Spring is here and the days are getting longer once again and we here at the AGEC and our partners are busy with classes and programs. For this article, I will be reviewing the final “M” of the age-friendly framework of care; mentation. Previously, we have reviewed the overall concept of the 4M’s framework, the first “M” of “what Matters” (the cornerstone of the framework), Medication, and in the summer, we reviewed Mobility. The last one is Mentation. We all are familiar with the many aspects of mentation, but we will do a quick review as we fold it into our 4M’s framework of age-friendly care!

Mentation has many facets and is very complex as we all know. However, we must do our best as healthcare professionals to prevent, identify, treat and manage any conditions related to mentation including the most common mentation issues with older adults; dementia, depression, and delirium. 

In general, we must support cognitive functioning, independence, and dignity. We must also assess for modifiable contributors to cognitive impairment. This might include chronic conditions such as cardiovascular diseases, obesity, and diabetes; medications, social life factors, lack of physical activities, poor diet and hydration, extraneous environment factors, excessive stress, lack of quality sleep, hearing loss, and many others. Some are of course modifiable and some are not. But any factor that is modifiable and can be addressed, can certainly affect mentation.

We should also ask them and their caregivers about any confusion, memory loss, or mood changes while considering the requirement for further evaluations. We should also consider social referrals and community type referrals that might address factors such as loneliness, transportation, and dietary needs. Other referrals might also be need to address financial stress and concerns. In summary, many factors affect mentation and many are modifiable. We must ascertain the difference and adjust factors that can improve quality of life and what matters to the older adult.

Again, this was just a quick overview of “Mentation”, and there is a lot more to learn and apply with this “M”, but I hope it helps to inform and remind us to use the 4 M’s and to always consider each “M” within the context of What Matters Most. If you want to learn more, additional information can be found at

https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx.

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

There is a prevalence of hypertension among the United States (U.S.) population. High blood pressure, also known as hypertension, affects nearly one out of four adults in the U.S (American Heart Association [AHA], 2023). Hypertension is defined as having a systolic blood pressure or the top number of 130 mmHg or higher, and diastolic or the bottom number of 80 mmHg or higher (AHA, 2023). Uncontrolled hypertension can lead to additional health problems such as heart attack, stroke, heart failure, kidney disease, visual disturbances, headaches, tinnitus, and even cognitive impairments. Overtreatment of hypertension can have adverse effects as well. Providers treat hypertension with antihypertensives (blood pressure lowering agents), and / or diuretics (fluid pill). These agents can have adverse effects when used inappropriately, especially in the geriatric population. Some adverse effects can include hypotension (low blood pressure), bradycardia (low heart rate), dizziness, diaphoresis (sweating), loss of balance, and even falls. Many geriatric clients take multiple medications regularly, this is known as polypharmacy. Therefore, accurate assessment of blood pressure is crucial for competent treatment in the geriatric population. Blood pressure measurements taken during a medical visit may be temporarily elevated due to various reasons. Recommending that clients take blood pressures in and out of the office can be useful in proper diagnosis and treatment.

Unintentional elevation of blood pressure is not uncommon during episodes of anxiety or nervousness. People may experience higher blood pressure readings in a medical office when compared to those collected at home or alternate settings. These readings may vary widely. This can be a challenge for healthcare providers in adequately treating true hypertension. Hypertension is treated based on readings obtained during medical visits. Some clients are encouraged to keep a log of their blood pressure readings taken at home and bring the log with them when they visit their provider, this is no exception for the older population.

There are many contributing factors why blood pressure readings can vary. Those factors include client’s position, stress level, caffeine or alcohol intake, nicotine consumption, talking, walking, movement, as well as comfort level. Position is important for accurate blood pressure measurement. The arm being used to take the blood pressure needs to be well rested at chest level, on a flat surface, and legs uncrossed with feet flat on the floor. There are many people who feel anxious when they go to see their healthcare provider. When someone feels anxious, it tends to temporarily raise their blood pressure and cause their heart rate to become elevated. Some refer to this as “white coat syndrome”. Studies show that as many as one in three people have white coat syndrome (Centers for Disease Control and Prevention [CDC], 2023). Anxiety or nervousness upon arrival for a medical appointment may be due to several other reasons as well. These reasons can include driving in traffic, interaction with staff at medical office, or waiting for provider can increase anxiety. 

When a client presents to their healthcare provider, their blood pressure is usually obtained upon arrival after walking to the exam room. For some of the geriatric population, walking can be strenuous and therefore cause a temporary elevation of blood pressure. The nurse may, at the same time, be asking the client questions which results in talking and moving. This can result in false blood pressure readings as well. The person obtaining a client’s blood pressure should ask them if they recently smoked a cigarette, drank alcohol, or consumed caffeine as they can influence blood pressure. If the client is experiencing any type of pain, this can lead to elevated blood pressure as well. Often the older population may suffer from pain in muscles or joints. Proper position and size of the blood pressure cuff can also alter the reading. It is important for the cuff to fit snug, but not too tight around the upper arm. Using a blood pressure cuff that does not fit properly can distort the reading. It is important for clients to bring their blood pressure monitor they use at home to clinic visits so verification of readings can be established.

Skillful techniques used to obtain blood pressure can lessen the chance of overtreatment or misdiagnosis of hypertension. By following these steps, it can help obtain a true blood pressure reading:

·        Proper positioning of the blood pressure cuff. It is important to take blood pressure with a cuff that fits properly, over bare skin, and not through clothing.

·        Do not eat or drink anything within 30 minutes of blood pressure being measured.

·        Sit comfortably with feet flat on the floor, uncrossed, and arm well rested at chest level.

·        Do not talk or move while blood pressure is being measured.

·        Clients may need time after arrival before blood pressure is taken to help decrease anxiety or nervousness.

·        If the client has an elevated blood pressure, recheck it prior to end of the visit for comparison.

Obtaining a blood pressure measurement is the gold standard for diagnosis and management of hypertension. Healthcare providers need to be mindful before prescribing antihypertensives for an elevated blood pressure reading obtained during an office visit. Being mindful can result in providing optimal care for all patient populations, including the geriatric population. It is important for providers to ensure accuracy of blood pressure measurements even if it involves performing a second reading during the visit. Obtaining a second reading can offer comparison and further investigation for the proper diagnosis and treatment of hypertension. Reminding patients to take and record their blood pressure at alternate locations, such as home, can be beneficial in their plan of care and to achieve higher outcomes.

References

Centers for Disease Control and Prevention. (2023, March 17). High Blood Pressure. https://www.cdc.gov/bloodpressure/measure.htm

American Heart Association. (2023, March 8). Blood pressure measurements in the clinic may vary widely between doctor’s visits. https://www.heart.org/en/news/2023/03/08/blood-pressure-measurements-in-the-clinic-may-vary-widely-between-doctors-visits

By Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP

Polypharmacy is common in the treatment of older adults with chronic conditions, particularly when multiple medications are recommended by highly regarded treatment guidelines. Often, polypharmacy is necessary, and the benefits will outweigh the risks. However, when polypharmacy occurs unnecessarily, risks exceed benefits. An addition of a new drug may result in polypharmacy and places patients at risk for additional side effects and increased costs. Prescribing cascades are one way that unnecessary medications are added to a patient’s regimen. Prescribing cascades occur when new symptoms are interpreted as a new medical condition rather than a medication side effect (Rochon & Gurwitz, 1997, pp.1096-1099).   Optimal management is deprescribing the culprit medication or switching to another agent which does not have the same unwanted side effect instead of adding an unnecessary prescription. There are certain situations when it is reasonable to use one drug to treat the side effect of another. For example, opioid-induced constipation is treated best with a stimulant laxative. The difference is two-fold: first, there are no substitutes for opioids in the management of certain types of pain and second, the symptom is recognized as a drug side effect that requires laxatives for treatment.

A common prescribing cascade occurs with calcium channel blockers (CCBs) that cause peripheral edema in 2-25% of patients. One study showed that patients who were newly dispensed a CCB were twice as likely to receive a loop diuretic within 90 days of follow-up compared to patients dispensed an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (Savage et al., 2020). The peripheral edema caused by CCBs is from fluid shifts rather than fluid overload. A diuretic is ineffective in this situation. Its use, especially in older adults, could cause dehydration, falls, urinary incontinence, and/or electrolyte imbalance.

When reviewing a patient’s medication regimen, it can be difficult to identify if a prescribing cascade occurred unless the sequence and timing of the prescriptions are known. Digging into the medical record and sorting through the information on symptoms and timing can be challenging. Patients often are unaware of the prescriber’s thought process when adding a new medication, thus are unable to provide additional details. Older adults may attribute new symptoms to “growing older” or a disease process rather than a side effect of a medication.

McCarthy and colleagues developed a tool, “Think Cascades”, in an attempt to streamline the process of identifying clinically important prescribing cascades affecting older patients (McCarthy et al., 2022). They conducted a literature review to identify possible prescribing cascades and supplemented the list with examples reported by clinicians that were not found in the literature search. This provided a final list of 139 unique prescribing cascades. Using a modified Delphi process with three rounds of ranking by 31-40 expert panelists from six different countries, they whittled the list down to 30 cascades. Panelists were asked what factors influenced their ratings. First, the severity of the side effect and second, the ability of clinicians to anticipate and manage the side effect without prescribing a secondary medication. The last step was for the study team to remove duplications and identify cascades that aligned with their study definition of clinical importance.



The table below presents the nine highly rated prescribing cascades included in the Think Cascades tool. Clinicians should familiarize themselves with these combinations to avoid tumbling down a prescribing cascade and to identify opportunities to deprescribe unnecessary medications to treat side effects of other agents.

References

McCarthy, L. M., Savage, R., Dalton, K., Mason, R., Li, J., Lawson, A., Wu, W., Sternberg, S. A., Byrne, S., Petrovic, M., Onder, G., Cherubini, A., O’Mahony, D., Gurwitz, J. H., Pegreffi, F., & Rochon, P. A. (2022). ThinkCascades: A tool for identifying clinically important prescribing cascades affecting older people. Drugs & Aging, 39(10), 829–840. https://doi.org/10.1007/s40266-022-00964-9

Rochon, P. A., & Gurwitz, J. H. (1997). Optimising drug treatment for elderly people: The prescribing cascade. BMJ, 315(7115), 1096–1099. https://doi.org/10.1136/bmj.315.7115.1096

Savage, R. D., Visentin, J. D., Bronskill, S. E., Wang, X., Gruneir, A., Giannakeas, V., Guan, J., Lam, K., Luke, M. J., Read, S. H., Stall, N. M., Wu, W., Zhu, L., Rochon, P. A., & McCarthy, L. M. (2020). Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Internal Medicine, 180(5), 643. https://doi.org/10.1001/jamainternmed.2019.7087 

One of the fastest growing populations in the United States are adults aged 65 and over (Caplan, 2023). As people live longer, the likelihood of having one or more chronic illness increases; nearly 64% of older adults have two or more chronic illnesses (Boersma et al., 2020). The 4Ms Framework is designed to help older adults and their caregivers to safely navigate the complexity of chronic conditions in any health setting (Emery-Tiburcio et al., 2021). This framework emphasizes the importance of medication, mentation, mobility, and what matters to the older adult and their family caregivers (Emery-Tiburcio et al., 2021). It is important that health care providers are trained to assess each of these 4Ms with every contact, helping to reduce poor health outcomes for older adults (Emery-Tiburcio et al., 2021). For these reasons, the 4Ms Framework is being incorporated into undergraduate nursing student curricula.

To begin to understand the concept of the 4Ms through experiential learning, nursing students engage in an immersive sensory workshop. The purpose of the workshop is to allow students to experience a variety of sensory changes that might occur with aging and chronic illness, while emphasizing the importance of maintaining safety, independence, and quality of life. A series of sensory stations were designed and adapted from Home Instead (2024) and Quality and Safety Education for Nurses (QSEN, 2022), described as follows. Students experience visual changes, such as cataracts, macular degeneration, glaucoma, or hemianopsia by altering the lenses on glasses with tape or petroleum jelly. Hearing loss is simulated through the use of cotton balls during a game of “telephone” and during group discussion. Changes in taste are demonstrated through the use of unsalted crackers and club soda. In addition to these bland items, students are given the option to eat a cracker without chewing to simulate dentition changes. For olfactory changes, students plug their noses and try to identify look-alike seasonings (e.g., paprika and chili powder; sugar and salt). Students also experience tactile changes in both hands and feet. Cotton balls are placed in the tips of gloves, reducing a sense of touch in fingertips; wooden sticks can be added to the fingers to demonstrate a reduction in joint mobility. Dry beans or corn kernels are placed in socks to allow students to walk while experiencing the discomfort of neuropathy.

At each sensory station, students are asked to perform a task that an older adult may need to perform. For example, students may attempt to read small-print material or find the correct pill out of a weekly pill container while experiencing vision loss. Students attempt to maintain dexterity while opening a pill bottle or picking up a small pill while experiencing tactile and joint changes. At the end of the workshop, students engage in a debriefing discussion, reflecting on their experience and feelings before and after the workshop, and how it will influence their nursing care of an older adult. As reiterated by QSEN (2022), these activities may also help nursing students develop empathy for the older adult with sensory changes.

This workshop is one of many steps in enveloping the 4Ms into nursing curricula. It provides students with a small personal glimpse into the importance of the 4Ms and the challenges that older adults (and their caregivers) may face. What matters is addressed by emphasizing the importance of quality of life. Medication and mentation issues are experienced through visual and hearing challenges. The importance of maintaining mobility is experienced through tactile and joint challenges. Additional development and incorporation of the 4Ms Framework into undergraduate nursing curricula is crucial, ongoing work. Future steps will help undergraduate nursing students integrate the 4Ms into their nursing assessment and care of older adults and their caregivers.

References



Boersma, P., Black, L., & Ward, B. (2020). Prevalence of multiple chronic conditions among US adults, 2018. Preventing Chronic Disease, 17. http://dx.doi.org/10.5888/pcd17.200130

Caplan, Z. (2023, May 25). U.S. older population grew from 2010 to 2020 at fastest rate since 1880 to 1890. United States Census Bureau. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html

Emery-Tiburcio, E., Mack, L., Zonsius, M., Carbonell, E., & Newman, M. (2021). The 4Ms of an age-friendly health system. American Journal of Nursing, 121(11), 44-49. DOI: 10.1097/01.NAJ.0000799016.07144.0d

Home Instead. (2024). DIY ways to experience sensory loss. Retrieved from https://www.homeinstead.com/care-resources/health-conditions/wonder-what-lose-your-senses-diy-activities-can-help/#:~:text=Loss%20of%20feeling%20could%20threaten,the%20tips%20of%20plastic%20gloves.

Quality and Safety Education for Nurses. (2022). Developing empathy for older adults with sensory deficits (for face-to-face learners and distance learners). Retrieved from https://www.qsen.org/strategies-submission/developing-empathy-for-older-adults-with-sensory-deficits-(for-face-to-face-learners-and-distance-learners).