Bereavement and Loss: Understanding Grief in Older People.

Everyone experiences grief from time to time, but older people are more likely to experience grief simply because they live longer. Grief, bereavement, and mourning are different elements associated with death of a loved one. For most people, grief follows a fairly predictable trajectory, and over time resolves. One of the most used descriptions of grief was developed by Elizabeth Kubler-Ross and it is reviewed herein. However, for some people, grief becomes unbearable and chronic leading to prolonged grief disorder. For clinicians, it's essential to differentiate between prolonged grief disorder and major depressive disorder. Older people who experience unbearable grief often need medication to deal with some of its symptoms, which include depression, anxiety, hypertension, and lack of sleep. Older people also need considerable support as they deal with grief so that they do not become isolated, experience comorbidities, or spiral into physical and mental decline. Little specific research has examined pharmacists' opportunities to help older people who have prolonged grief, but some data suggest that these patients are more likely to visit the pharmacy and need medication more than others.

Telehealth: Moving Older People Along the Adoption Trajectory.

Although the concept of telehealth has been in development for many years, the global pandemic galvanized its growth and utility. In general, people adopt technological advancements at different velocities that, when plotted in a chart, resemble a bell-shaped curve. People who are quick to adopt new technologies are designated innovators, while those who are the very last to adopt new technologies are dubbed laggards. Often, older people fall into the laggard category for several reasons including physical, mental, and emotional barriers. In some cases, they lack the technology or experience with various programs that would make such programs accessible. Regardless, telehealth has proven its worth as a way to deliver care in areas distant to the health care provider when physical examination is unnecessary. It can reduce the likelihood of exposure to contagious disease. Telehealth also has the potential to reduce unnecessary emergency department visits, and long-term care facilities that have used telehealth have demonstrated cost savings. Little study has been conducted to determine how pharmacists are using telehealth, but after examining available research on telehealth, pharmacists can identify pitfalls and implement steps that reduce barriers for older people.

Insomnia Is Not a Normal Part of Aging: The Challenges of Safely and Effectively Managing Insomnia in Older People.

Almost everyone has sleep problems from time to time, and often, simple nonpharmacologic interventions can improve sleep hygiene. When nonpharmacologic interventions fail, patients often request and may even require treatment with hypnotics. Insomnia is a heterogeneous disorder. Patients with insomnia may have trouble falling asleep, staying asleep, or waking too early. Sleep disturbances are especially common in older people because of changes in sleep architecture. Though this population may benefit from hypnotics to improve sleep, these drugs increase the risk of polypharmacy, drug interactions, and adverse drug effects, such as falls and cognitive impairment. Pharmacists must consider patient-specific factors to ensure older patients who require hypnotics receive an appropriate drug for an appropriate duration.

Treating Erectile Dysfunction with Prescription Medications & Natural Products: A Pharmacist's Guide.

Stigma surrounding erectile dysfunction creates a difficult environment for appropriate management. Knowledge of the condition and treatment options presents a unique opportunity for pharmacists to optimize a safe and affordable plan that meets patient needs.

Alcohol-Related Dementia: Rethink How Much You Drink.

People have consumed alcohol for centuries. Most clinicians who work with people who have dementia acknowledge that alcohol may cause or exacerbate dementia's symptoms. Alcohol-related dementia (ARD) has been recognized since the 1960s, but clinicians rarely use this diagnosis. Regardless, it is common and develops pursuant to long-term excessive alcohol consumption. It may, in some cases, evolve into Wernicke-Korsakoff syndrome. Diagnosis can be obscured if patients are not truthful about their alcohol consumption. Often, friends or family provide a better picture of the patient's alcohol history than patients do themselves. Thiamine treatment may prevent or improve symptoms. Abstinence from alcohol is critical, but it is difficult for older people with long histories of heavy drinking. Consultant pharmacists can help the heath care team develop nuanced care plans for patients who have ARD.

Skin Tears in Older People.

Skin tears are a common occurrence in older people, though many are unfamiliar with them until late in life. These painful wounds are more likely to occur with age as the skin experiences age-related changes. Numerous factors including declining dermal thickness and loss of elasticity contribute to their development. Risk increases in patients who need assistance with activities of daily living or who need help transferring from bed or chair. Polypharmacy is a risk factor. Prevention is the best approach, but once skin tears develop, treatment needs to be tailored to the tear's grade.

