Anticoagulants are common medications in the PACE environment and are used to prevent blood clots from forming in the body. Popularly known as “blood thinners,” these medications require serious scrutiny from medical personnel when making decisions about care and other medications for PACE participants. Normally, blood clotting is an essential function of the body to protect itself against excessive bleeding in the event of an injury. In other circumstances, though, blood clots can become a dangerous threat to health and well-being if they travel through the blood vessels to the heart, lungs, or brain. Therefore, anticoagulants are typically used in the PACE environment for participants who suffer from:
Also, participants in the PACE environment who have had a synthetic heart valve implanted or received knee or hip replacement are generally on some form of anticoagulant. Let’s take a look at how and why anticoagulants are used within the PACE environment—and examine the risks and benefits.
Every year in the United States, approximately 900,000 people suffer a pulmonary embolism or deep vein thrombosis, resulting in 100,000 deaths. At least 25 percent of individuals who suffer a pulmonary embolism die suddenly without any warning symptoms. Men and women who are at a higher risk for blood clots include those who have atherosclerosis, diabetes, heart failure, irregular heart rates, immobility, obesity, and malignancy. Prescribing anticoagulants following an initial blood clot is vital, considering 30 percent of those who have a blood clot will have another clotting incident within ten years. Half of blood clots occur during or soon after surgery or a hospital stay. Many within the PACE environment display one or more risk factors for forming blood clots. [Tweet “#Anticoagulant use is common in the #PACE environment, but it requires some careful considerations.”]
Although anticoagulants are commonly called “blood thinners,” they do not make the blood thinner. They serve a dual purpose of:
Anticoagulants defeat blood clots by reducing the blood’s ability to clot, either by inhibiting vitamin K or by stopping other clotting factors from operating.
While this is good news for eliminating clots or reducing their risk, it raises the risk of prolonged bleeding should a person suffer a cut or nick. This is the primary risk and unwanted side effect of anticoagulants.
Anticoagulants are available as either oral or injectable products. Oral medications are generally used for ongoing prophylaxis in the outpatient setting for easier administration.
A benefit of the new oral therapies in the PACE environment is they do not require routine blood monitoring. Injectable products are typically used more at the beginning of therapy, especially when treating an existing clot.
In recent years, several new oral anticoagulation therapies were approved by the FDA—Eliquis® (apixaban), Pradaxa® (dabigatran), Savaysa® (edoxaban), and Xarelto® (rivaroxaban). These anticoagulants defeat blood clots by inhibiting thrombin (Pradaxa) or factor Xa (Eliquis, Savaysa, and Xarelto).
The above medications are short-acting compared to warfarin (Coumadin®). So, if therapy is missed, interrupted, or irregular, there is a risk for breakthrough strokes.
If regular therapy is a concern, these medications may not be the best option within the PACE environment, and warfarin may be the likely anticoagulant of choice.
As mentioned above, while the desired results of anticoagulants are admirable and desired, the most undesirable effect is an increased risk for prolonged bleeding. While administering vitamin K has a reversing effect for the anticoagulant warfarin, others do not have reversing agents.
An interest certainly exists for developing reversal agents for the other mentioned products, but none are available at this time.
When switching to warfarin from Eliquis, Pradaxa, Savysa, or Xarelto, those in the PACE environment will need to continue current anticoagulant therapy in addition to the warfarin until their INR reaches effective levels. This should take about five days.
With Pradaxa, medical professionals recommend stopping therapy after one to two days on warfarin, so long as renal function is normal. If renal function is impaired, wait until day three to stop administering Pradaxa.
PACE participants have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.
flu complications among elderly adults cost a staggering $56 billion. Adults who are 65 and older, including PACE participants, are at a higher risk for encountering complications from the flu virus. This is especially true for those with underlying health conditions. The enormous clinical and economic burden from influenza outbreaks has long motivated vaccine manufacturers to invest in developing an improved annual flu vaccine for senior adults. One vaccine, licensed in the United States in 2009, and known as the trivalent inactivated influenza vaccine Fluzone High-Dose, has demonstrated better efficacy and effectiveness compared with standard-dose influenza vaccines in older adults. [Tweet “Is the high-dose #fluvaccine really better for #PACE participants?”]
