- Email: [email protected]
GAPNA 30th Conference: Improving Lives of Older Adults—Practice & Policy
OFFICIAL SECTION OF THE
Gerontological Advanced Practice Nurses Association
GAPNA 30th Conference: Improving Lives of Older Adultsd Practice & Policy Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist Assistant Professor of Nursing University of Mississippi Medical Center Jackson, MS GAPNA celebrated its 30th annual conference in beautiful Washington, DC, September 14e18, 2011. The conference was opened by Evelyn Duffy, presiding president who welcomed the largest attendance in GAPNA’s historyd430 advanced practice nurses (APNs) and students. There were two preconference sessions, one focused on geriatric pharmacology and the other on research, and both were well attended. All sessions of the conference were recorded, allowing attendees to potentially attend all presentations virtually via GAPNA’s online library. Mary Wakefield PhD, RN, Administrator of the Health Resources and Services Administration (HRSA), delivered the keynote address with a passionate discussion about how APNs will play a key role in the health of our nation as well as participate as key players in health care reform. APN’s importance will increase in all types of practice in caring for the growing geriatric population. Our profession will be important in the delivery of quality care, assurance of safety in practice, and impact the overall health of the geriatric population, our nation’s most vulnerable people. The nursing profession has shown a commitment to excellence in care and shares many of the same goals that HRSA has for our nation’s health care. There are tremendous opportunities for APNs in the evolving Affordable Care Act (ACA), but there are many challenges ahead as nursing as well as our nation moves forward on this agenda. HRSA has a large portfolio with a tremendous impact on health care. The agency uses its $9.7 billion annual budget to manage 80-plus grant programs in partnership with state, local, and community organizations across the country. HRSA’s Community Health Centers Program supports more than 1100 grantees at more than 8100 sites dotted across our country’s landscape. This
Geriatric Nursing, Volume 32, Number 6
primary care infrastructure serves 19.5 million individuals with the ability to collect data on performance outcomes, which is available on HRSA’s website. The National Health Service Corps offers financial incentives for repayment of student loans to health care providers in exchange for service in underserved communities. HRSA also offers scholarships to schools in efforts to increase the number of health care providers to meet the growing needs of our nation’s health care system. Other programs include the Maternal and Child Health Block Grants promoting services and screening for mothers and young children and the Ryan White HIV/AIDS Program providing screening, diagnosis, and management for more than half a million individuals. HRSA’s Office of Rural Health Policy has noted a greater proportion of elders residing in rural settings, which is creating challenges to accessing health care. An emphasis has been to address this issue through supporting telemedicine, allowing monitoring as well as health care conferencing to meet the health care needs of individuals in rural areas. The Poison Control Center is another service offered to the community that has seen a shift from issues with children ingesting poisonous substances to a greater use of this service addressing elders with issues surrounding polypharmacy as well as health care providers using this service to assist in care for their elderly clientele. And an additional service noteworthy of mentioning is the oversight of the national Organ Procurement and Transplantation Network. This program is striving to get the word out that older individuals can donate their organs even up to 60-70 years of age, which will ultimately expand donations and save more lives. The push is to make older individuals as well as health care providers aware of the ability of older persons to donate later in life. There is support and belief in the worthwhile contributions nurses are making to our nation’s health care. This is evidenced by the appointment of nurses into key positions: Mary Wakefield as head of HRSA and the appointment of Marilyn Tavenner as second in command for the Centers for Medicare Services (CMS). Key offices at HRSA led by nurses include the Ryan White HIV/AIDS Program, the Bureau of Health Professions, the Office of Health Equity, and the Office of Global
465
Health Affairs. The nursing profession is contributing significantly to health care. which is being justly recognized by the Obama administration. President Obama has been a strong nursing advocate and views the nursing profession in its devotion to health care and working to improve health care for the right reasons, recently stating, “Nurses aren’t in health care to get rich, they are in it to care.” Our nation needs all health care providers, and APNs should be allowed to work to their optimal potential and abilities to advance the health of the American public. This is not just an opportunity; it is an expectation of the American public. The most controversial topic surrounding health care today is the Affordable Care Act, which is purported to be striving to make sweeping changes to health care delivery. This program parallels other previously proposed and proven programs that also faced opposition and controversy. It is difficult to believe that before Medicare, more than half of seniors had no health insurance and no means to pay for care. But the Social Security System and Medicare were developed; both were highly controversial at their inception and are now widely praised as having a positive impact on the American public and health care. Nurses are playing decisive roles in the planning as well as implementation of many programs improving America’s health care system. Many are leaders in expanding primary care delivery and increasing the number of community health centers. These efforts are increasing access to health care services and improving management of chronic disease. Another focus is on investing in people and keeping people healthy, which makes good common sense as opposed to a reactive approach to health care when costs for care are markedly more expensive. The Affordable Care Act plans to increase health care for millions more Americans, which will increase the demands on the health care delivery system. There will be more seniors seeking health care from the front-line primary care providers, many of whom are APNs. There will be more nurse managed health centers to meet the needs of the public for access to care, preventive services, and for comprehensive health care management. APNs are leading the models of primary care delivery systems, bringing expertise in geriatric care as well as community-based geriatric care to make an impact on health care outcomes. These are in line with HRSA’s immediate goals of improving 466
health care systems, which will be accomplished by devoting funding to the National Health Service Corps to increase the number of health care providers. There are initiatives in place to promote geriatric care. HRSA is partnering with the American Geriatric Society and the National Organization for Nurse Practitioner Faculty to get the word out through e-mail alerts. This will assist in making more health care professionals aware of the student loan repayment program, which is now accepting applications from those professionals who may only seek to work parttime in underserved areas. There will be an emphasis on promoting wellness in the American society through annual wellness visits, a key preventive health screening service that seniors will no longer be required to have a co-pay to utilize. Another benefit for seniors will be the opportunity for our elders living on limited incomes who are falling in the “donut hole” for paying for prescription drugs. They will be offered a program that provides a 50% discount on certain medications with plans to eliminate the “donut hole” by 2014. It is proposed to make it illegal for any insurance company to deny coverage to children with certain diagnoses, and this will extend to seniors by 2014 as well. Today, advanced practice nursing is the fastest growing segment of primary care providers. HRSA plans to partner with APNs to encourage a team approach to health care delivery to optimize this care. Because it has been noted that 1 in 5 of all seniors have 5 or more chronic conditions and these individuals consume a significant portion of all health care dollars spent, the aim is to have better coordination of care. There will be many opportunities to work in a variety of settings from primary care to multiple specialties. Every clinician as well as every patient will be empowered to assist in optimizing care. Champions are needed to increase access to care and to offer efficient, high-quality health care. To track all of these programs or for more information, go to www.Healthcare.gov.
