UAMS

From the Director’s Desk

Fall 2020 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Happy fall everyone! I just want to take a brief moment of your time to wish you a great and safe fall and winter. I know 2020 has been extremely challenging for most of us, but we are persevering. We at the AGEC have actually learned and grown a LOT. We have converted most of our programs so that they are available via virtual platforms and have actually increased our reach in many ways. We now understand (somewhat anyway) and utilize new and diverse technologies to present our programs, improve our communications, and extend our reach.

We have tried to concentrate on how we can help older adults learn about and adapt to e-visits and telemedicine and how we can use virtual platforms to keep educating older adults and healthcare professionals. We have developed “how-to” videos on such things as hand washing, using gloves, How to Join a Zoom call, and Learning the Zoom Screen. We have also developed new tools to help older adults stay active and social by providing virtual physical activity classes and informational topics on Facebook, Instagram and Twitter. We are also making an effort to reach those older adults in their homes, maybe isolated at home, by continually working with our partners who provide local services to older adults such as churches and senior centers.

I am not sure what the fall/winter of 2020/2021 will bring, but we are continually working, changing and trying to keep ready for the upcoming challenges. We are and want to continue to be part of positive change. If you have ideas for us, please let us know!

Stayed tuned to the AGEC website, Facebook page, Instagram, and Twitter accounts for upcoming exciting programs and please share the embedded links regarding the Zoom videos to your patients and family members who might benefit! Stay safe everyone, and remember to get your flu shot and to remind your patients to get theirs too!!!

Over the Counter Topical Agents for Arthritis Pain

Fall 2020 Newsletter

By Catherine Jensen, Doctor of Pharmacy Candidate, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Osteoarthritis is the most common form of arthritis and is the leading cause of disability in adults.¹ Roughly 40% of adults in the United States will develop this disease in at least one hand by 85 years of age². Non-pharmacological therapies recommended for osteoarthritis include weight loss and resistance exercises, but these treatments are seldom enough. According to the American College of Rheumatology (ACR) osteoarthritis guidelines, topical NSAIDs like diclofenac should be considered before other topical agents and oral NSAIDs. This is due to the lower risk of systemic exposure and superior efficacy noted through clinical trials^3,4.

Ingredients of topical arthritis pain medications with example products are listed in Table 1. Topical lidocaine is also available for neuropathic or burn pain, but is not recommended for arthritis pain.

Table 1: Over The Counter Topical Medications for Arthritis Pain^1,5,6,9
Ingredients	Brand Name Examples	Advantages	Disadvantages	Usual Area of Use
Menthol, camphor	Icy Hot Gel, Biofreeze, Tigerbalm	Cooling sensation with immediate effect	Does not treat inflammation or pain	Hand, knee, back
Salicylates	Bengay, Aspercreme, Myoflex	Cooling sensationSlight anti-inflammatory effectScented/unscented	Avoid with aspirin allergy	Knee, hand, foot
Capsaicin	Capzasin-HP creamZostrix, Capsiderm	Treatment of pain Potential adjunct agent when other therapies not tolerated	Skin irritation Poorly absorbed, Difficult adherence	Knee, hands
Diclofenac (NSAID) 1% gel	Voltaren Gel	Treatment of painGI & renal effects of oral NSAIDs unlikely	Skin irritation, Delayed pain relief, Difficult adherence	Knee, hand, foot

Until recently, diclofenac 1% gel (Voltaren) was only available by prescription⁵. This product provides both analgesic and anti-inflammatory actions to the affected joints. Safety and efficacy of diclofenac 1% gel on knee osteoarthritis was proven in three randomized double-blind multicenter trials³. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) assessed pain (scale 0-20) and physical function (0-68) after 12 weeks. Patients 65 years and older showed significant improvement in pain (-5.3 vs. -4.1 p=0.02) and physical function (-15.5 vs -11, p=0.004) from baseline compared to placebo. There was also a significant decrease in pain on movement in the diclofenac group (-33.7 vs. -26.4, p=0.02).³ Study participants had over 90% adherence despite using a medication that requires application four times daily. Patients should be counseled on the importance of adherence and to not expect immediate relief.

Capsaicin is derived from chili peppers and acts as a counterirritant to pain. The agent is also useful for neuropathic pain. Capsaicin causes a depletion of substance P from sensory neurons, resulting in a numbing effect⁶. Capsaicin also requires application 3-4 times a day however, it requires a longer time to absorb into the skin before washing^6,7. A meta-analysis of 28 randomized-controlled trials explored the efficacy of capsaicin in osteoarthritis pain. Capsaicin trials were evaluated as low quality, but did show superiority to placebo when used at recommended doses (0.41, CI 0.17-0.64)⁷. Use of capsaicin on the hands is difficult, given the need to avoid touching the face or eyes after application to avoid burning. There is also concern for long-lasting nerve desensitization with chronic capsaicin use^6,8. The low quality evidence and adverse effects limit the use of capsaicin topical products for osteoarthritis to second line therapy after topical diclofenac. This meta-analysis also evaluated topical NSAIDs and found them overall superior to placebo based on effect size (0.30, CI 0.19-0.41).

Ingredients like camphor, menthol, and salicylates provide a distraction from pain through a cooling or warming sensation on the skin. These agents may provide an immediate feeling of relief but overall studies have shown mixed efficacy^4,9. Despite having been available for many years, there is limited data on their use.⁴ Menthol, camphor, and salicylate products are not currently recommended by the ACR guidelines for osteoarthritis pain management⁴. However, side effects with menthol and camphor products are few when used topically except to note that salicylates as a derivative of salicylic acid should not be used in patients with an aspirin allergy.⁹

Use of topical agents must be carefully guided in a geriatric population due increased absorption potential with the thinning of the skin in older adults and if heat is applied to the affected joint before or after topical application. Increased permeability may increase the risk of systemic side effects like that seen in oral NSAID medications. Topical agents are an important option because of easy application for patients suffering from mild to moderate osteoarthritis pain. The introduction of topical diclofenac to store shelves increases the availability of a therapy with evidence of providing significant pain reduction and improved physical function in patients with osteoarthritis.

References:

Osteoarthritis (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
Arthritis By The Numbers: Book of Trusted Facts & Figures (2019). Arthritis Foundation. Section Two: OA Facts (p17-27). Retrieved from https://www.arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-abtn-final-march-2019.pdf
Baraf, H. S., Gloth, F. M., Barthel, H. R., Gold, M. S., & Altman, R. D. (2011). Safety and efficacy of topical diclofenac sodium gel for knee osteoarthritis in elderly and younger patients: pooled data from three randomized, double-blind, parallel-group, placebo-controlled, multicentre trials. Drugs & aging, 28(1), 27–40. https://doi.org/10.2165/11584880-000000000-00000
Kolasinski S., Neogi T., Hochberg M.,et. al. (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. American College of Rheumatology. Vol. 72, No. 2, February 2020, pp 149–162 DOI 10.1002/acr.24131
FDA Approves Three Drugs for Nonprescription Use Through Rx-to-OTC Switch Process (2020). S. Drug & Food Administration. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-three-drugs-nonprescription-use-through-rx-otc-switch-process.
Altman, R. D., Barthel, H. R. (2011). Topical therapies for osteoarthritis. Drugs, 71(10), 1259-1279.
Persson, M., Stocks, J., Walsh, D. A., Doherty, M., & Zhang, W. (2018). The relative efficacy of topical non-steroidal anti-inflammatory drugs and capsaicin in osteoarthritis: a network meta-analysis of randomised controlled trials. Osteoarthritis and cartilage, 26(12), 1575–1582. https://doi.org/10.1016/j.joca.2018.08.008
van Laar, M., Pergolizzi, J. V., Jr, Mellinghoff, H. U., et al. (2012). Pain treatment in arthritis-related pain: beyond NSAIDs. The open rheumatology journal, 6, 320–330. https://doi.org/10.2174/1874312901206010320
Rubbing It In (2019). Harvard Health Publishing. Retrieved from https://www.health.harvard.edu/pain/rubbing_it_in

Dementia Training for First Responders

Fall 2020 Newsletter

By Laura Spradley, MS
Outreach Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

Why do first responders need training regarding dementia and Alzheimer’s disease, you may ask? There are approximately 58,000 Arkansans aged 65 and older that have a diagnosis of Alzheimer’s disease, a specific type of dementia. This number is predicted to increase by 19% by 2025 when Arkansas will have approximately 67,000 older adults with Alzheimer’s disease (1). Because of this projection, first responders will increasingly need training in understanding dementia and Alzheimer’s disease, the behaviors sometimes associated with the disease, and how best to interact with this growing segment of our population.

The Arkansas Geriatric Education Collaborative is here to help. We have provided dementia training to over 1,200 first responders to date. The program is available in-person and virtually. The in-person program takes 2-3 hours to present and the virtual program can be viewed one module at a time or the six program modules may be complete consecutively, all at one time, in about 2 hours.

The program trains first responders in the basics of understanding dementia and Alzheimer’s disease – the signs and symptoms and then how best to communicate with someone with dementia. Helpful communication tips and visual reinforcement scenarios are included. The program discusses important behaviors and scenarios first responders may encounter such as wandering, elopement, aggressive behaviors, delusions, repetitive behaviors, hallucinations and hoarding. AGEC also felt it important to include a module about elder abuse. This module teaches both how to recognize the signs of elder abuse and how to report possible elder abuse. The final module in the series discusses tips and scenarios on how best to assist a person with dementia in the event of a natural disaster.

Upon completion of the modules, the individual requests a certification of completion by email. This free, online program is approved for 2.0 CLEST hrs. for police and 2.0 CE hours for EMS personnel. The program has been a big success and has had participation by first responders and other health care professionals in several states.

When COVID restrictions are lifted, AGEC will once again offer the two-hour program in person. To schedule a First Responder Dementia Training Program, send your request to AGEC at agec@uams.edu.

If you are a first responder, know a first responder, or know a first responder organization that may be interested in this program please share this article or information with them. Contact Laura Spradley, Outreach Coordinator with the AGEC at 501-526-7482 with additional questions.

https://www.alz.org/media/documents/arkansas-alzheimers-facts-figures-2018.pdf

Meet Our 2020 Geriatric Fellows

UAMS AGEC 2020 Geriatric Fellows

Robin McAtee, PhD, RN, FACHE, Director and Ronni Chernoff, PhD, FAND, FASPEN, AGEC Associate Director are pleased to announce awardees for the 2020 Junior Faculty Fellowships in geriatrics at the Donald W. Reynolds Institute on Aging at UAMS. Obioma Nwaiwu, MD, PhD and Stephanie Trotter, PhD, RN were notified of the decision in June 2020. The fellowship program objective is to support the career development of professionals who want to specialize in academic and clinical geriatrics. The award includes $30,000 in salary support and supported attendance for each at (1) national geriatric conference.

Obioma Nwaiwu, MD, PhD

Obioma Nwaiwu, MD, PhD obtained his medical degree from University of Ibadan, Nigeria, a PhD in Health Services Research from Texas A&M Health Science Center, and completed his family medicine residency at the University of Arkansas for Medical Sciences. He was accepted into the geriatric fellowship program at UAMS in 2019 and has now joined the Department of Geriatrics as an assistant professor. His passion for improving access to care and reducing disparity for vulnerable older adults started prior to his medical education. Over the past few years, he has been involved in multiple projects aimed at improving access and care for vulnerable older adults and he has collaborated with the community leaders in this effort. He is very interested in helping older adults to reduce their fall risk and partnered with Area Agencies on Aging in Texas to implement and evaluate falls reduction programs. He is also an Aging Research in Criminal Justice & Health Network Scholars Awardee where he plans to evaluate the need, capacity, and interest in improving access to care of incarcerated older adults in Arkansas through provision of geriatric consultation services.

Stephanie Trotter, PhD, RN

Stephanie Trotter, PhD, RN began a second career in 2010, when she chose nursing as a second career path. She completed her baccalaureate nursing degree in 2012 and a PhD in nursing in 2017 both at UAMS. She loves the diversity and limitless opportunities available in this healthcare field. While obtaining her undergraduate degree, she was selected for the Hartford Center for Geriatric Nursing Excellence externship. During this experience, she developed a passion for the health and well-being of Arkansas’ geriatric population and this is where her teaching and research has since focused. Her dissertation work focused on age-specific differences in time perspectives, health beliefs, and behaviors of hypertensive adults. Dr. Trotter is a faculty member of UAMS’ College of Nursing where she strives to cultivate respect and passion for the geriatric population in undergraduate nursing students. She feels that as a nurse educator, it is her calling to prepare the next generation of nurses to care for older adults. In her free time, she enjoys family time, including her four-legged family members, and home improvement projects.

From The Director’s Desk

Spring 2020

Is this a new AGEC era?

What a difference a few weeks make. Last time I wrote this newsletter, we at the AGEC were preparing for a very busy end of winter and early spring with several exciting programs and activities scheduled! We were all really looking forward to better weather and traveling the state to conduct programs and see our community-based and academic partners in action. And now…. we are still very busy, but differently.

As most people, we have started working part-time at home and part-time on campus. We have also greatly changed the way we are delivering programs and activities. We have had to spend time learning new systems and thinking about how to do things differently – while socially distancing ourselves! Below are a few examples of how we are adapting and changing.

We are converting community programs into virtual forums:

Dementia Friendly Business – Converting in-person coaching to virtual/online program
Converted our popular community forum “Understanding Dementia & Alzheimer’s Disease” to an online program via BlackBoard Collaborate
Converted Lunch & Learn series with Alzheimer’s’ AR and Community Based Organizations from in-person to online.
With our AR-IMPACT partner, we have completed four on-line programs: Alternative Pain Relief and Self-management amidst the Opioid Crisis; Tips for the Busy Clinician; Opioids and Falls; and Recognizing and Responding to Suffering
Transforming community programs (some educational and some exercise programs) to on-line versions while encouraging our older adults to participate online. For example: Presenting Ageless Grace online (via Facebook) and to date, along with our partners in this venture we have had over 5000 hits!
Working with our clinical partner with QI activities via phone conferences

As we learn new ways of delivering our programs and grant activities, we want you to stay connected with us. If you have unique ideas about how to reach and connect with health professionals who specialized in geriatrics or the older adults themselves and/or their caregivers, or the general community, please share them with us! We are all in this together and are striving to meet the needs of older Arkansans while improving their health and wellbeing!

Polypharmacy: Definition, Causes, and Solutions

By Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Definitions

Polypharmacy may be defined as a number of medications, ranging from as few as two to as many as 21. The most common numerical threshold for polypharmacy is 5-6 or more medications. However, a patient with diabetes, chronic kidney disease, hypertension and heart failure is easily prescribed more than 6 medications if treated according to accepted guidelines making them all potentially appropriate for the individual. Polypharmacy may be defined as use of potentially inappropriate medications as identified by a set of criteria such as the AGS 2019 Beers Criteria.(1) These criteria list medications whose risk usually outweighs potential benefit when used in older adults. Yet another definition of polypharmacy is limited to the presence of medications in the patient’s list that are unnecessary, which is defined as medications that are not indicated, dosed in excess, continued beyond an adequate duration, duplications, or causing adverse events. The most stringent definition of polypharmacy involves evaluation of each medication a patient receives according to 10 questions which comprise the Medication Appropriateness Index.(2)

Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Are the directions practical?
Are there clinically significant drug-drug interactions?
Are there clinically significant drug-disease/condition interactions?
Is there unnecessary duplication with other drugs(s)?
Is the duration of therapy acceptable?
Is this drug the least expensive alternative compared to others of equal utility?

If any of the questions receives a negative response, the drug use is not appropriate and polypharmacy is present. In research applications, the first three questions are given more weight in the assessment. This helps the clinician know to focus on indication, effectiveness, and dosage.

Causes

The causes of polypharmacy are many, but include the patient’s use of multiple physicians and pharmacies, disease state guidelines recommendations for multiple medications, prescribing cascades, and direct-to-consumer advertising. When a patient sees multiple physicians, communication between providers is necessary to prevent prescription of duplicate medications. In addition, prescribing cascades may result when one prescriber is unaware of the therapy recommended or prescribed by a previous prescriber. Additional medications to be considered are over-the counter medications and supplements that the patient consumes without the knowledge of the provider. This results in a further increase in drug interactions and adverse drug events. If a patient uses different pharmacies, assessment of important drug-drug interactions may be lacking as each pharmacy will likely only have a partial list of medications.(3, 4)

The prescribing cascade is defined as when a new medication is prescribed for a symptom that is misinterpreted as a new medical condition when it is actually an adverse drug reaction or side effect. An example is shown in Figure 1.

Prevention and Intervention

The first step in prevention of inappropriate polypharmacy is to perform a medication regimen review whenever a new medication is being considered for prescription. An adverse drug effect may be the cause of a symptom and require adjustment or discontinuation of a currently prescribed agent instead of addition of a new one. Non-pharmacological interventions are preferred for many chronic illnesses and should be promoted to older adults.

Secondly, the clinician can identify inappropriate polypharmacy exists for an older adult through use of various tools that can aid in identifying medications that may be unnecessary. Annual or more frequent review of the medication regimen is recommended.(5) Taking the time to carefully consider each medication and its risk/benefit in light of a patient’s circumstances is important, especially as a patient becomes frail with an increased susceptibility to adverse effects.

References:

American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. 2019 updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67:674-94 DOI: 10.1111/jgs.13702
Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.
Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. 1997;315:1096-9.
Scott IA, Gray LC, Martin JH,Mitchell CA. Minimizing inappropriate medictions in older populations: a 10-step conceptual framework. Am J Med. 2012;125:529-37.
Choosing Wisely. An initiative of the ABIM Foundation. https://www.choosingwisely.org/societies/american-geriatrics-society/ Accessed 30 April 2020.

Age-Friendly Healthcare in Rural Arkansas

By Leah Tobey, MBA, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

My name is Dr. Leah Tobey and I am the clinical coordinator for the AGEC team. As part of our HRSA Geriatric Workforce Enhancement Program, we have goals to improve clinical health outcomes of older adults in the primary care setting. Our partnered clinics are with ARcare, a federally qualified healthcare clinic network. Specifically, the two clinics where we partner with to improve outcomes for older adults are ARcare England and ARcare Augusta. I help provide up-to-date and evidenced-based trainings to clinicians, particularly focused on age-friendly work practices, tests and measures to enhance patient experiences and improve outcomes of older adults in these rural areas.

As a member of the 2020 Institute for Healthcare Improvement (IHI) Age-Friendly cohort, we at AGEC have requested the ARcare clinics to implement the 4Ms framework to optimize the care of older adults. This framework is not a program, but rather a shift in how care is provided. The 4Ms framework consists of: What Matters to the older adult, high-risk Medication review, cognitive and Mentation screens, and Mobility tests for fall prevention. Through a variety of geriatric-focused trainings, including the 4Ms framework, our first goal was to improve the clinician’s knowledge of best practices of caring for older adults. We then collected baseline data of common health related indicators for older adults, such as uncontrolled hypertension, diabetes, number of patients prescribed high-risk medications like opioids and older adults who experience frequent falls. The 4Ms framework for age-friendly care has been well-received and AGEC is continuing to monitor how and when this framework is being implemented into primary care, including Medicare annual wellness visits.

We know the population of older adults, specifically the Baby Boomer population, continues to increase, and we expect the 4Ms framework will be a helpful guide to ensure that older adults are delivered safe, age-friendly healthcare. This framework helps to ensure patients move safely every day in order to maintain function and do what Matters most to them (ihi.org). We have seen promising results in several areas, for example, assessing Mobility with fall screens has improved over 50% in one year in the ARcare England clinic. ARcare England also had a 30% increase in annual wellness visits for Medicare patients in one year. We continue to address areas of improvement, using the 4Ms framework as a helpful guide to care. As I mentioned above, the 4Ms framework includes Mentation screens specifically for the presence of the 3D’s: Dementia, Delirium and Depression. Early, accurate screening procedures will allow the clinicians to prevent, identify, treat, and manage cognitive changes noted in an older adult patient. When cases of depression or dementia are caught early, we want the ARcare clinicians to have the knowledge to treat with age-friendly care and also provide helpful community resources for patients and their families. This goal coincides with the healthy aging programs the AGEC brings to Arkansans across our state.

Despite difficult times recently, we at AGEC have been busy creating and providing clinical trainings to continue building upon the early, positive results within ARcare. I’m happy to report as of March 2020 ARcare England and Augusta have been awarded the certification of being “Age-Friendly Healthcare Systems” by the Institute for Healthcare Improvement. We are looking forward to continued improvements in health-related indicators for older adults in our rural ARcare communities and to making them more age-friendly.

From The Director’s Desk

Winter 2020

Happy New Year and Happy New Decade from all of us at the Arkansas Geriatric Education Collaborative! I am excited to be writing to you as we begin a brand new decade! Here at the AGEC we have an exciting year planned as we being programs for healthcare professionals and students, community members, caregivers, and older adults.

Reflecting back on the last 3 months of 2019, we had several very successful programs. These included: a 2 day train-the-trainer program where six individuals were recertified in Ageless Grace and 32 individuals were certified to be lay leaders. They can now go to their perspective audiences all over Arkansas and conduct Ageless Grace classes. We also hosted our fall webinar which featured Dr. Masil George who presented on Palliative Care for People with Dementia. Attendance was great with 78 attendees. Another exciting event was National Family Caregiver Month in November where we brought in Mr. Don Guess (an advocate of older adults from the Arkansas Farm Bureau) to conduct an interview that was shown on Facebook as a video. It has had over 6,400 views! We also launched a Caregiving Tips video series that will continue throughout 2020. The AGEC also launched our First Responder Dementia and Elder Justice Online Training and have had over 70 completers to date!

As we look to the first few months of 2020, we will sponsor Geriatric Grand Rounds January 28th with Margaret Pauly, MS, RD, LD and Stephan Dehmel, MD whose program will be titled Gut Check: Are you prescribing the right foods for your elderly patients?. We will also be working closely with our clinical partner ARcare in England, AR. We will be learning with them as we endeavor to help them become the first Age-Friendly Health System in AR. “Age-Friendly Health Systems” is an initiative of the John A. Hartford foundation and the Institute for Healthcare Improvement. The initiative’s goal is to rapidly spread the 4Ms Framework (Medication, Mentation, Mobility, and what Matters to the older adult) to 20% of the US hospitals and medical practices by the end of 2020. We are excited about this challenge as is ARcare!

Our academic partners completed another great semester of training the next generation of healthcare providers and our five Geriatric Student Scholars began their work with the AGEC.

Thank you for all you do for older adults in Arkansas and we look forward to continuing to partner with many of you to expand and improve services and programs.

What’s New in the 2019 Guidelines for Community-Acquired Pneumonia?

By Blaze Calderon, Juliana Oguh, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Several factors increase the frequency of infection and pneumonia in older adults including lowered immune function, the presence of comorbid conditions, and nursing home residence.¹ Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary tissue that is acquired outside of a health care setting.² CAP is a leading cause of morbidity and mortality worldwide. The clinical presentation of CAP ranges from mild pneumonia, characterized by fever, cough, and shortness of breath, to severe pneumonia, characterized by sepsis and respiratory distress.²In 2019 the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) released an update to their 2007 guidelines on CAP.³ This marks the first update in over a decade. This update is especially important to geriatrics because CAP is one of the most common and fatal infectious diseases seen in this patient population.⁴

Major changes introduced in the new guidelines:

Instead of defining severe CAP based on the location of treatment (inpatient or ICU), the new guidelines have introduced a validated definition in which 3 or more minor or 1 major criteria must be met in order to classify the diagnosis as severe CAP. Minor criteria are: respiratory rate ≥ 30 breaths/min, PaO2/FiO2 ratio ≤ 250, multilobar infiltrates, confusion/disorientation, blood urea nitrogen level ≥ 20 mg/dl, leukopenia, thrombocytopenia, hypothermia, and hypotension requiring aggressive fluid resuscitation. Major criteria are septic shock with need for vasopressors and respiratory failure requiring mechanical ventilation.
Sputum and blood cultures should be obtained if possible for patients with severe disease (without delaying antibiotic therapy), but the new guidelines expand this recommendation to include inpatients empirically treated for MRSA or Pseudomonas aeruginosa.
Macrolide monotherapy (i.e, azithromycin, clarithromycin) may be used for outpatients, but only in areas where pneumococcal resistance to macrolides is reported to be less than 25%.
The new guidelines do not recommend procalcitonin levels to decide if antibiotic therapy should be initiated. These are reserved for identifying when to discontinue antibiotics in hospital acquired or ventilator associated pneumonia.
Corticosteroids are not recommended, but may be considered in patients with refractory septic shock.
The healthcare associated pneumonia (HCAP) category was introduced in 2005. The most recent recommendations are to stop using this categorization to determine if extended-spectrum antibiotics should be used. Instead, the presence of local epidemiology and risk factors decide if MRSA or P. aeruginosa coverage is needed for CAP. There is an emphasis on de-escalation of antibiotic therapy based on culture results.
In the previous guidelines, empiric therapy for severe CAP was a beta lactam + macrolide or beta lactam + fluoroquinolone. Now a beta lactam + macrolide is preferred. This is due to the increase risks identified with fluoroquinolone therapy.
Finally, follow up chest imaging is not recommended for patients who are improving.¹

The approach to diagnosis and management of pneumonia in older adults is generally the same as in the general population, although older adults are more often afflicted with severe disease or sepsis.¹ The fact that most patients with community-acquired pneumonia can still be treated with tried-and-tested regimens like macrolides or macrolides and beta lactam antibiotics that have been used for decades is encouraging in the face of concerns over increasing antibiotic resistance. When treating older adults, the use of broader empiric treatment initially is common due to increased risk of drug resistance, and higher incidence of severe forms of pneumonia. The new guidelines may improve tailored antibiotic use in older adults with the change in definition of severe CAP, and focus on de-escalation of therapy when possible.

References:

Mody, L. Approach to infection in the older adult. In: UpToDate, Schmader, K.E. & Givens, J., UpToDate. Waltham, MA, 2019.
Ramirez, J.A. Overview of community-acquired pneumonia in adults. In: UpToDate, File Jr., T.M. & Bond, S., UpToDate. Waltham, MA, 2019.
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Griffin, M. R. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200 (7), e45-e67.
Niederman, M. S., & Ahmed, Q. A. (2003). Community-acquired pneumonia in elderly patients. Clinics in geriatric medicine, 19(1), 101-120.