CAPT. Chad Garrett 0:10 Good morning or good afternoon we'll be starting here in just about a minute thank you so much for joining us today Unknown Speaker 0:19 if you're not currently following us on x you can scan that QR code you Speaker 1 0:52 again as join us, if you want to use the chat where are you from? Where are you joining us from in the chat box? That would be great. Thank you. And with that, Mr. Smith, you have the comms. Christopher Smith, NPA 1:09 Thank you. Thanks. Chad, good afternoon. Everybody. Hello and welcome to the National Institute of Corrections, clinical pearls webinar series. My name is Chris Smith, and I'm a national program advisor with the National Institute of Corrections, we are thrilled to have you join us today for this informative nine part series exploring the integration of clinical pharmacists into primary care and highlighting proven approaches for correctional team medicine. Before we begin today's session, I'd like to cover a few important housekeeping items. First, each webinar in this series is scheduled to last approximately an hour. The sessions will be recorded and once captioned and made 508 compliant, will be available on our on our Nic, website this is a Listen Only event, meaning participant microphones are muted. However, we strongly encourage engagement through our WebEx chat function. Please use the chat function to share your thoughts, ask questions and request technical support. We will address as many questions as possible during our Q and A portion at the end of the webinar to practice the chat function. Everyone, please type the answer to the following question into your chat what was one of your favorite TV shows, cartoons or movies growing up. Go ahead and type that into your chat function right now, and let's let's share what our Favorite TV show, cartoon or movie was growing up you I see lots of good shows popping up when I was really young. Mine was GI Joe. As I grew up, I don't know if you guys remember V, like the old version, this new one they tried a couple years ago, didn't work for me, but the old, the original one worked. Worked well, alright, I appreciate everybody's tight in your shows. And then end of the chat. Thank you very much. If you experience any audio difficulties, we recommend connecting to the webinar audio via telephone using the number provided in your registration confirmation email throughout this series we want to hear from you. You can always email the health programs manager, Mr. Chad Garrett at ca Garrett, dot B, O, p.gov, with any comments, concerns or ideas for future events, I and my team for Nic, including some great staff from the NIC library, will be posting information in the chat during the presentation. Again, if you have any questions, please type them into the chat and we will answer as many as we can at the end of the webinar. Alright, everybody again. I welcome everybody to the presentation, and please take it away. Chad, think. Speaker 1 4:21 Garrett, I believe you're on mute. You're on mute. Chad, yeah, thank you. Mr. Smith, it CAPT. Chad Garrett 4:26 is the mission of the NIC to advance public safety by shaping enhancing correctional policies and practice through leadership learning and innovation. Correctional healthcare is facing a demographic reckoning the silver tsunami a term coined to capture the surging wave of adults is crashing into the prison systems nationwide. Correctional facilities across the country quietly transform into de facto geriatric care. Units The complexity of caring for aging adults in custody has never been more urgent or more intricate. The. The once young adult incarcerated population is graying, bringing with it a growing wave of age related physiological changes, co morbidity, poverty, pharmacy challenges, chronic disease management becomes less about treatment and more about orchestration, requiring a symphony of specialized knowledge, medication, safety, preventative care, and above all else, dignity and practice. This isn't just about aging. It's about aging. Well even behind bars. Remember older adults behind bars are not simply older versions of younger inmates. Enter commander hunt and Commander Stoner, two dynamic leaders in correctional pharmacy care who are here to share strategies that transcend the pill cart and redefine geriatric patient care in a high security setting together, these two dynamic leaders represent the front line of innovation and geriatric Correctional Health Care. Their insights are not only informed by deep clinical experience, but shared by service resilience and a commitment to optimizing outcomes for aging adults in custody. In this session, they will equip you with the strategies, tools and mindset necessary to meet the demands of the silver tsunami, because aging with dignity should be the standard, even behind bars, and with that, commanders, the Unknown Speaker 6:21 floor is yours. Speaker 2 6:26 Well, thank you for that, Chad, that was very good morning. My name is Commander Chantal hunt, and I'm the Chief pharmacist at the United States Federal Penitentiary in Tucson, Arizona. I'm proud to be a board certified geriatric pharmacist, working with an excellent team of providers here caring for our patient population. Our population includes approximately 2200 adult males requiring frequent medical supervision and attention. This classifies us as a care level three facility, which is just one step below a medical center after an epic failure as an Air Force airplane mechanic, I decided to choose a different career path, and went to pharmacy school. After reflecting back on this 12 year journey, I'm grateful for this new career, and also so are the pilots. So being a pharmacist is not just about dispensing medication, it's about dispensing full compassion and care for our patients. Next, I'd like to introduce you to our CO presenter, Lieutenant Commander Kara Stoner, Speaker 3 7:31 good morning and good afternoon. I am Lieutenant Commander Kira Stoner, prior to joining Federal Medical Center Fort Worth, I completed my residency training and worked in the acute care setting before I transitioned from the acute care setting to the critical illness recovery hospital and inpatient rehab. I worked there for eight years. Our focus was on long term acute care for critically and chronically ill patients. These patients often required a minimum length of stay of at least 21 days, and our average patient age was 62 here at Federal Medical Center, Fort Worth, I am the chief pharmacist. We have approximately 1600 adults in custody. We're a medical center, so we have an administrative facility security level, where we have all security levels, and