Home Safety, Managing Vision, Drugs, Physical Exercise Cut Back On A Senior’s Fall Risk, CDC, Specialists Say (Part 2 of 2)

Australian Group Exercise Program–Lord, et al.
This study evaluated a 12-month group exercise group for frail older adults. The program was tailored to each participant’s abilities. Overall, the fall rate was 22 percent lower among people who took part in the program, and 31 percent lower among participants who had fallen in the previous year, compared with those who were not in the program.
POPULATION: Ages ranged from ages 62 to 95 although nearly all were 70 years or older. Most study participants were female. Participants lived in retirement villages and most were independent.
GEOGRAPHIC LOCALE: Sydney and Wollongong, Australia
FOCUS: Increase participants’ strength, coordination, balance and gait, and increase their ability to carry out activities of daily living such as rising from chair and climbing stairs.
PROGRAM SETTING: Programs were conducted in common rooms in residential care community centers and senior centers within the retirement villages.
DURATION: One-hour classes were held twice a week for 12 months. The program consisted of 4 successive 3-month terms.
KEY ELEMENTS: Information was not provided by the principal investigator.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Stephen R. Lord, PhD Neuroscience Research. Australia Barker Street, Randwick Sydney NSW 2031, Australia Tel: +61 (2) 9399 1061 Fax: +61 (2) 9399 1005 e-mail: [email protected]

Yaktrax Walker — McKiernan.
This study tested the effectiveness of the Yaktrax Walker, a lightweight traction device that fits over shoes, to prevent falls among older adults when walking outdoors on ice and snow. During the winter months, participants in the Yaktrax intervention group were half as likely to slip and about 60 percent less likely to fall compared to the group that wore their usual winter footwear. Participants in the intervention group also experienced significantly fewer minor fall-related injuries.
POPULATION: Participants were community-dwelling adults aged 65 or older who had fallen at least once in the previous year. About 60 percent were female.
GEOGRAPHIC LOCALE: Rural central and northern Wisconsin, United States FOCUS: Using a traction device that fits on shoes to improve stability when walking on ice and snow.
PROGRAM SETTING: Participants used the Yaktrax Walker on their own in the community.
DURATION: This study took place during the winter of 2003-04.
KEY ELEMENTS: People must be able to safely put on and take off the Yaktrax Walker or leave the device on a dedicated pair of shoes or boots that are only worn out of doors. Shoes should be measured to assure proper fit of Yaktrax Walker. Yaktrax Walker must not be worn indoors. Yaktrax Walker should be inspected for breakage and replaced if broken.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Fergus Eoin McKiernan, MD Center for Bone Diseases Marshfield Clinic 1000 North Oak Avenue Marshfield, WI 54449, United States e-mail: [email protected]

Veterans Affairs Group Exercise Group — Rubenstein et al.
This study evaluated a structured group exercise program for fall-prone older men. During the 3-month program, participants were two-thirds less likely to fall compared with those who did not take part in the program. Note: This study calculated the fall rate as the number of falls per hour of physical activity.
POPULATION: All participants were aged 70 or older and lived in the community. All were males who had at least 1 of these fall risk factors: leg weakness, impaired gait, mobility, and/or balance; and had fallen 2 or more times in the previous 6 months.
GEOGRAPHIC LOCALE: Los Angeles, California, United States
FOCUS: Increase strength and endurance and improve mobility and balance using a low-to moderate-intensity group exercise program.
PROGRAM SETTING: The program was conducted at a Veterans Affairs ambulatory care center.
DURATION: Three 1 1/2-hour sessions a week for 12 weeks.
KEY ELEMENTS: Using a group format and providing a wide variety of exercise activities.
Focusing on strength, balance and endurance. Providing personal encouragement and reinforcement
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Laurence Z. Rubenstein, MD, MPH VA Medical Center, GRECC (11e) 16111 Plummer St. Sepulveda, CA 91343, United States Tel: 818-895-9311. Fax: 818-891-8181 e-mail: [email protected]

Falls Management Exercise (FaME) Intervention — Skelton et al.
This study examined the effectivenss of an individualized, tailored group and home-based exercise intervention designed to improve participants’ dynamic balance and core and leg strength, and to recover their ability to get down to and up from the floor. After 36 weeks, the fall rate in the exercise group was reduced by one-third. Over the entire study, which included a 50-week follow-up period, the fall rate was reduced by 54 percent.
POPULATION: Participants were women aged 65 or older, living independently, who had fallen 3 or more times in the previous year.
GEOGRAPHIC LOCALE: London, United Kingdom
FOCUS: Improve balance and strength
PROGRAM SETTING: Group classes were conducted at 4 locations in London in Community Leisure Centers (gym facilities that have rooms for exercise classes). Home exercises were performed in participants’ homes.
DURATION: The pre-exercise assessment lasted about 40 minutes. One-hour group classes were held once a week for 36 weeks. 30 minutes of home exercises were done twice a week.
KEY ELEMENTS: To be successful, the exercise program should last at least 36 weeks.It should include a minimum of 2 hours per week of combined group and home exercises. Exercise must be progressive, continually increasing in intensity, resistance, weight, and challenging balance. Exercises must be tailored to each individual’s needs and abilities, both in group classes and at home. It is desirable but not essential to include floor work to reduce fear of falling and improve falls efficacy.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information. Dr. Dawn Skelton Reader in Aging and Health School of Health, HealthQWest A236 Govan Mbeki Building Glasgow Caledonian University Cowcaddens Road, Glasgow G4 OBA, United Kingdom Tel: +44 (0) 141 331 8792 e-mail: [email protected]

Central Sydney Tai Chi Trial — Voukelatos, et al.
This study evaluated the effectiveness of a community-based Tai Chi program to reduce falls among people aged 60 or older. One-hour classes were offered once a week for 16 weeks in community settings by experienced instructors who taught their regular programs using several styles of Tai Chi. After the 24-week follow-up period, the fall rate among Tai Chi participants was one-third lower and the rate of multiple falls was 46 percent lower than the rates for participants who did not take Tai Chi.
POPULATION: Participants were healthy people aged 60 or older who lived in the community. About 84 percent were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Improve balance and reduce falls.
PROGRAM SETTING: Tai Chi classes were conducted at community locations such as town halls and senior centers. Locations were chosen based on accessibility (e.g., accessible by public transportation, room accessible without climbing stairs), geographic diversity, and options for no- or low-cost sustainability after the study was completed.
DURATION: One-hour per week for 16 weeks.
KEY ELEMENTS: Limit class size to 12 people to maximize the attention each participant can get from the instructor. Incorporate relaxation and lowered center of gravity exercises into each class. It is important that participants maintain an upright (straight) posture at all times to reduce the risk of falling. Forms of Tai Chi that require participants to squat while moving or to get into positions that are not totally upright should be modified appropriately. Instructors need to be aware of participants’ comfort levels as well as any medical or physical conditions that may limit their ability to perform certain Tai Chi movements. Tai Chi movements should be introduced gradually so that participants are not exposed to too many new movements at once.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Alexander Voukelatos, PhD Sydney Southwest Area Health Promotion Service Level 9 (North), KGV building Missenden Road, Camperdown New South Wales 2050, Australia e-mail: [email protected]

Simplified Tai Chi — Wolf et al.
This study compared a 15-week program of Tai Chi classes that used 10 simplified movements, with a balance training program. After 4 months, the risk of falling more than once among participants in the Tai Chi classes was about half that of people in the comparison group. Participants reported that after the study they were better able to stop themselves from falling by using their environment and appropriate body maneuvers. After the study ended, almost half the participants chose to continue meeting informally to practice Tai Chi.
POPULATION: All were 70 years or older and lived in the community. Most study participants were female.
GEOGRAPHIC LOCALE: Atlanta, Georgia, United States
FOCUS: Improve strength, balance, walking speed, and other functional measures among seniors using Tai Chi.
PROGRAM SETTING: The program used facilities in a residential retirement community.
DURATION: The 15-week program included: Twice weekly 25-minute group sessions; Weekly 45-minute individual contact time with the instructor, and; Twice daily 15-minute individual practice sessions at home without an instructor.
KEY ELEMENTS: This program needs to be led by a very experienced Tai Chi grand master. No elements should be changed in order to replicate these results among seniors who are similar to study participants.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Steven L. Wolf, PhD, PT, FAPTA Department of Rehabilitation Medicine Emory University School of Medicine 1441 Clifton Road NE Atlanta, GA 30322, United States Tel: 404-712-4801 Fax: 404-712-5895 e-mail: [email protected]


The VIP Trial — Campbell et al.
This study looked at the effectiveness of 2 interventions to reduce falls and fall injuries in older people with poor vision. The home safety program consisted of a home hazard assessment by an occupational therapist followed by home modifications and recommendations for behavior change. The home exercise program consisted of a combination of strength and balance exercises (the Otago Exercise Program modified for people with poor vision) plus vitamin D supplements. Only the home safety program was effective in reducing falls. The home safety group had 61 percent fewer falls and 44 percent fewer injuries compared to those who received social visits.
POPULATION: Participants were community-dwelling seniors aged 75 or older with poor vision. Two-thirds of the participants were female.
GEOGRAPHIC LOCALE: Dunedin and Auckland, New Zealand
FOCUS: Assess and reduce home hazards and encourage changes in behavior.
PROGRAM SETTING: The program took place in participants’ homes of equipment that could lead to falls. The occupational therapist and participant then agreed on which recommendations to implement. The occupational therapist helped the participant obtain any necessary equipment and oversaw payment for the home modifications. Home modifications and equipment costing more than NZ$200 were funded by the local Board of Health and items costing less than this were funded by the participant or from research funds. The occupational therapist made a follow-up visit if equipment needed to be installed.
DURATION: The intervention consisted of 1 or 2 home visits. The first visit lasted about 2 hours. If the occupational therapist needed to approve new equipment, they made a second visit 2 to 3 weeks later. The second visit lasted about 45 minutes.
KEY ELEMENTS: The occupational therapist’s advice rather than the environmental changes was key. A trained and experienced occupational therapist is critical to the success of this intervention.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: A. John Campbell, MD Department of Medical and Surgical Sciences Dunedin School of Medicine Dunedin, New Zealand e-mail: [email protected]

Home Visits by an Occupational Therapist — Cumming et al.
This intervention used an occupational therapist (OT) who visited participants in their homes, identified environmental hazards and unsafe behaviors, and recommended home modifications and behavior changes. Fall rates were reduced by one-third but only among men and women who had experienced 1 or more falls in the year before the study.
POPULATION: All participants were 65 or older and lived in the community. More than half of the participants were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Assess and reduce home hazards.
PROGRAM SETTING: The program was conducted in participants’ homes.
DURATION: One-hour home visit with a follow-up telephone call 2 weeks later. Total contact time was approximately 2 hours.
KEY ELEMENTS: Using an experienced occupational therapist is critical. These researchers emphasized that this study should not be used to justify widespread, untargeted home modification programs implemented by people who do not have skills in caring for older people.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Robert G. Cumming, PhD School of Public Health, Building A27 University of Sydney Sydney NSW 2006, Australia Tel: +61 (2) 9036 6407 Fax: +61 (2) 9351 5049 e-mail: [email protected]

Falls-HIT (Home Intervention Team) Program — Nikolaus, et al.
This intervention provided home visits to identify environmental hazards that can increase the risk of falling, provided advice about possible changes, offered assistance with home modification, and provided training in using safety devices and mobility aids. The fall rate for participants was reduced 31 percent. The intervention was most effective among those who had experienced 2 or more falls in the previous year; the fall rate for these participants was reduced 37 percent.
POPULATION: Participants were frail community-dwelling older adults who had been hospitalized for conditions unrelated to a fall, and then discharged to home. Participants showed functional decline, especially in mobility. All were 65 or older and lived in the community. Three-quarters were female.
GEOGRAPHIC LOCALE: Mid-sized town, Southern Germany
FOCUS: Assess and reduce fall hazards in participants’ homes.
PROGRAM SETTING: Intervention team members contacted patients once or twice while they were hospitalized to explain the program. The program took place in participants’ homes.
DURATION: The program consisted of 2 or more home visits, each lasting about 1 1/2 hours. After the participant was discharged from the hospital, 3 home visits typically were needed to provide advice on recommended home modifications and to teach the participant how to use safety devices and mobility aids. On average, the total individual contact time was 8 hours.
KEY ELEMENTS: Participants met all intervention team members at the hospital before they were discharged, which facilitated follow-up.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Thorsten Nikolaus, MD Medical Director/CEO Bethesda Geriatric Clinic and Professor of Geriatric Medicine University of Ulm Zollernring 26, 89073 Ulm, Germany Tel: +49 731 187 185 Fax: +49 731 187 389 e-mail: [email protected]


Stepping On — Clemson, et al.
This study used a series of small group sessions to teach fall prevention strategies to community-dwelling older adults. The fall rate among participants was reduced about 30 percent compared with those who did not receive the intervention. The intervention was especially effective for men. The fall rate among male participants was reduced almost two-thirds.
POPULATION: Participants were individuals who had fallen in the previous year or who were concerned about falling. All were 70 or older and lived in the community. Most study participants were female.
GEOGRAPHIC LOCALE: Sydney, Australia
FOCUS: Improve self-efficacy, empower participants to make better decisions and learn about fall prevention techniques, and make behavioral changes.
PROGRAM SETTING: Initial sessions were conducted in easily accessible community settings. Refreshments were provided before and after the sessions to give participants an opportunity to talk to each other and with the facilitators and content experts. Follow-up visits took place in the participants‘ homes.
DURATION: • Seven weekly 2-hour program sessions • A 1- to 11⁄2-hour home visit, 6 weeks after the final session • A 1-hour booster session 3 months after the final session
KEY ELEMENTS: Using content experts is critical. It is also important to let each expert know what is expected of them, to provide feedback, and to make sure each focuses on fall prevention. The Stepping On manual is essential for all program facilitators and provides a step-by-step guide to running the 7-week group program. It outlines topic areas and provides the background information for each content expert. Chapters include: Essential background information for understanding the conceptual underpinning of the program and the group process; Valuable content information for all the key fall prevention areas that can be used to train local experts participating in the program; A guide to useful resources; Handouts for group participants; Ideas on recruitment and evaluation, and; Work is ongoing to develop training workshops and certification for Stepping On program leaders.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Lindy Clemson, PhD Associate Professor in Aging, Head of Discipline (Occupational Therapy) Faculty of Health Sciences, The University of Sydney Cumberland Campus, PO Box 170 Lidcombe 1825, Australia Tel: +61 (2) 9351 9372 Fax: +61 (2) 9351 9166 E-mail: [email protected]

PROFET (Prevention of Falls in the Elderly Trial) — Close, et al.
This intervention provided medical assessments for fall risk factors with referrals to relevant services and an occupational therapy home hazard assessment with recommendations for home modifications. After 12 months, those in the intervention group were 60 percent less likely to fall once and 67 percent less likely to fall repeatedly (at least 3 times), compared with those who did not receive the intervention.
POPULATION: Participants were seniors who had been treated for a fall in a hospital emergency department. All were aged 65 or older and lived in the community. Two-thirds of participants were female.
GEOGRAPHIC LOCALE: London, United Kingdom
FOCUS: Identify medical risk factors and home hazards, and provide referrals and/or recommendations to reduce fall risk and improve home safety.
PROGRAM SETTING: The medical assessment took place in an outpatient hospital clinic. The occupational therapy assessment took place in participants’ homes.
DURATION: The average length of the medical assessment was 45 minutes. The average length of the home assessment was 60 minutes.
KEY ELEMENTS: For medication review and modification, a medical specialist rather than a general practitioner is recommended.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Jacqueline Close, MD Neuroscience Research Australia Barker Street, Randwick Sydney NSW 2031, Australia Tel: +61 (2) 9399 1055 Fax: +61 (2) 9399 1005 E-mail: [email protected]

Accident & Emergency Fallers — Davison, et al.
This multifaceted intervention was designed for people who fell repeatedly. Participants received a medical fall risk assessment by a geriatrician at the hospital and had in-home assessments by physical and occupational therapists. Each participant received an individualized intervention designed to reduce their fall risk factors. After 12 months, the fall rate in the intervention group was 36 percent lower than the rate in the comparison group.
POPULATION: Participants were men and women aged 65 or older. All had experienced at least 1 fall in the past year and also had been treated in the emergency department for another fall or fall injury. About three-quarters of participants were female.
GEOGRAPHIC LOCALE: Newcastle, United Kingdom
FOCUS: Identify and modify each participant’s fall risk factors.
PROGRAM SETTING: The medical assessment was conducted in a hospital and the physical therapy and home assessments were conducted in participants’ homes.
DURATION: On average, participants visited the hospital twice for the medical intervention. The initial hospital assessment took 1 hour and the medical intervention visit was 20 minutes. Participants received 2 physical therapy intervention visits; the initial physical therapy assessment took 45 minutes and the intervention lasted 15 minutes. The occupational therapy visit took 45 minutes and the follow-up visit about 1 month later lasted 20 minutes.
KEY ELEMENTS: Multifactorial assessments and interventions conducted by highly trained individuals in each of the 3 disciplines.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. John Davison Falls and Syncope Service and Institute for Aging & Health Royal Victoria Infirmary Newcastle upon Tyne NEI 4LP, United Kingdom Fax: (+44) 191 222 5638 E-mail: [email protected]