Anxiety Disorders in Older People.

Anxiety disorders may be the most common mental disorder among older people. Experts estimate the prevalence of anxiety to be between 1.2% and 15% in community samples and 1% and 28% in medical settings. These patients manifest the symptoms of anxiety, and they are also at risk for increased disability, decreased health-related quality of life, and possibly mild cognitive impairment. For this reason, it is important for pharmacists to understand the challenges in assessing anxiety and the treatment options that are safe and effective for older people. Additionally, pharmacists must be able to communicate well with these patients despite their tendency to perseverate and fixate.

Social Determinants of Health: How Environmental Factors Affect Health.

Increasingly, public policy makers, professional organizations, and academics are discussing social determinants of health-the conditions in which people live, work, and age. The impetus for the discussion is a growing awareness that medication and any type of health care is a poor substitute for improving a patient's living conditions. Health care is a necessary but insufficient intervention when people develop chronic disease. Addressing the social determinants of health that include poverty, food insecurity, health literacy, neighborhoods, and the environment is essential if we are to improve an individual's overall health. This is the focus of population health, and to address social determinants of health adequately, the medical team needs to expand to give all team members overlapping duties. It also needs to include social workers and legal representatives. Pharmacists may wonder how the theories associated with social determinants of health can be incorporated into their practices. This article discusses a number of different approaches.

Older Adults Without Medical Support Systems: How Pharmacists Can Help.

The term "elder orphan" is an emerging description of an individual older than 65 years of age who lacks dependents or close family members on whom to rely for assistance, particularly in dealing with health problems. As the number of elder orphans continues to grow, this population is increasingly at risk. Some social determinants of health affect the elder-orphan population disproportionately, including financial security, housing, and transportation. Medication nonadherence may be a sign of increasing isolation and unaddressed problems. Elder orphans may have difficulty managing their health care, and pharmacists can help by identifying patients without support systems may be able to act as valuable assets to these patients. Brown-bag medication reviews, medication therapy management, and thorough medication reconciliation are excellent interventions to prevent medication misadventure. Identifying other medical professionals and services that can support the elder orphan is also prudent.

Gabapentin: Change is in the Wind.

In the midst of a national opioid crisis, Americans have a heightened awareness of the potential for prescription drugs that can be abused. One drug-gabapentin-is frequently prescribed in long-term care facilities for seizures and postherpetic neuralgia, and its use is a growing concern globally. Approved for two uses, but used off-label for many others, gabapentin can induce euphoria at high doses. In older adults, clinicians prescribe it for seizures, pain, migraine, and aggression associated with dementia, among other things. Gabapentin's rapid onset of action, side effect profile, limited drug-drug interactions, and extensive pharmacokinetic data in renal impairment have made prescribers comfortable using it in older adults. This gabapentinoid-a cousin to the Schedule V drug pregabalin-has seen widespread recreational abuse and has led to its reclassification in the United Kingdom and in several U.S. states. Consultant pharmacists need to be aware that the evidence behind off-label use is scant; withdrawal is likely after as few as three weeks of treatment; and drug diversion is possible, even likely. In addition, it is the tenth-most prescribed medication in the United States.

Medication Safety, Adherence, and Deprescribing in Patients With Dementia.

Patients with dementia face challenges with medication adherence because of the nature of the disease. Not only is adherence difficult in individuals with dementia, but the majority of this patient population also has comorbidities that make comprehension of complex treatment plans difficult. A large analysis of patients with dementia showed that 12% had only dementia as a diagnosis, 70% had at least two comorbidities, and 48% had at least three comorbidities. Proper medication adherence is important to prevent progression of these comorbidities and decline in overall health. However, as dementia progresses, the risk of taking certain medications may outweigh the benefits. Therefore, the treatment team needs to reassess medication lists over time. Incorrect medication use can pose a major safety concern for this patient population. Pharmacists can have conversations with patients and the patients' family members to discuss goals of care to determine if deprescribing is an option.

Outside Looking In: A Pharmacist's Personal Journey With Family Elders.

