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GR AFHS URI.2-22-21-HO version.pptx
- 1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Grand Rounds Joshua Murdock PharmD Mary McCormack FNP Topic: Age-Friendly Health Systems: Upper Respiratory Infection (URI) in the Older Adult Feel free to chat in the chat box. Remember to change your chat to ‘Everyone’ so we may all benefit from your comments. To Unmute your line: Click on your screen and then the microphone at the top of screen. Then click Unmute Call Aimee Kleppin DNP, FNP-BC
- 2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Providing Age-Friendly Care The goal is for all care with older adults to be Age-Friendly care, which: • Follows an essential set of evidence-based practices; • Causes no harm; and • Aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: • What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences • Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation • Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults • Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- 3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. How to Integrate 4Ms Care into the Clinic Visit What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: • What is most important for you during today’s visit? • What are you looking forward to this week? • What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? • Consider discussion about advance care planning if appropriate for the visit • During development of care plan: I would like to individualize your treatment with what matters most to you Medication • Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies • Reconcile medications with electronic health record • Cross-check for medications that may be on the AGS Beers© Criteria list Mentation • Assess patient’s ability to register, use kiosk, follow directions • Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© • Screen for dementia using the Mini-Cog™ • Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility • Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test • Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- 4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Learning Objectives At the end of this session, providers will be able to: • Identify AGS Beers Criteria© medications that place older adults 65 years of age and over at risk for adverse events • Reinforce proper identification of ingredients in over-the-counter medications for upper respiratory infections • Identify the interrelationship of the 4Ms in the context of an acute or chronic condition • Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- 5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Upper Respiratory Infection (URI) (S) Situation: Randall is a 66 year old male presenting to the clinic complaining of sinus pressure and nasal congestion for 1 week. He has been taking over-the-counter cold products but not feeling better. He usually plays tennis daily but has been unable to since getting sick. (B) Background: PMH: Hypertension Medications: lisinopril 10 mg PO daily, multivitamin 1 tablet PO daily, Mucinex in “the blue box daily” for past 5 days Social: Lives in private home with wife of 40 years. Non-smoker and denies alcohol use. Exercise: Walks a mile every morning with his wife; plays tennis regularly with wife and friends
- 6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Upper Respiratory Infection (URI) (Cont.) (A) Assessment: VS: BP 156/90 mmHg, HR 98/min, Temp 99.9F, RR 14/min, SpO2 98% on room air Repeat BP and HR = 146/86 mmHg, HR 90/min Mentation: PHQ-2 = 0 (negative); Mini-Cog = 5 (negative) Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair. General: Neatly groomed, pleasant Sinuses/Nose: Bilateral maxillary sinus tenderness, deviated septum, erythematous nares Respiratory: Lungs resonant and clear bilateral all lobes Cardiac: Mild tachycardia, regular rate, S1, S2, no murmur (R) Recommendation: Let’s discuss…
- 7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Recommendations • Initiate nasal saline irrigation and steam • Initiate fluticasone propionate nasal spray 1 spray each nostril daily for 1 week • Discontinue multi-symptom, over-the-counter cold medications • Educate that some over-the-counter cold remedies may increase blood pressure • Educate regarding importance of reading ingredients on any over-the-counter product • BP check in 1-2 weeks at PCP office or at clinic • Reinforce healthy lifestyle and exercise regimen • Encourage return to usual activities as tolerated
- 8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Pharmacological Considerations Over-the-Counter Medications Side Effects Decongestants Tachycardia, palpitations, hypertension, nervousness Antihistamines Anticholinergic side effects: Dry mouth, urinary retention, glaucoma, confusion, cognitive impairment; Ventricular arrhythmias; Prolonged QT interval Note: Anticholinergic burden is a concern in the care of older adults. Medications with anticholinergic properties may cause adverse events including: confusion, dizziness, falls An Anti-Cholinergic Burden (ACB) calculator is available at: http://www.acbcalc.com A score of ≥3 is associated with increased cognitive impairment and mortality.
- 9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Back to the case… Summary: ASSESS and ACT ON the 4Ms as a set What Matters: Know and act on each patient’s specific health outcome goals and care preferences • Tailor plan so URI can be treated sufficiently that patient is able to return to full activity level Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters • Treat URI as viral cause. Keep in mind antibiotic stewardship; Treat with antibiotics per guidelines if evidence of infection is clear after other treatments tried or sign/symptoms worsen • Avoid anticholinergic drugs Mentation: Focus on dementia and depression and delirium • Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper • Continue activities and socialization Mobility: Maintain mobility and function and prevent/treat complications of immobility • Encourage daily mobility; Encourage to resume usual activity, exercise, tennis as tolerated Provide 4Ms brochure with suggestions for patient/family to share with primary care provider including follow up that upper respiratory infection resolved, hypertension management, back to usual activity level • Don’t forget to scan into the EHR whenever individualized.