The No Falls Intervention — Day, et al.
This study looked at the effectiveness of group-based exercise in preventing falls when used alone or in combination with vision improvement and/or home hazard reduction. The intervention components focused on increasing strength and balance, improving poor vision, and reducing home hazards. The group-based exercise was the most potent single intervention; when used alone, it reduced the fall rate by 20 percent. Falls were reduced further when vision improvement or home hazard reduction was combined with exercise. The most effective combination was the group-based exercise with both vision improvement and home hazard reduction. Participants who received all 3 components were one- third less likely to fall.
POPULATION: All participants were aged 70 and older and lived in the community. Sixty percent were female.
GEOGRAPHIC LOCALE: City of Whitehorse, Melbourne, Australia
FOCUS: Increase strength and balance, improve poor vision, and reduce home hazards.
PROGRAM SETTING: The exercise program was delivered in community settings such as exercise rooms in fitness centers and community health centers. The vision intervention was delivered via usual services available in the community. Participants went to their optometrist or ophthalmologist if they had one. If any further action was required, it was facilitated using normal services such as hospitals for cataract surgery, optometrists for new glasses, and general practitioners or ophthalmologists for medication if required. The home hazard intervention was conducted in participants’ homes.
DURATION: Exercise: Weekly 1-hour group classes for 15 weeks and 25 minutes of daily home exercises. Vision improvement: Duration depended on the specific intervention (such as cataract surgery or new glasses). Home hazard reduction: Duration depended on the length of time the home modifications were left in place by the participant.
KEY ELEMENTS: Although the most effective single component was the NoFalls exercise program, the complete program should be followed because partial implementation may not reduce falls.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Lesley Day, PhD, MPH Accident Research Centre Building 70, Monash University Wellington Road Clayton Victoria 3800, Australia Tel: +61 (3) 9905 1811 Fax: +61 (3) 9905 1809 E-mail: [email protected]

The SAFE Health Behavior and Exercise Intervention — Hornbrook, et al.
The Study of Accidental Falls in the Elderly (SAFE) health behavior intervention was a program of 4 group classes on how to prevent falls. The classes addressed environmental, behavioral, and physical risk factors and included exercise with instructions and supervised practice. The home safety portion included a home inspection with guidance and assistance in reducing fall hazards. Overall, participants were 15 percent less likely to fall compared with those who did not receive the intervention. Male participants showed the greatest benefit.
POPULATION: All were participants were 65 or older and lived in the community. About 60 percent of participants were female.
GEOGRAPHIC LOCALE: Portland, Oregon, and Vancouver, Washington, United States
FOCUS: Reduce risky behaviors, improve physical fitness through exercise, and reduce fall hazards in the home.
PROGRAM SETTING: No information was available on where risk education and group exercise classes took place. Home safety inspections were conducted in participants’ homes.
DURATION: Two home visits, each lasting about 15 minutes. Four weekly 11⁄2-hour classes (including 20 minutes of supervised exercise) over a 1-month period
KEY ELEMENTS: Information was not provided by the principal investigator.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Mark C. Hornbrook, PhD Chief Scientist The Center for Health Research, NW/HI/SE Kaiser Permanente Northwest 3800 North Interstate Avenue Portland, OR 97227-1110, United States Tel: 503-335-6746 Fax: 503-335-2428 E-mail: [email protected]

Multifactorial Fall Prevention Program — Salminen, et al.
This multifaceted fall intervention consisted of a geriatric fall risk assessment with counseling and guidance in fall prevention; home hazards assessment and modification; group and home-based exercise; group lectures on topics related to fall prevention; and monthly participation in a psychosocial group. The intervention did not reduce falls overall. However, falls were decreased 41 percent in participants who had experienced 3 or more falls in the previous year and 50 percent in participants with more symptoms of depression.
POPULATION: Participants were seniors aged 65 or older who lived in the community or in housing that provided occasional assistance, had no or little cognitive impairment, and had experienced at least 1 fall in the past year. Eighty- four percent of participants were female.
FOCUS: Assess and address each participant’s specific fall risk factors, improve physical fitness, provide information and counseling on fall prevention, assess and modify home hazards, and provide psychological support.
PROGRAM SETTING: The fall risk assessment, counseling, and group exercise classes were conducted in the Pori Health Center or at home for those participants living in assisted housing. Lectures and psychosocial groups were held in a senior center. The home-based exercises and home assessment were carried out in participants’ homes.
DURATION: • 45-minute fall risk assessment • 45-minute home hazard assessment • 45-minute information and counseling session • 45- to 50-minute group exercise class once every 2 weeks plus 25 minutes of exercise at home 3 times per week • 1-hour health lecture once a month • 1-hour psychosocial group session once a month.
KEY ELEMENTS: • Individual risk factor assessment, treatment, and/or referral by a physician. Exercise classes led by a trained physical therapist or physical therapy student, combined with at-home exercises tailored to each participant • Exercise intensity must increase progressively over time • Monthly lectures by various health professionals on topics related to • falling, followed by a question and answer period • Individual guidance on fall prevention • Home hazards assessment and written safety recommendations • Monthly psychosocial group sessions.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Marika J. Salminen, PhD Family Medicine Lemminkäisenkatu 1 FI-20014 University of Turku Turku, Finland E-mail: [email protected]

The Winchester Falls Project — Spice, et al.
This study evaluated the effectiveness of 2 fall interventions. The primary care intervention consisted of fall risk assessments by nurses followed by referrals to other professionals. The secondary care intervention involved multidisciplinary fall risk assessments (by a doctor, nurse, physical therapist, and occupational therapist), followed by appropriate interventions and follow-up if necessary. Only the secondary care intervention was effective in reducing falls. Compared to the group who received usual care, participants in the secondary care multidisciplinary intervention were half as likely to fall, a third less likely to sustain a fall-related fracture, and 55 percent less likely to die in the year following the intervention.
POPULATION: Participants were community-dwelling adults aged 65 or older who had sustained 2 or more falls in the previous year. About three- quarters were female.
GEOGRAPHIC LOCALE: Mid Hampshire, United Kingdom
FOCUS: Assess fall risk factors and provide individualized interventions.
PROGRAM SETTING: Baseline assessments were conducted in a multidisciplinary clinic with referrals for interventions and follow-up if necessary.
DURATION: Fall risk assessments took about 2 hours. The amount and duration of the follow-up interventions varied by the type of interventions received.
KEY ELEMENTS: Doctors, nurses, physical therapists, and occupational therapists used a structured in-depth assessment instrument.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. Claire Spice Department of Medicine for Older People Portsmouth Hospitals NHS Trust Queen Alexandra Hospital Southwick Hill, Cosham PO6 3LY, United Kingdom E-mail: [email protected]

Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) — Tinetti, et al.
This study used a tailored combination of intervention strategies based on an assessment of each participant’s fall risk factors. Participants were about 30 percent less likely to fall compared with people who did not receive the intervention.
POPULATION: Participants were members of a health maintenance organization. All were 70 or older and lived in the community. Most participants were female.
GEOGRAPHIC LOCALE: Farmington, Connecticut, United States
FOCUS: Identify and modify each participant’s risk factors.
PROGRAM SETTING: The intervention was delivered to participants in their homes.
DURATION: The intervention was conducted over a 3-month period. The amount and duration of contacts varied by the type of interventions received.
KEY ELEMENTS: The assessments need to be clearly linked to the intervention components. The minimum risk factor interventions include (1) postural blood pressure and behavioral recommendations; (2) medication review and reduction (especially psychoactive medications); (3) balance, strength, and gait assessments and interventions; and (4) environmental assessment and modification. It is essential that the progressive balance and strength exercise program includes both supervised and at-home (unsupervised) components.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Mary Tinetti, MD Department of Epidemiology and Public Health Yale University School of Medicine Internal Medicine-Geriatrics, PO Box 208025, New Haven, CT 06520-8025, United States Tel: 203-688-5238 Fax: 203-688-4209 E-mail: [email protected]

A Multifactorial Program — Wagner, et al.
This study tested a moderate-intensity intervention that used tailored strategies based on assessments of each participant’s risk factors. After 1 year, participants were 10 percent less likely to fall and 5 percent less likely to have an injurious fall, compared with people who received usual medical care.
POPULATION: All participants were 65 or older and lived in the community. About 60 percent of participants were female.
GEOGRAPHIC LOCALE: Seattle, Washington, United States
FOCUS: Reduce disability and/or falls by: improving physical fitness, modifying excessive alcohol use, improving home safety, reducing psychoactive medication use, and improving hearing and vision.
PROGRAM SETTING: Participants received the assessments and interventions from a nurse at local health maintenance organization (HMO) centers. Participants conducted a home assessment or had it done by a family member or volunteer.
DURATION: The initial visit consisted of a 1- to 11⁄2-hour interview. The length and number of subsequent sessions varied by the type of interventions selected for each participant.
KEY ELEMENTS: The nurse’s follow-up phone contacts and home visits may have had positive effects on participants’ health that were independent of the interventions for specific risk factors.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Edward H. Wagner, MD, MPH Group Health Research Institute 1730 Minor Avenue, Ste. 1290 Seattle, WA 98101, United States Tel: 206-287-2877. E-mail: [email protected]


“Did You Know?” brochure, Active Rx Active Aging Centers, 201 E. Ogden Ave., Hinsdale, IL Corner of York and Ogden, (888) 960-4562.

“National Estimates of the 10 Leading Causes of Nonfatal Injuries Treated In Hospital Emergency Departments, United States,” Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Data Source: NEISS All Injury Program operated by the Consumer Product Safety Commission (CPSC), 2010.

Stevens, Judy A., PhD; A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults; Second Edition, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, (2010),https://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf and http://www.cms.gov/PrevntionGenInfo/Downloads/Exercise%20Re-port.pdf

Stevens, Judy A., PhD; and Burns, Elizabeth, MPH, A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults; Third Edition, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, (2015), https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_compendium-2015-a.pdf

“Stopping Elderly Accidents, Deaths and Injuries” (STEADI) Tool Kit, Center for Disease Control and Prevention’s (CDC) Injury Center for health care providers, http://www.cdc.gov/injury/STEADI.

Home Safety, Managing Vision, Drugs, Physical Exercise Cut Back On A Senior’s Fall Risk, CDC, Specialists Say (Part 1 of 2)

by Vladimire Herard

Uncluttering his or her private home and spaces, checking vision needs, managing illnesses and medications and conducting physical exercise and therapy reduce a senior’s risk of falling and prevent injuries, the Centers for Disease Control and Prevention (CDC) says.

Through its suite of online and offline educational materials to instruct and guide seniors, their families and their physicians about fall risk and injury prevention, the CDC makes the following recommendations:

–Clear floors and other spaces in the home of debris to avoid accidents;

–Check and care for vision to improve spatial judgment;

–Manage chronic illnesses and medications with side effects that affect physical balance, and;

–Practice physical exercise and obtain physical therapy services to correct balance-related conditions.

Specifically, the CDC creates, releases and updates its “Stopping Elderly Accidents, Deaths and Injuries (STEADI) Tool Kit,” an online raft of instructional works that measures, treats and recommends solutions for seniors, their families and friends, based on the risk of falling.

The STEADI took kit can be found at the agency’s website at http://www.cdc.gov/injury/STEADI.

The federal agency also collaborates with the Centers for Medicare and Medicaid (CMS) and the RAND Corporation to make available “A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults,” a guidebook to teach public health physicians and senior care providers about 22 of the most effective, research-based falls prevention programs globally.

Editions of the compendium by researchers with the CDC’s National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention and the Home and Recreation Injury Prevention Team are available at the agency’s website at https://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf and http://www.cms.gov/PrevntionGenInfo/Downloads/Exercise%20Report.pdf and https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_compendium-2015-a.pdf.

On the private sector side, physical therapy facilities offer one-on-one physical therapy, small group strength therapy and programs meant to address balance, cognitive function flexibility, mobility, strength and overall physical wellness and to improve the independence of senior patients.

These facilities focus on examining and treating neurological, orthopedic, vestibular and balance disorders that can lead to falls in seniors.

Federal research demonstrates the extent to which senior patients at risk for falls and injuries need physical therapy services: one out of three adults over the age of 65 fall annually and those who do are two to three times more likely to do so again. At that age, most adults lose 33 percent of their 30-year-old levels of strength.

Overall, seniors seek a sense of control over their lives and independence and falls can hamper their efforts to stay self-sufficient. Fall injuries can cause physical disability as well as a lack of independence and a lowered quality of life.

In 2000, the CDC reported, fall injuries cost the nation $19 billion and this figure rose to $34 billion in 2015. To reverse these trends would mean to comprehend that falls are not a prerequisite for aging and that scientifically-based prevention interventions can decrease their incidence.

Additionally, two-thirds of members of the Baby Boom generation, who have already begun to age in this decade, are now enduring chronic illnesses that restrict their physical capacities.

By the time, they reach age 74, 25 percent of the men and 66 percent of the women will not be able to hold a 10-pound bag of groceries, federal research shows.

STEADI Tool Kit Brochures, Material

Through its STEADI toolkit, the CDC provides a set of educational materials for physicians and senior long-term care providers and a separate collection for senior patients and their families.

For physicians, the agency releases an “algorithm flow chart for fall risk assessments and interventions; directions for conducting gait, strength and balance assessments; fact sheets about falls, medications and fall risk factors; a pocket guide for fall prevention algorithm and prevention; a summary checklist for fall risk factors; a wall chart for integrating fall prevention into practice; referral forms and recommended fall prevention classes; materials for talking with patients about fall prevention, and; instructions for measuring orthostatic blood pressure.”

For patients, the agency publishes a self-risk assessment brochure titled “Stay Independent”; a brochure titled “Postural Hypotension: What It Is and How To Manage It”; a brochure titled “What YOU Can Do To Prevent Falls: Proven Strategies To Prevent Falls”; a home safety brochure titled “Check for Safety: A Home Fall Prevention Checklist for Older Adult” by the CDC and the MetLife Foundation; and a one-page instructional handout on chair rise exercise.

Particularly with its “What YOU Can Do To Prevent Falls” brochure as part of the took kit, the CDC urges senior patients to commit to four actions to prevent falls: start a physical exercise program; allow a healthcare provider to review their medicines; have their vision examined, and; improve the safety and security of their homes.

For physical exercise, the agency explains that exercise reduces a senior patient’s chances of falling by making him or her physically stronger and imbuing in him and her a overall sense of mental and emotional well-being. The most successful forms of exercise that improve physical balance and motor coordination include Tai Chi.

Failing to maintain an exercise regimen promotes physical weakness and boosts a senior patient’s risk of falls, the CDC states in its brochure. Senior patients are asked to consult their primary care, family practice or internal medicine physician for the most suitable exercise program.

On the subject of medications, the agency requests that senior patients permit their doctors to review their drugs, including the over-the-counter prescriptions. These drugs include psychoactive medications such as benzodiazepines, antidepressants, nonsteroidal anti-inflammatory drugs, and antipsychotics and certain illnesses such as stroke, Alzheimer’s disease and Parkinson’s disease.

A class of drugs known as glucocorticoids and that treat several types of diseases such as arthritis, asthma, Crohn’s disease, lupus, and other diseases of the lungs, kidneys, and liver) can also weaken bone density, leading to falls and bone fractures.

Some types of medicinal therapy that, too, negatively impact bones include treatment with “anti-seizure drugs, such as phenytoin (Dilantin®) and barbiturates; gonadotropin releasing hormone (GnRH) analogs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone,” researchers say.

The CDC argues that, as patients age, medicines change the way they operate in their bodies. Some drugs, or a cocktail of them, can make a senior patient dizzy, which can lead to falling and injury.

With respect to vision, the agency instructs senior patients to have their sight examined by their optometrists and ophthalmologists at least once annually. The CDC says that seniors may wear the wrong glasses or may endure a condition like glaucoma or cataracts that restrict their ability to see, which, in turn, poses a danger for falling and injury.