A randomized, controlled FIM12 study proved the overall effectiveness of the high-dose flu vaccine. In this study, 31,989 participants were enrolled from 126 research centers in Canada and the United States.
According to this study, among those 65 years or older, Fluzone High-Dose provided better protection and induced significantly higher antibody responses against laboratory-confirmed influenza than Fluzone Standard-Dose.
Investigators from the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and the U.S. Food and Drug Administration reported that the high-dose vaccine was 22 percent more effective than the standard-dose vaccine for the prevention of probable influenza.
It was also 22 percent more effective in preventing flu-related emergency room visits and hospital admissions, both important factors among PACE participants.
A critical health question for senior adults—and PACE centers—is the cost-effectiveness of the high-dose flu vaccine. Could the vaccine reduce the significant economic burden of flu outbreaks in adults older than age 65?
In one study of cost analysis, the high-dose trivalent inactivated flu vaccine is a cost-saving alternative to the standard-dose vaccine. Moreover, the additional cost of administering a high-dose instead of a standard-dose vaccine produced a staggering 587 percent financial benefit to the healthcare system.
The majority of those savings came through reductions in cardiorespiratory hospital admissions related to the flu. The study results indicate that the high-dose vaccine saved costs over the analyzed two-year period, and therefore showed better cost-effectiveness than most other strategies used.
Although initial costs for the high-dose flu vaccine are higher than the standard-dose vaccine, results of cost analyses favor the high-dose vaccine, mainly because of the reduction of hospital admissions.
PACE providers must focus on patient-centered care while considering the well-being of the participant and the cost savings when recommending immunizations during flu season.
Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>
Participants, family members, and providers in the PACE environment should all be familiar with medications and medical conditions that increase the risk of falls. Medications—and their side effects—are one of the major causes of falls in the elderly. Because of the potential for injury when an older person falls, everyone in the PACE environment should be aware of which medications or conditions come with an increased risk of falls. When it’s possible, providers should seek safer alternative medications or even reduce medications to the lowest effective dose as a fall prevention strategy.
The ultimate goal of PACE, including PACE pharmacy, is to provide members of the PACE population with high-quality care that keeps them independent and active, allowing them to remain in the home while receiving the services they need. An essential element of such services is medication reconciliation.
Older adults are often on multiple medications—and these medications are often stopped and new medications ordered, as medications are changed over time. Medication changes can cause confusion for members of the PACE population, for caregivers, and for participants’ family members. Lack of communication between PACE participants and healthcare providers during care transitions contributes significantly to medication safety errors. That’s why it’s vitally important for PACE pharmacy providers and other members of the multidisciplinary team to thoroughly review these changes with participants and their caregivers, ensuring they understand what is happening and why.
With an increased number of medications—which are often prescribed by multiple physicians, including specialists—comes an increased number of potential problems. Side effects, possible duplicate therapies, and the possibility of drug interactions are just some of the serious issues that can arise.
Clinical consults play an important role in ensuring safety among the PACE population. These consults, in which a geriatric-specialized pharmacist reviews participant medications on a regular basis, include a number of safety checks, including:
Clinical consults serve a dual purpose: They help promote positive outcomes for members of the PACE population, while helping PACE centers contain costs and make efficient decisions.
Communication and participant/caregiver engagement are essential to ensure all parties are working from the same plan. PACE pharmacy services work along with all members of the participant’s multidisciplinary medical team to ensure continuity of care.
This integrated model of care aims to improve the quality of life of participants within the PACE population with chronic care needs by providing necessary medical and pharmacy services, including medication reconciliation.
Medication reconciliation, part of the clinical consult, carefully reviews a participant’s medication regimen, lowering the risk of preventable medication errors and potential hospitalization.
Health literacy education is designed to ensure each participant understands his or her therapies—taking into consideration hearing, vision, or physical impairments; language barriers; and/or the ability to understand written text.
Optimal, effective medication management for the PACE population utilizes both written and visual tools, along with health literacy information, to help participants and their family members understand their medication regimens.