- 10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Interprofessional Team Discussion…
- 11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Acknowledgements Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A. Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
- 12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Thank You
Editor's Notes
- Today’s topic is: Upper Respiratory Infection (URI) in the Older Adult
- The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older. What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- This slide provides information to help integrate 4Ms care into the clinic visit. This is the basis of providing Age-Friendly care. You will become familiar with the Age-Friendly Health Systems 4Ms Framework logo. What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: What is most important for you during today’s visit? What are you looking forward to this week? What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? Consider discussion about advance care planning if appropriate for the visit During development of care plan: I would like to individualize your treatment with what matters most to you Medication Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies Reconcile medications with electronic health record Cross-check for medications that may be on the AGS Beers© Criteria list Mentation Assess patient’s ability to register, use kiosk, follow directions Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© Screen for dementia using the Mini-Cog™ Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- At the end of this session, providers will be able to: Identify AGS Beers Criteria© medications that place older adults 65 years of age and over at risk for adverse events Reinforce proper identification of ingredients in over-the-counter medications for upper respiratory infections Identify the interrelationship of the 4Ms in the context of an acute or chronic condition Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- S: Situation: Randall is a 66 year old male presenting to the clinic complaining of sinus pressure and nasal congestion for 1 week. He has been taking over-the-counter cold products but not feeling better. He usually plays tennis daily but has been unable to since getting sick. B: Background: PMH: Hypertension Medications: lisinopril 10 mg PO daily, multivitamin 1 tablet PO daily, Mucinex in “the blue box daily” for past 5 days Social: Lives in private home with wife of 40 years. Non-smoker and denies alcohol use. Exercise: Walks a mile every morning with his wife; plays tennis regularly with wife and friends.
- A: Assessment: VS: BP 156/90 mmHg, HR 98/min, Temp 99.9F, RR 14/min, SpO2 98% on room air Repeat BP = 146/86 mmHg; Repeat HR = 90/min Mentation: PHQ-2 = 0 (negative); Mini-Cog = 5 (negative) Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair. General: Neatly groomed, pleasant Sinuses/Nose: Bilateral maxillary sinus tenderness, deviated septum, erythematous nares Respiratory: Lungs resonant and clear bilateral all lobes Cardiac: Mild tachycardia, regular rate, S1, S2, no murmur R: Recommendation: Let’s discuss…
- These are some recommendations for the case: Initiate nasal saline irrigation and steam Initiate fluticasone propionate nasal spray 1 spray each nostril daily for 1 week Discontinue multi-symptom, over-the-counter cold medications Educate that some over-the-counter cold remedies may increase blood pressure Educate regarding importance of reading ingredients on any over-the-counter product BP check in 1-2 weeks at PCP office or at clinic Reinforce healthy lifestyle and exercise regimen Encourage return to usual activities as tolerated
- It is important to note that many over-the-counter medications have side effects, especially in older adults. Here are some examples: Decongestants may cause tachycardia, palpitations, hypertension, and nervousness. Antihistamines may have anticholinergic side effects such as dry mouth, urinary retention, glaucoma, confusion, and cognitive impairment. They may also cause ventricular arrhythmias and prolonged QT intervals. Also, note that anticholinergic burden is a concern in the care of older adults. Medications with anticholinergic properties may cause adverse events including confusion, dizziness, and falls. An Anti-Cholinergic Burden (ACB) calculator is available at the website provided: http://www.acbcalc.com. A score of ≥3 is associated with increased cognitive impairment and mortality.
- Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set. What Matters: Know and act on each patient’s specific health outcome goals and care preferences Tailor plan so URI can be treated sufficiently that patient is able to return to full activity level Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters Treat URI as viral cause. Keep in mind antibiotic stewardship; Treat with antibiotics per guidelines if evidence of infection is clear after other treatments tried or sign/symptoms worsen. Avoid anticholinergic drugs. Mentation: Focus on dementia and depression and delirium Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper Continue activities and socialization Mobility: Maintain mobility and function and prevent/treat complications of immobility Encourage daily mobility; Encourage to resume usual activity, exercise, tennis as tolerated Provide 4Ms brochure with suggestions for patient/family to share with primary care provider including follow up that upper respiratory infection resolved, hypertension management, back to usual activity level Don’t forget to scan into the EHR whenever individualized.
- Team discussion: Joshua Murdock pharmacist, Dr. Stephen Sebastian physician?