In terms of home safety and security, the CDC teaches senior patients that, statistically, half of all falls and subsequent injuries take place in the home. To prevent falls, the agency recommends that seniors and their families be mindful of the following when making their private homes safer and more secure:

–Remove items that encourage tripping such as papers, books, clothes and shoes from the staircases and other areas in which they walk;
–Discard small throw rugs or use tape to keep them from slipping and causing a fall;
–Maintain items that are used most often in cabinets where they can easily reach without a step stool;
–Order the installation of grab bars near the toilet or in the tub or shower of their bathrooms;
–Apply non-slip mats in the tub and on the floors of showers;
–Enhance lighting in their home as they will need brighter lights for their vision as they age;
–Place light-weight curtains or shades in different rooms throughout the home to reduce glare;
–Request the installation of handrails and lights on all staircases;
–Put on shoes both inside and outside of the home, and;
–Do not go barefoot or wear slippers.

Vestibular, Balance Disorders

Many physical therapists, possibly with certification in mechanical diagnosis and therapy (MDT), provide orthopedic, neurological and vestibular consultation to prevent falls and injury risk among its patients.

In their offices, physical therapists and their staff may offer a complete balance, fall risk and strengthening program that local-area neurologists and ear/nose/throat (ENT) physicians may use.

Typically, the gamut of physical therapy services include arthritis/chronic pain, back pain, balance disorders, carpal tunnel syndrome, dizziness and arm, shoulder and leg pain, fracture, fibromyalgia, temporomandibular joint dysfunction (TMJ), neck pain, neuropathy, occupational injuries, Parkinson’s disease, pre- and post-surgical rehabilitation, sports injuries, sprains, strains and whiplash, stroke and multiple sclerosis.

For such offices, a referring physician base includes cardiologists, ear/nose/throat (ENT) physicians, family practice physicians, internal medicine physicians, neurologists, neurosurgeons, obstetrics/gynecologists, orthopedic surgeons, otoneurologists, pain medicine specialists, physiatrist, podiatrists and sports medicine specialists.

Before the staff can provide a patient with services for balance, fall risk and strength training, he or she must have his or her medical history examined. He or she must undergo a balance self-test, satisfying the following conditions:

–The patient may have fallen in the past year;
–The patient may have taken medications for two or more chronic illness: heart disease, hypertension, arthritis, anxiety or depression;
–The patient may have suffered a stroke or another neurological problem, impacting his or her balance;
–The patient may use a walker or wheelchair or may need assistance with his or her mobility, and;
–The patient must have had numbness or a loss of sensation in his or her legs or feet.

An audiologist begins a diagnosis of a senior patient at risk for falls and injury by testing his or her hearing and balance to evaluate the proper function of his or her inner ear balance system and hearing mechanisms.

If the audiologist discovers a problem, he or she will refer the patient for treatment whether it is vestibular therapy or medical/surgical remediation. The patient will be sent to an ear/nose/throat (ENT) specialist or a physical therapist. Physical therapy for balance disorders calls for training and certification to conduct the appropriate exercises and regimens.

A fully-equipped and functioning physical therapy center will use computerized equilibrium tests to review the sensory and motor elements of a patient’s balance system.

Sensory tests will investigate inner ears, eyes and joints that participate in balance control. Our motor tests will examine the patient’s ability to carry out coordinated movements, both voluntary and involuntary, to keep his or her balance.

The tests will discover the root cause of a patient’s balance problem and will form the base of a customized physical therapy program for him or her.

In particular, the patient may suffer from vestibular (inner ear) disorders, which are related to his or her balance. Vestibular disorders can lead to anxiety, difficulty concentrating, dizziness, fatigue, hearing changes, imbalance, nausea, vertigo and other symptoms.

Such symptoms may devastate the life or health of a patient, causing him or her to not function fully and rendering him or her incapable of working, maintaining ties with family and friends and keeping up a normal quality of life.

Vestibular disorders can stem from aging, allergies, head trauma, heart disease, nerve neuronitis (decreased nerve function), poisoning, viral infection and other illnesses of the inner ear.

Making a diagnosis and planning treatment for vestibular disorders is challenging, in part, because such illnesses are not invisible, making it hard for individuals to comprehend the attendant disabilities.

Senior patients are cautioned to seek out physicians and specialists with the proper credentials to appropriately diagnose and treat their balance disorders.

CDC’s Compendium

The CDC’s Compendium is targeted at providing public health groups and senior long-term care and short-term care facilities with the information they need to find the most appropriate fall prevention programs to suit the needs of seniors in particular communities.

The publication process for the Compendium began when the Centers for Medicare and Medicaid (CMS) assigned the RAND Corporation in 2003 to examine pre-existing research on fall prevention programs, which occurred by process of elimination.

RAND searched for literature and found 826 studies of which 95 qualified for further review because they met the following requirements: involved seniors aged 65 and older; used a randomized or controlled clinical study format; recognized falls as an outcome, and; calculated the number of falls three months before the start of a prevention program.

Out of the qualifying 95, about 57 cited falls as an outcome and 38 revealed the number of subjects who fell once or their monthly rates of falling. RAND singled out these 38 studies for further study and to decide on the success of their programs under the categories of physical exercise, education or awareness, environmental change or a combination of different types of solutions.

In reviewing the remaining 38 selected by RAND, CDC acknowledged those that had the following in common: involved community-dwelling seniors aged 65 or older; used a randomized or controlled clinical study format; recognized falls as an outcome, and; presented meaningfully successful fall prevention results.

The agency purged the collection of one study that focused on nursing home patients, four that did not prioritize falls and 25 that did not provide substantial outcomes. This left eight, two of which had to be combined because they represented the same study.

Then, the CDC found seven additional qualifying studies after RAND published its report on its findings. As a consequence, the first edition of the Compendium, which contained 14 studies released before Dec. 31, 2004, was published in 2008.

The first Compendium sets the format for the ones to follow, which include study summaries, intervention descriptions, summary tables, contact information, a bibliography and appendices.

The agency sought to update the original Compendium in 2009. A search of trials of fall prevention programs released between Jan. 1, 2005 and Dec. 31, 2009 turned up 86 studies. Two programs were scrapped because they were duplicated.

Of the total 84, the CDC trimmed off 20 that were not randomized controlled trials, 15 that did not center upon community-dwelling seniors aged 65 and older, 27 did not prioritize falls and 14 did not register meaningful successes in preventing falls. The remaining eight were published between January 2005 and December 2009 and were placed in the second edition of the Compendium in 2010.

In the second edition, the categories of fall prevention programs included exercise-based activities, home modifications and multifaceted interventions. The third edition added to two more categories — single interventions and clinical programs — to the pre-existing three groups.

The resulting 22 programs are aimed at addressing a variety of beneficiaries. Some are meant to accommodate the oldest of the elderly, some are designed for a special segment such as the blind and others are made for particular circumstances such as walking on ice and snow. The following summaries convey a portion of the basic information about the 22 programs as they appear in the second edition of the compendium.


Stay Safe, Stay Active — Barnett, et al.
This study used weekly structured group sessions of moderate-intensity exercise, held in community settings, with additional exercises performed at home. Participants were 40 percent less likely to fall and one-third less likely to suffer a fall-related injury compared with those who did not receive the intervention.
POPULATION: Participants were individuals at risk for falling because of lower limb weakness, poor balance, and/or slow reaction time. All were aged 67 or older and lived in the community. About two-thirds of participants were female.
GEOGRAPHIC LOCALE: Southwest Sidney, Australia
FOCUS: Improve balance and coordination, muscle strength, reaction time and aerobic capacity.
PROGRAM SETTING: Classes were conducted in local indoor lawn bowling and sports clubs that hosted community programs for various sports and exercise activities, comparable to United States: community exercise, sports and recreation facilities. Many lawn bowling and sports clubs also included other indoor attractions such as restaurants, meeting facilities and movies.
DURATION: A total of 37 1-hour classes were conducted once a week over a 1- year period.
KEY ELEMENTS: This study used health practitioners to assess and recruit participants. General practitioners are in an ideal position to both identify older people at risk of falls and to support their participation in an exercise program when appropriate. The program used existing services and facilities in the community so it is likely to be sustainable and transferable to other settings.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information; Anne Barnett, MPH Physiotherapy Department Bankstown Hospital, Locked Mailbag 1600 Tel: +61 (9) 722-7154, Fax: +61 (9) 722-7125, e-mail: [email protected]

The Otago Exercise Program — Campbell et al. and Robertson et al.
This intervention, tested in 4 randomized controlled trials and 1 controlled multi-center trial, was an individually tailored program of muscle-strengthening and balance-retraining exercises of increasing difficulty, combined with a walking program. This extensively tested fall prevention program is now used worldwide. Overall, the fall rate was reduced by 35 percent among program participants compared with those who did not take part. The program was equally effective for men and women. Participants aged 80 years and older who had fallen in the previous year showed the greatest benefit.
POPULATION: Participants were aged 65 to 97 years and lived in the community.
GEOGRAPHIC LOCALE: Dunedin, New Zealand
FOCUS: Improve strength and balance with a simple, easy-to-implement and affordable home-based exercise program.
PROGRAM SETTING: The program was conducted in participants’ homes and was intended for people who did not want to attend, or could not reach, a group exercise program or recreation facility.
DURATION: The exercises took about 30 minutes. Participants were encouraged to complete the exercises 3 times a week and to walk outside the home at least 2 times a week. Exercises then were continued on an ongoing basis. In 3 trials, the exercise program was prescribed for 1 year and in 1 trial was extended to 2 years.
KEY ELEMENTS: PTs should understand the research evidence on which the program is based and avoid adding or subtracting exercises from the set used in the trials, as this particular combination of exercises worked to reduce falls.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information; M. Clare Robertson, PhD Research Associate Professor Department of Medicine, Dunedin School of Medicine University of Otago, P.O. Box 913 Dunedin 9054, New Zealand Tel: +64 (3) 474 7007 extension 8508 Fax: +64 (3) 474 7641 e-mail: [email protected]

Erlangen Fitness Intervention — Freiberger, et al.
This study examined 2 interventions to reduce falls: a psychomotor intervention that focused on body awareness, body experience, and coordination; and a fitness intervention that focused on functional skills, strength, endurance, and flexibility. Both interventions included group classes, home-based exercises, and physical activity recommendations. Only the fitness intervention was effective in reducing falls. Compared to the control group, participants in the fitness group experienced 23 percent fewer falls.
POPULATION: The participants were community-dwelling, physically active people in very good health, aged 70 or older. Slightly more than half were male.
GEOGRAPHIC LOCALE: Erlangen, Germany
FOCUS: Improve functional skills, strength, endurance and flexibility.
PROGRAM SETTING: The group classes were conducted at the University of Erlangen-Nuremberg, Institute of Sport Science, and the home-based portion was carried out in participants’ homes.
DURATION: One-hour classes were held twice a week for 16 weeks. In addition, participants were instructed to perform selected exercises at home on a daily basis between sessions and after the program ended.
Strength, endurance and functional skill exercises, including balance and gait training, should increase in intensity over the duration of the program. Trainers must attend the program training.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Dr. Ellen Freiberger Institut fur Sportwissenschaft und Sport Friedrich-Alexander-Universitat Erlangen-Nurnberg Gebbertstrasse 123b, DE-91058, Erlangen, Germany Tel: +49 9131 852 5464 Fax: +49 9131 852 5002 e-mail: [email protected]

Tai Chi: Moving for Better Balance–Li, et al.
This study compared the effectiveness of a 6-month program of Tai Chi classes with a program of stretching exercises. Participants in the Tai Chi classes had fewer falls and fewer fall injuries, and their risk of falling was decreased 55 percent.
POPULATION: Participants were inactive seniors aged 70 or older. Three-quarters were female. All participants lived in the community.
GEOGRAPHIC LOCALE: Portland, Oregon, United States
FOCUS: Improve balance and physical performance with Tai Chi classes designed for older adults.
PROGRAM SETTING: The Tai Chi programs were conducted in community settings such as local senior centers and adult activity centers.
DURATION: One-hour classes were held 3 times a week for 26 weeks, followed by a 6-month period in which there were no organized classes.
Program settings can include facilities such as senior centers, adult activity centers and community centers. An average class size of 25 is ideal for effective learning and teaching. For this program to be successful, participants should attend Tai Chi classes at least 2 times a week and participate actively in class. Tai Chi can also be used in rehabilitative settings where the emphasis is on retraining balance in older adults.
CONTACT: Practitioners interested in using this intervention may contact the principal investigator for more information: Fuzhong Li, PhD Oregon Research Institute 1715 Franklin Boulevard Eugene, OR 97403, United States Tel: 541-484-2123 e-mail: [email protected]

Multi-Specialty Teams Help Seniors Manage Diabetes (Part 2 of 2)

Vision Impairments

Pharmacists, podiatrists, dentists and dental hygienists as well as optometrists and ophthalmologists are asked to examine diabetics for the most common diabetes-related eye diseases: retinopathy, double vision, vision fluctuations, cataracts, macular edema and ocular nerve palsy.

A comprehensive diabetic eye exam takes into consideration the following factors: visual acuity, visual fields, pupillary reaction, intraocular pressure, cranial nerves, a slit-lamp exam and a dilated retinal exam.

Diabetes is the condition most responsible for new incidence of blindness in adults aged 20 to 74 years of age. Retinopathy triggers 12,000 to 24,000 new cases annually. Diabetics are encouraged to care for their eyes by undergoing a complete vision exam yearly, including a dilated eye test with intervention if retinopathy is discovered.

Diabetics are 25 times more likely to develop blindness than those not afflicted with the condition. Particularly, diabetics who use cigarettes, eat poorly and do not control their blood sugar levels are at greater risk for cultivating eye conditions.

Because diabetes causes patients to heal slowly from wounds or injuries overall, eye conditions, including minor corneal scratches, ought to be taken seriously by optometrists and ophthalmologists.

Diabetes retinopathy is a diabetic eye complication caused by excess blood sugar damaging the blood vessels of the eye, leading to breakdowns, leaks or blockage.

This may lead to retinal hemorrhage and compromised delivery of oxygen to the retina, which may translate into the growth of deformed vessels. Such vessels are delicate and can break easily, resulting in the loss of vision.

One out of every 12 diabetics aged 40 years and older suffer from retinopathy. Research finds that aspirin use is safe in use for diabetics with retinopathy and the condition is treatable and preventable.

Poor blood sugar level control and a long history of diabetes can raise the risk of senior patients with type 1 and type 2 diabetes developing retinopathy. Thus, self-management of blood sugar, blood pressure and lipid can reduce or delay this risk by 76 percent in diabetics.

Early detection of retinopathy can cut back on the risk of retinopathy-related vision loss by 90 percent in diabetics. Still, half of all diabetics are not having their eyes examined or are found to have developed too advanced a stage of these eye conditions to be treated in time. Additionally, diabetics are in danger of contracting glaucoma and cataracts.

Enhanced therapy lessens the presence of retinopathy by 27 percent and retinal laser photocoagulation surgery can cut the risk from the most aggressive form of the illness, also known as proliferative diabetic retinopathy (PDR), to at least 4 percent.

Optometrists and ophthalmologists can supply such vision aids as simple hand magnifiers or optical devices for diabetics who have lost their sight to retinopathy. Eye care professionals can also seek to provide a comprehensive suite of care and services to allow visually-impaired diabetics to keep their dignity and control their diabetes.

Senior diabetics are at risk for developing cataracts, which represents a clouding of the eye lens with aging being the main cause of this condition. The lens focuses images that enter the eye onto the retina. A clouding would mean limited vision and more sensitivity to glare. More than half of seniors have cataracts.

Glaucoma is a condition damaging the optic nerve. The nerve carries images in the retina to the brain so obstruction of this transfer means the development of blind spots or field loss, which eventually leads to complete blindness.

A dilated eye exam, visual field testing, intraocular pressure testing and other exams provide a view of the optic nerve and can detect glaucoma early, making treatment possible.

With patients aged 40 years or older, about 2.2 million suffer from glaucoma while another 1.1 million don’t know they have the illness. African-American seniors are two times likely to develop glaucoma as their white peers.

Diabetics may complain about the onset of double imagery because of damage to the nerves from the brain to the eye. This warrants an immediate visit to the optometrist or ophthalmologist.

Double vision, an ocular complication, can be mistaken by a diabetic or a specialist other than an optometrist or ophthalmologist as stroke or another neurological condition, which can needlessly lead to radiological exams.

This complication may be due to mononeuropathy or damage to a single nerve. As a solution, third-nerve palsies take place with pupillary sparing in 80 percent of these cases. Most diabetics suffering from this condition experience healing within two to three months and double vision can be managed with special lenses.

Poor control of blood sugar levels can lead to fluctuation in vision. Poor blood sugar level control can cause fluid imbalance in the lens, which triggers the fluctuations.

