Increased Use of Medical Marijuana: Skepticism vs. Evidence.

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

Concierge Pharmacy: A Potential Arena for Senior Care Pharmacists.

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

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

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

Medical-Legal Partnerships: A Healing Collaboration.

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

Addressing the Shortage of Geriatric Specialists.

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

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

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

The Ketogenic Diet: Making a Comeback.

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

Wandering: Unearthing New Tracking Devices.

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

Long-Term Care and Cultural Competence.

The United States has historically been a melting pot of cultures. Today the population has changed because many immigrants are now older than past immigrants, are frequently retired, and have chronic diseases that need careful management. Health care providers need to be culturally competent to deliver effective health care to these diverse populations. Over the years, health care systems and providers have become much more aware of the needs of minority populations. They accommodate language differences and individuals' ingrained beliefs that may affect health care and learn how to ask the questions that will elicit the information they need to treat patients. Today, while the American health care system meets more of the needs of minority populations, the needs of smaller minority populations may languish or be overshadowed by the unique needs of individual groups or difficult experiences or immigration histories, such as Cambodian immigrants, Indian Asians, and even veterans of U.S. conflicts. This article makes the case for greater cultural competence and offers ideas and suggestions that can be applied to any small minority population.

Medication Refusal: Resident Rights, Administration Dilemma.

Occasionally, residents actively or passively refuse to take medications. Residents may refuse medication for a number of reasons, including religious beliefs, dietary restrictions, misunderstandings, cognitive impairment, desire to self-harm, or simple inconvenience. This action creates a unique situation for pharmacists and long-term facility staff, especially if patients have dementia. Residents have the legal right to refuse medications, and long-term care facilities need to employ a process to resolve disagreement between the health care team that recommends the medication and the resident who refuses it. In some cases, simple interventions like selecting a different medication or scheduling medications in a different time can address and resolve the resident's objection. If the medical team and the resident cannot resolve their disagreement, often an ethics consultation is helpful. Documenting the resident's refusal to take any or all medications, the health care team's actions and any other outcomes are important. Residents' beliefs may change over time, and the health care team needs to be prepared to revisit the issue as necessary.

The Illusion of Perfect Memory.

Memory is not infallible, and certain memory problems or glitches are normal. Most people notice that they experience more memory shortcomings as they age. Omission deficits and commission deficits are common and include transience, absentmindedness, tip-of-the-tongue experience, misattribution, suggestibility, bias, and persistence. Each of these has a different cause, and researchers have looked for interventions that can decrease the frequency and severity of these common problems. Though some people worry that memory glitches foreshadow dementia, that is not usually the case. Understanding how memory falters can assist pharmacists in helping patients provide better medical histories and improve adherence. It is useful when collecting reliable information if incident reports rely on eyewitness accounts. It can also help them improve pharmacists' own memories, and understand why memory may change over time.

Deep Brain Stimulation and Medication Management in Parkinson's Disease.

Current medical treatments for Parkinson's disease (PD) are symptomatic, not curative. Over time, patients need additional medications, increased doses, and increased dosing frequencies to control symptoms. Often, medications lose their effectiveness or side effects become intolerable. Deep brain stimulation (DBS) is a surgical option that, unlike other surgical procedures for PD, is externally adjustable and reversible. DBS is best employed in patients whose symptoms have responded to medication, but escalating doses or dosing frequencies are limiting in some way. During the perioperative period, clinicians must manage medication very carefully. Depending on lead placement and the patient's unique symptom constellation, medication changes are likely. Pharmacists who have a good understanding of the procedure can provide exceptional care and counseling.

Olfaction: New Understandings, Diagnostic Applications.

Estimates indicate that 14 million Americans have olfactory dysfunction. As with other senses, such as sight and hearing, olfaction frequently declines with age. Impaired olfaction can be a warning sign of Parkinson's disease, sometimes occurring before motor symptoms develop. It's also an initial symptom of Alzheimer's dementia (AD); the amyloid plaques and tangles characterizing AD invade the olfactory bulb and hippocampus early in its course, hampering odor identification. Olfactory dysfunction is associated with some serious problems, including inability to smell warning odors (fire, gas) and impaired ability to taste food. Standardized, validated methods are available to measure several different dimensions of olfactory function, including odor identification, discrimination, and threshold levels. Researchers are currently studying the unique olfactory deficits associated with different conditions in hopes of identifying new, noninvasive tools for early diagnosis and treatment. Drugs may cause or contribute to olfactory dysfunction, but it can be difficult to pinpoint offending medications.

Drug-Device Combinations: Are They Appropriate for the Aging Population?

Hundreds of marketed products combine drugs with delivery devices. Experts estimate that these drug-device combinations (DDCs) generated nearly $24 billion in sales in 2014. DDCs appeal to clinicians and consumers for several reasons. Drugs delivered with a technology-assist may cause fewer side effects, avoid systemic exposure, result in a higher degree of efficacy, or create consistent blood levels. When physicians prescribe a DDC, consultant pharmacists have a unique role: ensuring patients can use the DDC appropriately. Available DDCs require some degree of eye-hand coordination, and older individuals often have difficulty with vision, dexterity, and grip strength. This review primarily discusses three types of DDC: those designed for diabetics, inhalers, and transdermal DDCs, and the characteristics that can challenge older patients.

Oncology's Trojan Horse: Using Viruses to Battle Cancer.

In 2016, the American health care system was faced with more than 1.6 million new cases of cancer, and individuals older than 65 years of age will be affected disproportionately. Many older individuals are poor candidates for traditional treatments (e.g., chemotherapy, radiation) because of actual or potential treatment-related adverse events. Researchers continuously look for novel therapeutic strategies, and an exciting new one is on the horizon: virotherapy. Viruses' ability to infect and kill human cells makes them promising cancer treatments. The greatest success has been seen in acute lymphocytic leukemia. To date, four genetically engineered oncolytic viruses have been approved globally by several countries' health regulatory agencies, but several challenges remain. Only one, talimogene laherparepvec (T-Vec), is available in the United States. Treatment-naive patients tend to respond better than patients receiving T-Vec as second-line therapy. Other good candidates for T-Vec include elderly patients who do not tolerate checkpoint inhibitors (the leading immunotherapy in advanced melanoma). Researchers continue to look for ways to increase oncolytic viruses' clinical potency. Once they do, these agents will become effective cancer therapy. ABBREVIATIONS: GM-CSF = Genetically modified colony-stimulating factor, HIV = Human immunodeficiency virus, HSV-1 = Herpes simplex virus, OV = Oncolytic virus.

Euglycemic Diabetic Ketoacidosis: Hidden in Plain Sight.

A recent increase in euglycemic diabetic ketoacidosis (euDKA)-a metabolic state with plasma bicarbonate exceeding 10 mEq/L and blood glucose levels lower than 300 mg/dL-has caught regulators and providers by surprise. It's been more than 40 years since the British Medical Journal expanded the "panorama of diabetic metabolic upsets" with an article on euDKA. Although still rare, the occurrence of euDKA is becoming slightly more common. Unlike the more widely known diabetic ketoacidosis, this condition is devoid of blood glucose elevation. Over two years, the Food and Drug Administration (FDA) Adverse Event Reporting System database linked 73 episodes of euDKA to the use of one of the newest drug classes used in diabetes, the SGLT-2 inhibitors. Subsequently, FDA issued a warning in May 2015 regarding this class of medications. FDA's continued investigation led to a labeling change for this class in December 2015, describing increased risk of euDKA. Health care providers, patients, and caregivers need to increase vigilance, as this seemingly silent complication can be fatal.

Implementing change: involving employees to improve outcomes.

Increasingly, pharmacy workplaces are larger organizations that rely on policy and clinical guidelines to direct professional practice. Often, cost-cutting, profit-making, service-improving, and process-streamlining ideas are needed but difficult to identify or implement. By involving employees more closely in the change process using participative management (PM), managers reap tremendous reward. PM focuses on employee collaboration to develop and implement consistent, effective policies and procedures. This process recognizes employees' creative, emotional and intellectual needs and often improves the organization's public face as well. In addition, consumers perceive this approach to be socially responsible management. Managers can implement PM in a number of ways, applying it to problems or processes. PM has some pitfalls, but overall, if the workplace culture adapts to accommodate its principles, PM usually provides numerous benefits for organizations, their employees, and their customers.

Bereavement and Loss: Understanding Grief in Older People.

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

Preventing pneumococcal disease: intergenerational issues.

In the United States, approximately four million people contract pneumococcal infections each year, and elders and children are at an increased risk of contracting these infections. Since the late 1800s, researchers have searched for a vaccine that covers the many serotypes of Streptococcus pneumoniae. Today, three vaccines are available, and each possesses subtle differences. Notwithstanding the positive impact from each vaccine type, the incidence of diseases caused by serotypes that are not included in specific vaccines tends to increase in children and certain adult populations with underlying illnesses. While these increases are usually small compared with the overall reduction in disease, some clinicians and patients question the effectiveness of vaccinations. Pharmacists need to promote pneumococcal vaccination and emphasize the need to also receive annual influenza vaccine.

Drug-induced rash: nuisance or threat?

Drug-induced rash is the most commonly reported drug reaction and occurs in a dizzying array of presentations. Changes in lean and fat body tissue, gastrointestinal acid and mucosal permeability, cardiac output, and renal and hepatic metabolism can affect drug absorption, distribution, metabolism, and elimination. Elders may develop cutaneous eruptions from drugs or biologics and be more sensitive to topical medications. Almost all medications have been associated with rash to some degree. Consultant pharmacists should be able to distinguish between the rashes that are uncomfortable from those that are potentially life-threatening. Some drug therapies tend to induce or aggravate "companion" rashes. With select medications, rash is a clinical indicator that the medication is working. Extensive or unusually painful drug-induced skin conditions are rare, but often require fast action by health care providers to direct the patient to life-saving help. Many of these rashes are associated with high mortality, severe complications, and potential chronic disability. Awareness of the drugs that are most likely to cause a rash can help consultant pharmacists work with the clinical team to arrange appropriate care.