William Simonson

An Interprofessional Approach to Reducing the Risk of Falls Through Enhanced Collaborative Practice

Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty‐five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long‐term care, hospital, and home health settings for a structured intervention: a 4‐hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence‐based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long‐term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long‐term care settings.

When will there be a cure for dementia

There are now more than 5 million Americans suffering from Alzheimer’s dementia (AD) at an annual financial cost to the U.S. health care system of

Developments in geriatric cancer chemotherapy

200 billion a year but of course the real cost is the human tragedy that this disease causes as people lose their ability to function and as caregivers, often spouses and other family members, struggle to provide proper care for their loved ones. With the increasing baby boomer population, the number of Americans with Alzheimer’s dementia could skyrocket to 15 million by 2050 at an annual cost of

Cranberry products for urinary tract infections

1.2 trillion.1 The extent of this rapidly developing crisis has not escaped the government, academic research laboratories and the pharmaceutical industry which are pouring significant dollars into research to find a cure for this menace. In order for a safe and effective drug to be developed research scientists must first define a disease on a molecular level. That has not yet been accomplished for AD however the understanding of the pathogenesis of AD has increased greatly since the early 1990s resulting in increasing optimism that better treatments can be developed.2 AD is currently perceived as a protein aggregation disorder and researchers now know that a protein called amyloid-beta (Ab) plays an important role in the pathogenesis of AD. Aggregates of this protein are present in the extracellular plaques that are found in the brains of those with AD and it is now thought to be a toxin that leads to the dysfunction of neurons eventually leading to the extensive neurological damage that is the hallmark of this disease.2 Briefly, Ab is produced when beta amyloid precursor protein is improperly cleaved.3 It is an important step inwhat is referred to as the amyloid cascade hypothesis which researchers are targeting in order to prevent, or at least significantly delay, the ultimate damage

An aspirin a day…Does that make sense?

Historically, cancer chemotherapy has involved the use of intravenously administered toxins that target rapidly dividing cells. Since cancer cells are typically some of the most rapidly dividing cells in the body the theory was that these drugs would preferentially deliver their lethal effect to cancer cells while sparing nonmalignant cells. Unfortunately, other rapidly dividing cells fell victim to these treatments including those in the bonemarrow, oral mucosa and gastro-intestinal tract, giving cancer chemotherapy the potential to have serious and sometimes lethal side effects. Dosing protocols took into account, and were sometimes titrated by, the degree of toxicity. For example, some protocols specified downward dosage adjustments based on drug-induced decreases in the white blood cell count. This enabled clinicians to maintain a positive risk/benefit relationship between the therapies and the patients. Often elderly patients were more sensitive to the toxic effects of chemotherapy compared to younger adults and were therefore not always good candidates for many cancer chemotherapies. However, recent developments in cancer therapy, including the development of safer, more targeted therapies that can be administered by mouth, rather than by intravenous infusion, will make it possible to provide important treatment options to elderly cancer patients. Modern anti-cancer treatments are no longer targeting themass destruction of rapidly dividing cells. Rather, they are increasingly designed to target specific cancer cells through a variety of unique mechanisms. For example, some new agents harness the benefits of monoclonal antibodies which are essentially compounds that are designed to seek out, bind with, and selectively kill cancer cells, leaving the normal cells to continue producing needed blood cells, protect the lining of our GI tracts, and so on. An example of this type

Putting proton pump inhibitors into perspective

With the advent of the Antibiotic Stewardship Program, signed into law by President Barak Obama in 2014, antibiotic use will fall under increasing scrutiny. The interdisciplinary health care team will increasingly collaborate to reduce, and ideally eliminate, irrational and unnecessary use of antibiotics. This includes incorrectly using antibiotics to treat viral infections, unnecessarily long courses of antibiotic therapy and use of potentially dangerous antibiotics when safer agents are available. With antibiotic use going under a microscope it is likely that caregivers and patients will also look for natural alternatives to commercially manufactured antibiotics. Urinary tract infection (UTI) is one of the most common conditions for which antibiotics are routinely used in the older patient. Treatment regimens vary depending on a number of factors including the type and severity of infection andwhether it is acute or recurrent. The approach to antibiotic treatment of UTI has improved over time. It has been demonstrated that rather than a prolonged 10e14 day course of therapy, which was commonly prescribed decades ago, an acute, uncomplicated UTI can be treated with a short course of an appropriate antibiotic including nitrofurantoin monohydrate macrocrystals, 100 mg twice daily for 5 days or TMP-SMZ, 160/800 mg twice daily for three days.1 This approach makes sense from a pharmacologic and bacteriologic perspective because these antibiotics are excreted unchanged by the kidneys and each of these medications is concentrated in urine at levels that are far greater than that needed to eradicate typical bacterial pathogens. These shorter courses of antibiotic therapy are likely to decrease the cost of therapy and the risk of adverse antibiotic-induced side effects and will also likely reduce possible complications including the development of antimicrobial resistance and the occurrence of major alterations in the intestinal microbiome which can have profound negative consequences including putting the patient at increased risk of developing clostridium difficile infection.2