Pharmacology Update GAPNA 2011 by Manju T. Beier Kimberly Ratcliff, MSN, ACNP-BC The 2011 GAPNA Convention once again enjoyed a lively pharmacology update from Manju T. Beier, PharmD, CGP, FASCP. Topics included Geriatric Nursing, Volume 32, Number 6
new drugs, Food and Drug Administration (FDA) safety alerts, prescribing criteria updates, and future Alzheimer’s dementia medications. The new direct thrombin inhibitor dabigatran (Pradaxa) was FDA-approved in October 2010 to reduce risks of strokes and systemic emboli in patients with nonvalvular atrial fibrillation (AF). This drug has been approved in other countries for treatment and prevention of venous thromboembolism. Ninety-five percent of all AF cases are nonvalvular. Because dabigatran is 80% excreted in the kidneys, dose reductions are necessary in those patients with chronic kidney disease. There are pros and cons for use of this agent: one con is there is no antidote or reversal agent. A pro is that no laboratory monitoring is necessary, which could be a significant cost savings compared with warfarin therapy. Patients must avoid using any nonsteroidal anti-inflammatory agents (NSAIDS) or aspirin-containing agents with this medication because concurrent use does increase risk of bleeding substantially. However, at FDA-approved dosing, dabigatran showed decreased intracranial hemorrhage vs warfarin in the RELY clinical trials. Study also shows fewer drug-to-drug and food-to-drug interactions than warfarin. Two new anticoagulants, rivaroxaban and apixaban, have also been FDA-approved. These drugs are Factor Xa inhibitors. Rivaroxaban is a once daily oral anticoagulant approved in July 2011 for prevention of deep vein thrombosis (DVT) in knee or hip replacement surgery. Stroke prevention indications are still pending. For more information, consult the ROCKET-AF study. Apixaban is superiorly more efficacious than aspirin in those patients who cannot tolerate warfarin for AF. When compared with warfarin, apixaban showed less cerebrovascular accidents (CVAs) secondary to ischemic emboli, decreased bleeding, and decreased mortality. Although the drug costs substantially more, there are no labs needed and it is essentially hassle free. Follow the ARISTOTLE study for more information on AF comparison. A new antiplatelet agent ticagrelor (Brilinta) has been approved for prevention of cardiovascular events in patients with acute coronary syndrome. Unlike clopidogrel (Plavix), this drug is reversible. According to the PLATO study, dyspnea is increased 38% in patients beginning as early as the first week of therapy. Usually dyspnea is mild to moderate and transient. In Geriatric Nursing, Volume 32, Number 6
those patients requiring aspirin, the maximum dose should be 81 mg. Use cautiously in those patients with bradycardia. Drug interactions with digoxin and statin drugs were noticed. Twice daily dosing is required, so compliance does become an issue. Of note, clopidogrel does go generic in May 2012. Follow the PEGASUS trial for new updates on ticagrelor. Clostridium difficile diarrhea has a new antibiotic known as fidaxomicin (Dificid). In infections that have not been cured with metronidazole (Flagyl) and vancomycin, this drug has been shown to be efficacious. Fidaxomicin does provide a lower risk of reoccurrence of C. difficile, and the twice daily dosing helps patients comply better with treatment. The price tag is impressive at $2800 for a 10-day course. The oral formulation of vancomycin (Vancocin) costs $1300 for a 10day course. However, it is interchangeable to have the injectable form of vancomycin reconstituted for use orally, which would cost approximately $60 a day. This drug could be for those patients with severe recurrent C. difficile infections. Linagliptin (Tradjenta) is the third oral DPP-4 inhibitor approved by the FDA for treatment of Type II diabetes mellitus. The other 2 are sitagliptin and saxagliptin. Of note, linagliptin is a oncedaily dose, and there is no change in dosage for patients with renal impairment. Daliresp (roflumilast) is a PDE 4 inhibitor, which is a new class used to treat chronic obstructive pulmonary disease (COPD). Dosing is 500 mg daily without regard to food. However, there are serious neuropsychiatric side effects such as anxiety, depression, and sleep deprivation. The use of this drug is reserved for severe uncontrolled COPD. Two new drugs have been approved for treatment of hepatitis C. Boceprevir (Victrelis) and telaprevir (Incivek) were developed to be used in conjunction with other medications. These drugs are significant because of their efficacy for genotype I infections versus the current standard of care. However, the limitations will probably outweigh the use of these drugs. With the use of telaprevir, there have been serious skin reactions, including Steven-Johnson syndrome, and anemia. The cost of using Incivek in a 25-week course is $25,000 to $50,000. The FDA has placed several drugs on the safety alert list. Some of these drugs are dronedarone (Multaq), linezolid (Zyvox), and 467
468
Table 1.
