

this is not alays the most efffect resource

Front 139

Care Managers community resource

Back 139

Private pay
$50-$200/hour plus a $50-$300 initial assessment fee
Usually an MSW or RN – many are certified
Helpful for families separated by long distances
Services offered
www.SeniorsResourceGuide.com
Area Agency on Aging
http://www.carecolorado.net/list10_co_Aging_Services_senior_centers.htm

Front 140

Adult Day Programs
community resource

Back 140

www.SeniorsResourceGuide.Com
Full or half-day programs
Costs average about $60-80 per day
Adults who need supervision and socialization
Cognitively impaired

socialization
activities
nutrition assey of how doing

Front 141

Home and Community Based Services (HCBS) community resources

Back 141

Medicaid waiver program for limited income
Longterm Care Options determines eligibility
Referral through county
In-home services for elderly, physically handicapped, or blind adults
Services can include:
adult day care programs
respite care for family caregivers
home health for nursing care
personal assistance services
care planning and case management
covers cost of assisted living
other services necessary to avoid nursing home placement



medicaid progream
have to be low income to be eligable

Front 142

transportation: personal vehical

Back 142

Safety can be assessed by
DMV
Spalding Rehabilitation (test to see if safe to drive)
Cost of owning a personal vehicle on a fixed income

Front 143

public transportation service

Back 143

RTD – transportation training classes
Access-A-Ride

Front 144

Transportation: Medicaid-covered for medical appointments only

Back 144

LogistiCare
Some cab services

for peps on medicaid

Front 145

transportation: Low-Cost or Free Services

Back 145

First Ride

Front 146

transporation: medication delivery

Back 146

for Rx

Front 147

transportation: handicapped status

Back 147

MD certification form to DMV

Front 148

Legal Forms (social services)

Back 148

MDPOA/Health Care Proxy (medical durable power of attorney)
COR Status – Colorado Directive
Five Wishes (developed by hospice and talkes through the decision making process)
Conservatorship
Guardianship (gives someone else all the health decision making rights, court appointed)

Front 149

Medical Durable Power of Attorney(MDPOA)

Back 149

MDPOA vs. POA
MDPOA vs. MPOA
“durable” = the agent has the power to make decisions even if the the individual becomes incapacitated
MPOA ends when the person becomes incapacitated
courts may be required to appoint a guardian or conservator
MDPOA must be signed by an adult with capacity, designating a person to make health care decisions on his/her behalf
Goes into effect when the person loses capacity
a physician must certify the loss of capacity in writing
Treatment may not be given to or withheld from the person if he or she objects
whether or not the person has capacity

Colorado Statute: Medical Durable Power of Attorney
http://www.nrc-pad.org/images/stories/PDFs/colorado_mpoastatute.pdf
dessginates someelse to make decesion when the other person cannot

Front 150

“durable” =

Back 150

the agent has the power to make decisions even if the the individual becomes incapacitated

Front 151

when feeling out a MDPOA what state of mind does the person have to be in

Back 151

the right mind (duh)

Front 152

COR Status

Back 152

Any directive must be physically present at the time of medical intervention, otherwise full resuscitation will occur
CPR Directive Bracelet or Necklace

DNR – Do not Resuscitate
Withhold CPR (Cardio-Pulmonary Resuscitation)
rescue breathing + chest compressions
Shocks (AED)


DNI – Do not Intubate
Breathing tube placed down throat and hooked to respirator

Full-COR
All medical interventions possible to restart the heart
CPR, AED, Etc

Front 153

DNR

Back 153

Do not Resuscitate
Withhold CPR (Cardio-Pulmonary Resuscitation)
rescue breathing + chest compressions
Shocks (AED)

Front 154

DNI

Back 154

Do not Intubate
Breathing tube placed down throat and hooked to respirator

Front 155

Full-COR

Back 155

All medical interventions possible to restart the heart
CPR, AED, Etc.

Front 156

Five Wishes

Back 156

Addresses medical, personal, emotional, and spiritual needs
Is legally recognized in 40 states including Colorado
Does not to have to be signed by a lawyer
Notarization is optional in Colorado
Requires the signatures of two witnesses
Can be filled out by anyone at any age
http://www.agingwithdignity.org

recognized in 40 states

Front 157

Colorado’s legal definition of capacity

Back 157

lacks ability to satisfy essential requirements for physical health, safety, or self-care, even with appropriate and reasonably available technological assistance
unable to effectively receive or evaluate information or both or make or communicate decisions
Needs cannot be met by less restrictive means
(American Bar Association Legislative Updates, December 2007)

MD can determine

Front 158

competence

Back 158

Court determines “competence”
Judge makes a decision based on the information presented
Judgment for either guardianship and/or conservatorship

Front 159

Conservatorship

Back 159

Conservators have legal authority to manage an individual’s financial affairs
Conservators become the Representative Payee for the individual’s government benefits
Can pay bills, access banking accounts, and make financial decisions on the individual’s behalf

Front 160

Guardianship

Back 160

Guardians have the authority to make decisions regarding all aspects of an individual’s care (except financial)
Requires assessment of a person’s functional status
Psychological evaluation and medical exam must clearly describe the history, nature, and degree of disability
There must be “clear and convincing evidence” that the person is incapacitated
Can fill out guardianship paperwork without a lawyer
www.guardianshipallianceofcolorado.org

last resort, a lot of assesment needed

court doesn't easily appoint

Front 161

Medicare

Back 161

Passed in 1965 as part of the Social Security Act
Entitlement program for people 65+, people on disability, and people with end-stage renal disease