When blood sugar levels are raised, the lens grows thicker and the resulting changes in vision may lead to nearsightedness or farsightedness. When blood sugar levels drop, the lens returns to its normal size. With inconsistent blood sugar level control, diabetes with glasses will find it hard to determine the best lenses to wear for their changing eyesight.

The NIH-CDC workgroup instructs specialists to ask diabetics the following questions about their eye health:

–Whether they are aware of the connection between diabetes and eye health, the risk of diabetic retinopathy, its responsibility for blindness and avoidance through sound blood sugar level control;

–Whether they know that, as diabetics, they are at risk for developing such eye conditions as cataracts and glaucoma and such symptoms as fluctuations in vision, double vision or dry eye;

–When they have last had a comprehensive dilated eye exam and whether they have one yearly and a regular eye screening to avoid blindness due to diabetic retinopathy;

–If they have reported eye symptoms to their primary care physicians and have a prescription for eyeglasses, contact lenses or vision aid, and;

–How often and long do they suffer from these eye symptoms and whether they report any changes in eyes or visions such as blurriness, spots, redness or pain to their primary care physicians, optometrists or ophthalmologists.

Dental Loss

Pharmacists, podiatrists, optometrists and ophthalmologists as well as dentists and dental hygienists are asked to check their senior diabetics for the following diabetes-related oral health conditions: changes in teeth, periodontal disease and oral candida (thrush).

A comprehensive oral exam will take teeth, gums, periodontal probing, intraoral lesions, infections or masses and insufficient saliva flow into consideration.

Diabetes can cause changes in the teeth and mouth. Dentists and dental hygienists are most concerned about how diabetes affects the health of gums and periodontal tissues.

Poor blood sugar level control is linked to gingivitis and other periodontal conditions. Symptoms of diabetes and dental illness include a neurosensory disorder known as burning mouth syndrome, problems in taste, abnormal wound healing and a fungal infection known as candidiasis.

Senior diabetics with oral health problems will note that they have a fruity breath, caused by a colorless, flammable, liquid substance known as acetone (a simple ketone used in nail polish), frequent xerostomia or dry mouth or a change in the thickness of their spit or saliva. This is dangerous as dry mouth can usher in an increase of dental decay.

Besides fruity breath, thickness in saliva, dry mouth and possible dental decay, xerostomia is also characterized by gum disease, especially red, swollen and bleeding ones or gums pulling from the teeth, pus between gums, loose teeth or change in bite or tooth position and candidal infection or thrush.

Dental problems in senior diabetics are connected with other discoveries such as a vast loss of fluids through excess urination, infection, a change in connective tissue and function, neurosensory malfunction, microvascular changes, drugs causing dry mouth and increased sugar concentration in saliva.

Cigarette use worsens these oral conditions, researchers say. However, often senior diabetics focus on other problems or complications tied to diabetes and oral care can be neglected. Aside from blood sugar level control, they say, sound oral hygiene can alleviate all of these problems.

Senior diabetics are two to three times more likely than non-diabetics to develop periodontal disease, such as periodonititis. Periodontal disease is an infectious, chronic, inflammatory illness that damages connective tissue and bones supporting teeth and leading to tooth loss.

Among individuals with type 1 and type 2 diabetes, periodontal disease is more likely to develop, especially more quickly and in a much more severe form than in non-diabetics. Research finds a powerful association between diabetes and periodontal disease.

Not only are diabetics more prone to periodontal disease but also this condition can make blood sugar level control harder. Oral care that includes treating periodontal disease may help diabetics control their blood sugar levels.

Research has found a relationship between an individual’s resistance to insulin and inflammatory disease. Swollen periodontal tissue, which can be as large as an adult’s palm in size, contains blood vessels and can be subject to ulcers. This infection may poison the blood with bacteria.

Such infection can cause the liver to produce “acute-phase proteins such as C-reative protein (CRP), serum amyloid A, and fibrinogen.” The level of these proteins can be raised in the blood of patients with periodonititis and have been known to damage other vital organs.

As a result, periodontal disease can ultimately lead to the development of other such illnesses as diabetes mellitus and heart disease.

The NIH-CDC workgroup says this can all be avoided by using periodontal probing by a dentist or dental hygienist as a diagnostic tool that can measure diabetics’ reactions to treatment with the following questions:

–Whether they are aware of the connection between poor control of blood sugar levels and gum disease and that oral care can control diabetes;

–Whether they practice sound dental hygiene such as brushing teeth after eating, flossing at least once daily and proper denture management;

–Whether they conduct monthly oral self-exams and contact their dentists or dental hygienists if they find signs of infection such as sore, swollen or bleeding gums, loose teeth and ulcers, and;

–Whether they experience symptoms that suggest infection such as bad taste, bad breath or pain and can determine when problems require medical attention.

Heart Conditions

Type 2 diabetics are twice to four times as likely to suffer from cardiovascular disease or endure a stroke than non-diabetics. Heart disease is the main cause of death for diabetics.

However, research in recent years have shown that there are clinical approaches that can prevent or delay the onset of complications of diabetes as well as the illness itself.

Some studies, such as the national Diabetes Control and Complications Trial (DCCT), demonstrate that blood sugar level control decreases the risk of microvascular disease in type 1 diabetics.

Namely, blood sugar level control translated into a 76 percent decrease in eye conditions, including 63 percent in retinopathy, a 54 percent drop in nephropathy and a 60 percent plunge in neuropathy.

The United Kingdom Diabetes Study (UKPDS) demonstrated that type 2 diabetics enhanced blood sugar level control from an A1C of 7.9 percent to that of 7.0 percent, leading to a decrease in the risk by 25 percent for microvascular disease; 17 percent to 21 percent for retinopathy, and; 24 percent to 33 percent for albuminaria, a disease in which the protein, albumin, is present in the urine.

Additionally, lower A1C also cut down the risk of macrovascular disease with a 16 percent decrease in heart disease and a 24 percent decrease in cataracts. The UK study also finds low blood sugar level control not only decreased diabetic complications but also led to blood pressure control.

The study concluded that “tight blood pressure” lessened the risk of retinopathy progression by 34 percent; vision loss by 47 percent; diabetes-related deaths by 32 percent; microvascular disease by 37 percent; heart failure by 56 percent, and; stroke by 44 percent.

Moreover, clinical trials like the Appropriate Blood Pressure Control in Diabetes Trial (ABCD) and Heart Outcomes Prevention Evaluation Study (HOPE) also demonstrates that an ACE inhibitor decreases the risk of heart failure, stroke or cardiovascular deaths by 25 percent to 30 percent in patients with type 2 diabetes and delays the development of kidney damage of diabetes.

Drug Therapy

Aside from pharmacists, podiatrists, optometrists and ophthalmologists, dentists and dental hygienists must confer with their senior diabetics for the following “drug management” issues: inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions.”

Specialists must consult with their senior patients about strategies for managing their medications such as in their “use, monitoring treatment, self-treatment, over-the-counter (OTC) medications, selecting and using a blood sugar meter, cost control and coordination of care.”

Individuals most at risk for drug-related issues include those with severe long-term illnesses, take five or more medicines and those who see a variety of specialists. For professionals, this means complete reviews of drugs and their records, training of senior patients to comply with drug regimens and assessments of the way in which patients react to therapy to intervene properly and to coordinate and maintain plans of care.

The latest drugs and medical technologies give senior patients and physicians choices for treating diabetes and its complications. If not properly administered, however, they can lead to serious disease, disability or death.

Research in 2001 found that improper use of drugs nationally costs $177 billion a year in hospital re-admissions, extra therapy and visits to the doctor’s office, a boost from $76.5 billion in 1995.

Worse still, research averages that 218,000 drug-related deaths per year are due to misused drugs. Aside from inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions,” researchers also examine untreated illnesses and drugs with no particular treatment goal.

Research also finds that over half of patients with chronic illness do not take their drugs appropriately. More than 60 percent of diabetics do not control their blood sugar levels. Of all high blood pressure and cholesterol patients, about 65 percent and 49 percent consecutively, are not able to reach their intended health goals.

As a result, researchers advise specialists to urge their senior patients to comply consistently with proper drug use directives and minimize lethal drug interactions and to track their conduct. These actions maximizes health outcomes and results in savings to the healthcare system, they say.

Diabetics ought to forge a relationship with a pharmacist who can supervise drug regimens, advise on how to self-administer drugs and inform them about other methods of controlling their diabetes.

The NIH-CDC workgroup prods specialists, especially pharmacists, to ask diabetics the following questions about their drug management strategies:

–Whether their drug routines are individualized for the best times to take these medications, avoiding side effects and poor drug interactions;

–Whether they use compliance aids, the proper dosage forms and a drug delivery system to effect proper drug use;

–Whether they are using nonprescription treatments such as vitamins, minerals, herbals, nutritional supplements or skin-care products, (Research finds that more than 57 percent of diabetics use alternative therapies.);

–How serious and urgent are their complaints, what is the appropriate level of self-administration warranted for the drugs they take and what warnings are there for the drugs they use;

–How much is a follow-up or a referral to another specialist warranted;

–Whether they use a blood sugar monitoring device and are properly trained to use it, knowing about the results, the correct actions to take and the appropriate times to seek help, and;

–Whether they know how to lower the costs of drugs and supplies through private insurers, prescription drug programs, Medicare and Medicaid, generic medications and coverage for referrals to other specialists.

Coordination of Care

Researchers acknowledge that comprehensive diabetic care is riddled with problems as it is provided by several specialists in different types of facilities. There may be changes in drug regimens when senior patients visit their physicians or at the time of severe illness or hospital stays.

When a patient stricken with numerous complications of diabetes and taking a cocktail of drugs to treat them, including over-the-counter medications, herbals and supplements, they and their specialists must practice careful self-administration and management.

Research shows that collaborative drug therapy management (CDTM), given by pharmacists and other specialists, revealed the myriad problems faced by patients’ in 65 percent of their drug routines.

Still, more research found that CDTM ended in decreased incidence of disease as well as lower costs linked to fewer doctors’ visits, emergency hospital visits and hospital stays.

Through coordinated care, all the specialists in a medical team as well as the patient can take advantage of a single point of contact to provide the appropriate drug regimens, instructions and essential tracking for effectiveness and drug interactions.

As a consequence, the NIH-CDC workgroup urge specialists to commit to the following in promoting the comprehensive diabetic care approach to addressing a patient’s medical needs:

–Encourage medical leadership to set up policies and procedures for quality diabetic care in a strategic plan;

–Recruit and consult with a designated diabetes coordinator and the care team;

–Instruct patients to perform self-management drug actions per the NDEP and ADA protocols;

–Rework the healthcare delivery system to allow for the use of registries and tracking mechanisms for appointments;

–Review charts for the office visits in the same system;

–Manage cases with a care coordinator using the same system;

–Make and back up medical decisions using flowsheets and electronic health records, and;

–Build relationships with local community organizations.


American Academy of Ophthalmology, http://www.aao.org

American Academy of Optometry, http://www.aaopt.org

American Academy of Periodontology, http://www.perio.org

American Association of Clinical Endocrinologists, http://www.aace.com

American Association of Diabetes Educators, http://www.diabeteseducator.org

American College of Clinical Pharmacy, http://www.accp.com

American Dental Association, http://www.ada.org

American Dental Hygienists Association, http://www.adha.org

American Dietetic Association, http://www.eatright.org

American Optometric Association, http://www.aoa.org

American Pharmacists Association, http://www.aphanet.org

American Podiatric Medical Association, http://www.apma.org

American Public Health Association, http://www.apha.org

American Society of Health-System Pharmacists, http://www.ashp.org

HRSA Health Disparities Collaboratives, http://www.healthdisparities.net

National Association of Chain Drug Stores, http://www.nacds.org

National Community Pharmacists Association, http://www.ncpanet.org

National Diabetes Information Clearinghouse, http://diabetes.niddk.nih.gov

National Eye Institute, http://www.nei.nih.gov

National Heart, Lung and Blood Institute, http://www.nhlbi.nih.gov

National Institute of Dental and Craniofacial Research, http://www.nidcr.nih.gov

National Optometric Association, http://www.natoptassoc.org

Multi-Specialty Teams Help Seniors Manage Diabetes (Part 1 of 2)

A multi-disciplinary medical team of pharmacists, podiatrists, optometrists, ophthalmologists, dentists and dental hygienists best assist seniors in managing their diabetes by addressing medication, foot health, vision impairments, dental loss, and heart conditions, researchers at the U.S. Centers for the Disease Control (CDC) and Prevention and the U.S. National Institutes of Health (NIH) say.

While most of the aforementioned categories of physicians may not have time to take on these different aspects of diabetes outside of their specialties, they may be able to ask questions and provide their senior patients with advice during regular visits, check-ups and exams, the National Diabetes Education Program’s (NDEP) Pharmacy, Podiatry, Optometry and Dental Professionals Work Group of CDC and NIH say.

The joint-federal agency working group releases their annual reference guide titled Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals to train medical professionals to converse with aging diabetics about treating their condition with insulin, drugs, proper diet, exercise and sleep.

The booklet’s recommendations on how to diagnose and manage pre-diabetes and diabetes are based on clinical work and research by the medical professional trade organization American Diabetes Association (ADA). It and other specialty-based literature and materials are available at ndep.nih.gov.

Affected professionals also include primary care, family practice or internal medicine physicians, physician assistants, endocrinologists, certified diabetes educators, nurses, nurse practitioners, registered dietitians, cardiovascular specialists, renologists, neurologists, psychologists, psychiatrists and social workers.

Certified diabetes educators are trained healthcare providers who can counsel and train diabetics about their condition by setting behavioral goals and discussing health issues. A diabetes educator is usually a nurse, dietitian or pharmacist certified to guide and instruct patients about diabetes and self-care.

Diabetes Prevalence and Impact

Deemed severe, common, expensive but able to be controlled, diabetes is considered the sixth leading cause of death in the country and impacts at least 21 million individuals with at least 6.2 million undiagnosed. It costs the nation nearly $200 billion in direct and indirect expenses.

Nationally, diabetes ranks first among all long-term, deadly diseases as the cause of lower limb amputation that is not connected to trauma, first as the cause of acquired blindness and first as the cause of kidney disease ending up in dialysis.

The condition also contributes significantly to heart disease, being its number one cause of death in the country. At least 65 percent of senior diabetics die from heart failure.

Meanwhile, the prevalence of diabetes increases. Federal research shows it has more than tripled in the last 25 years from 5.8 million to the current 21 million, and in some states, over 25 percent of adults are diabetic. Projections will continue to be high. By the year 2050, the number of diabetics is expected to reach 39 million.

With current trends, one out of every three individuals nationwide will contract diabetes in his or his adulthood and may find his or her life span reduced by 10 to 15 years.

There are three forms of diabetes, type 1, type 2 and gestational diabetes. Federal research shows that, as of 2005, about two-thirds of adults nationwide were obese with the body mass index (BMI) of over 25, contributing to the onset of diabetes in this segment of the population.

In fact, the incidence of obesity has jumped by 61 percent since 1991, leaving more than 60 percent of adults overweight. A high body mass index and obesity pose the greatest risks to individuals for developing diabetes.

Type 1 is defined an autoimmune disease that is characterized by the destruction of insulin-producing beta cells. This version of diabetes can take place at any age but most especially in childhood or young adulthood.

Type 1 diabetes patients can develop ketoacidosis, a diabetic complication in which the body releases excess blood acids also known as ketones. Diabetics must take insulin daily whether by injection, insulin pump or inhalation.

Additionally, type 1 diabetics must test their blood sugar several times every day, follow a customized meal plan and take part in physical exercise.

Type 2 diabetes is connected to insulin resistance. The pancreas produces insulin but it is not recognized or used by other body tissues. Patients of this form of diabetes are treated with insulin, drugs or both. Otherwise, the condition can be controlled with an individualized food plan and physical exercise.

The development of type 2 diabetes is multifactorial, with insulin resistance, sedentary lifestyle, advancing age and obesity contributing to this increase.

This version of diabetes hits nearly 10 percent of the country’s population of young adults and double of the senior segment with a high incidence among those who are obese and physically inactive.

Still, the number of type 2 diabetics among children and teens is increasing, a n important concern as the number and intensity of complications grow with age.

Type 2 diabetes affects African Americans, Hispanics, Native Americans, Alaska Natives, Hawaiians or other Pacific Islanders and they are all two times as likely to have the condition as whites of the same age group. Some sectors of the Native American population suffer the highest rates of diabetes in the world.

The third form, gestational diabetes, involves glucose intolerance in women at the time of pregnancy. Gestational diabetes is most likely to take place among African Americans, Hispanics and Native Americans. It also occurs in obese women with a family history of diabetes.