Types of Arthritis1-3
Geriatric Nursing, Volume 32, Number 6
Rheumatoid Arthritis
Osteoarthritis (aka Degenerative Joint Disease)
Cause
An autoimmune disorder that affects the lining of a person’s joints, causing pain, swelling, and problems with movement. It can eventually result in bone erosion and joint deformity.
Osteoarthritis is also referred to as degenerative joint disease and is the most common form of arthritis in older individuals. It occurs when cartilage in the joints wears down over time.
Symptoms
< Joint pain < Joint swelling < Joints that are tender to the touch < Red and puffy hands < Firm bumps of tissue under the skin on the arms also referred to as rheumatoid nodules < Fatigue < Morning stiffness that may last for hours < Stiffness and pain worse in the morning; may last up to 2 hours after rising or stiffness and pain after periods of inactivity
< Symptoms progressively worsen over time < Joint pain is worse during or after movement < Tenderness of joint with palpation or pressing on joint < Loss of flexibility < Grating sensation with joint movement, also referred to as crepitus
Typical Presentation
< Pain in joint is worse during or after activity or use of the joint
Gouty Arthritis An accumulation in joints of uric acid or urate crystals, causing inflammation and intense pain. An acute flare-up is referred to as a gout attack. Normally, the body produces uric acid when it breaks down purines which are substances that are found naturally in the body as well as found in certain foods. Urate crystals can form when a person has high levels of uric acid in the blood. < A gout flare-up: an acute attack of pain in a jointcommonly affects the great toe < Pain in joint may begin suddenly then linger for weeks < Pain in joints commonly moves to different joint
< <
Redness, swelling, and warmth of the affected joint Movement irritates or worsens the symptoms
Geriatric Nursing, Volume 32, Number 6
Diagnosing
< Physical examination < X-rays < Blood test: Elevated sed rate (ESR)
< Physical examination < X-rays < Blood test: Normal ESR
Medication Management
< Nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen, naproxen, or other prescriptions medications < Stronger pain medications < Steroid medications < Antirheumatic medications < Immunosuppressant medications < Fish oil < Other prescription medications < Use ice alternating with heat therapy < Exercise to stretch and strengthen as well as maintain or improve balance < Relaxation techniques < Gait and balance assessment as well as gait training with use of assistive devices if necessary
< Acetaminophen < NSAIDS such as ibuprofen, naproxen, or other prescriptions medications < Stronger pain medications < Steroid medicationsdinjections or oral therapy
Lifestyle Management
< < < <
Use heat therapy Nonstressful exercise Relaxation techniques Balance assessment and gait training with use of assistive devices if necessary
< Physical examination < X-rays < Blood tests to assess uric acid levels; possible elevated uric acid level < Joint aspiration to assess for presence of urate crystals < NSAIDS such as ibuprofen, naproxen, or other prescriptions medications including colchicine and indomethacin < Steroid medications
< < < <
Rest when a joint is inflamed Increase fluid intake Avoid alcohol Eat only a moderate amount of protein; limit daily intake of meat, fish. and poultry to 4 to 6 ounces < Consider alternative management: coffee, vitamin C 500 mg daily, and increasing intake of blackberries, blueberries, purple grapes and raspberries or black cherry pills 1000 mg daily
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simvastatin (Zocor). Dronedarone is indicated for management of paroxysmal atrial fibrillation. The PALLAS trial has shown that there are increased death rates related to strokes and liver failure with this medication. Strict monitoring of liver function tests is required. Linezolid has been linked with serotonin syndrome because the drug is a monoamine oxidase inhibitor. When using this linezolid for last resort and emergent treatment for methicillin-resistant staphylococcus aureus with a patient taking a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI), they must be stopped immediately. Once treatment with linezolid has concluded, wait 2-5 weeks before restarting SSRI or SNRI. The FDA has recommended the maximum dose for simvastatin is 80 mg because of the increased risk of muscle damage. Renal function must be reviewed and periodic creatine phosphokinase should be drawn. There is only a 6% drop in low density lipoprotein (LDL) from a 40-mg dosage to a 60-mg dosage. Crestor should be considered in patients who have problems with simvastatin. Other items discussed by Dr. Beier were the STOPP and START criteria developed in the United Kingdom. The STOPP criteria are used to focus on avoidance of potentially dangerous medications prescribed to the elderly population. The START criteria are used to focus on identifying under treatment or prescribing omissions in the elderly. The Pharmacology Update provided answers to many questions regarding Pradaxa and the other anticoagulant medications. Dr Beier has a unique ability to capture an audience’s attention and provide useful practical information for nurse practitioners to retain and begin using immediately in practice. GAPNA has found an invaluable speaker for many conventions to come.
