Socioeconomics of Aging

Casus 1

JR is an 83 y/o resident of an independent living facility. She lives alone as her spouse passed on several years ago. She is referred to pharmacy services for concerns over her medication management skills.

Upon arrival at her apartment she gives you several printouts of her
medication list from her physician office and she hands you a box which holds her medication vials. On inspection there are several different doses of some of her medications. Her medication lists also vary in dose from what is contained in the box. JR states she is unable to remember what doses she should be taking, nor what she is taking them for.

Which social issue is impacting JR ability to
manage her medication?

1. Change in social support
2. Change in coping mechanism
3. Change in economic status
4. Change in function

JR is taking the following medications:

Levothyroxine 75mcg daily

Lasix 40mg once a day

Potassium 10mEq once a day

Benazepril 10mg once a day

Amlodipine 5mg once a day

Gabapentin 300mg three times a day

Atorvastatin 10mg at HS

Before suggesting a plan to improve JR’s medication management what should be done?

1. Asses her cognitive status
2. Screen for other adherence issues
3. Screen for falls
4. Asses her financial resources

Which of the following methods would best improve JRs medication management
and adherence?

1. Fill a weekly pill box
2. Provide an updated list of her medications and schedule
3. Set an alarm for the time(s) she should take her medications
4. Provided an updated list, schedule, and follow up in a few days

A decrease in societal support may lead to
which of the following?

1. Decreased access to medical care
2. Improved economic status
3. Decreased out of pocket expense
4. Improved health status

Casus 2

FJ is an 80 y/o male who presents to the clinic complaining of depression. He lost his spouse about one year ago. He lives alone, and doesn’t drive. He has no family nearby. A neighbor drives him to appointments. He gets groceries delivered. He looks more disheveled than usual, and smells of urine. He states, “there just isn’t anything to get up for anymore.” You inquire about his sleep and social activities. FJ states he dozes on and off during the day in front of the TV, and gets about 10h of sleep at night. FJ tells us he used to go to the Moose lodge every night to play cards and have a few beers with the guys, but he can’t get there anymore. You ask about his current drinking habits and he states he has about 6 beers every night. He gets extremely irritable with your questioning and “just wants a pill to make this go away.”

According to the National Institute on Alcohol Abuse and Alcoholism what are the recommendations for alcohol consumption for adults over 65?

1. Males: 2 drinks per day Females: 1 drink per day
2. There are no recommendations for adults over 65
3. 1 drink per day, no more than 7 in a week
4. The risk outweigh the benefit of any alcohol use

What sign symptom of substance abuse is FJ displaying that is not also a symptom of depression?

1. Disheveled appearance
2. Sleeping more than usual
3. Urine smell
4. Irritiability

According to the US Preventative Services Task Force how often should every older adult be screened for substance abuse?

1. Every 5 years
2. Every 3 years
3. Every other year
4. Every year

FJ has an Audit-C score of 6.
What should be the next step?

1. Brief alcohol counseling
2. Alcohol anonymous
3. Admission to a nursing home
4. Psychiatric admission

Which of the following could be a sign of alcohol withdrawal to look out for during a hospitalization of an older adult?

1. Somnolence
2. Tachycardia
3. Dyspnea
4. Low blood pressure

Casus 3

EM is a 72 y/o female who has just been diagnosed with pancreatic cancer. The oncologist has informed her and her family that although treatment will prolong her life for about a year, they should start planning for her wishes in end-of- life. With an interdisciplinary team present, she and her family fill out a living will and she designates a power of attorney.

Her living will state that she does not wish to be resuscitated, hospitalized, have a feeding tube, or be placed on a respirator.

Casus 3 vervolg

The Advanced Directive (AD) is put on her file at the oncologist’s office. In the coming months she is placed on hospice care and is nearing death.

EM awakens in the middle of the night gasping for air and turning blue. Her husband cannot think straight and calls 911. He does not have a copy of her AD and EMTs insert a breathing tube and rush her to the hospital. She is no longer conscious at the hospital and her husband calls her son the POA who brings her AD to the hospital. She can breathe on her own with oxygen and is resting comfortably.

What should the healthcare team do in this situation?