Grane Rx partners with PACE centers to provide participants with medications that are delivered directly to the home in easy-to-understand packaging that includes clear directions on when medications should be taken. The packaging also includes both visual and written cues on what medications are for, as well as how they should be taken.
These tools, in combination with medication reconciliation, help limit the risk of avoidable drug errors and other potential problems.
Want to learn more about the impact Grane Rx can have on your PACE center and your services to the PACE population? Start the conversation by calling (412) 449-0504 or emailing email@example.com.]]>
incidence of constipation is higher in older populations when compared to younger populations. And it’s even more common in older women.
While constipation is not considered a natural consequence of aging, the PACE population is affected by age-related physiologic changes that may contribute to constipation.
Some of these changes include:
The good news, though, is that through both non-pharmacological and pharmacological treatments, PACE pharmacy providers can help older adults belonging to the PACE population get a handle on constipation.
While there are various prescription and over-the-counter medications that are effective in relieving constipation symptoms, there are also a number of non-medication options that can help.
Many of these options can be used with medications to improve constipation symptoms in PACE participants. However, before employing a pharmacological treatment option, it’s worth trying the following non-pharmacologic ones:
Of course, there are pharmacologic options available to help manage constipation. Various laxatives and prokinetic agents are often used to treat constipation, including in the PACE population.
Bulk laxatives, which includes Methylcellulose, Polycarbophil, and Psyllium, work by absorbing water from the intestinal lumen to increase stool mass and soften stool consistency.
Because it can take anywhere from 12 hours to three days for bulk-forming laxatives to work, they are not recommended for the immediate relief of constipation.
Emollient laxatives or stool softeners, such as Docusate, work by allowing water to enter the bowel more readily.
These laxatives are generally well-tolerated, but are not as effective as psyllium in the treatment of constipation.
It’s important to note that in chronically ill older adults, stool softeners are not considered effective, as they generally take between 12 and 72 hours to work.
And finally, though mineral oil is a common go-to for chronic constipation, it’s not a recommended treatment. Experts have noted a severe complication of this medication—the risk of aspiration—and emphasize the importance of heightened awareness among caregivers and post-acute pharmacy providers regarding the potential dangers of inappropriate mineral oil use.
Osmotic laxatives, such as Lactulose, Magnesium Citrate, and Sorbitol, help alleviate constipation by causing water to secrete into the intestinal lumen via osmotic activity.
This class of laxatives tends to show effectiveness roughly one to two days following administration.
It’s important to note that these laxatives should be used carefully among adults in the PACE population who have congestive heart failure and chronic renal insufficiency.
Stimulant laxatives, like Senna and Bisacodyl, work by boosting intestinal motility and water secretion into the bowel.
This class of laxatives generally produces bowel movements within hours, but may cause abdominal cramping because of the increased peristalsis. Typically, stimulant laxatives take between six and 12 hours to work.
In adults belonging to the PACE population, a combination of senna and bulk laxative has shown to be more effective than lactulose in improving stool frequency and consistency. In addition, stimulant laxatives can be used on an as-needed basis, so long as participants carefully follow the manufacturer’s instructions.
Prokinetic agents, which include medications like Tegaserod and Misoprostol, have been studied for the treatment of slow transit constipation—though they haven’t been approved by the U.S. Food and Drug Administration for this indication.
Larger trials are needed to confirm the efficacy and safety of the long-term use for chronic constipation. To date, Tegaserod, in particular, has shown to not improve older adults’ symptoms of abdominal pain/discomfort, even though it increases bowel movements.
If a PACE participant is started on one of medications discussed in this article, it is extremely important to continually monitor him or her for the continuation or relief of symptoms.
Additionally, it is recommended to monitor for diarrhea and/or increased bowel movements, which may lead to needing to discontinue medication use.
Though helpful in alleviating constipation symptoms in older adults, laxatives are a drug class that may be potentially unnecessary after period of time. These agents tend to stay on participants’ medication lists for longer periods of time than may be clinically necessary, and there are potential harms associated with long-term laxative use, including:
Because of the risk of long-term harm, it’s essential to reassess the need for laxatives once the participant’s symptoms of constipation are alleviated.