At the time of pregnancy, mothers are treated to have their blood glucose levels stabilized so as to not affect their infants. Afterward, five to 10 percent of gestational diabetics are discovered to have type 2 diabetes. Indeed, women with gestational diabetes harbor a 20 percent to 50 percent risk of contracting diabetes over the next five to 10 years.

Other forms diabetes stem from genetics such as “maturity-onset diabetes of youth,” surgery, drugs, malnourishment, infections and other illnesses. They make up 1 percent to 5 percent of such cases.

Prevention Tools

About 54 million individuals aged 40 to 74 years of age — an age group that makes up 40.1 percent of the country’s population — suffer from pre-diabetes, which endangers them into developing type 2 diabetes.

Without action, pre-diabetics can advance to type 2 by a rate of 10 percent higher every year. They also have a higher risk of heart disease and stroke.

Pre-diabetes, “a condition in which blood glucose levels are higher than” what is considered healthy “but not in the diabetes range,” is described as “impaired fasting glucose (IFG) of 100 to 125 mg/dL or impaired glucose tolerance (IGT) diagnosed by a post 75-gram glucose challenge of 140 to 200 mg/DL.”

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of NIH can assist patients and providers in determining whether they are at risk for pre-diabetes. Federal research identifies three types of prevention: primary prevention to keep diabetes from occurring and secondary prevention to prevent complications in those who are already stricken with diabetes (e.g., prevention of foot disease).

Still, a third version, called tertiary prevention, means avoiding worsening complications such as an amputation from injury to a diseased foot or death.

These three levels of prevention occur because of the high financial and non-financial costs of diabetes. Federal research shows that more than 4,100 individuals per day are diagnosed with diabetes. As a result, 55 lose their sight, 120 undergo renal failure and 230 lose a limb to amputation — daily.

To test for diabetes, medical professionals will perform finger sticks or forms of laboratory testing. To qualify to conduct laboratory testing, professionals must be registered with the Centers for Medicare and Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendment (CLIA) of the law governing the policy and procedures of the federal agency.

The amendment sets quality standards for accuracy, reliability and timeliness of test results no matter what types of tests are performed. Three classes of tests and certification have been set and the categories depend on the level of difficulty and effort of the method used.

It has set up rules for each category of testing calling for quality control and documentation processes. Some states have added more requirements for different laboratory sites or medical professionals. For more information, professionals are asked to consult their state agency and the CMS website at http://www.cms.gov/clia/.

To help those who already have diabetes, the guide, Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals, provides detail on the type of drugs that best manage blood sugar, including insulin, as well as blood pressure and cholesterol.

The booklet concentrates on diabetes-related complications affecting foot health, vision, oral care and medication therapy issues. Using clinical graphics, including patient education posters to be hung in a medical office, and four specialty-based prevention brochures, it aims to encourage interdisciplinary medical team work to treat diabetes and make appropriate patient referrals.

Additionally, another booklet, the Working Together Medications Supplement, instructs on how to understand and properly use medications meant to control diabetes and can be used to organize team care. Package inserts or another guide titled the Physicians’ Desk Reference include prescribing information.

The Working Together Medications Supplement guide provides insights for professionals and senior patients on such issues as:

–The different types of insulin and the appropriate times to administer them so as to not conflict with a scheduled procedure;

–The most common symptoms of medication use to help a medical specialist to pinpoint a problem and make an appropriate referral to another specialist;

–Reduction of adverse interactions of drugs prescribed by different specialists;

–Avoidance of accidental overdosing or underdosing by generating awareness of medication names, strengths and dosages, and;

–Making the most of each visit, check-up or exam to teach patients about how to correctly use prescribed drugs and to receive drug use counseling from a primary care physician or pharmacist.

Physicians, specialists and other medical professionals can access the reference guides, which are all free, at the Centers for Disease Control and Prevention’s continuing education website, http://www2a.cdc.gov/TCEOnline/ and fill out an evaluation form and post-test.

Taken together, the guides are meant to help professionals identify the different type of diabetes and to prevent complications; to practice key messages to senior patients about diabetes; to articulate the most pressing concerns about drug therapy, foot health, vision and oral care for diabetics, and; to interpret the outcomes of the Diabetes Prevention Program (DPP).

According to the American Diabetes Association Standards of Medical Care, Diabetes Care reference guide, professionals are required to train senior patients to pay attention to their hemoglobin A1C, a test that shows their average blood glucose over three months (the goal is an A1C of less than 7 or 150 mg/dL), a blood pressure reading at less than 130/80 mm Hg, and a cholesterol count of less than 100 mg/dL.

With such training, senior patients are expected to practice sound self-management habits. They can maintain a customized, healthy meal plan with the help of the dietitian, participate in physical exercise, avoid cigarette smoking with guidance from a certified diabetes educator, and take prescribed drugs properly with counseling from a pharmacist.

Social workers can help coordinate government services for patients, especially seniors, and mental health professionals can assist them with depression and other mental illness issues as they pertain to diabetes.

Resources geared at assisting them can be found at the NDEP’s Better Diabetes Care Web site at http://www.betterdiabetescare.nih.gov/WHATpatientcentereddimensions.htm.

Finding the Time

Pharmacists, podiatrists, optometrists, dentists and dental hygienists may not find time to look at a senior patient’s medications, feet, eyes or teeth, especially if each category of physician feels entrenched in his or her specialty, members of the joint CDC-NIH work group say.

However, specialists are capable of sending direct messages to their senior patients about health problems or issues they have noticed. Instead of opening a statement with wording such as, “You should see someone about that … ,“ a specialist could tell his or her patient that, “I recommend that you … “

For example, a pharmacist does not need to be a podiatrist, an optometrist or ophthalmologist or a dentist or dental hygienist or perform an exam to determine when a senior patient presents with a problem that warrants the attention of another category of specialist, the workgroup members say.

A minute is all that is needed, for example for a pharmacist, to view a senior patient’s foot, mouth or eye to ask some questions about medications, supplies or cigarette use, they say.

By merely mentioning the problem a pharmacist, for instance, may have identified, he or she reinforces the need for prevention once he or she examines the issue before referring the patient to another specialist-colleague, goes the argument of the workgroup.

A pharmacist, podiatrist, optometrist, ophthalmologist, dentist or dental hygienist can support comprehensive diabetic care by going beyond his or her specialty to point out potential issues and then make a referral with an “I recommend … “ statement.

CDC-NIH workgroup members say patients will be grateful to specialists for taking their health and well-being into consideration, setting up a referral system and adopting a comprehensive team-care approach with their professional peers.

Foot Health

Besides podiatrists and as part of a comprehensive diabetes care team, pharmacists, optometrists, ophthalmologists, dentists and dental hygienists and other specialists ought to watch their senior patients for the most common diabetes-related foot issues: neuropathy, vasculopathy, dermatological conditions and musculoskeletal problems.

To assess for peripheral sensory neuropathy or the loss of sensation in the feet, specialists should check for the senior patient’s experience of tingling, burning, numbness or sensation of bugs, crawling on the skin of the feet. Podiatrists seek to detect this foot condition by using an instrument known as the Semmes-Weinstein 5.07 (10 gram) monofilament.

Senior diabetics with neuropathy are nearly two times more likely to suffer from ulcers in the feet than their peers without this condition. For senior diabetics with both neuropathy and foot deformity, the danger of cultivating ulcers is 12 times greater. Still, furthermore, senior diabetics with a history of foot disease, including previous amputations or ulcers, face a worsening risk of up to at least 36 times greater.

The demographics most at risk for lower-extremity ulcers and amputations are members of the male gender, non-Hispanics, African Americans, seniors and diabetics of at least 10 years, having past cigarette use and having a history of poor blood sugar control or heart, eye and kidney complications.

A comprehensive foot exam for diabetics includes evaluating “pulses, sensation, foot biomechanics,” which is defined as foot structure and function, and nails. NDEP medical literature titled Feet Can Last A Lifetime describes how to use this monofilament to conduct a complete foot exam and can be accessed at ndep.nih.gov.

Vasculopathy represents the cramping of calf muscles when walking, also known as “charley horse”, which leads to several rest periods bet. The cramping stems from insufficient blood in the area below the knee, caused by the blocking of the arteries, which commonly happens in the lower extremities of senior diabetics.

Nighttime severe cramping and toe aches are known as rest pain and is treated by walking or allowing the feet to hang over the side of the bed. This particular symptom means there is an end-stage blood vessel disorder and tissue ischemia, all of which comes before the onset of diabetic gangrene.

Neuropathy is cited by clinical research as being most responsible for ulceration and related foot complications. However, an inadequate blood supply can also lead to bad ulcer healing and, thus, amputation. Both neuropathy and not enough blood should be factored into a complete diabetic foot exam and care.

Dermatological conditions are exemplified by feet corns and callouses, also hyperkeratotic lesions, which are the result of “elevated mechanical pressure and shearing of the skin.” These conditions come before the “breakdown of skin” and cause “blisters or ulcers.”

Additionally, “surface lacerations and heel fissures or maceration (softening by wetness)” can all result in infection. “Corns, callouses, toenail deformity and bleeding under the nail” may be symptoms of neuropathy. “Fungus infections of skin or nails” become secondary infections that must be treated immediately.

“Musculoskeletal symptoms” in diabetic feet may emerge with “muscle-tendon imbalances” because of motor neuropathy. Such deformities include the hammertoes, bunions, high-arched foot or flatfoot, which raises the possibility for irritation of the foot in the shoe.

A patient’s style of life and his or her family history can determine the status of foot health. Senior diabetics who smoke are four times more likely than smokers without diabetes to acquire lower-extremity vascular disease.

Consuming foods high in fat and sodium and remaining physically inactive can lead to insufficient long-term control of blood glucose and place the patient at risk for diseases of the peripheral nervous system and blood vessels.

Additionally, a family history of illnesses of the blood vessels in the brain and coronary artery disease may mean a greater risk of lower-extremity arterial complications. Foot types or shapes may make a patient more vulnerable to biomechanical deformities that could end in skin breakdown.

Senior patients with neuropathy are highly likely to acquire degenerative arthropathy, also known as Charcot foot, that targets the joints and results in a red, swollen and deformed foot that can be taken for cellulitis. A Charcot foot usually means little to no pain and may progress over weeks to months before a specialist discovers it in a patient.

Radiological imagery may reveal a collapse of joint structure and can be taken for osteomyelitis. Therapy for Charcot foot is a light cast, in the absence of any swelling, and special shoes to correct changed biomechanics. If Charcot foot is not treated, the senior patient’s feet can degenerate into greater deformity, ulcers and, in the end, amputation.

Podiatrists and specialists in general should watch for senior patients who complain that their shoes don’t fit or wear slippers or shoes with portions cut out to adapt to changes in foot shape or limping.

The American Diabetes Association (ADA) and the American Podiatric Medical Association (APMA) take into consideration two forms of risk for developing diabetic foot complications: high risk and low risk.

The symptoms of high risk for developing foot disease include a “loss of protective sensation, absent pedal pulses, foot deformity, a history of foot ulcers and prior amputation.” By sharp contrast, for low risk, none of these symptoms exist.

To prevent low-risk senior patients from advancing to high risk, both professional trade associations, the ADA and the APMA, ask specialists to urge them to control their A1C, or hemoglobin blood sugar levels, blood pressure readings and cholesterol count and to quit smoking for those using cigarettes.

To assist high-risk senior patients, both organizations ask specialists to help patients guard against developing ulcers through self-management training, foot care and using the proper footwear. Light trauma “such as stubbing a toe or stepping on a sharp object” is the event most likely to lead to acquiring ulcers.

As a result, specialists are asked to stress to senior patients and their families the need to take the initiative to clear out walking areas, especially near the bed and the route to the bathroom, and to use night lights to enable a senior patient to see in the dark.

Additionally, high-risk senior patients must know who and when to call about their foot health issues. Same-day emergency calls to a primary care physician or podiatrist will likely be about a puncture wound, ulcer, redness or new foot pain. For less urgent issues such as patients with callouses or thick or ingrown nails, a podiatrist should be phoned and visited within a matter of days.

Nearly 20 percent of senior diabetics who visit their primary care physicians or specialists for check-ups or exams will present a foot health issue. With each visit, their doctors must ask their senior patients to take off their socks and shoes and check both feet for problems.

The likelihood of developing foot ulcers among diabetics is 15 percent. Worse still, the probability of diabetics with kidney complications and undergoing dialysis at risk for foot complications is higher but is treatable.

A podiatrist or other specialists are asked to pose senior diabetics the following questions when probing for foot care problems:

Whether they know how diabetes affects their feet, that diabetes puts them at risk for ulcers, which can result in amputations, and that foot care can prevent this;

Whether they have had a comprehensive foot exam in the past year and, in particular, one by a podiatrist, and a foot inspection by a primary care doctor, and;

How do they care for their feet daily and if their care regimen includes looking and touching for cuts, bruises, puncture wounds, corns or callouses, redness or pus; cleaning the feet’s skin and nails daily; drying in between toes; checking the insides of shoes for materials before wearing them and avoiding walking barefoot at all times.

Specialists can also refer senior diabetic patients to foot care literature from NDEP in English and Spanish at ndep.nih.gov.

Research Makes Gastrointestinal Health A Senior Care Priority (Part 2 of 2)

Gastrointestinal Problems

The NCI identifies the most common gastrointestinal problems examined by gastrointestinal specialists or gastroenterologists as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding.


Constipation is the slow, uncomfortable and possibly painful movement of dry, hard stool through the large intestine. This condition worsens as more fluid is absorbed and the waste becomes drier and harder.

If waste matter is not removed from the intestine at least once a day to three per day and at least three per week, physicians may diagnose a senior patient with constipation.

A physician assesses for constipation by reviewing the history of a patient’s bowel habits, including distention, gas passage, cramping and rectal fullness, a change in diet and drug use and by conducting occult blood tests and regular physical exams.

A lack of physical activity, a form of disability or social barriers such as the lack of bathroom accessibility, can cause constipation. So, too, can depression and anxiety brought on by cancer treatment or pain, insufficient water or fluid intake and the ingredients of certain pain relievers, though these last two factors can be managed.

To manage constipation, doctors may suggest that patients increase their intake of fiber through fruits, vegetables, whole-grain cereals, breads and bran and water or other fluids.

In fact, research was conducted involving senior patients, including cancer patients, to compare the medical care effectiveness, cost and management of a natural laxative mix of raisins, currants, prunes, figs, dates and prune versus the use of stool softeners, lactulose and other laxatives. The results found the natural laxative mix to be more medically and cost efficient.


By contrast, while constipation is uncomfortable and painful, fecal impaction is dangerous. Impaction is the collection of dry, hard waste matter in the rectum or colon.

Most senior patients with impaction may exhibit circulatory, cardiovascular or respiratory problems more than gastrointestinal issues but the main symptoms are back pain and bladder, urethra and urinary problems, especially frequent urination.

Physicians assess for impaction by asking the patient questions about constipation, using instruments to listen for bowel sounds, examining the abdomen to determine the level of gastrointestinal activity and conducting a rectal exam for the presence of stool in the rectum or colon and an abdominal X-ray for such features as gas passage.

Stool movement around impaction may produce diarrhea and coughing. It may also lead to stool leakage, which comes with nausea, vomiting, abdominal pain and dehydration.

Such a patient may be found in a confused or disoriented state and suffering from fever and high or low blood pressure. If not detected and addressed immediately, impaction may result in death.

The main causes of impaction are opioid medication, a lack of physical exercise or activity, changes in diet, psychiatric illness or abuse of laxatives. In fact, laxative abuse aimed at decreasing constipation is considered the major cause of impaction. Overuse of laxatives makes the colon insensitive to natural reflexes caused by distention.

Doctors treat impaction by watering and softening the stool for removal. They use enemas that incorporate oil retention, tap water or hypertonic phosphates to moisten the bowel and remove the stool. Often, docusate, mineral or olive oil and glycerin suppositories are used.

Occasionally, after an enema is used, a patient may be disimpacted digitally to address the remaining waste matter.

Bowel Obstruction

Large or small bowel obstruction is a partial or complete blockage of the bowel by a method other than constipation and impaction. Eighty percent of bowel obstructions take place in the small intestine while the other 20 percent happens in the colon. A physician may make a determination of obstruction if there is no gas.

An obstruction is classified by three ways: the type of obstruction, the mechanism of obstruction (whether mechanical or nonmechanical) and the part of the bowel in question. Often, it is termed “twisted bowel.”

Total or partial obstruction is typically caused by structural disorders like bowel lesions connected to cancer, post-surgical abdominal problems or hernias. Additionally, a patient with a colostomy, a type of surgery that re-directs a part of the colon to avoid a damaged part of the gastrointestinal tract, are at risk of developing constipation.

There are four types of obstruction: simple in which one site is blocked; closed-loop with blockage in two places; strangulated involving decreasing blood flow, and; incarcerated when the strangulated state is not resolved.