we're a step above Chantal facility, where we have care level four and care level three mental health. Inside of our institution, we also have a 40 bed inpatient nursing care center where our average inpatient age is 64 and most patients are actually 68 years old. We'll talk a little bit more about specifically the inpatient unit further into the presentation for our disclosures. Neither myself or Shantelle have anything to disclose. I am going to read this for our purposes. The authors have no financial disclosures or conflicts of interest with the presented material in this presentation. Opinions expressed in this presentation are those of the authors and do not necessarily represent the opinions of the Federal Bureau of Prisons or the Department of Justice. Products presented in this presentation are not endorsed by the BLP as exclusive products. Care decisions, clear decisions for patients need to be individualized based on patient factors our objective objectives today, we want to identify unique considerations for aging incarcerated adults. We're going to evaluate medications for changing risk benefit profiles over the patient's lifespan, and we want to apply evaluation tools for aging incarcerated adults. So let's get started. Chantelle, who or what are we talking about? Speaker 2 9:44 Thank you. Kara, so what is an aging adult? The American Geriatric Society would consider any person greater than the age of 65 as an aging adult. But with our incarcerated population, we would consider any adult over the age of 55 as an aging adult. This is. A result of living in a suspensible environment and the stressful daily living conditions of incarceration. So let's discuss how this affects our aging population. Pharmaceutical care of older adults differs from that of younger adults for multiple reasons. These physiological changes affect the body, body's homeostasis. For example, in the central nervous system, there's a decreased brain mass, reduced mental speed and slower cognitive processing, increasing the risk of delirium and dementia. With the gastrointestinal system, there may be inflammation of the stomach lining, which causes delayed drug absorption, the heart also decreases its ability to relax, potentially causing heart failure or even increasing the high blood pressure risk. Kidneys can define and function as well affecting the clearance also of medications, the muscle mass will decrease, causing frailty and increasing the risk of falls, and then scan within which could lead to pressure ulcers. Unknown Speaker 11:08 Probably the most notable Speaker 2 11:09 effect of the physiological changes that we all recognize is hidgen is hearing, ambition, loss. This causes miscommunications with patients, and could also risk isolation so patients are less likely to communicate if they're not being well heard. So what does all this mean for this aging population? This means that physiological changes required a targeted preventative health strategies to be to maintain well being and reduce these complications. So for example, with cardiovascular health, we would modify treatment of blood pressure and cholesterol goals. So there's no need to really be as strict with these patients as you would non adult or non aged patients. So anyone under the 65 years of age would have a different goal than what our aging population, as and as I discussed earlier, aging adults have reduced relaxed heart relaxation, which would also increase the risk of hypertension. So providers should implement regular blood pressure monitoring and should continue statin therapy for patients that are high risk, and potentially include diet modifications to combat these physiological changes, because aging does alter insulin sensitivity, which would increase diabetes complications, our providers should avoid overly aggressive glucose lowering therapies, especially in frail patients, and we should adjust medications based upon kidney function. So it's really important to individualize these changes with each patient. Unknown Speaker 12:49 Cancer Prevention. For example, Speaker 2 12:51 though older adults have an increased risk of cancer, screening decisions should be a balance of life expectancy versus the benefit of the screen. So for colorectal cancer screenings, we would not be recommending those in patients greater than 75 years of age, as the benefit is small. However, vaccinations play a significant role in preventing potentially fatal infections in our population. As we age, our immune response weekends increasing infection risk, especially in our confined settings. So to prevent outbreaks in a correctional setting, routine vaccinations like influenza, pneumococcal and shingles should be offered, at least to prevent severity of illness. How can we assist with some of these recommendations? Kiera, Speaker 3 13:47 the role of the pharmacist can differ when managing medication therapy from those aging, those aging and incarcerated adults due to their unique health needs and considerations. So a little bit more about our inpatient unit. Here we are Medical Center, and so we have those 40 beds, and there are two pathways to admission. We have a pathway for short stay patients. So think of those that may have went to the hospital and they need to complete two weeks of IV antibiotics. We need to contain that IV access and make sure we're administering the antibiotics. So they will stay in the inpatient unit until their antibiotics are complete, we remove the access, and then they will return to the general population. Those are our short stayers. The vast majority of patients admitted are going to be our long term residents. So they are the ones who can no longer function on the compound. They may require more complex medication management or some degree of nursing care or assistance with their ADLs. Those that are admitted to our inpatient unit are reviewed by a pharmacist monthly, so once every 30 days, and this is where the magic really happens. I love to know what a patient's Why is for their admission, because it kind of helps to guide what their what my thought process is going to be. When I'm looking at their medication profile, their labs and everything else as I'm doing my chart review, here are some of the areas that I would focus on once I'm admitted, once they're admitted, so indication and geriatric patients, careful consideration needs to be given to whether medication is truly necessary. Many other adults are prescribed medications for conditions they no longer have or they may have outgrown. As a pharmacist, we can ensure that the indication for each medication is still relevant and beneficial given the patient's age, comorbidities