Adult Nurse Practitioner-Gerontological Nurse Practitioner Update Summary by Lisa Byrd, PhD, FNP-BC, GNP-BC, and Cindy Luther, DSN, FNP, GNP Joan M. Stanley, PhD, CRNP, FAAN, FAANP, is the senior director of education policy at the American Association of Colleges of Nursing (AACN). Dr Stanley serves as AACN’s representa470
tive to the Advanced Practice Registered Nurse (APRN) Consensus Process, which developed the model for APRN regulation. There are changes occurring which will affect credentialing of the geriatric nurse practitioner (GNP) and the geriatric clinical nurse specialist (GCNS) in the very near future. Currently an advanced practice registered nurse (APRN) may prepare and take the GNP or GCNS examinations independently of any other certification. By 2015, those wishing to take the GNP certification examination will be required to be prepared to take a combined test: Adult-Gerontology Primary Care Nurse Practitioner, Adult-Gerontology Acute Care Nurse Practitioner, or the AdultGerontology Clinical Nurse Specialist (Primary Care A-GNP, Acute Care A-G NP, or A-G CNS). This will require preparation to include didactic as well as clinical training across the entire adult age spectrum from young adult to the frail elderly. After 2015, all certified GNPs and GCNSs must maintain their certification; if their certification lapses, additional education and re-examination will likely be required. Because after 2012, the NP and CNS must be educationally prepared across the entire adult age spectrum to sit for the new A-G NP or A-G CNS examinations, the GNP and GCNS who has allowed his or her certification to lapse would no longer be eligible for reexamination by testing. Other requirements for APRN education programs will also be put into place as the transition to the Consensus Model for APRN Regulation is implemented. After 2015, all new APRN programs, including those preparing the Adult-Gero NP or CNS, must be preaccredited or preapproved before admitting students. Each APRN program must also 1) document on the transcript/official document the role and population the APRN will be prepared to care for and 2) include a wellness component. All APRN programs will include 3 separate core courses (referred to as the 3 Ps): 1) advanced pathophysiology across the life spandfrom prenatal to death of old age (all programs must include all age groups and not be limited to the patient population the program will be preparing the NP or CNS to serve); 2) health assessment of all systems and advanced techniques; and 3) pharmacology for all age populations and must include broad categories of all pharmacologic agents. The John A. Hartford Foundation is funding an initiative to assist faculty with the transition of NP and CNS program curricula, updating adult Geriatric Nursing, Volume 32, Number 6
programs to include geriatric content. New national competencies for the Primary Care AdultGerontology NP and the Acute Care A-G NP and the A-G CNS have been developed.. APRN resources for integrating gerontology content into the NP and CNS curriculum will include a faculty resource center, webinars, interactive case studies, and a variety of other web-based resources. There was also an update on the transition of APRN education programs to the doctor of nursing practice (DNP) degree. There has been a notable and steady increase in the numbers of APRNs and other nurses prepared in advanced areas of practice graduating from DNP as well as PhD programs in recent years. The AACN membership has set a target date (2015) for this transition for APRN entry into practice to be at the doctor of nursing practice (DNP). AACN is working with schools to make this transition but also recognizes that some schools will not transition their APRN programs by this date for a variety of reasons. For more information on these issues, go to www.aacn.nche.edu.
MAKE PLANS TO ATTEND GAPNA’s 31st Annual Conference Promoting Clinical Excellence Through Vision, Vitality and Visibility September 19e22, 2012 Red Rock Casino Resort Las Vegas, Nevada Abstracts for presenting at conference are due December 5, 2011 For more information, please visit www.GAPNA.org
the practitioner correctly diagnoses the type of arthritis a person has and develops an appropriate plan of care (Table 1). General ways to manage the symptoms of arthritis include the following:
maintain an optimal weight (obesity causes extra stress on the joints), maintain mobility and exercise (water aerobics is an option-less stress on joints), and medication management.
References Arthritis: Differentiating the Type of Arthritis and Planning Ways to Manage the Problem(s) Lisa Byrd, PhD, FNP-BC, GNP-BC Arthritis is a common ailment in many older individuals that causes pain, stiffness, and problems with mobility, as well as disability. It is an inflammation of the joints and affects nearly half the people over age 651,2 and one of the leading causes of immobility in elders. There are ways to keep an older person as mobile as possible with the least amount of pain and disability if
Geriatric Nursing, Volume 32, Number 6
1. Geriatric Nursing Review Syllabus. Core curriculum in advanced practice nursing. 2nd ed. New York: The John Hartford Foundation Institute of Geriatric Nursing, New York University; 2007. 2. Wright W. Osteoarthritis management today: minimizing pain and maximizing quality of life. Adv Nurse Pract 2004; 12:24-31. 3. Kane R, Ouslander J, Abrass I, et al. Essentials of clinical geriatrics. New York: McGraw Medical; 2009.