To determine bowel obstruction, physicians may examine a patient for abdominal pain, vomiting and gas or stool passage and may conduct a white blood cell count, electrolyte panel, urinalysis, sepsis, flat or upright abdominal films, enemas and gastrointestinal series.

To treat and manage obstruction, doctors may perform volume resuscitation, elecrolyte imbalances, transfusion support, distended bowel decompression efforts via intestinal tubes, a change in diet and the use of stents.


As diagnosed, diarrhea is an unhealthy increase in stool liquid and frequency of passage of more than three instances of waste matter from the intestine in a 24-hour period. It can span more than four days but less than two weeks. While considered less prevalent than constipation, diarrhea is considered chronic if it lasts more than two months.

Increasingly, the process of cancer care, especially radiation therapy and the stress and anxiety caused, antibiotic therapy, bone marrow transplants or gastrointestinal surgery, are among the main causes of diarrhea and the results can be physically and emotionally damaging.

Diarrhea can change a senior patient’s diet, prompt dehydration, cause electrolyte imbalance, stop function, induce fatigue, affect skin health, restrict physical activity and can be dangerous.

To manage diarrhea, physicians may treat such conditions as impaction; change the laxative therapy in use and the diet of the patient in question for low-fiber, mineral-rich foods that don’t upset the digestive tract; introduce opioid and aspirin use, and; increase liquid intake of water, broths, weak teas, caffeine-free soft drinks, clear juices and gelatin.

Radiation Enteritis

Radiation enteritis is a disorder of the large and small bowels that occurs during and after a session of radiation therapy to the abdomen, pelvis or rectum. The large and small bowels are vulnerable to radiation meant to treat cancer. While radiation dosages can effectively control cancerous tumors, normal tissues can be damaged in the process.

To assess radiation enteritis, physicians may seek out acute signs of injury to the digestive tract after the first session of radiation therapy and up to eight weeks later though some symptoms may present after many months or years. The signs include nausea, vomiting, abdominal cramping and pain, weight loss, and watery diarrhea.

The incidence of radiation enteritis may involve the following factors: dosage of therapy; tumor size and extent; the volume of the bowel treated; other symptoms and illnesses experienced by the patient; the malfunction of the digestive tract in terms of the absorption of fat, lactose, bile salts and vitamin B12; the level of pain felt by the patient; the nature of accompanying discharge, and; the presence of blood in the tract.

To manage enteritis, doctors will consider the level of diarrhea, dehydration, lack of absorption of nutrients and pain and discomfort experienced; attempt to address these with medicine such as brand-name Kaopectate and Immodium liquid formulas, opioids, steroid foams and replacement enzymes; changes in diet, including the use of lactase, fish, poultry and meat, fruit, white bread and toast, pasta, potatoes, vegetables and dairy products; bowel surgery, and; physical rest.

Gastrointestinal Perforation

Gastrointestinal perforations are holes in the wall of the stomach, small intestine, large bowel or gall bladder and a matter of medical emergency. Perforations are generally caused by illnesses such as appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection and inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. They lead to leakage of intestinal substances into the abdomen, leading to a form of inflammation called peritonitis.


Anthrax, an infectious disease caused by the bacteria called bacillus anthracis, involves the skin, the gastrointestinal tract or the lungs. This illness, which affects hoofed animals such as sheep and goats, inflicts humans who come into contact with them.
Typically, farm workers, veterinarians and tannery and wool workers tend to be patients. They may contract cutaneous anthrax through a cut or scrape on the skin, inhalation anthrax through the lungs with anthrax spores and gastrointestinal anthrax through anthrax-tainted meat.


Gastroenteritis/colitis, an inflammation of the stomach or intestine due to infection by the virus cytomegalovirus (CMV), is caused by a herpes-type virus related to one that leads to the onset of chickenpox.

Throughout their lives, most people confront the virus by saliva, urine, respiratory droplets, sexual contact and blood transfusions. It creates mild or no symptoms in healthy individuals.

However, some individuals with weak immune systems can develop CMV infections, including patients receiving chemotherapy for cancer, treatment for AIDS and immune-suppressing drugs after an bone marrow or organ transplant.

Those with strong immune systems may acquire CMV infections from a physical injury, kidney failure or infection.

Laxative Overdose

Laxative overdose can take place when an individual accidentally or intentionally ingests more than the normal or recommended amount of drugs. Some overdoses in children are by accident but adults primarily abuse laxatives to lose weight.

The toxic ingredients in the most abused laxatives are bisacodyl (Dulcolax), carboxymethylcellulose, castor oil, docusate, glycerin, lactulose, magnesium citrate, magnesium hydroxide, magnesium oxide, magnesium sulfate, malt soup extract, methylcellulose, milk of magnesia, mineral oil, potassium bitartrate and sodium bicarbonate, psyllium, psyllium hydrophilic mucilloid, senna and sodium phosphate.

Angiodysplasia of the Colon

Angiodysplasia of the colon, which involves enlarged and fragile blood vessels in the colon that result in bleeding in the gastrointestinal tract, primarily affects senior patients. It relates to the aging and degeneration of the blood vessels.

Research is still determining the cause of this illness. The greatest cause are normal spasms of the colon that enlarge blood vessels in the gastrointestinal tract.

With severe swelling, a small route develops between a very small artery and vein, which is called an arteriovenous fistula. It is in that portion of the colon wall that a senior patient may experience bleeding.

Angiodysplasia of the colon is not connected to the diseases of the blood vessels, cancer and diverticulosis, another condition of intestinal bleeding in senior patients.

Gastrointestinal Bleeding

Gastrointestinal bleeding refers to bleeding that starts in the upper part of the small intestine to include the small and large bowels in the digestive tract, which starts from the mouth and ends with the anus.

The extent of bleeding ranges from miniscule that can only be detected by laboratory testing to massive and it may indicate serious illness. Long-term microscopic bleeding can mean anemia. Severe massive bleeding can result in hypovolemia, shock and death.

The bleeding can take place at any age from the time of birth onward. The level and location of bleeding dictates what type of tests will be conducted to find the cause. Once bleeding is detected, a number of treatments are available to stem it.

Causes of gastrointestinal bleeding include anal fissure, aorto-enteric fistula, arterio-venous growth, diverticulum, cancer of the small intestine, colon cancer, cow’s milk allergy, Crohn’s disease, duodenal ulcer, dysentery, esophagitis, gastric ulcer, hemorrhoids, intestinal polyps, intestinal obstruction, intestinal vasculitis, nosebleed, portal hypertensive gastropathy, radiation injury to the bowel, stomach cancer and ulcerative colitis.

Foodborne Illnesses

With age, the immune system gradually ceases to function, leading to a decrease in the level of disease-fighting cells and an increased risk of infections. Exacerbating this is the frequency of surgeries by senior patients, which further compromises the body’s ability to ward off infections.

This makes it easier for foodborne illnesses to take hold, James L. Smith, a microbiologist with the U.S. Department of Agriculture concluded in his research.

Smith arrived at this finding after reviewing data from foodborne illnesses at nursing homes, conducting regular physical exams, studying the immune and digestive systems of seniors and looking at the importance of long-term exercise in strengthening the immune system.

Additionally, with aging, inflammation of the lining of the stomach and a drop in stomach acid takes place. The stomach is instrumental in restricting the amount of bacteria in the small intestine so that a decrease in stomach acids raises the danger of infection if it is digested with food or liquid.

Worsening this condition is the deceleration of the digestive process, enabling the spread of bacteria, fungi and viruses in the gut and the development of poison.

Malnutrition is connected to foodborne illness in that it leads to more infections and takes place with seniors in part because of a decrease in the pleasure of eating, the use of various medicines, digestive illnesses, nondigestive diseases, physical disabilities or depression, all of which may lead to a loss of appetite. Sound nutrition is key to keeping a healthy immune system.

Symptoms of foodborne illness include diarrhea, abdominal cramping, fever, blood or pus in the stools, headache, vomiting and severe exhaustion. This depends on the type of bacteria involved and the sum of toxins digested.

The symptoms can present themselves a half-hour after eating or may not arrive for days or weeks. They may start in a day or two but can stay as long as a week to 10 days. In healthy individuals, foodborne illnesses don’t last long and are not dangerous but they can be both lengthy and lethal in seniors.

In the case of foodborne illness, senior patients or their families must act immediately, Smith says in his research. Seniors must store and mark a portion of the suspect food, recording the food type, the date, the time consumed and the moment the symptoms began.

They must obtain treatment, call their local jurisdictional health department if they digested the food at a large event, from a restaurant or food facility and contact the Food and Drug Administration’s (FDA) consumer food information line if they have questions, he says.

Senior patients must also avoid food poisoning in the future by removing uncooked foods from their diets. Their physicians advise them to steer clear of raw fin fish and shellfish, including oysters, clams, mussels and scallops; unpasteurized or untreated milk or cheese or fruit or vegetable juices; soft cheese such as feta, Brie, Camembert, blue-veined and Mexican-style cheese; raw or uncooked egg or egg products such as salad dressings, cookie or cake batter, sauces and egg nog; raw meat or poultry, and; or raw alfalfa sprouts.

Most fruit or vegetable juices in the nation — amounting to 98 percent — have been treated to eliminate bacteria. The FDA requires companies to place warnings on their products.

Natural Foods, Herbal Remedies for Gastrointestinal Health

Aside from the aforementioned treatments and modes of management for gastrointestinal illnesses as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding, a variety of natural foods and herbal remedies exist to treat these conditions.

To respond to these diseases, physicians also recommend the use of chamomile tea, green tea, high-fiber flaxseeds, oats, omega-3s, flax oil, ginger, milk thistle, psyllium, saw palmetto, high-fiber hot peppers, onions, sweet red bell peppers, rice, barley, cabbage, beets, carrots, Brussels sprouts, cauliflower and water.

Chamomile tea has and still remains a remedy for relaxation, to cure insomnia and to soothe an aching stomach. Being researched for its antioxidant, antispasmodic and antiseptic properties, it has been used to treat skin irritation, intestinal cramps and wracked nerves. In tea form, chamomile is drunk three to four times daily to eliminate gastrointestinal upset.

Flaxseeds contain protein, dietary fiber and omega-3 fats and can be found in breads and cereals. Flaxseed oil is a rich source of lignans, a plant compound with hormone-like effects on the body, and omega-3 alpha-linolenic acid, a fatty acid that makes up 55 percent of its oil and is anti-inflammatory and boosts the immune system.

Omega-3s and lignans cut back on the risk of certain types of cancer such as breast, colon, prostate and uterus. Physicians recommend grinding the flaxseeds into a coffee grinder before placing them on bread, pancakes or muffin batters. The flax oil also are used as a supplement and can be placed in salads.

Ginger has long been used as a digestive aid as it enables the secretion of digestive juices in the stomach. Research also finds that ginger is effective in treating nausea, especially from motion or sea sickness and from surgery.

The most natural means of using ginger is to make infusions from grated or sliced ginger root though dosage isn’t calculated. For powdered root, the dosage of ginger is 150 milligrams to 1 gram in capsule several times a day.

It can also be obtained as candied or crystallized ginger at gourmet or Asian markets. A one-inch square is equal to one 500-mg capsule.

However, ginger is not recommended for individuals enduring chemotherapy if their blood cell count is low as it functions as a blood thinner and could place a senior patient at risk for internal bleeding.

Green tea is also useful as an herb to hydrate patients and contains antioxidants that defend against bacteria, which is important as dehydration can lead to constipation. Aside from teas, senior patients are also urged to drink plenty of fluids, particularly water.

Milk thistle, because of its active ingredient silymarin, can guard liver cells against poisons, including medications, viruses and radiation. In fact, it fights inflammation and disease caused by alcoholism, toxins and poisonous mushrooms and can help a liver reconstruct with no side effects.

Diabetics are asked to speak with their physicians about watching their blood sugar while taking milk thistle. A normal dosage amounts to 140 milligrams in a capsule two to three times per day.

Psyllium contains soluble fiber through the dried husks of its seeds. It lowers blood cholesterol and functions as a laxative on an over-the-counter basis. It is also present in some cereals. The FDA approved health claims on cereals containing psyllium.

The agency mandates that each product contain at least 1.7 grams of fiber per serving. Senior patients must drink plenty of water and other drinks when eating psyllium-rich cereals or it can lead to gastrointestinal blockage.

Saw palmetto serves as an inflammatory agent but it also offers relief to men suffering from benign prostatic hyperplasia, or BPH, or the slow but gradual growth of the prostate gland. Daily dosing amounts to 160 milligrams twice. The herb also works well with others such as nettle root and pumpkin seed extract without serious side effects.

Some processed medicines used by senior patients can be used with herbs. Some blood thinners and anti-clotting agents can work with Asian ginseng, dong quai, ginkgo, ginger, feverfew and garlic. However, heart drugs like digoxin produce negative interactions when mixed with Asian ginseng or St. John’s wort.

As a result, senior patients must follow instructions when dosing herbals. Researchers ask seniors over the age of 70 to take about 80 percent of the recommended adult dosage of any herbal preparation. Seniors who are frail or cannot take some drugs should begin with half the recommended dosage of medicines.

Some foods have been billed as colon cleaners when eaten raw. These include hot peppers, onions and sweet peppers. Oats join flaxseeds as being highest in soluble and insoluble fiber. Other foods that also known to cleanse the digestive tract include barley, beets, Brussels, cabbage, carrots, cauliflower and watermelon.


Altshuler, Larry, M.D., and Connors, Martha Schindler, “Seniors and Health,” Gastrointestinal Health Program, http://www.sentara.com/HospitalsFacilities/Hospitals/Bayside/Pages/bayside-programs-serivces.aspx

American Accreditation Healthcare Commission, http://www.urac.org.

American College of Gastroenterology, http://www.acg.gi.org.

American Gastroenterology Association, http://www.gastro.org.

Gastrointestinal Bleeding, http://www.healthcentral.com/ency/408/003133trt.html

“Gastrointestinal Complications: Supportive Care – Health Professional Information,” National Cancer Institute, http://cancer.gov

“Gastrointestinal Health in Seniors,” http://health.howstuffworks.com/herbal-remedies.htm

International Foundation for Functional Gastrointestinal Disorders (IFFGD), http://www.iffgd.org

“Keys To Gastrointestinal Health,” http://www.helium.com/knowledge/10322-keys-to-gastrointestinal-health

Liver Foundation, http://www.liverfoundation.org

National Digestive Diseases Information Clearinghouse, http://digestive.niddk.nih.gov

Research Makes Gastrointestinal Health A Senior Care Priority (Part 1 of 2)

Research on newer long-term illness issues, personal habits and socioeconomic trends are prompting senior care facilities to make gastrointestinal health one of its top medical concerns, healthcare providers, federal biological science investigators and medical policymakers say.

Documented key trends factoring into the decisions of senior long-term care and short-term care facilities to prioritize gastrointestinal health include the aging of the Baby Boomers, past and present drug abuse, alcoholism and cigarette smoking, the onset of cancer and other deadly diseases, environmental pollution, the use of bottled water, poor eating, sleeping and exercise habits and a struggling economy.

All impact the health of the digestive tract, research reveals, as aging in general without intervention from a proper diet, obtaining enough sleep and practicing physical exercise places gastrointestinal health in decline.

Namely, abuse of certain categories of drugs such as heroin cause constipation. Alcoholism undermines the function of the liver. Smoking, environmental pollution and sometimes contaminated bottled water can lead to heartburn, gastroesophageal reflux disease (GERD), peptic ulcers, liver disease, Crohn’s disease, colon polyps, pancreatitis and gallstones.

Radiation and other therapies to treat cancer causes gastrointestinal problems. An economic crisis is likely to negatively affect an individual’s eating, sleeping and exercise routines and, thus, affect gastrointestinal health, which is dependent on them.

Research by federal agencies such as the National Cancer Institute (NCI), the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), the Food and Drug Administration (FDA) and professional trade associations such as the Liver Foundation, the American Accreditation Healthcare Commission, the American College of Gastroenterology, the American Gastroenterology Association, and the International Foundation for Functional Gastrointestinal Disorders connects the importance of the soundness of the gastrointestinal tract to overall physical and mental health.

With the outpouring of research on the total health of seniors and gastrointestinal illness over the years, senior care facilities have begun to collaborate more with nutritionists/dietitians, gastrointestinal specialists/gastroenterologists, surgeons, critical care nurses, activities directors, exercise specialists, physical therapists, occupational therapists, message therapists, medical assistants and radiologists to treat and rehabilitate their patients.

The digestive tract includes the mouth, teeth, esophagus, stomach, small and large intestines, rectum, anus, liver, pancreas and gallbladder. Care providers, researchers and policymakers say keeping the tract healthy is vital to good health, which means that each of these components must work properly.