and quality of life considerations, effectiveness, older adults often respond differently to medications due to age related changes in their metabolism, organ function and the immune system, as Chantal mentioned, we evaluate efficacy and review labs to evaluate whether or not the drug is effective, considering factors like their renal or their liver function and even their cognitive status. Pharmacists can also look at dosages and directions as patients age and the changes begin to show they can impact how the medications are absorbed, distributed, metabolized and excreted. Another area I focus on will be the drug drug interactions. So there are several different sites you can use, one being a Lexicomp, and you can look at the you can plug in all the medications and see if there are drug drug interactions that flag. Anything that's going to be a risk level D or risk level x, we're going to communicate with the provider on whether that needs to be stopped or if we need to have it make a recommendation for an alternate medication. And sometimes it needs to be something like spacing the medications from each other. Again, older adults often take multiple medications to manage various chronic conditions, and this increases that risk of having a drug drug interaction. We take a look at drug disease interactions. Also, the risk of drug disease interactions is higher in the geriatric patient as many have multiple chronic conditions such as diabetes, hypertension, arthritis or heart disease. As a pharmacist, we can ensure that the prescribed medications do not worsen these underlying diseases. For example, certain medications can exacerbate conditions like heart failure, kidney disease or cognitive impairment. As patients, medication lists begin to get longer as they age, duplication is the area we need to look out for. They're often prescribed multiple medications by different specialists, which increases the risk of duplication. For example, two different providers may prescribe medications for the same condition, like multiple anti hypertensives or even multiple statins, and the pharmacist can help identify and prevent this once we've cleaned up the list, we also need to make make sure that the duration of therapy is appropriate. Pharmacists help assess whether the duration of therapy, particularly when dealing with conditions like acute infections or temporary conditions, is appropriate. We'll also review whether ongoing medications are still necessary, especially as a patient's health status changes. A big area that we catch, a lot of things and we can make an impact with, is adherence or compliance. Oftentimes, if a patient is admitted and they've been on an anti hypertensive they may not have actually been taking it on the compound the way they should have, and then once they're admitted to the inpatient unit with closer oversight, direct observed therapy, they're now improving their compliance. They're taking it every day, and we may see an in an overshoot of our goal. So adherence is important, and it can be essential to review, because providers may not be aware of how the patient is taking the medication. Adverse effects. Geriatric patients are more vulnerable to adverse effects because of polypharmacy and age related changes in how drugs are processed in the body, the pharmacist can monitor closely for side effects, especially those that could significantly impact the patient's quality of life, such as cognitive disturbances, falls or drug induced delirium. We also work to prevent adverse effects through appropriate dose adjustments and selecting medications with a lower risk profile. And the last area will be deprescribing. We'll talk about this more in detail later, but de prescribing is especially important for older adults who may be on multiple medications. So with that, there is a common thread you may have heard throughout what the pharmacist role is. As we talk about polypharmacy, it's the most commonly. Is most commonly defined as five or more medications. 40% of patients age 65 years or older, take five to nine medications, and 18% of those take 10 or more. One in five drugs commonly used in elderly patients may be inappropriate. Did you know that polypharmacy is the number one predictor of adverse drug events? These include falls, hospitalizations and. Even death, approximately 50% of hospitalized patients receive one or more unnecessary drugs. Studies have found that focusing on minimizing polypharmacy indicates that de prescribing may be associated with potential benefits, including resolution of adverse drug reactions, improved quality of life and medication adherence. Adverse drug events can result from drug interactions, inappropriate prescribing or medication mismanagement in aging adults. Adverse drug events often manifest as cognitive impairment, falls or cardiovascular events, older adults are seven times as likely to have adverse drug events that require hospitalization. We want to consider underlying causes before we add an additional medication. We also want to recognize when it's time to make a dose adjustment for the patient's age and their renal impairment during transitions of care, whether into the out of the hospital or back into the institution. We can implement a medication review that and review medications that may no longer be needed. And lastly, we can educate. We can provide education to mitigate these risks. Our goal is to minimize harm and ensure that medications are doing more good than harm. Speaker 3 21:30 Let's dive into a specific type of medication risk. What exactly is anticholinergic burden? It is a cumulative effect of taking multiple medications that have anticholinergic properties leading to adverse outcomes. While Anticholinergics are used for various conditions, their cumulative effect can significantly harm older adults. So if we have a patient on one medication from each of these classes, or every one of them, the cumulative effect will lead and increase their anticholinergic burden. Common medications contributing include antihistamines like diphenhydramine, which are often used for allergies, can also cause drowsiness. Antidepressants such as amitriptyline or antipsychotics like chlorpromazine and muscle relaxant such as Cyclobenzaprine, are also notable contributors. These medications are linked to higher rates of falls, cognitive decline and even dementia in the long term. As we go forward, you'll see how managing anticholinergic burden through derescribing can mitigate these risks. So Speaker 3 22:45 the impact of anticholinergic burden is significant in aging adults, especially those in correctional facilities, where comorbidities and