Front 162

medicare part a

Back 162

Hospital Insurance
Home health & acute medical rehabilitation


free with ss or disabled

Front 163

medicare part b

Back 163

Supplementary Medical Insurance
Doctor’s visits & primary care

must pay for

Front 164

medicare part c

Back 164

Medicare Advantage Program
Managed care/HMO

Front 165

medicare part d

Back 165

Voluntary outpatient prescription drug coverage

Front 166

Medicaid

Back 166

state-based health insurance program for low-income

Front 167

medicaid for 65+

Back 167

http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1205745756665
Eligible for SSI and/or Old Age Pension
Income limit is $699 per month
Asset limit is $2,000 for an individual
Asset limit is $3,000 for a couple
Car and home not considered assets
Money in banks, investments, etc.
This amount is considered to be for burial

Front 168

long term care with medicaid

Back 168

Long Term Care Medicaid (nursing home)
http://www.colorado.gov/cs/Satellite?c=Page&cid=1205745755264&pagename=HCPF%2FHCPFLayout
Must be eligible for SSI or SSDI
(Either 65+ or disabled)
Income limit is $2,022 per month
Spouse’s income is not considered
Individual resource limit is $2,000
Individual resource limit is $4,000 for a couple if sharing a room or $3,000 if separate
$109,560 limit under spousal impoverishment protection (excluding house and car)
State can put a lien on the home
Seek legal advice

Front 169

to be on medicaid how much can be in savings

Back 169

</= 2000

Front 170

is your house considered an asset to medicaid

Back 170

yep

Front 171

how many peps can be in a medicaid nursing home room

Back 171

up to 3

Front 172

housing: independent living

Back 172

$238-$2,828/month
Residential home, senior high-rise, retirement community, etc.
Some senior housing accepts Section 8
Low-income subsidy for elderly
The majority of older adults continue to live at home

Front 173

housing: assisted living

Back 173

$1,100-$4,330/month
Can add care packages
Range from 8-118 beds
Memory Care Communities/Alzheimer’s Assisted Living
$1,950-$4,600/month

Front 174

housing: skilled nursing facility

Back 174

$3,750-$7,740/month
Long-term, skilled care
4.5% of adults over the age of 65 (AoA, 2006)

Rn on staff

Front 175

Home Health Services

Back 175

Home health services are designed to provide health services to people living in their own homes, rather than in health facilities or institutions
Most companies require at least a 2-hour minimum
Costs range, depending on the service
Home health costs in Denver $22/hour on average

Federal Long Term Care Insurance

care comes to you skilled and not skilled

Front 176

what are home health services covered by

Back 176

Medicare?
Skilled care for homebound older adults
Nursing, Physical Therapy, and Speech Therapy are the only stand-alone services
Home health aide/CAN, Social Work, and Occupational Therapy is covered only if skilled care is being received
Medicaid?
Home and Community Based Services covers ongoing long term care needs
Private Pay?
Companionship care, medication management, overnight aides, homemaker services, etc.

Front 177

Durable Medical Equipment

Back 177

Hospital beds, wheelchairs, walkers, bathroom equipment, etc.
Prescription required
MD, PA, NP
Private pay, Medicare, Medicaid
Medicare will not pay for any bathroom equipment
Can use private companies
National Medical
Praxair
Apria

prescribed by the doctor, PA, NP

medicar pays 80% if have

Front 178

Oxygen (social services)

Back 178

Must be ordered by MD, PA, NP
Sleep study must be completed for a C-Pap (Continuous Positive Airway Pressure)
Sleep apnea
Overnight oximetry test must be completed for overnight oxygen
Exception: if person is already on daytime oxygen
Equipment
Rent-to-Own
Medicare co-pay averages $35/month
Many changes in regulations

typically 80% coverage

Front 179

Palliative Care

Back 179

Consultation service related to goals of care and symptom management
Medicare covered under the hospice benefit

Front 180

Hospice

Back 180

Umbrella benefit for all diagnosis-related care
In-home medical team: nursing, CNA, dietician, pharmacy consultant, chaplain, social worker
attending physician (hospice MD or your own PCP)
In-home medications, equipment, family support
Inpatient: respite care and services for severe symptom management
Hospice required to have a bereavement program

Front 181

Certification Process for Hospice

Back 181

Who is a candidate?
Must have a physician’s order
Must have a terminal diagnosis with a prognosis of 6 months or less
Each certification period is for 90 days
An individual can be discharged from hospice and later re-qualify
Medicare and Medicaid pays

Front 182

Hospice Pharmacy

Back 182

Own formulary
“Care Pack” (no RX necessary)

Front 183

You are working in a community pharmacy in a large city. You have several elderly patients, one of whom, Mr. S, has been filling his prescriptions at your pharmacy for years. At one point, Mr. S used to drive himself to pick up his medications, but more recently has been relying on friends to help him. You know that he is a widower and his only child lives several states away.
Mr. S takes several controlled narcotics for pain relief, and usually picks his refills up immediately. The last time you saw him, which was about two months ago, you noticed that he looked disheveled, moved very slowly, and did not seem as alert as he previously had.
Mr. S seems to have declined significantly and has not picked up his medications, which were filled several days ago. You know that he receives his care at a nearby clinic that has two nurses and a social worker on staff. You are concerned about Mr. S and know that he needs his medications soon.
What do you do?

Back 183

call social worker at the clinic

if no social worker on staff or at the clinic
-involve the family members in in good relations (talk to pt)
-if lives with family and being neglected --> adult prootection services

if the patient continues to decline: can't make decisions to take care of himself needs higher level of care
-gaurdianship (have to have a dr. to see if meets criteria for incapacity athen court appointed)