Food is digested before it enters the small intestines where much of the process takes place between the enzymes in saliva and the stomach. More enzymes are made in the small intestines and pancreas. The remainder goes into the large intestine or the colon. Water is purged from what has not been digested.

However, with enzymes decreasing with age, digestion slows down as does, also, the body’s ability to take in nutrients. When this occurs, seniors start to lose benign bacteria, which leads to overuse of the liver and kidneys and courts a wide range of illnesses.

Symptoms of a deteriorating digestive tract include bloating, indigestion and constipation. As conditions worsen, so do the symptoms. Still, a malfunctioning tract can recover with proper nutrition. Enzymes to aid digestion can be bought in supplements to counteract bloating, indigestion and constipation.

Senior Care Concerns

In hospitals and senior care facilities, leadership-level dietitians advise directors of the nutrition department on management and development of clinical services and supervisors of the gastrointestinal surgery and critical care department on delivery, practice and design. These dietitians are expected to have extensive clinical nutritional experience and knowledge of gastrointestinal surgery and critical care.

In the case of seniors, they are aware that this cohort of patients face a unique set of health problems. Dietitians understand that the bodies of seniors differ from that of others and they are more vulnerable to a variety of illnesses and their attitudes towards health care are different as well.

Aging causes patients to change in body weight and composition as both men and women weigh more as they transition from young adult to middle age to senior adulthood. By their 70s, they start to lose weight. As they age, the bodies of seniors regulate blood pressure, body temperature and fluids less efficiently.

Illnesses in seniors can interrupt cell production. For instance, Alzheimer’s disease can lead to the early death of brain cells and Parkinson’s disease can eliminate an excessive number of nerve cells. By comparison, cancer delays cell death and enables cancer cells to proliferate.

The sum of these changes affect how a senior lives, the amount and the type of physical exercise he or she conducts as well as his or her health care needs.

Aside from the fact that seniors present a specific set of health concerns, no single aging adult has the same problems. No two seniors age at the same rate. Additionally, even within one senior, not all body systems changes are entirely synchronized.

Seniors process medicines, whether herbal or pharmaceutical, differently than young and middle-aged adults.

Seniors weigh less and have more body fat than they have muscle. As the percentage of body fat increases, the bodies of seniors metabolize drugs and other substances in fatty tissue, which means that these elements stay in their bodies longer and may be more stronger than similar medications in the bodies of young and middle-aged adults.

These medications collect in the bodies of seniors because their kidneys don’t function as effectively as they did when they were younger adults. As a result, for example, nonsteroidal anti-inflammatory drugs, also known as NSAIDs, are more at risk of causing gastrointestinal bleeding and kidney trouble in seniors than in young or middle-aged adults.
Gastrointestinal Health

Especially after a gastrointestinal surgical procedure or therapy, dietitians provide senior patients with advice about improving their health. While a variety of reasons exist for poor gastrointestinal health, food is the main one.

As a result, dietitians recommend that seniors prevent a range of digestive diseases, including gastrointestinal ones, by eating properly. This means eating a balanced diet of protein, carbohydrates and fats, fresh foods and fiber-rich fruits and vegetables.

A balanced diet clears the intestines, improves bowel movements and decreases constipation. Whole wheat carbohydrates are more fiber-rich than white-flour-based ones.

Seniors are encouraged to consume five portions of fruit and vegetables per day as part of the recommended daily intake with research revealing that this habit guards against life-threatening illnesses such as cancer and maintains a healthy digestive tract.

They are advised to drink fresh and uncontaminated water, specifically two liters, which does not include coffee, tea or carbonated drinks, to stay hydrated and flush out poisons. Two liters equals six glasses daily. Habitual coffee drinkers are asked to remember to drink a glass of water after each cup as coffee has a dehydrating effect on the body.

In an age of national fracking and offshore oil and gas drilling, private home walls tainted by lead paint, radon gas seeping underground, carbon monoxide in homes and garages and electromagnetic waves emanating from nearby electrical poles and generators and other forms of environmental pollution, activities such as drinking safe, purified water becomes more critical to gastrointestinal health.

Tainted water contains bacteria, which may damage the intestines and destroy the digestive system, leading to vomiting and diarrhea.

Additionally, dietitians ask senior patients to steer clear of spicy foods. Extra spices cause high acidity and alkaline content in the intestines, kidney problems requiring dialysis and severe burning.

High acidity can be halted by consuming such foods sparingly, keeping the blood stream at a pH of 7.4 and using liver salts. For similar reasons, seniors are asked to avoid sour foods.

They are cautioned to eat light meals every two hours or to generally eat little but often and to space meals apart daily. Eating a large meal within hours of sleep for the night should be avoided.

Such practices, dietitians say, improve gastrointestinal health by decreasing the burden on the liver and the small intestine from which the blood supply declines and absorption of the nutrients from large amounts of food is made more difficult.

Seniors are also recommended to shy away from foods containing high fat, including deep-fried foods, and to adopt a low-fat diet instead. Avoiding high fat in the diet, dietitians say, prevents the development of gall stones.

Patients are told to cease smoking and drinking excess alcohol, as both or either lead to the formation of small sores in the stomach known as ulcers, compromising gastrointestinal health.

While seniors are prescribed a cocktail of painkillers and anti-inflammatory medication, they are instructed to avoid excess as these, too, lead to stomach ulcers.

Seniors are also advised to stop eating foods that cause allergies and this habit will lead to sounder gastrointestinal health. Symptoms include vomiting, itchy spots on the skin and reddishness around the mouth.

They are asked to take part in a moderate amount of daily exercise, especially those related to the abdomen, yoga or relaxation through message therapy as these are the means of ensuring sound gastrointestinal health and avoiding mental stress. Mental stress leads to gastrointestinal illness, particularly acidity in the stomach and ulcers.

Swimming is ideal as a form of exercise because it not only keeps a patient fit but also tones all the major muscle groups of the body.

Dietitians say sufficient hours of sleep and sleeping at the same time every night also leads to optimal gastrointestinal health as insufficient sleep leads to depression, which triggers unsoundness eating habits that compromise gastrointestinal health.

Gastrointestinal Exams, Programs

Physicians also recommend that seniors, especially those with gastrointestinal problems, participate in specific radiological health programs that include esophageal and anorectal manometry, pelvic muscle retraining, also known as biofeedback, and defecography.

The NCI and the American College of Gastroenterology report that colon and rectum cancers are the fourth most commonly diagnosed cancers and are second among cancer deaths nationally. Screening for colorectal cancer is regularly permitted by most insurers for patients aged 50 years or older and patients with family histories of cancer.

Some common gastrointestinal exams include colonoscopy, liver biopsy, paracentesis, esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancretography (ERCP), endoscopic ultrasound, and percutaneous endoscopic gastrostromy (PEG). Pulmonary tests include bronchoscopy, thoracentesis, bracheotherapy and tracheostomy. Other programs include photodynamic therapy.

Symptoms that warrant a esophageal motility study (EMS) include heart burn, difficulty swallowing, unexplained chest pain, pre-operative evaluation, anti-reflux surgery and diagnostic tool to identify scleroderma, achalasia and nutcracker esophagus.
Conditions that qualify for 24-hour pH monitoring include heart burn, difficulty swallowing, unexplained chest pain, chronic cough and hoarseness.

Problems that satisfy the need for anorectal motility with electromyography (ARM w/EMG) include evaluation of fecal incontinence, chronic constipation, evaluation of rectal pain, retraining on incontinence, pre-operative evaluation, rectal surgery and anal surgery.

To undergo radiological defecography, senior patients must present with the symptoms of prolapsed rectum, intussusception and enterocele. To receive pelvic muscle retraining, patients must exhibit symptoms of fecal incontinence, chronic constipation, difficult evacuation and anal pain.

Physicians also steer senior patients, who experience bleeding, pain, swallowing difficulties and a change in bowel movements, in the direction of endoscopy services that include non-invasive gastrointestinal and pulmonary procedures that last an hour to three hours on an outpatient basis.

Endoscopy involves examining inside the human body with an endoscope, a flexible tube holding a small camera. The type of endoscope used is named for the organs of the body they are meant to examine such as an arthroscope for the joints, a bronchoscope for the lungs, cystoscope for the bladder and a laparoscope for the abdomen.

A gastrointestinal endoscope is inserted through the mouth or anus or rectum and an ultrasound probe can be added to the endoscope, thus called an endoscopic ultrasound.

Small instruments can be used to take samples of possibly diseased tissues. Probes that pertain to the gastrointestinal tract include colonoscopy for colon polyps or colon cancer, EGD or esophagogastroduodenoscopy, enteroscopy and sigmoidoscopy. A patient may be asked to clear out his or her large intestine by enemas and laxatives to prepare for these tests.

For senior patients suffering from diarrhea, physicians may may also order fecal smears, a lab test to inspect a stool sample for bacteria, fungi, viruses or other type of microorganisms that start illnesses in the gastrointestinal tract.

There are multiple ways to collect the sample. One is to capture it in plastic wrap in a washroom and keep it in a clean container in the doctor’s office. Once the physician receives the results of the lab test, he or she can prescribe the most appropriate antibiotic treatment.

Doctors can also direct senior patients to take a rectal culture, a lab test to determine the type of microorganisms that cause gastrointestinal illnesses. With this type of test, a cotton swab is placed in the rectum, turned around and retrieved. A smear is used to grow bacteria or other organisms to observe the culture for growth.

The culture may be carried out in a hospital or nursing home to test a senior patient for vancomycin-resistant enterococcus or VRE in their intestine, a highly communicable disease.

Gastrointestinal Gas

Gastrointestinal gas is defined as flatus or gas eliminated by burping or passing through the rectum. Research finds that individuals produce a normal quota of about one to three pints a day and experience flatulence 14 times a day though some believe they release too much.

The gas is made mostly of odorless substances, carbon dioxide, nitrogen, hydrogen and oftentimes methane. Foods containing carbohydrates cause gas while foods with fats and protein cause little.

The unpleasant scent stems from bacteria in the large intestine that emit gases containing sulfur. The gas comes from swallowed air and the breakdown of undigested foods by benign bacteria in the large intestine.

Air swallowed by a person is also known as aerophagia. Any person can swallow air when eating and drinking. Still, eating and drinking quickly, chewing gum, drinking with a straw, smoking and wearing loose dentures can cause some individuals to breathe in more.

Symptoms of gas include belching, flatulence and abdominal bloating and pain. Crucial factors are likely how much gas the body eliminates and an individual’s sensitivity to gas in the large intestine.

However, large amounts of flatus may signal an abnormality in which the intestine absorbs nutrients, especially if diarrhea or weight loss is present.

While eliminating gas is a healthy, daily digestive process, physicians recommend the omission of certain foods, including high-fat ones, from a patient’s diet to cut down on bloating and discomfort. Scaling back enables the stomach to empty more quickly, letting gas move onto the small intestine.

Gas-emitting foods include broccoli, baked beans, beer, brussels sprouts, cabbage, carbonated drinks, cauliflower, chewing gums, citrus fruits, corn, eggs, greens, milk products, oats, onions, potatoes, red wine and wheat. Doctors also recommend the start of a lactose-free diet to cut down on human gas emissions.

Enzymes such as lactase supplements aid digestion of carbohydrates and empower individuals to eat foods that produce gas. For example, the enzyme product Beano cuts down on gas production connected with baked beans.

Decreasing the amount of air swallowed or aerophagia is also presented as a solution. Aerophagia is associated with excess salivation and many physicians recommend avoiding such habits as too much gum chewing or smoking. They also seek to treat such digestive conditions as peptic ulcer, which may lead to hypersalivation or nausea.

A Conflict of Interest In Independent Pharmacy Consulting

Independent pharmacies that both dispense medications and provide consulting services to long-term care facilities at the same time, present a conflict of interest and may land themselves and the facilities in trouble, the U.S. Centers for Medicare and Medicaid (CMS) and other federal agencies say.

It is important for third-party pharmacies to provide consulting services without dispensing drugs so as to bring greater accountability, transparency and competence to medication choice, administration and overall business activities to satisfy state and federal inspection and review requirements, the agencies add.

Research from the U.S. Department of Health and Human Services, with the Agency on Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), finds that the Baby Boomer generation continues to age while the number of seniors over 85 will increase by 90 percent over the space of 20 years — with a total elderly population of 34 million.

Third-party independent pharmacies are increasingly serving the prescription needs of long-term and short-term care patients in those facilities, especially seniors.

With such an aging segment of the nation in need of medical care, pharmacies have grown instrumental in meeting their treatment needs and decreasing the costs to the facilities caring for them.

However, the CMS, federal regulators and policymakers say their daily business undertakings have raised issues of integrity. Some pharmacies who both distribute drugs and advise medical facilities have been reported to look out for their own best interests, especially in terms of profit-making, rather than root out the flaws or errors in a client’s medication policies and practices.

This compromises the quality of drugs, the appropriateness of their administration and medical outcomes for their patients, pointing to point a need for independent pharmacies to provide consultation without distributing drugs, they conclude.

Federal laws, Regulations

The Affordable Care Act of 2012 mandates that a long-term care facility carry out the recommendations of a third-party consultant pharmacist, including advice concerning drug formularies.

While the law recognizes the importance of recommendations made by a third-party consultant pharmacist to a long-term care facility, the nursing staff employed there are not imposed upon to execute these directives without inspections from a state agency.

Still, a long-term care consultant pharmacist’s enforcement of a drug formulary influences the facility’s negotiation of a drug manufacturer’s rebates.

Additionally, a number of states make exceptions to the responsibilities of long-term care consultant pharmacists.

For example, in Colorado, consultant pharmacists are expected to fulfill the tasks of legal compounding, evaluate the implementation of policies of the state’s Pharmacy Advisory Committee and publish quarterly reports to the committee on the status of pharmacy activity.

Under Idaho law, consultant pharmacists must supervise services when their employer-nursing facilities use more than one manufacturer of drugs. Such pharmacists in Mississippi must attend board-approved workshops to be trained in their duties.

In Oklahoma, they must assist with drug destruction and converse with the staff of their employer-facilities about policies and procedures related to destroying medications.

Overall, most states throughout the country are expected to authorize third-party consultant pharmacists to provide these aforementioned services to the employing long-term care facilities.

Still, nursing homes and skilled nursing facilities have stand-alone agreements that spell out duties for pharmacy dispensing services and consultant pharmacy services. For instance, New Jersey is the only one calling for a separation of such services so that the consultant pharmacist cannot work for the dispensing pharmacy.

In October 2011, CMS released a draft regulation that called for more independence on the part of third-party pharmacists employed by consultant pharmacies to avoid the conflict of interests it found when it investigated such practices tied to long-term care facilities, serving mostly seniors.

Titled “Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to the Conditions of Participation for Long Term Care Facilities,” the draft rule focused on the agency’s concern with pharmaceutical manufacturers paying third-party long-term care pharmacies to have their staff consultant pharmacists urge doctors to prescribe their drugs to facility patients.

Consequently, CMS questioned the ability of third-party consultant pharmacists to review drug regimens impartially and to avoid compromising the quality of such evaluations and, thus, endangering the health and safety of patients. The agency also raised issues about long-term care pharmacists maintaining ties with pharmaceutical manufacturers.

Through its investigations of industry, CMS revealed that third-party, long-term care pharmacies outsource consultant pharmacists to nursing homes for compensation below the expenses of such pharmacies and below market value.

As a result of its findings, the agency stated that it pondered calling for long-term care facilities to hire independent pharmacists. By definition, an “independent” entity would be described as, for example, a licensed pharmacist not employed, under contract or connected otherwise to a long-term care facility’s pharmacy, pharmaceutical company or distributor.

The agency explained that it meant to rid a consultant pharmacist of any financial ties to any long-term care pharmacies or facilities that would prevent him or her from providing impartial drug regimen reviews and evaluations.

In April 2012, CMS unveiled a final rule that would not enforce such a regulation but instead invited comments on the topic. Still, the agency indicated that it would continue to examine the matter of enacting a rule to render long-term care consultant pharmacists independent.

The Role of Consultant Pharmacies in Long-Term Care

Over 20 years ago, industry experts say consultant pharmacies were formed to guarantee that long-term care patients receive the correct medications in the proper dosage at the right time.

Responding to projections of a growing aging population at the time, pharmaceutical companies developed dozens of drugs for each of the most chronic illnesses such as Alzheimer’s disease, diabetes, osteoporosis, rheumatoid arthritis and respiratory lung disorders, they say.

Overtime, such pharmacies evolved to empower 10,000 pharmacists nationwide to provide a broad range of administrative, distributive and clinical services to nearly two million mostly assisted living and skilled nursing facility patients. The most progressive pharmacies would be staffed with other medical professionals such as nurses, physicians, dietitians and laboratory staff.