polypharmacy are common, prolonged use of high anticholiner anticholinergic medications can lead to cognitive decline, memory loss and even delirium. Additionally, it increases the risk of falls, which is a major concern in this population. As pharmacists, we must work with the healthcare team to identify high risk medications and de prescribe them when necessary, starting with those that have the highest anticholinergic activity. So as we can see here in this image, exposure to anticholinergic and sedative and the increased sedative burden is linked to a 60% increase in fall related hospitalizations, which is a critical concern. Another significant effect of anticholinergic burden is its association with cognitive decline. Prolonged use of medium or high activity anticholinergic raises the risk of dementia by 50% Unknown Speaker 23:51 Lastly, mortality Speaker 3 23:52 rates are higher in populations exposed to anticholinergic drugs. In fact, studies show a 30% increase in mortality for those with high anticholinergic burden, which further underscores the need for more cautious prescribing and monitoring. Speaker 3 24:12 So here are a list of different groups associated with falls. We spent a little bit of time already discussing Anticholinergics, where falls are one of the most common and serious consequence of aging, especially again, in the correctional setting, all of these can increase the risk of falls. Opioids impact the CNS or the central nervous system. Anti diabetics, when overly aggressive, can cause hypoglycemia. Anti hypertensives can lead to hypo anti hypertensive can lead to hypotension and anticoagulants, while they don't directly impact the central nervous system, those who are on it and suffer a fall can have severe outcomes. It is important to regularly review medications in aging adults and identify those that may increase their fat. All risk. Speaker 3 25:06 Let's take a closer look at how anticholinergic medications impact the entire body. This visual helps us understand why these drugs can be especially harmful in older adults. So starting at the top in the brain, anticholinergic drugs can lead to drowsiness, dizziness, confusion and even hallucinations. These effects are particularly dangerous in aging adults who may already have baseline cognitive decline or dementia. The eyes can be affected too. Patients may experience blurred vision and dry eyes, which can lead to difficulty with reading, navigating their environment, and an increased risk of falls. The mouth is commonly affected. Dry mouth may seem minor, but in older adults, it increases the risk of dental decay, difficulty swallowing and nutritional issues. Moving to the heart, these drugs can cause tachycardia or rapid heart rate, which may worsen pre existing cardiovascular conditions Unknown Speaker 26:10 in the bowels. Constipation Speaker 3 26:11 is a common and often under reported issue. It can lead to discomfort, reduce appetite, and even bowel obstruction in severe cases, Unknown Speaker 26:23 the bladder is another Speaker 3 26:25 key area. Urine retention is especially problematic in older men with prostate enlargement. This can result in urinary tract infections, overflow, incontinence, or even the need for catheterization. Lastly, the skin, the body's largest organ. Anticholinergic medications impair the body's ability to sweat. This makes older adults particularly vulnerable to overheating and heat related illness, especially in the correctional environments that may not have consistent climate control or their ability to adjust it to their comfort. The takeaway here is that anticholinergic medications don't just affect the brain. They have wide ranging effects throughout the body, and when we consider these side effects alongside polypharmacy, frailty and chronic illness, it becomes clear why de prescribing these medications is such a high priority in geriatric care. Chantal, can you tell us a little bit more about D prescribing? Speaker 2 27:26 Thank you. Karen, yes. So what is d prescribing? It's the process of removing or reducing a dose of a medication which are now considered inappropriate in an individual so let's think of some things to evaluate. First, you want to confirm that each medication has an indication. For example, a patient returns from an extended hospital trip, or even just an overnight stay with an antacid medication during the hospital stay, it was ordered just for prophylaxis, which normally doesn't need to be continued. So this is an area where the pharmacist could really step in and do a chart review of all those patients coming back from the hospital and making sure that no unnecessary medications are being continued. Second, you'd want to identify meds for which harm may be outweighing the benefit, like Kara just discussed, all those anti cholinergics. So is it possible maybe to get rid of some of those and change to a different medication, or maybe not take at all. Next you want to consider the appropriateness of any drug. Was it prescribed to treat the side effect of another drug? Can it be stopped with discontinuation of the offending medication? So I think we've seen this quite a bit, where maybe a patient was on an opioid in the hospital, they come back to the facility, they're still taking or they're no longer taking the opioid, but they're still on a laxative medication. So it's just something to consider when we do a chart review as pharmacists, when they come back to the institution. But importantly, it's important to only stop one medication at a time, and then you'd want to taper certain medications. If this, if necessary, you'd need to stop a couple medications at the same time, and then not know which one is the culprit if symptoms return or there's withdrawal effect. Finally, after making these changes, we want to monitor the patient for worsening of their original condition or identify if they are actually having withdrawal symptoms, because deep prescribing is associated with potential benefits, including decreasing those adverse drug reactions improve quality of life and actually increasing medication adherence. So when we're making these changes with the aging population, it's really important to focus on the risk versus benefit of an intervention, for example, so quality of life and reducing med burden may be more important than preventing long term complications of diabetes. So this is like Kira was saying it really has to be. Patient Specific. So you want to tailor your de prescribing and your prescribing to the patient themselves, based upon their kidney function and the other parts of their physiological changes. Dementia medications should be reviewed and