Pharmacists who work in long-term care-or in any area of health care-are exposed to the health care system on a daily basis. While most of us recognize that the health care system has problems, especially at transitions of care, few of us appreciate fully how serious these problems can be. Certifying and accrediting agencies have encouraged health care providers to step out of their silos and work more collaboratively, and educators have emphasized understanding geriatric syndromes. A description of a personal journey through the health system-for both the patient and the caregiver-with two older individuals, this narrative discusses how difficult it is for patients to understand what's happening around them. It also discusses the clinical inertia in addressing geriatric issues and offers suggestions to health care providers facing similar situations.

Increased Use of Medical Marijuana: Skepticism vs. Evidence.

The use of medical marijuana-both the psychoactive tetrahydrocannabinol and its nonpsychoactive relative cannabidiol-is a growing practice in facilities served by senior care pharmacists. Currently, 30 states have approved its use under a variety of different regulations and for a number of conditions. Its use is bolstered by a growing number of Americans who support legalization of cannabis. Though oral synthetic cannabinoid compounds are approved by the Food and Drug Administration for chemotherapy-induced nausea and vomiting and appetite stimulation associated with AIDS, synthetic products differ from plant-derived products in several ways. In addition, use of these substances has created a regulatory and legal quagmire that differs considerably depending on the state in which the pharmacist practices. In long-term care, pharmacists face an entirely different set of challenges than pharmacists who practice in other settings: Increasingly, long-term care residents and their attending physicians are asking to use medical marijuana. This manuscript discusses how some long-term care facilities are accommodating this substance that federally and in many states is considered illegal. It also discusses some of the challenges faced by pharmacists who work in dispensaries.

Concierge Pharmacy: A Potential Arena for Senior Care Pharmacists.

Concierge pharmacy is an emerging area of practice that appears to be well suited for pharmacists who prefer flexibility in geriatric practice, a system in which patients pay a fee for personalized care and access to their pharmacists. Older adults are a natural population for concierge pharmacists because of their individual increasing medical needs. At this time, concierge pharmacists tend to provide care to individuals who can afford to pay out-of-pocket or who are auxiliary personnel in medical offices, which provides payment. Other reimbursement models exist, and each concierge pharmacist's practice will be unique. The largest barrier to unfettered pharmacy practice is the inability to practice autonomously. Pharmacists can look to nurse practitioners' moderately successful march toward nationwide independent practice as a model for their own bid to practice independently.

New Models of Care: How Pharmacists Can Provide Better Care at Lower Costs.

Pharmacists, highly trained and accessible health care professionals, continue to be underused in American communities. Helping pharmacists to make the best use of their extensive clinical education and skills is a primary focus for the discipline's leaders. The University of Connecticut School of Pharmacy's PRISM initiative ( PeRformance I mprovement for Safe Medication Management) creates opportunities to partner with other health professionals or programs to advance the pharmacist's role in the community. All stakeholders must understand the evolving health care climate as society moves toward "health care without walls" (i. e., health care that is innovative, convenient, and likely to be entirely different than previous models). This article discusses progress made in Connecticut to advance pharmacy practice and describes programs that, if replicated in other areas of the country, could significantly improve care for vulnerable populations, especially the elderly. Programs that have been especially useful have emphasized the difference between needing medical versus pharmacy services, and approached provision of care in entirely new ways.

Addressing the Shortage of Geriatric Specialists.

With a population that is increasingly "gray," our nation faces a shortage of primary care providers who specialize in geriatrics. The number of geriatricians per 10,000 adults older than 65 years of age has decreased steadily since 2000. Health care providers from all disciplines (medicine, nursing, and pharmacy) tend not to choose geriatrics as a specialty area. Some are intimidated by the complexity of caring for elderly patients with geriatric syndromes and multiple morbidities. Others, who have little exposure to geriatrics in their undergraduate and graduate programs, are simply unaware of the personal and professional rewards associated with practice in geriatrics. Some choose to pursue more lucrative career paths. Regardless, geriatrics is a rewarding area of specialty, and pharmacists can pursue additional training to become specialists. Few pharmacy curricula offer intense exposure to geriatrics and elder health care. Numerous ways exist for pharmacists to help close the geriatric care gap.