Seniors, who make up the majority of long-term and short-term care patients, are the main focus of third-party consultant pharmacy practice because they are the most likely to endure drug-related hurdles such as adverse drug reactions, toxic interactions, improper use and fatal, repeated drug administration. As a result, elderly patients account for billions of dollars in drug costs.

According to the American Society of Consultant Pharmacists (ASCP), third-party consultant pharmacists tied to long-term settings provide pharmacological services; educate facility staff and administrators about medicine; serve as clinical practitioners; advocate quality care for patients and families, and; join a patient’s medical team.

Third-party, long-term care consultant pharmacists review drug regimens (DRR); evaluate drug use; develop new formularies and drug distribution systems; assess the health of facility patients; create plans of care; promote infection control; support diet and nutrition services; craft clinical policy and procedure; order and interpret laboratory tests; participate in state surveys, and; engage in clinical research.

They also handle durable medical equipment (DME); perform surgical appliance fittings; counsel patients on pain management; initiate intravenous therapy for patients; create and improve quality assurance programs; manage enteral feeding products; ensure outpatient packaging compliance; provide home diagnostic services; maintain medical/surgical supplies, and; generate computer forms and reports.

Additionally, the federal agency CMS regulates third-party consultant pharmacists to visit licensed nursing facilities every 30 days to provide drug regimen reviews for all patients served.

Long-term and short-term categories of care served by third-party consultant pharmacies include acute care hospitals; adult day care; alcohol/drug rehabilitation centers; ambulatory care; assisted living; community-based care facilities; congregate care; continuing care retirement communities (CCRC); correctional facilities; group homes; health maintenance organizations (HMOs)/preferred provider organizations (PPOs); home health agencies; hospice or post-surgical/palliative care centers; industrial plants; mental institutions; nursing homes; senior independent living, and; skilled nursing facilities.

The most common categories of care that consultant pharmacies serve nationally are assisted living facilities with between 30,000 to 40,000 such centers caring for more than one million persons, and, skilled nursing facilities.

Throughout the country, the remaining most common categories include board and care with 32,000 licensed homes for 500,000 persons; adult day care with 10,000 projected to be built and maintained by the end of the decade, and; home health care at 14,000 such agencies serving six million patients.

Additionally, the pharmacies nationwide serve hospice care with 2,500 centers serving 340,000 persons a year; CCRCs to grow from 1,000 at present to 10,000 over the next few decades; senior independent living with more than 2,500 communities, and; senior citizen centers as 12,000 of them serve between five and eight million patients annually.

Insurance Company Audits

Independent pharmacies, especially those that dispense drugs and may or may not necessarily provide consulting services, must anticipate pharmacy compliance audits and more pharmacies have been subjected to them in recent years.

Before an audit occurs, an audit and compliance vendor/contractor will mail an independent pharmacy a notice, describing plans to visit this facility to carry it out. These vendors or contractors tend to represent third-party prescription insurance companies.

Two weeks before this appointment, an assigned representative will phone a pharmacy to confirm his or her visit. An independent pharmacy may be faxed a copy of all of the prescriptions that must be inspected. The pharmacy may not receive a entire code number but sufficient information to retrieve a prescription drug file.

On the day of the audit, the pharmacy may need hired help to assist with the retrieval, replacement, document management and delivery of the necessary paperwork during the whole process.

Hired help comes in the form of a pharmacy assistant or the pharmacy’s pre-existing ancillary team. A pharmacy needs an assistant or team because an auditor’s direct questions will become more complex if data is not made available.

Consequently, an independent pharmacy must ensure that the pharmacy assistant or team comprehends the company’s entire prescription billing and recordkeeping process as it will satisfy an auditor’s quest for answers.

First, a pharmacy must be sure to make its signature logs, whether electronic or manual, policies and procedures manuals and compound formula worksheets easily accessible. Auditors will request to see its policies to judge how the pharmacy handles compounding even if it performs very little. They may also demand to view its policies on delivering drugs to facilities or patient’s homes.

Some audits can truly escalate. They may examine claims submitted two years ago and may peruse at at least 100 or more prescriptions in an afternoon. Any gaps or inconsistencies may require an adjustment unless an audited pharmacy can produce documentation as evidence of the claim. A mere undocumented refill in a pharmacy’s computer may result in thousands of dollars in adjustments.

When the audit is complete, a pharmacy will receive reports about an auditor’s revelations and adjustments. Adjustments of several thousands of dollars may appear in the audit, which translates into money that the pharmacy may have already paid that an insurer may hold back from future payments until that sum is paid in its entirety.

In fact, it may not escape an audited pharmacy that the auditors focus most of their attention on drugs with the highest potential for financial withholding. An audit may review all of the most expensive prescriptions, insulin pens and vials, brand-name inhalers and any other drug that was reimbursed for more than $500.

While this aspect of the audit is clearly imposing, a pharmacy still has legal recourse to appeal its findings. By state or federal law, an audited pharmacy has 30 days to send documentation that challenges these adjusted claims.

An audited pharmacy is urged to examine all adjustments meticulously. If a prescription lacks refill authorization, the pharmacy should consult a prescribing physician and explain the circumstances of the audit. In turn, the physician must account for the missing refill documentation on letterhead and most are willing to cooperate to assist a pharmacy in this endeavor.

Adjustments of drug supplies that last a matter of days can be appealed for partial pay. Even partial pays on costly drugs can be worthwhile. Categories of drugs that warrant calculations include insulin, drops, topicals, inhaled therapy and liquids.
Challenges To Independence

Many in the industry agree with federal agencies on the importance of third-party independent pharmacists forming their own consulting practices without dispensing medicines whether they’ve just completed their studies or have worked in their professions for a long time.

However, industry experts also acknowledge the difficulties faced by pharmacists to create their own entities with the roles they play in patient care, payment and reimbursement trends and the manner in which they deliver care.

Under the new payment and modes of delivery that include accountable care organizations (ACOs) and bundled Medicare/Medicaid payments, third-party consultant pharmacists are finding it harder to deliver cost-effective, quality patient services that would help avoid hospital admissions as required by the federal ACA law and the CMS’ Hospital Readmission Reduction Program.

Third-party independent pharmacies face the challenges of decreased reimbursements, shrinking margins and large national drug chains planning mergers and acquisitions, thus raising the potential for them to act with a conflict of interest such as making profits off distributing drugs.

However, these same pharmacies are providing new types of services such as medication therapy management and synchronization and are searching for new opportunities to grow and achieve different means of generating incomes.

Developing Independent Practices

Industry experts say that a third-party, independent consultant pharmacy is not restricted to a choice few practitioners and a specific academic degree is not required.

They say that any licensed pharmacist can open up an independent practice as long as they have a solid background in pharmacotherapy, an interest in the field of geriatrics and are grounded in an understanding in the drug and therapy needs of this age cohort.

In other words, knowing how to make recommendations to long-term care facility staff and administrators and understanding what drugs and dosages should be used for seniors is a good start for a long-term care pharmacist who wishes to grow an independent consultant practice.

Such an independent consultant pharmacist will become a Certified Geriatric Pharmacist under the National Commission for Certifying Agencies (NCCA), the accrediting body created to evaluate and regulate pharmacists, ensuring that they have the requisite knowledge in geriatric pharmacotherapy and ability to provide drug care to elderly patients.

To start their practice, experts say, independent pharmacists would have to decide how much it would cost to provide services in order to structure pricing to charge the employing long-term care facilities.

They must also consider travel time, vehicle wear, technology equipment, repair and upkeep and printing costs into their budgets. All of these costs depend on the location of the facility and the number of patients they plan to serve.

Starting out, some of an independent pharmacist’s problems include the starting expense to the employing long-term care facility. Prior to such an arrangement, experts say, long-term care facilities have not borne the costs of a pharmacist’s time because long-term care consultant facilities have always used pharmacist staff as a means of reducing costs.

To convince a prospective employer to accept his or her services, an independent consultant pharmacist must be able to prove that his or her pharmaceutical care skills command a higher price, they say.

Such demonstration tactics include pharmaeconomic reviews for the facility’s patients. Medicare pays for the care of a facility’s patients on a daily basis and any funds saved from obtaining drugs would boost the facility’s income.

This, in turns, reduces the risk of hospital readmissions and ensures that drugs are carefully monitored so that the facility can avert punitive financial fees during surveying.

Industry experts say that, before embarking on building an independent pharmacy practice, a consultant pharmacist ought to explore the opportunity. He or she must conduct market research, ask relevant questions and attempt to answer them on their own.

Specifically, a consultant pharmacist must discover how many facilities exist in their location. He or she must learn whether new nearby entities like his or hers are opening and if his or her market is expanding, experts say.

The independent pharmacist must determine if these prospective long-term care facilities are pleased with the quality of services they are receiving from these rivals and exactly where the gaps in performance are.

The consultant pharmacist must find out what he or she have to offer that is different from that of his or her competitors. He or she must know how he or she would make use of his or her present talents and relationships for this new pharmacy practice.

The pharmacist must also decide what type of investment would be needed to start his or her business, the advantages and disadvantages, the staff needed and the strategy he or she devised to land his or her first assignment.


To get started, Mark Prifogle, CEO of Grandview Pharmacy in Brownsburg, Ind., assembled multiple resources to enable consultant pharmacists to begin.

Aside from the above-mentioned recommendations for planning a launch of an independent pharmacy practice, other tools are available at the following sites:

–McKesson Corporation at McKessonAlternateSiteRx.com and by e-mailing [email protected];

–The U.S. Centers for Disease Control and Prevention at http://www.cdc.gov;

–The National Consultant Pharmacists Association at http://www.ncpaltc.org;

–Managed HealthCare Associates at http://www.mhainc.com;

–The National Association of Boards of Pharmacy at http://www.nabp.net/boards-of-pharmacy, and;

–RxOwnership.com website, specifically for starting, buying and selling pharmacies.


Alves, Jared BS, BA; Yee, Colin MPH; Coppage, Mary BA; Lukens, Ellen MPH; Advani, Protima MA; “Long-Term Care Pharmacy: the Evolving Marketplace and Emerging Policy Issues,” Avalere Health LLC, October 2015, pp. 1-33.

Leuck, Peter, “Pharmacy Compliance Audits: What Pharmacists Can Expect,” http://www.pharmacytimes.com/contributor/steve-leuck-pharmd/2016/07/pharmacy-compliance-audits-what-pharmacists-can-expect (Last accessed: Jan. 4, 2017)

McKesson Corporation, “Becoming a Long-Term Care Pharmacy: Opportunities and Important Considerations,”, 2015, pp. 1-16.

Simonson, William PHARM.D., is Associate Professor of Pharmacy Practice, Oregon State University, and Associate Professor of Pharmacy Practice, Oregon Health Sciences University, both in Portland, “Practitioner Update: Pharmacy Practice in the Long-term Care Environment,” Journal of Managed Care Pharmacy, Vol. 3. No.2 Mar/Apr 1997, pp. 189-94.

The Lewin Group, “CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services: Long-Term Care Pharmacy Primer,” (Prepared for the U.S. Centers for Medicare and Medicaid Services), Dec. 30, 2004, pp. 1-38.

Panasonic’s HomeTeam Connects Grandparents, Grandkids With Books, Games

Though living far away, Grandma wants to connect with the little ones but they are not very engaged and communicative at their young ages.

And her grandchildren need a family member to help practicing their speaking skills, reading and writing and expanding their learning through games.

This is where Panasonic’s HomeTeam video chat software comes in, said Todd Rytting, chief technology officer of Panasonic who held a briefing and demonstration of the product and the connection between healthy aging and technology at an annual conference of the American Society of Aging.

ASA is a California-based 5,000-member, multi-disciplinary organization addressing different aspects of aging.

Panasonic HomeTeam software stores hundreds of games and books so grandparent and grandchild can play and read together.

“Grandparents [want to] connect with grandchildren,” said Andrea Schneider, public relations contact with Motorola Mobility Public Relations on behalf of Panasonic’s Health and Wellness Solutions department, which develops technology for the healthcare market. “[When you are only] 5 years old, it’s hard to get going.

“The service allows grandparents to browse through books. [Their children have their] favorite animals or characters.

“[The grandchildren and grandparents] flip through pages of books. [The] grandchildren [are] learning how to read. [They are] practicing reading books.”

Panasonic’s HomeTeam staff of executives, managers and software developers released and explained their product, an online service that uses an app for the tablet, laptop and computer to access interactive books and games with video calling.

The user can download the app from the Apple App Store or Google Play and can use Androids or OS ipads.

The program enables “tech-savvy” grandchildren to read and play and grandparents to coach or guide them from a long distance, empowering the children to learn and their grandparents to form lasting relationships with them.

“It’s about an experience,” Schneider said. “It started with Skype. [Grandparents ask their grandchildren], ‘What did you do? Something? Nothing?’ You create stories and jokes. [It] brings families in [the] spirit.”

The service is accessible for free for 30 days and then a premium subscription takes effect afterward either at $8.99 monthly or at $89.99 yearly.

“One only needs to subscribe,” she said. “You see who we try to call. [You] enter someone’s e-mail address. [You] read books and games. [There is] conference e-mailing. [You] see and hear each other talk.”

Panasonic has worked with publishers such as Houghton Mifflin Harcourt Publishing company and Disney and game developers to obtain and store 2,500-plus popular children’s books and games on the website, including Star Wars, Marvel and Pixar products.

“[In terms of books, I] recently read all favorites,” Schneider said. “[There are] animal adventures [for] different ages [such as]Curious George. You click on the book. It will bring it up. [It] brings up context.”

Books and games include math flash cards, Word Aventures for vocabulary, Curious George Gets a Medal, Curious George Goes to the Hospital, Martha Speaks: Leader of the Pack and Just Grace, Checkers, Tic-Tac-Toe, Go Fish to Word Play, Chess and Animal Math.

“Each game has a tutorial,” Schneider said. “[The tutorials] show [the child] how to play. [They have] a match. A child has to know [what games he or she wants to play such as] Tic Tac Toe.

“There is a video conference. [They] read a nighttime story. You get to experience it together. You heart the book.”

Jerry Kurtze, director of new business development and innovation of Panasonic. explained that the service helps grandparents and grandchildren find interesting subjects to discuss since children under aged 10 tend to answer questions with monosyllabic replies, cannot deepen the substance of their topics and don’t speak long enough to build ties with family members.

“[Our target market is for children aged] 3 to 10,” Kurtze said. “When they get above 10, [it is hard to connect them with their grandparents]. It’s hard to get the children at ages 11, 12, 13.”

Add to this geographical, cultural and generational differences and a child’s grasp of e-mail, Skype and text messaging within nuclear families and both parties have serious challenges to overcome, she added. HomeTeam is aimed at providing grandparents and grandchildren common ground, lasting conversations and enjoyment.

“[There is no more closeness with the] nuclear family,” Schneider said. “[There is] long distance.”

HomeTeam software presents a book selected by either the grandparent or grandchild and both start to read. When one person turns the page electronically on his or her computer screen, the page is also turned in the other’s system as well. The same applies for moves during a Chess or Checkers game.

The book or game is the centerpiece of both parties’ attention but a video chat box appears on the side so they can see and speak with each other. E-mail and invitations functions are also featured to enable family members to contact and choose one another for discussion.

“[If grandparents and grandchildren want to] play games, [you go to the home screen and click] ‘go to all,’” Schneider said. “You see games available. [There are plenty of] games that [involve] younger children and young grandparents.

“There is a camera on the side. You can hear the decrease or increase [in volume]. You can hear yourself talking. All the tablets come with microphones and cameras. This is the home screen. I [can] see what’s online.

“There is a closed network. I [can choose to only have them if I] want my family members. My loved ones accept invites. “

Kurtze said that Panasonic’s HomeTeam was the result of two years of research, collaboration with company executives, managers and software developers and outreach to the healthcare market.

“We did not know what to do,” he said. “The number one [priority] is socializing with the family. We [were] led to this discussion [and] we tested sharing Web, technology and support. We found the big thing, [which was] games, books and reading.”

The more the development team learned about the public’s wants and needs, the more they were able to form partnerships with other companies and acquire text and game material, Kurtze said.

“We get a variety [of books] like Curious George,” he said. [These were for] simple reading. [These are] base-level books.”

Schneider said the team will continue research in order to offer more titles. “One of the developers [is involved in] testing,” she said. “We do criticize [the programs to improve them] and work [with] grandparents and children.”

Panasonic’s Health and Wellness Solutions department plans to add more instructional material overtime, Kurtze added.

“We will have informational books [in the future],” he said. “[These books will] teach about animals, science or [other subjects]. There’s a new medium.

“We will learn what people want. [We will] continue to add. [Then we will] adjust [our offerings accordingly].”