reassessed at least every three months for efficacy. If there appears to be no improvement in the medication, then you could potentially discontinue that as well. Also, if you look at dyslipidemia, a patient that has an astvd risk and is greater than the age of 75 would benefit from statin use, but there's less evidence that a statin benefits patients greater than 75 years of age with cardiovascular disease, so you'd want to consider backing off for side effects and interactions with patients that have dementia or life expectancy for less than one year. Something else to think about is that if a patient's tolerating a high intensity statin, I wouldn't stop that. Then if you look at the gastrointestinal system in treating reflux disease, most of us see that patients are treated with a proton pump inhibitor like omeprazole or Prilosec, for example, but they carry an increased risk of infection and cause fractures and electrolyte deficiencies. So this is another area that you'd want to target when you're doing a chart review as a pharmacist or even any provider, the hypertension target goals should be patient specific, so consider all aspects of the patient to include their preference. Do they have a risk of falls? Do they currently have dementia? Do they have an inability to live independently because of the orthostasis? Also, if you look at insomnia, insomnia itself is associated with impaired cognition, performance, fatigue and even trauma. So we want to really review all the medications that cause insomnia and just really benefit, or review of the risk outweighs the benefit. So getting rid of those offending medications is actually the goal. You would still encourage sleep hygiene over medications to treat the insomnia with any patient, but especially in the older population. When it comes to osteoporosis, we would consider stopping oral bisphosphonates after five years, unless the patient is at high risk of fractures, who then would benefit from longer treatment. But you could still continue to just continue to suggest adequate intake of calcium and vitamin D. So now that you kind of reviewed the risk and benefit about the process of de prescribing. Let's talk about some of these barriers. So the biggest barrier is the patient, right? So they received a prescription from their doctor with refills, and they're adamant about taking it, because that is assigned to them. They should never stop, right? And then the patient also remembers improvement when the medication was initiated. So they're still hoping for future benefits, even if it's not working. Currently, they're hoping, if I just still take it for a little bit longer, maybe it will then work. But as noted during a routine primary care appointment, patients typically expect to spend around 15 to 20 minutes with a provider, and all of this time is just not enough to address all their medical concerns and discuss all aspects of the de prescribing process. So this is really important. This is an area where pharmacists can step in and maybe have a separate appointment with the patient and describe to them how to stop taking the medication and educate them on what the benefit will be. I just think that a 15 minute appointment is just not enough for any provider to go through all of these aspects of their care, especially with all the chronic conditions they're suffering from at the time. There could also be pressure from their family or, ironically, even help other healthcare professionals that are hesitant to stop these medications because the patient's been on them chronically. Another fear is that the patient thinks that if they stop taking the medication, they're going to return back to their previous state, or then have symptoms, or actually have withdrawal symptoms. So these are all important things to discuss, and that's why we can really make an impact if we can just educate each patient, and actually sometimes even their providers, about what the risk benefit is for each of their medications. But it's not just up to the pharmacist, so we really have a unique area here with a multi disciplinary team, and how this team can really impact the barriers to treatment in our aging population. So luckily for us, our patients can't go very far, and we get to manage them. I know it's always seems like health services is just a whole different department when you talk to corrections, when they're like, oh, that inmate. Does it actually use. This wheelchair, and so it's just nice if we can rely on correctional management and have them tell us if they notice that the inmates aren't making their call outs, or they notice a difference in their daily habits, and then they can also reassure us that the inmates are properly housed. So maybe there was a cell change and now the inmates on a top bunk or on a top tier, or maybe he's done in, no longer in a handicap cell, so there's no assistance railings or modified room. And also, we have a great psychology staff here that does groups and has has classes for the inmates, and maybe they're noticing a difference in their demeanor or increased irritation. Also, if you're lucky enough to have a social worker, I know it's very slim at most places, they can also access or make sure that they're receiving all their necessary appointments, maybe their necessary supplies, for example, something like incontinence products, hearing a batteries or even catheters. So they're just reassuring that they have all their needs met with the food service staff. They can ensure that these dietary modifications that the providers have implemented are actually being given to the inmates, or that they're obtaining them. I know on ours, we can they can choose whether they choose their dietary modification or not. So that's something that we would like to know as the medical providers. And then also, you want to ensure that there's appropriate follow up scheduled with the medical provider to discuss the medication benefits and adverse effects and educate them about the appropriateness of medications and D prescribing. So once again, that's an area where a pharmacist could really step in, especially if there's a lack of providers at your facility. So I think we're at a good point now to discuss the patient example. So Jay Z is a 68 year old male. He returns to the facility after an extensive inpatient stay in an outside community hospital. He's been back in the unit and was found delirious and walking around the unit looking for his tow truck. He's refusing to go back to his self account. The probationary officer is calling for backup to enforce policy. 