1. Notify hospice and transfer back home
2. Remove oxygen and see if she remains stable
3. Keep her hospitalized since she is comfortable
4. Run tests to rule out pneumonia

Casus 4

You are seeing EA an 82 y/o Asian female to check her INR. She is accompanied by her 20 y/o grandson. Her INR is high so you ask about her diet and medication compliance. She says she doesn’t remember if she took her medication every day. Her grandson pipes in, "you can’t remember anything you dumb old lady, how many times do I have to tell you to take the medicine?" EA falls silent as you turn to fill out her dosing schedule.

What should be the next step
in her treatment?

1. Nothing
2. Ask grandson to leave the room and not speak to his gm that way
3. Ask grandson to leave the room and screen for abuse
4. Call protective services

Casus 5

SS is an 82 y/o male who is returning home with his wife after a short term rehabilitation stay at a local nursing home for a hip fracture. He is able to walk with a walker, needs minor assistance with ADL’s, and has mild memory impairment. The interdisciplinary team has decided that he is safe to return home with a home health nurse, PT, and OT. They recommend a shower chair in his shower, grab bars installed near the toilet and in the shower, a walker, and a home health aide 3x/week for assistance with showering.

Which of the following is covered under Medicare Part B?

1. Grabs bars
2. Home health aid
3. Shower chair
4. Walker

SS and his wife are worried about their ability to pay for all of this even though their income is above the poverty level.

Which of the following would best to recommend as a source of assistance?

1. State Medicaid office
2. Local Area Agency on Aging office
3. Medicare website
4. Medical equipment supplier

Casus 5 vervolg

The home health nurse arrives at SS home and begins the needs assessment. She notices that there may be a problem with medication
management and makes a referral to the pharmacist. SS is using a pill box to organize his medications and his wife fills it. On inspection of the current pillbox, the pharmacist notes that there are missed doses and the PRN hydrocodone/acetaminophen 5/325 is set up four times a day. The wife seems flustered with the pharmacist’s questions and states, “this is all just too much for me to handle” I have my own medications too you know. 

After completion of the initial assessment what would be the first step in developing the pharmacist’s care plan for medication management?

1. Asking about medication related problems
2. Asking about patients goals for pharmacotherapy
3. Asking about other methods of management
4. Asking about difficulty taking medication

Casus 5 vervolg

It is decided that the home health nurse will fill SS’s pillboxes to ensure they are correct. His meds include: 

Glipizide XL 10mg daily, Metoprolol succinate 50mg daily, Simvastatin 20mg at bedtime, Hydrocodone/APAP 5/235 Q6h PRN, Acetaminophen 500mg twice a day, Gabapentin 300mg three times a day, Celexa® 40mg daily 

Which adherence assessment tool would be most useful for the pharmacist to re-assess whether the care-plan is working and make changes if needed?

1. Hill bones compliance scale
2. MARS
3. SEAMS-MAQ
4. SEAMS

In the case of SS and his wife, what would be one of the most important aspects of the initial caregiver assessment?

1. Substance abuse
2. Elder abuse
3. Caregiver knowledge
4. Caregiver resoures

Casus 6

A nurse on the Alzheimer’s unit of a nursing home is approaching two patients who appear to be in an escalating argument over a game being played. She reaches out and taps the closest resident on the shoulder and sternly asks, “What is going on here?” The resident that she touched swings and hits the nurse in the face. 

 

What could the nurse have done better in communicating with these residents?

1. Approach from the front
2. Smiling as she approaches
3. Use a more soothing touch
4. Use of hand gestures

Casus 7

Mr. + Mrs. R are both in their mid-70’s, active, and independent. Mr. R suffers from a massive stroke one night at dinner and is rushed to the hospital. He now has left hemiplegia and expressive aphasia. He is wheelchair bound and needs assistance of two people to transfer from one surface to another. Mrs. R would like to take him home, but realizes that she is unable to care for him herself. Their children live fairly close but each has families of their own. They both have state pensions and social security and would like to be as close as possible to each other so they can see each other every day. Mrs. R does not want to give up her independence but is willing to sell the house.

What would be the best option for level of care for Mr. and Mrs. R?

1. Assisted living for the couple
2. Nursing home care for the couple
3. Continuing Care Retirement Facility
4. Group home care

Mr. and Mrs. R are transitioned to the environment recommended. Which of the following problems that occur at discharge increases the risk for another transition of care to occur?

1. Careful medication reconciliation
2. Good communication between providers
3. Lack of medication monitoring
4. Too many medication refills

Einde!