0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.09.008
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Gerontological Advanced Practice Nurses Association
GAPNA 30th Conference: Improving Lives of Older Adultsd Practice & Policy Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist Assistant Professor of Nursing University of Mississippi Medical Center Jackson, MS GAPNA celebrated its 30th annual conference in beautiful Washington, DC, September 14e18, 2011. The conference was opened by Evelyn Duffy, presiding president who welcomed the largest attendance in GAPNA’s historyd430 advanced practice nurses (APNs) and students. There were two preconference sessions, one focused on geriatric pharmacology and the other on research, and both were well attended. All sessions of the conference were recorded, allowing attendees to potentially attend all presentations virtually via GAPNA’s online library. Mary Wakefield PhD, RN, Administrator of the Health Resources and Services Administration (HRSA), delivered the keynote address with a passionate discussion about how APNs will play a key role in the health of our nation as well as participate as key players in health care reform. APN’s importance will increase in all types of practice in caring for the growing geriatric population. Our profession will be important in the delivery of quality care, assurance of safety in practice, and impact the overall health of the geriatric population, our nation’s most vulnerable people. The nursing profession has shown a commitment to excellence in care and shares many of the same goals that HRSA has for our nation’s health care. There are tremendous opportunities for APNs in the evolving Affordable Care Act (ACA), but there are many challenges ahead as nursing as well as our nation moves forward on this agenda. HRSA has a large portfolio with a tremendous impact on health care. The agency uses its $9.7 billion annual budget to manage 80-plus grant programs in partnership with state, local, and community organizations across the country. HRSA’s Community Health Centers Program supports more than 1100 grantees at more than 8100 sites dotted across our country’s landscape. This
Geriatric Nursing, Volume 32, Number 6
primary care infrastructure serves 19.5 million individuals with the ability to collect data on performance outcomes, which is available on HRSA’s website. The National Health Service Corps offers financial incentives for repayment of student loans to health care providers in exchange for service in underserved communities. HRSA also offers scholarships to schools in efforts to increase the number of health care providers to meet the growing needs of our nation’s health care system. Other programs include the Maternal and Child Health Block Grants promoting services and screening for mothers and young children and the Ryan White HIV/AIDS Program providing screening, diagnosis, and management for more than half a million individuals. HRSA’s Office of Rural Health Policy has noted a greater proportion of elders residing in rural settings, which is creating challenges to accessing health care. An emphasis has been to address this issue through supporting telemedicine, allowing monitoring as well as health care conferencing to meet the health care needs of individuals in rural areas. The Poison Control Center is another service offered to the community that has seen a shift from issues with children ingesting poisonous substances to a greater use of this service addressing elders with issues surrounding polypharmacy as well as health care providers using this service to assist in care for their elderly clientele. And an additional service noteworthy of mentioning is the oversight of the national Organ Procurement and Transplantation Network. This program is striving to get the word out that older individuals can donate their organs even up to 60-70 years of age, which will ultimately expand donations and save more lives. The push is to make older individuals as well as health care providers aware of the ability of older persons to donate later in life. There is support and belief in the worthwhile contributions nurses are making to our nation’s health care. This is evidenced by the appointment of nurses into key positions: Mary Wakefield as head of HRSA and the appointment of Marilyn Tavenner as second in command for the Centers for Medicare Services (CMS). Key offices at HRSA led by nurses include the Ryan White HIV/AIDS Program, the Bureau of Health Professions, the Office of Health Equity, and the Office of Global
465
Health Affairs. The nursing profession is contributing significantly to health care. which is being justly recognized by the Obama administration. President Obama has been a strong nursing advocate and views the nursing profession in its devotion to health care and working to improve health care for the right reasons, recently stating, “Nurses aren’t in health care to get rich, they are in it to care.” Our nation needs all health care providers, and APNs should be allowed to work to their optimal potential and abilities to advance the health of the American public. This is not just an opportunity; it is an expectation of the American public. The most controversial topic surrounding health care today is the Affordable Care Act, which is purported to be striving to make sweeping changes to health care delivery. This program parallels other previously proposed and proven programs that also faced opposition and controversy. It is difficult to believe that before Medicare, more than half of seniors had no health insurance and no means to pay for care. But the Social Security System and Medicare were developed; both were highly controversial at their inception and are now widely praised as having a positive impact on the American public and health care. Nurses are playing decisive roles in the planning as well as implementation of many programs improving America’s health care system. Many are leaders in expanding primary care delivery and increasing the number of community health centers. These efforts are increasing access to health care services and improving management of chronic disease. Another focus is on investing in people and keeping people healthy, which makes good common sense as opposed to a reactive approach to health care when costs for care are markedly more expensive. The Affordable Care Act plans to increase health care for millions more Americans, which will increase the demands on the health care delivery system. There will be more seniors seeking health care from the front-line primary care providers, many of whom are APNs. There will be more nurse managed health centers to meet the needs of the public for access to care, preventive services, and for comprehensive health care management. APNs are leading the models of primary care delivery systems, bringing expertise in geriatric care as well as community-based geriatric care to make an impact on health care outcomes. These are in line with HRSA’s immediate goals of improving 466
health care systems, which will be accomplished by devoting funding to the National Health Service Corps to increase the number of health care providers. There are initiatives in place to promote geriatric care. HRSA is partnering with the American Geriatric Society and the National Organization for Nurse Practitioner Faculty to get the word out through e-mail alerts. This will assist in making more health care professionals aware of the student loan repayment program, which is now accepting applications from those professionals who may only seek to work parttime in underserved areas. There will be an emphasis on promoting wellness in the American society through annual wellness visits, a key preventive health screening service that seniors will no longer be required to have a co-pay to utilize. Another benefit for seniors will be the opportunity for our elders living on limited incomes who are falling in the “donut hole” for paying for prescription drugs. They will be offered a program that provides a 50% discount on certain medications with plans to eliminate the “donut hole” by 2014. It is proposed to make it illegal for any insurance company to deny coverage to children with certain diagnoses, and this will extend to seniors by 2014 as well. Today, advanced practice nursing is the fastest growing segment of primary care providers. HRSA plans to partner with APNs to encourage a team approach to health care delivery to optimize this care. Because it has been noted that 1 in 5 of all seniors have 5 or more chronic conditions and these individuals consume a significant portion of all health care dollars spent, the aim is to have better coordination of care. There will be many opportunities to work in a variety of settings from primary care to multiple specialties. Every clinician as well as every patient will be empowered to assist in optimizing care. Champions are needed to increase access to care and to offer efficient, high-quality health care. To track all of these programs or for more information, go to www.Healthcare.gov.