15 staff members from all departments respond, and Jay Z begins to run around the unit screaming. Speaker 2 37:27 So let's take a look at this when it comes to enforcement and policy. So I'm going to ask a few questions. If you want to just type some of your answers in the chat, we'll discuss them. So are all adults in custody expected to be within policy. Unknown Speaker 37:51 Let me Speaker 2 37:53 Yes. Okay, well, that's correct, so the textbook answer is yes, but obviously there are times when other methods are utilized to gain adherence to policy. So I know the Bureau of Prisons is very pro de escalation, so there will be times where, obviously we're going to try to de escalate. But let's see if, in Jay Z's case, maybe something else could have been done. So can special units be established for dementia or mental health concern patients. Oh, yes, that's reassuring. So obviously, given resources are available, special units could be implemented at each institution or facility. So like Kira was talking about, we do have medical centers that have inpatient beds. Fort Devens actually has a dementia unit, and actually, here in Tucson, it's not a unit, but it's a program, and it was developed to create a more structured, pro social environment for individuals with severe mental illness, and there's been great benefit with that program. So next, let's look back to that probationary officer and say, can only trained officers and staff be assigned in these units? Unknown Speaker 39:17 Okay, so Speaker 2 39:19 not necessarily only have to be trained officers and staff, but can potentially de escalate a situation by adjusting response because of their training. So like in our rise unit that I was speaking over our program, the all the officers are trained specifically on the care level three mental health patients that we have there, and what their specific diagnosis is and maybe how to de escalate the situation a little bit differently than how it's handled on the regular units on our institution. So given Jay Z's condition, do you think that he should be restrained? Speaker 2 39:59 Okay? So Thank. Should so of course, staff and inmate safety are first priority, and then if the de escalation process fails and restraints are utilized, we should continue to evaluate it frequently, since, since restraining an inmate can exasperate delirium and dementia in our patients. So let's look at what the underlying cause of Jay Z's outburst is today. So we want to look at a delirium assessment so a multiple of events or conditions could contribute to the delirium. So let's look back at Jay Z and see if he has any of these factors that can contribute to that, and I must add, it's very extensive. So does he have dementia? Did he have a history of delirium? Is there any functional impairment? Is there visual a hearing impairment? Does he have depression? Did he have a history of a stroke or a TIA? Was there alcohol misuse? Is he greater than the age of 75 is he taking multiple medications? Did we use physical restraints? Does he have abnormal labs? Is there a current infection? Is does he have a recent surgical history, history of trauma, or Lastly, if he's suffering from any acute or chronic pain. So as you can see, this is quite extensive of what could be causing Jay Z's delirium. So given this list of risk contributing, given this list of contributing risk factors, let's see how the responding staff responded to the situation. So first off, the staff. Psychologist was part of the staff, and she expressed to the rest of the group, he has dementia, and this outburst is not intentional. So she suggested utilizing familiar people to escort, motivate Jay Z to a quiet area. Physical restraints were not utilized, and Jay Z calms down and re acclimates the unit. He's then escorted to MediCal. So now Kira what happens in the medical evaluation? Speaker 3 42:12 Nava needs a medical to see a provider. The provider orders labs and conducts an assessment. During his interview, Jay Z reports he lost his hearing aids when he returned from the hospital. He's not been able to hear the announcements for Chow, so he's only been eating snacks from commissary for the last four days. The provider then consults the pharmacist and learns that Jay Z has not been receiving directly observed therapy, and he's missed several doses of his medication. Unknown Speaker 42:41 So what did we learn? Speaker 3 42:42 Jay Z's outburst was a clear sign of delirium, likely triggered by factors such as medication changes, hospitalization and potential environmental stressors. Delirium in older adults is common, especially after hospitalization or when medications are altered, or even when they stop taking them. It's crucial for staff to recognize these signs early and respond appropriately to ensure the patient's safety and well being. In Jay Z's case, the staff psychologist played a pivotal role in de escalating the situation by providing insight into his dementia and offering strategies for calming him down. This really highlights the importance of multi disciplinary team approach, where various professionals can contribute their expertise to manage complex situations. It's also a reminder of how important medication management and directly observed therapy can prevent missed doses and the associated complications and consequences, particularly in older, older adults who may have cognitive decline, awareness from educators and other aspects of the multiple, excuse me, multi disciplinary team like the nurse or the officer could have expressed concerns earlier and noted his change in condition. This may have caught this with and prevented the lead to this behavior. Unknown Speaker 44:03 Let's take a look at a second case. Speaker 3 44:07 BC is an 80 year old male admitted to the inpatient unit after failing to function with medication management and ADLs on the compound. He has been incarcerated for 20 years of a life sentence. We can see here his past medical history includes diabetes, type two, hyperlipidemia, hypertension, dementia and bipolar disorder. So as a pharmacist, if he's been admitted to my unit, my wheels are already starting to spin, thinking about what his past medical history indicates, what medications I should be expecting, what labs I'd be looking for, Unknown Speaker 44:42 and so on. Speaker 3 44:45 So on admission. Here are his labs, vitals. His blood pressure is 100 over 56 heart rate is 51 so a little bit low. He's alert and oriented times two. So he's alert and oriented to person in place, but not to time. Time, and if we take a look at his medication list, we can see a few things stick out. He's got amitriptyline as an antidepressant, but also has a significant anticholinergic burden, this could be contributing to some cognitive decline. We know he has diabetes, and he's got that managed with insulin. He's got Glargine, 86 units twice a day, and regular 10 units three times a day. So a hefty amount. So I'll be considering, what are his blood sugars looking like? He's also has gabapentin, which is used for neuropathy or could be used for anxiety, but coupled with amitriptyline, could contribute to some sedation and cognitive impairment. Also for blood pressure, he's got two different medications, Metoprolol and Losartan, which may be essential. But let's take a look further. Let's take a look at what potential changes we might make for BC. Unknown Speaker 45:57 It's our first question, what is Speaker 3 45:59 the most appropriate hemoglobin, a 1c go for BC, we've got this as a poll. So if you'll take a look at your screen and select your answer, give you a few seconds for this. So CAPT. Chad Garrett 46:11 yep, the poll is open. If you want to go ahead and select your answer, Speaker 1 46:22 we've got a few answers rolling in. It looks like, looks like it's fairly well distributed. Okay, well, let's go through each one, then Speaker 3 46:38 I don't actually see any responses for D, so I'm happy about that. So let's start from the top. Actually answer a was less than 6% B was less than 7% C was less than 8% and D due to age, no specific goal is needed, so we always want to make sure that diabetes management is still individualized. Just because of his age doesn't mean that we throw care to the wind. We still want to make sure that we have a goal and it's individualized to the patient. While option, a, less than 6% seems like a nice round number to hit, it could be too strict for an elderly patient and have a higher risk of hypoglycemia. B, less than 7% could be reasonable for some older adults, but may still be too aggressive in this patient, I'll be targeting less than 8% it's going to be more appropriate for his elder, for his elderly age, and with his multiple comorbidities, his declining cognitive status And then his fall risk. All right, question two. So the pharmacist is now doing a chart review, and notices his labs, his repeat lipid panel is below with a total cholesterol of 130 his LDL is 68 his HDL is 60. The pharmacist noticed that he's on atorvastatin and for sepa, but there's no triglyceride. So they request that that be added on, and triglyceride level comes back as 90, which is low. What recommendation would you make regarding B, C's lipid management? We're Unknown Speaker 48:16 going to load the pole Speaker 3 48:17 option A, continue the Torval statin 80, and discontinue the vase pa B, continue with SEPA and discontinue atorvastatin. C, we're going to just keep both or D, we're going to discontinue both. CAPT. Chad Garrett 48:33 All right. Blow is open. If you guys want to go ahead and throw your answers in there, you Unknown Speaker 48:45 right now it looks like nobody has selected D, okay, CAPT. Chad Garrett 48:51 most people have selected a, but we have a few B's and C's All Unknown Speaker 48:55 right. Speaker 3 48:56 So the it's not clear why BC is on buceppa, his triglyceride levels are already low, and there's no indication for it to be used based on his current lipid profile. So Option A is actually going to be the best. We're going to continue the atorvastatin and discontinue Vaseline, since his triglycerides are already low, continuing the Vaseline is not really going to provide any significant additional benefit. Option B, where we were continued to accept, again, no additional benefit, so we wouldn't want to continue both. And then option D kind of hints at what Chantelle told us when we're de prescribing. We want to just stop one agent at a time, so then we can see if that provides any additional benefit. So the best answer here is to continue atorvastatin as it's going to be essential for managing his cholesterol and maintaining his cardiovascular health in the face of diabetes and hypertension. Unknown Speaker 49:54 All right. Question Speaker 3 49:56 Three BC has now been experiencing some cognitive decline. And there are concerns about the impact of his medications on his blood pressure management and his overall well being. His recent vital signs are as follows. So remember, on admission, his blood pressure was 100 over 56 today, it's 98 over 60 while he's lying down and 110 over 71 standing, he has a resting heart rate of 58, beats per minute. What change would you suggest to the provider to address his blood pressure? Unknown Speaker 50:32 All right, so that poll is open. If CAPT. Chad Garrett 50:33 you guys want to throw your answers Speaker 3 50:34 in, yep, our options are, stop the Metropolitan reduce the Losartan, continue his blood pressure medication as is, or we can add another anti hypertensive Unknown Speaker 50:52 looks like CAPT. Chad Garrett 50:55 we've got most people selecting a and b is a distant second, and C is a distant third, awesome. Speaker 3 51:03 So A is going to be the most appropriate recommendation to stop the Metoprolol. This is going to address this low blood pressure, and it's also going to give the added benefit of eliminating or alleviating the bradycardia, as his heart rate is already low, that low heart rate and low perfusion could be contributing to his cognitive decline and overall well being. After we stop the metropolis, we want to monitor carefully his blood pressure and his heart rate. Low starting can likely be continued, but his dose may need adjustment based on further follow up, we definitely don't want to add any additional anti hypertensives or leave his regimen as is. As we can already see, it's having some impact. All right, last question for this case, what medication should be considered for de prescribing? Overall, Speaker 3 52:00 the amitriptyline, the insulin, Glargine, gabapentin, or all of them at the same time. Unknown Speaker 52:09 All right, that poll is open. Unknown Speaker 52:19 We've got the answers kind of rolling in here. Give it a few more seconds. Give it a few more seconds. Unknown Speaker 52:35 All right, Chad, how's it looking? CAPT. Chad Garrett 52:37 We've almost got a tie between A and C with one person thinking we should delete all of them at the same time. Speaker 3 52:47 Well, if we stop all of them at the same time, we never know which one was having the most impact. I'd also not recommend stopping his goerging. I do think it's a hefty dose. We can probably cut it back and not be as aggressive with controlling his his diabetes, but we definitely don't want to completely stop it. Interested to see that there's a tie between the amitriptyline and the Gabapentin. So amitriptyline has a high anticholinergic burden. It definitely