Medical-Legal Partnerships: A Healing Collaboration.

Medical providers know that there are some conditions they can't treat because the condition is caused or exacerbated by social conditions and are known as "social determinants of health." ThIs classic example-a patient has asthma, lives in a moldor cockroach-infested apartment, has no resources to move, and has a landlord who refuses to clean or exterminate bugs- exemplifies why patients need legal advocates to improve their health. This article discusses medical-legal partnerships (MLPs), models in which medical providers refer patients to attorneys to represent them to resolve such problems. MLPs recognize social determinants of health and foster collaboration between attorneys and health care providers. Originally developed to advocate for children, many MLPs now focus on the vulnerable elderly, individuals at the end of life, and veterans. As these collaborations grow, it's important to spread the word among health care providers and to engage all collaborators. Today, more than 300 MLPs across the nation have documented remarkable achievements. The authors hope that in the future, pharmacists will become MLP team members and help patients address many of their medication-related problems.

Aging in Place: Our House Is a Very, Very, Very Fine House.

As 10,000 American baby boomers turn 65 years of age every day between 2017 and 2030, society needs to help our aging population find ways to handle the restrictions and limitations that come with increasing age: visual impairment, hearing loss, osteoarthritis, dementia, and other conditions common in older adults. Institutional or long-term care for elderly individuals costs an average of $82,000 to $92,000 per person per year and varies by location. Care in an assisted living facility costs $43,500 per person annually. Living in a personal home or residential setting-aging in place-by contrast, costs an average of $23,000 per person per year. Successful aging in place encompasses safety, health, and economic security. Numerous aging-in-place programs exist in contained geographic areas (towns and counties) or in areas that promote community living (e. g., cohousing or homesharing) or focus on special interests like the arts. Two such programs, the naturally occurring retirement community (NORC) model and the Village model, seem to have had the most success. Elderburbs-older, age-unfriendly communities not focused on residents' health care and mobility needs-remain and can present unique problems. Handheld technology or that integrated into housing can improve the standard of living, help elders improve their functioning, and even monitor medication. The aging-in-place movement presents numerous opportunities for consultant pharmacists.

The Ketogenic Diet: Making a Comeback.

Americans have embraced a large number of diets in an attempt to manage obesity, improve quality of life, and address specific health problems. Among diets developed to address health problems, the ketogenic diet has had a long and variable history. Developed in the 1920s by a faith healer to help children with epilepsy, this diet induces a state that mimics carbohydrate starvation. As medications became available and effectively addressed seizures, the diet fell out of favor. During the last few decades, researchers and clinicians have learned that it can be useful in children and adults with refractory epilepsy and a variety of other conditions. Once again, pharmacists may encounter patients who are employing dietary management of serious health problems. This very high-fat diet almost eliminates carbohydrates from the patient's food selection. The result is the substitution of ketone bodies as a source of energy. Today's ketogenic diet has been modified with scientifically proven adjustments to increase palatability and help with adherence. Effective for some forms of epilepsy, the ketogenic diet also seems to have some utility in Alzheimer's disease, Parkinson's disease, and glaucoma, and many Americans are using it to lose weight. Consultant pharmacists may field questions about this diet, its potential to correct or alleviate health conditions, and its limitations. The article discusses the ketogenic diet's strengths, limitations, potential mechanisms, and use in a number of conditions with an emphasis on the elderly.

Wandering: Unearthing New Tracking Devices.

Wandering away from home or facilities is dangerous for patients with dementia and stressful for families and caregivers when those who go missing cannot be located. Up to 60% of Alzheimer's disease patients wander, and up to 50% of those who are not found within 24 hours face serious injury or death. Currently, no effective drug therapies exist to abate wandering, which has multiple causes, but emerging technologies offer a promise of comfort in being able to easily locate a missing loved one. As of 2012, 41 states had enacted Silver Alert programs that broadcast information about missing, vulnerable adults. Numerous technologies, such as wearable global positioning system trackers and temporary barcodes worn on fingernails, exist to ease the fears of families and caregivers, locate residents, and hasten their return. While these strategies offer promise, issues of expense, effectiveness, privacy, and ethics remain.