Pharmacology Update GAPNA 2011 by Manju T. Beier Kimberly Ratcliff, MSN, ACNP-BC The 2011 GAPNA Convention once again enjoyed a lively pharmacology update from Manju T. Beier, PharmD, CGP, FASCP. Topics included Geriatric Nursing, Volume 32, Number 6
new drugs, Food and Drug Administration (FDA) safety alerts, prescribing criteria updates, and future Alzheimer’s dementia medications. The new direct thrombin inhibitor dabigatran (Pradaxa) was FDA-approved in October 2010 to reduce risks of strokes and systemic emboli in patients with nonvalvular atrial fibrillation (AF). This drug has been approved in other countries for treatment and prevention of venous thromboembolism. Ninety-five percent of all AF cases are nonvalvular. Because dabigatran is 80% excreted in the kidneys, dose reductions are necessary in those patients with chronic kidney disease. There are pros and cons for use of this agent: one con is there is no antidote or reversal agent. A pro is that no laboratory monitoring is necessary, which could be a significant cost savings compared with warfarin therapy. Patients must avoid using any nonsteroidal anti-inflammatory agents (NSAIDS) or aspirin-containing agents with this medication because concurrent use does increase risk of bleeding substantially. However, at FDA-approved dosing, dabigatran showed decreased intracranial hemorrhage vs warfarin in the RELY clinical trials. Study also shows fewer drug-to-drug and food-to-drug interactions than warfarin. Two new anticoagulants, rivaroxaban and apixaban, have also been FDA-approved. These drugs are Factor Xa inhibitors. Rivaroxaban is a once daily oral anticoagulant approved in July 2011 for prevention of deep vein thrombosis (DVT) in knee or hip replacement surgery. Stroke prevention indications are still pending. For more information, consult the ROCKET-AF study. Apixaban is superiorly more efficacious than aspirin in those patients who cannot tolerate warfarin for AF. When compared with warfarin, apixaban showed less cerebrovascular accidents (CVAs) secondary to ischemic emboli, decreased bleeding, and decreased mortality. Although the drug costs substantially more, there are no labs needed and it is essentially hassle free. Follow the ARISTOTLE study for more information on AF comparison. A new antiplatelet agent ticagrelor (Brilinta) has been approved for prevention of cardiovascular events in patients with acute coronary syndrome. Unlike clopidogrel (Plavix), this drug is reversible. According to the PLATO study, dyspnea is increased 38% in patients beginning as early as the first week of therapy. Usually dyspnea is mild to moderate and transient. In Geriatric Nursing, Volume 32, Number 6
those patients requiring aspirin, the maximum dose should be 81 mg. Use cautiously in those patients with bradycardia. Drug interactions with digoxin and statin drugs were noticed. Twice daily dosing is required, so compliance does become an issue. Of note, clopidogrel does go generic in May 2012. Follow the PEGASUS trial for new updates on ticagrelor. Clostridium difficile diarrhea has a new antibiotic known as fidaxomicin (Dificid). In infections that have not been cured with metronidazole (Flagyl) and vancomycin, this drug has been shown to be efficacious. Fidaxomicin does provide a lower risk of reoccurrence of C. difficile, and the twice daily dosing helps patients comply better with treatment. The price tag is impressive at $2800 for a 10-day course. The oral formulation of vancomycin (Vancocin) costs $1300 for a 10day course. However, it is interchangeable to have the injectable form of vancomycin reconstituted for use orally, which would cost approximately $60 a day. This drug could be for those patients with severe recurrent C. difficile infections. Linagliptin (Tradjenta) is the third oral DPP-4 inhibitor approved by the FDA for treatment of Type II diabetes mellitus. The other 2 are sitagliptin and saxagliptin. Of note, linagliptin is a oncedaily dose, and there is no change in dosage for patients with renal impairment. Daliresp (roflumilast) is a PDE 4 inhibitor, which is a new class used to treat chronic obstructive pulmonary disease (COPD). Dosing is 500 mg daily without regard to food. However, there are serious neuropsychiatric side effects such as anxiety, depression, and sleep deprivation. The use of this drug is reserved for severe uncontrolled COPD. Two new drugs have been approved for treatment of hepatitis C. Boceprevir (Victrelis) and telaprevir (Incivek) were developed to be used in conjunction with other medications. These drugs are significant because of their efficacy for genotype I infections versus the current standard of care. However, the limitations will probably outweigh the use of these drugs. With the use of telaprevir, there have been serious skin reactions, including Steven-Johnson syndrome, and anemia. The cost of using Incivek in a 25-week course is $25,000 to $50,000. The FDA has placed several drugs on the safety alert list. Some of these drugs are dronedarone (Multaq), linezolid (Zyvox), and 467
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Table 1.
Types of Arthritis1-3
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Rheumatoid Arthritis
Osteoarthritis (aka Degenerative Joint Disease)
Cause
An autoimmune disorder that affects the lining of a person’s joints, causing pain, swelling, and problems with movement. It can eventually result in bone erosion and joint deformity.
Osteoarthritis is also referred to as degenerative joint disease and is the most common form of arthritis in older individuals. It occurs when cartilage in the joints wears down over time.
Symptoms
< Joint pain < Joint swelling < Joints that are tender to the touch < Red and puffy hands < Firm bumps of tissue under the skin on the arms also referred to as rheumatoid nodules < Fatigue < Morning stiffness that may last for hours < Stiffness and pain worse in the morning; may last up to 2 hours after rising or stiffness and pain after periods of inactivity
< Symptoms progressively worsen over time < Joint pain is worse during or after movement < Tenderness of joint with palpation or pressing on joint < Loss of flexibility < Grating sensation with joint movement, also referred to as crepitus
Typical Presentation
< Pain in joint is worse during or after activity or use of the joint
Gouty Arthritis An accumulation in joints of uric acid or urate crystals, causing inflammation and intense pain. An acute flare-up is referred to as a gout attack. Normally, the body produces uric acid when it breaks down purines which are substances that are found naturally in the body as well as found in certain foods. Urate crystals can form when a person has high levels of uric acid in the blood. < A gout flare-up: an acute attack of pain in a jointcommonly affects the great toe < Pain in joint may begin suddenly then linger for weeks < Pain in joints commonly moves to different joint
< <
Redness, swelling, and warmth of the affected joint Movement irritates or worsens the symptoms
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Diagnosing
< Physical examination < X-rays < Blood test: Elevated sed rate (ESR)
< Physical examination < X-rays < Blood test: Normal ESR
Medication Management
< Nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen, naproxen, or other prescriptions medications < Stronger pain medications < Steroid medications < Antirheumatic medications < Immunosuppressant medications < Fish oil < Other prescription medications < Use ice alternating with heat therapy < Exercise to stretch and strengthen as well as maintain or improve balance < Relaxation techniques < Gait and balance assessment as well as gait training with use of assistive devices if necessary
< Acetaminophen < NSAIDS such as ibuprofen, naproxen, or other prescriptions medications < Stronger pain medications < Steroid medicationsdinjections or oral therapy
Lifestyle Management
< < < <
Use heat therapy Nonstressful exercise Relaxation techniques Balance assessment and gait training with use of assistive devices if necessary
< Physical examination < X-rays < Blood tests to assess uric acid levels; possible elevated uric acid level < Joint aspiration to assess for presence of urate crystals < NSAIDS such as ibuprofen, naproxen, or other prescriptions medications including colchicine and indomethacin < Steroid medications
< < < <
Rest when a joint is inflamed Increase fluid intake Avoid alcohol Eat only a moderate amount of protein; limit daily intake of meat, fish. and poultry to 4 to 6 ounces < Consider alternative management: coffee, vitamin C 500 mg daily, and increasing intake of blackberries, blueberries, purple grapes and raspberries or black cherry pills 1000 mg daily
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simvastatin (Zocor). Dronedarone is indicated for management of paroxysmal atrial fibrillation. The PALLAS trial has shown that there are increased death rates related to strokes and liver failure with this medication. Strict monitoring of liver function tests is required. Linezolid has been linked with serotonin syndrome because the drug is a monoamine oxidase inhibitor. When using this linezolid for last resort and emergent treatment for methicillin-resistant staphylococcus aureus with a patient taking a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI), they must be stopped immediately. Once treatment with linezolid has concluded, wait 2-5 weeks before restarting SSRI or SNRI. The FDA has recommended the maximum dose for simvastatin is 80 mg because of the increased risk of muscle damage. Renal function must be reviewed and periodic creatine phosphokinase should be drawn. There is only a 6% drop in low density lipoprotein (LDL) from a 40-mg dosage to a 60-mg dosage. Crestor should be considered in patients who have problems with simvastatin. Other items discussed by Dr. Beier were the STOPP and START criteria developed in the United Kingdom. The STOPP criteria are used to focus on avoidance of potentially dangerous medications prescribed to the elderly population. The START criteria are used to focus on identifying under treatment or prescribing omissions in the elderly. The Pharmacology Update provided answers to many questions regarding Pradaxa and the other anticoagulant medications. Dr Beier has a unique ability to capture an audience’s attention and provide useful practical information for nurse practitioners to retain and begin using immediately in practice. GAPNA has found an invaluable speaker for many conventions to come.
Adult Nurse Practitioner-Gerontological Nurse Practitioner Update Summary by Lisa Byrd, PhD, FNP-BC, GNP-BC, and Cindy Luther, DSN, FNP, GNP Joan M. Stanley, PhD, CRNP, FAAN, FAANP, is the senior director of education policy at the American Association of Colleges of Nursing (AACN). Dr Stanley serves as AACN’s representa470
tive to the Advanced Practice Registered Nurse (APRN) Consensus Process, which developed the model for APRN regulation. There are changes occurring which will affect credentialing of the geriatric nurse practitioner (GNP) and the geriatric clinical nurse specialist (GCNS) in the very near future. Currently an advanced practice registered nurse (APRN) may prepare and take the GNP or GCNS examinations independently of any other certification. By 2015, those wishing to take the GNP certification examination will be required to be prepared to take a combined test: Adult-Gerontology Primary Care Nurse Practitioner, Adult-Gerontology Acute Care Nurse Practitioner, or the AdultGerontology Clinical Nurse Specialist (Primary Care A-GNP, Acute Care A-G NP, or A-G CNS). This will require preparation to include didactic as well as clinical training across the entire adult age spectrum from young adult to the frail elderly. After 2015, all certified GNPs and GCNSs must maintain their certification; if their certification lapses, additional education and re-examination will likely be required. Because after 2012, the NP and CNS must be educationally prepared across the entire adult age spectrum to sit for the new A-G NP or A-G CNS examinations, the GNP and GCNS who has allowed his or her certification to lapse would no longer be eligible for reexamination by testing. Other requirements for APRN education programs will also be put into place as the transition to the Consensus Model for APRN Regulation is implemented. After 2015, all new APRN programs, including those preparing the Adult-Gero NP or CNS, must be preaccredited or preapproved before admitting students. Each APRN program must also 1) document on the transcript/official document the role and population the APRN will be prepared to care for and 2) include a wellness component. All APRN programs will include 3 separate core courses (referred to as the 3 Ps): 1) advanced pathophysiology across the life spandfrom prenatal to death of old age (all programs must include all age groups and not be limited to the patient population the program will be preparing the NP or CNS to serve); 2) health assessment of all systems and advanced techniques; and 3) pharmacology for all age populations and must include broad categories of all pharmacologic agents. The John A. Hartford Foundation is funding an initiative to assist faculty with the transition of NP and CNS program curricula, updating adult Geriatric Nursing, Volume 32, Number 6
programs to include geriatric content. New national competencies for the Primary Care AdultGerontology NP and the Acute Care A-G NP and the A-G CNS have been developed.. APRN resources for integrating gerontology content into the NP and CNS curriculum will include a faculty resource center, webinars, interactive case studies, and a variety of other web-based resources. There was also an update on the transition of APRN education programs to the doctor of nursing practice (DNP) degree. There has been a notable and steady increase in the numbers of APRNs and other nurses prepared in advanced areas of practice graduating from DNP as well as PhD programs in recent years. The AACN membership has set a target date (2015) for this transition for APRN entry into practice to be at the doctor of nursing practice (DNP). AACN is working with schools to make this transition but also recognizes that some schools will not transition their APRN programs by this date for a variety of reasons. For more information on these issues, go to www.aacn.nche.edu.
MAKE PLANS TO ATTEND GAPNA’s 31st Annual Conference Promoting Clinical Excellence Through Vision, Vitality and Visibility September 19e22, 2012 Red Rock Casino Resort Las Vegas, Nevada Abstracts for presenting at conference are due December 5, 2011 For more information, please visit www.GAPNA.org
the practitioner correctly diagnoses the type of arthritis a person has and develops an appropriate plan of care (Table 1). General ways to manage the symptoms of arthritis include the following:
maintain an optimal weight (obesity causes extra stress on the joints), maintain mobility and exercise (water aerobics is an option-less stress on joints), and medication management.
References Arthritis: Differentiating the Type of Arthritis and Planning Ways to Manage the Problem(s) Lisa Byrd, PhD, FNP-BC, GNP-BC Arthritis is a common ailment in many older individuals that causes pain, stiffness, and problems with mobility, as well as disability. It is an inflammation of the joints and affects nearly half the people over age 651,2 and one of the leading causes of immobility in elders. There are ways to keep an older person as mobile as possible with the least amount of pain and disability if
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1. Geriatric Nursing Review Syllabus. Core curriculum in advanced practice nursing. 2nd ed. New York: The John Hartford Foundation Institute of Geriatric Nursing, New York University; 2007. 2. Wright W. Osteoarthritis management today: minimizing pain and maximizing quality of life. Adv Nurse Pract 2004; 12:24-31. 3. Kane R, Ouslander J, Abrass I, et al. Essentials of clinical geriatrics. New York: McGraw Medical; 2009.
0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.09.008
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