is associated with an increased fall risk and cognitive impairment and even sedation. The gabapentin, while it's a high dose, it may still be needed for his neuropathic pain. I would start with prescribing the amitriptyline, first monitoring how he does, and then for those who say gabapentin, that'd be my next place to start. All right, we've got one more case. Case four, we have Dee. Dee is a 67 year old male currently residing in a penitentiary. His cell mate, AJA escorts him the sick call and speaks with the nurse. AJA explains that DD is just acting weird. He says he's confused on where he is. He's not going to work, he's not going to eat, and he's missing at least one meal per day. Didi has a past medical history of hypertension, depression, COPD and osteoarthritis. AJA also states, didi has been taking a lot of Motrin to help with his back pain, and he also expressed he's been getting up all hours of the night with frequent urination. So here are the observations that we know. He's forgetful. He's repeating, repeating the same question. He's got dizziness and dry mouth. He's refuses medications from his on the bar three times this week, is saying that he's missed child and not going to work, and deeding himself. Is reporting urinary urgency, but he can't fully void. Unknown Speaker 54:46 We've got his medication list Speaker 3 54:47 here, so we've got Benadryl at NIC to try and help him sleep, oxybutyl Trazodone and Albuterol inhaler that he takes as needed, and then the ibuprofen 600 is prescribed. But remember, they said he's also been taking Motrin Speaker 1 55:02 over the counter. So what's going on here, Speaker 3 55:10 if we're looking to de prescribe, what would you de prescribe? First, Benadryl, Lisinopril, ibuprofen or albuterol? Speaker 1 55:21 All right, I've thrown that poll open. We've got some answers coming in. Unknown Speaker 55:32 Give another couple seconds here, yeah. Unknown Speaker 55:40 All right, it looks like most people selected a CAPT. Chad Garrett 55:46 and the next answer was C, Unknown Speaker 55:49 okay, B and C tied. Now, Speaker 3 55:52 B and C tied. So when we review his mail list, the red fox pop up immediately. So diphenhydramine and oxybutyn both carry a high anticholinergic burden. Other concerns that stand out would have been as Trazodone as it has anticholinergic properties and sedative effects. But of the options listed, I would start with the diphenhydramine. I definitely understand the concern, and as a pharmacist, we can counsel and he doesn't need to take both the ibuprofen and the Motrin as it taken frequently, can cause renal issues and compound dizziness, but with the highest anticoa nic burden, I would stop the Unknown Speaker 56:30 Benadryl first. Great. You guys rocked those questions. Speaker 3 56:37 That concludes our presentation. We hope you feel confident that you can identify, evaluate and apply some of the knowledge that we shared here with you today. It looks like we've got about five minutes left, so we'll open the floor up for questions, Christopher Smith, NPA 56:53 ladies, so far we you have done such a great job in teaching the presentation that we have not gotten any questions during the presentation. So if anyone does have, oh, it looks we have one just popped up. Did I miss frequency of the PRN for dihydra from okay, this is another good point to point out that I am not the medical professional here. Speaker 3 57:16 You did. So for that case, the diphenhydramine was just nightly. PRN, it didn't specify. And so that would be a good thing that we could clarify as a pharmacist and even the provider. How often do you want that patient actually taking the diphenhydramine before they come back and we reevaluate whether it's effective or not? Unknown Speaker 57:34 Great question. All right, Christopher Smith, NPA 57:38 we have another couple of minutes if anybody else has a question they want to quickly type into the into the chat? All right? Well, it looks like Chad, we're getting no more questions to be submitted. We have one more put in real quick by Cassandra. When I was inpatient, it was typically on the profile, but rarely used. I assume that was on the frequency of PRN. All right, we have no more questions. CAPT. Chad Garrett 58:19 Well, to our brilliant speakers, thank you for your insight, your innovation and your relentless dedication to improving lives one carefully calculated dose at a time. Your work doesn't just move the needle resets that entire scale to our audience. Thank you for leaning in and learning with us and being part of this ongoing conversation, whether you're prescribing planning or just plain passionate about progress, your engagement matters. Correctional Health isn't just about containment. It's about care, connection, creating pathways to healing. Speaker 1 58:49 Correctional Health is public health. Please, please, CAPT. Chad Garrett 58:53 please take a few moments and complete the post course assessment. This allows us to continue to improve, and it gives us a chance to see what topics you guys are most interested in. Remember, this is a program for you, and the only way we can make it for you is you. You give us some of that insight you're going through. So as we close this critical conversation on caring for the aging, incarcerated adult, let's be clear, we are not merely managing medications and monitoring vital signs. We are upholding the constitutional and ethical obligations to deliver dignified, appropriate care to a rapidly growing, uniquely vulnerable population. The so called silver tsunami is not approaching, not approaching folks. It has already made landfall behind these prison walls, the intersection of aging, chronic disease, policy pharmacy and correctional constraints. It requires more than than just protocols. It demands purposeful practice, policy evolution and professional Unknown Speaker 59:49 empathy. So I CAPT. Chad Garrett 59:53 challenge you to not wait until your next audit or the next lawsuit or the next adverse outcome to. Hand, let's lead proactively, because in correctional as in life, how we care for the most vulnerable reflects who we truly are. And Correctional Health Care, remember is public health care. Thank you again for your commitment to the mission. Take care, but before you log off, Unknown Speaker 1:00:18 let me plug next week. CAPT. Chad Garrett 1:00:21 So next week we have diabetic pharmacotherapy beyond blood sugar, yay. So it will be at the same bat time, same bat channel. We hope to see you guys next week. Thank Speaker 1 1:00:36 you again for joining us. And with that, we're done. Have an excellent day. Thank you. Thank you. Bye. Transcribed by https://otter.ai