By properly following treatment guidelines, together we can work to minimize the recurrence and symptoms of constipation in PACE participants.
Those in the PACE population have unique medical needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504 or emailing firstname.lastname@example.org.
In PACE pharmacy, medications are typically dispensed to participants in monthly increments that are either picked up at the PACE center or delivered to the home. But what happens when a participant’s medication regimen needs to change in the middle of a cycle? Because PACE participants usually take multiple medications for a variety of medical conditions, it isn’t uncommon for physicians to switch out a medication or change its dosing. It also isn’t a problem. We’ve created a seamless process designed to handle medication regimen changes when they occur—without compromising participant safety or health. Read on to learn more. Let’s first take a look at the “why” behind our packaging. Medication nonadherence is a significant problem among the senior population and is especially critical for PACE participants. With this in mind, Grane Rx uses innovative packaging called SimplePacks when dispensing PACE pharmacy medications. This packaging is just one part of the overall Grane Rx PACE Pharmacy Solution, which is designed specifically with seniors in mind—featuring clear, understandable information about medications to encourage adherence. Each month, participant’s medications are packaged together inside two color-coded boxes: one for everyday medications and one for medications that are taken as necessary. Within those boxes, medications are packaged in SimplePacks, which are easily opened perforated packs of medications taken at the same time of day, whether morning, noon, evening or at night. This unique PACE pharmacy solution offers a much better medication management system than the bingo cards typically used by long term care pharmacy and other PACE pharmacy providers. The very thing that makes our packaging unique and innovative—our SimplePacks perforated pill packs—can seem like it would be tricky when medication changes are needed. But actually, that isn’t the case. [Tweet “A simple #PACEpharmacy process can make medication changes seamless”]
According to the National PACE Association, nearly half of PACE participants have been diagnosed with dementia. Yet, even with the challenges of dementia, they’re living on their own with the help of caregivers. What is the role of PACE pharmacy services in helping manage dementia and mitigate its side effects to the largest extent possible? PACE medication management for participants with dementia must be multifaceted to meet the unique challenges the participants and their caregivers face. Care for these participants must include educational components, enhanced medication safety and regular medication therapy reviews. Here’s a look at the medication-related challenges dementia presents.
By Jennifer Devinney, RPh, PharmD Polypharmacy is an often silent, but very serious, problem in PACE pharmacy today. It is defined as the administration of more medication than is clinically indicated, which represents unnecessary medication use. Thorough PACE medication management is key to limiting polypharmacy. Polypharmacy is especially prevalent in elder care where it has been estimated that approximately a quarter of patients are prescribed nine or more medications, with some studies showing much higher percentages of patients exceeding five, nine or ten medications.
When compared with long term care pharmacy, PACE pharmacy presents its own unique set of challenges. Because participants are in the home environment rather than in a long term care setting with clinicians on hand, questions, concerns and needs may arise at any hour of the day. That’s why around-the-clock PACE pharmacy staffing is vital. Having PACE pharmacy providers available 24 hours a day, seven days a week means that there’s always a geriatric pharmacy expert on hand who can help PACE center staff meet participant needs. This allows for a smoother process for PACE medication management. So what are the distinct advantages of having around-the-clock PACE pharmacy staffing for your PACE center? There are three main benefits.
The medication packaging used in long term care pharmacy has evolved over the past few decades, with rapid changes occurring just a few years ago. Most LTC pharmacy services providers today utilize medication punch cards to dispense medications to SNF residents or PACE participants. Medication punch cards were first used in the 1970s, when pharmacies began packaging together 30-day or larger supplies of medications. Current usage of punch cards can be traced back to 2009 when the Congressional Budget Office determined that medication waste in long term care would cost Medicare more than $5.5 billion by 2019. As a result of those findings, rules were issued in the next few years mandating that prescription medications in long term care pharmacies be dispensed in no greater than two-week increments. This drive to reduce medication waste led to the advent of punch cards for 7- or 14-day periods, rather than 30-day periods as they were previously. But when it comes to medication management, there’s a better kind of packaging than medication punch cards. Let’s take a look.