Revisiting non-steroidal anti-inflammatory medications

We all are familiar with the saying, “An apple a day keeps the doctor away” but we are more likely to take an aspirin (ASA) a day. Nearly 40% of US adults older than 50 years of age use aspirin for the primary prevention of cardiovascular disease (CVD) (prevention of first MI or stroke) or for secondary prevention of CVD (prevention of recurrence of MI or stroke).1 In this column I’ll look at the daily use of ASA and will summarize the most current thoughts and recommendations. Daily ASA use has become a routine part of the drug regimen of many elderly, particularly in “at-risk” individuals including those with diabetes mellitus; however, research published over the last five years calls in question the use of ASA for primary prevention of cardiovascular problems such as stroke and MI.2 My selection of this topic was triggered by recent discussions I’ve had with various prescribers. I was struck by the apparent confidence they had in their respective recommendations and was also struck by the difference in their recommendations including daily ASA dosage or whether I should even take it at all. Since drug therapy in the elderly is based primarily on a risk vs. benefit assessment I’ll first discuss the potential risk of daily ASA therapy. As with any drug, ASA is not free of side-effects. The problems most commonly associated with ASA use include bleeding, primarily in the gastro-intestinal tract and in the brain in the form of intracranial bleeding. Both the frequency and severity of these problems increasewith duration of ASA therapy and dose. There are a number of conditions and factors that can increase the risk of GI bleeds including history of GI ulcers or upper-GI pain, preexisting bleeding disorders, renal failure, severe liver disease and thrombocytopenia.2 Other problems that can increase the chance of both GI and intracerebral bleeding include use of anticoagulant drugs or

New drugs for Parkinson's disease

One of the most pertinent geriatric drug therapy mantras is “It’s a lot easier to start a drug than it is to stop a drug.”Medications that are considered to be safe and rather innocuous and medications that don’t always have a clear indication for use are much more likely to be started, not closely evaluated or reconsidered, and be used for periods of time longer, sometimes much longer, than necessary. One of the best examples of excessive use of a class of medications is the proton pump inhibitors (PPIs). This column is devoted to providing an updated perspective of the use of PPIs and will review some of the consequences of long-term PPI administration including comments on some new scientific studies. As a class, proton pump inhibitors have been a remarkable success. Numerous PPIs exist both as prescription and over the counter (OTC) medications and include omeprazole (Prilosec ), esomeprazole (Nexium ), pantoprazole (Protonix ) and lansoprazole (Prevacid ). The first prescription PPI became available in the US in 1989 and approval for OTC salewas granted in 2003. PPIs have been heavily promoted to prescribers and widely advertised to consumers. PPI use in the US includes 100 million prescriptions per year and countless numbers of OTC purchase with sales totaling well more than

Collaborative Falls Prevention: Interprofessional Team Formation, Implementation, and Evaluation

10 billion annually. More than 20 million Americans a year take a PPI.1 No doubt PPIs have done a stellar job controlling the symptoms of conditions related to excess stomach acid to the point where many people take a PPI chronically for months or years. In spite of their effectiveness, and apparent safety after short-term administration, new findings indicate that chronic administration may be associated with problems that the shortterm therapy evaluated in the original PPI research did not reveal. In response to this concern, the FDA has issued a series of communications warning of a number of potential problems associated

Biosimilar and interchangable biologic medications

Non-steroidal anti-inflammatory medications (NSAIDs) are among themost commonly used pain relievers. They are frequently used to treat pain and fever from many different longand shortterm medical conditions such as arthritis, menstrual cramps, headaches, colds and influenza.1 In 1984 ibuprofenwas the first NSAID to receive FDA approval in the United States. Now, 18 different NSAIDs have received FDA approval as over-the-counter (OTC) and/or prescription products and are available as tablets or as creams or gels to be applied topically. Early on it has been known that NSAIDs may cause gastric irritation and bleeding as well as reversible kidney damage. Since 2005 the FDA has required that all NSAIDs carry a “BoxedWarning” (commonly though incorrectly referred to as a “black-box warning”) that this class of medications may increase the risk of heart attack or stroke. After further review, in 2015 the FDA strengthened the warning and required additional information reflecting the following2: