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Increasing Pharmacist
Value Through Patient
Screening Assessments
Johnathan Hamrick, PharmD
Clinical Assistant Professor
Assistant Director of IPPE
Mercer University College of Pharmacy
Disclosure
I do not have (nor does any immediate family member
have) actual or potential conflict of interest, within the
last twelve months; a vested interest in or affiliation
with any corporate organization offering financial
support or grant monies for this continuing education
activity; or any affiliation with an organization whose
philosophy could potentially bias my presentation.
Learning Objectives
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Describe what is a CLIA waiver
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Identify and perform CLIA waived tests
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Screen patients for fall risk using the STEADI algorithm
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Understand the components of a Mini-Cog Assessment
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Perform an animal fluency test for dementia
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Describe the physical signs of dehydration
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Discuss the physical signs of stroke
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Identify the physical signs and symptoms of drug abuse
CLIA Waived Tests
Clinical Laboratory
Improvement Amendments
(CLIA)
• The Clinical Laboratory Improvement Amendments of 1988
(CLIA) regulations include federal standards applicable to all
U.S. facilities or sites that test human specimens for health
assessment or to diagnose, prevent, or treat disease.
• Waived tests are so simple and accurate that little risk of error
exists when done correctly. Examples of waived tests include:
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Certain testing methods for glucose and cholesterol;
Fecal occult blood tests;
Pregnancy tests; and
Some urine tests.
• A full list of CLIA waived tests may be found at:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/testswaived.cfm
Clinical Laboratory Improvement Amendments (CLIA). Center for Disease Control and Prevention Website https://wwwn.cdc.gov/clia/Default.aspx. Updated March 15, 2016. Accessed on May 23, 2016.
Enrolling in the CLIA Program
To enroll in the CLIA program, laboratories must:
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Complete an application;
Pay applicable fees;
Be surveyed, if applicable; and
Meet CLIA standards and become certified.
For more information and the application form, visit
https://www.cms.gov/Regulations-and
Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certific
ate_International_ Laboratories.html on the CMS website.
Clinical Laboratory Improvement Amendments (CLIA). Center for Disease Control and Prevention Website https://wwwn.cdc.gov/clia/Default.aspx. Updated March 15, 2016. Accessed on May 23, 2016.
Tips on Conducting
CLIA-Waived Tests
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Follow manufacturers instructions on how to use the device.
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Run and document controls frequently (prior to administering tests.)
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Conduct tests on a clean surface free.
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Keep a log of results and associate results back to control reading.
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If using to screen multiple patients, make sure device is approved for use
on multiple users and is not for single person use.
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Only use single-use lancets with safety mechanism.
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Ensure testing strips and other supplies are within date.
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Wear gloves.
Results Log Example
Demo
Glucose Screening
Fall Risk Assessment
Did you know?
• 1/3 of adults over the age of 65 fall each year
• Many patients who have fallen do not talk about it.
• The Most important intervention is to reduce or eliminate:
• Psychoactive drugs, especially benzodiazepines
• Any medications that have anticholinergic side effects
• Sedating OTCs, specifically diphenhydramine and diphenhydramine
containing products.
• You can make a difference by being proactive and asking all patients
65+ if they’ve fallen in the past year and use the STEADI Algorithm.
• STEADI = Stopping Elderly Accidents, Deaths, & Injuries
STEADI – Older Adult Fall Prevention. Center for Disease Control and Prevention Website http://www.cdc.gov/steadi/. Updated September 30, 2016. Accessed on May 23, 2016.
3 Questions to Ask
Your Older Adult Patients
• When you see patients 65 and older, make these three questions a routine
part of your exam:
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Have you fallen in the past year?
Do you feel unsteady when standing or walking?
Do you worry about falling?
• If your patient answers "yes" to any of these key screening questions, they
are considered at increased risk of falling. Further assessment is
recommended -> Initiate STEADI Algorithm.
STEADI – Older Adult Fall Prevention. Center for Disease Control and Prevention Website http://www.cdc.gov/steadi/. Updated September 30, 2016. Accessed on May 23, 2016.
STEADI – Phase 1
ASK patients if they’ve fallen in the past year, feel unsteady, or
worry about falling.
REVIEW medications and stop, switch, or reduce the dosage of
drugs that increase fall risk.
RECOMMEND vitamin D supplements of at least 800 IU/day with
calcium.
STEADI – Older Adult Fall Prevention. Center for Disease Control and Prevention Website http://www.cdc.gov/steadi/. Updated September 30, 2016. Accessed on May 23, 2016.
STEADI
Documents
http://www.cdc.gov/steadi/materials.html
Memory Screenings
Did you know?
• The number of Americans
living with Alzheimer's
disease is growing — and
growing fast. An estimated
5.4 million Americans of all
ages have Alzheimer's
disease in 2016.
• Of the 5.4 million Americans
with Alzheimer's, an
estimated 5.2 million people
are age 65 and older.
• Georgia statistics…
2016 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Accessed on May 26, 2016.
Quick Memory Screening
Tools
To be discussed:
1. Mini-Cog
2. Animal Fluency
Others:
1. General Practitioner Assessment of Cognition (GPCOG)
2. Memory Impairment Screen (MIS)
Mini-cog
3 Steps
1. Three Word Registration
2. Clock Drawing
3. Three Word Recall
Mini-Cog. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Updated January 19, 2016. Accessed on May 26, 2016.
Step 1: Three word
registration
• Look directly at person and say, “Please listen
carefully. I am going to say three words that I want
you to repeat back to me and try to remember. The
words are [give three unrelated words]. Please say
them for me now.”
• Examples: [dog, apple, house]; [banana, sunrise,
chair]; [leader, season, table]
• If the person is unable to repeat the words after
three attempts, move on to Step 2.
Mini-Cog. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Updated January 19, 2016. Accessed on May 26, 2016.
Step 2: clock drawing
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Say: “Next, I want you to draw a clock for me. First, put
in all of the numbers where they go.”
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When that is completed, say: “Now, set the hands to 10
past 11.”
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Use preprinted circle for this exercise.
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Repeat instructions as needed as this is not a memory
test.
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Move to Step 3 if the clock is not complete within 3
minutes.
Mini-Cog. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Updated January 19, 2016. Accessed on May 26, 2016.
Step 3: Three Word recall
• Ask the person to recall the three words you stated
in Step 1.
• Say: “What were the three words I asked you to
remember?”
• Record the person’s answers.
Mini-Cog. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Updated January 19, 2016. Accessed on May 26, 2016.
Mini-Cog Scoring
Mini-Cog. Alzheimer’s Association Website www.alz.org/documents_custom/minicog.pdf. Updated January 19, 2016. Accessed on May 26, 2016.
Animal fluency Test
• Ask the person to name as many animals as possible
within a 60-second time frame.
• If the person names 15 or fewer animals within the
60-second time frame this may indicate early stages
of dementia or the development of a cognitive
impairment.
• Note: This test is not enough to diagnose a person
with dementia. It is a screening tool to determine
potential memory problems and further testing may
be necessary.
Sager MD, MA; Hermann PhD, BP; LaRue PhD, A; Woodard PhD, JL, Screening for Dementia in Community-based Memory Clinics. Wisconsin Medical Journal 2006.105(7)25-29
Activity
Find a partner and perform a Mini-Cog and an Animal Fluency Test on each other.
Mini-Cog
Animal Fluency
Three Words Given:
List Animals Below:
___________ __________ __________
Clock Drawing:
Three Words Recalled:
___________ __________ __________
Score:_____
Total Number:______
Dehydration
Recognizing Dehydration
Mild to moderate dehydration is likely to cause:
• Dry, sticky mouth
• Sleepiness or tiredness — children are likely to be less active than
usual
• Thirst
• Decreased urine output
• No wet diapers for three hours for infants
• Few or no tears when crying
• Dry skin
• Headache
• Constipation
• Dizziness or lightheadedness
Dehydration. Mayo Clinic Website http://www.mayoclinic.org/diseases-conditions/dehydration/basics/symptoms/con-20030056. Updated February 12, 2014. Accessed on May 27, 2016.
Recognizing dehydration
Severe dehydration, a medical emergency, can cause:
• Extreme thirst
• Extreme fussiness or sleepiness in infants and children; irritability and
confusion in adults
• Very dry mouth, skin and mucous membranes
• Little or no urination — any urine that is produced will be darker than
normal
• Sunken eyes
• Shriveled and dry skin that lacks elasticity and doesn't "bounce back"
when pinched into a fold
• In infants, sunken fontanels — the soft spots on the top of a baby's head
• Low blood pressure
• Rapid heartbeat
• Rapid breathing
• No tears when crying
• Fever
• In the most serious cases, delirium or unconsciousness
Dehydration. Mayo Clinic Website http://www.mayoclinic.org/diseases-conditions/dehydration/basics/symptoms/con-20030056. Updated February 12, 2014. Accessed on May 27, 2016.
Stroke
Did you know…
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Each year, nearly 800,000 people in the U.S. experience a
stroke. That’s one stroke every 40 seconds.
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For every person that dies from stroke, more than 5 times
that many will survive, and for them the physical damage it
causes can be enormous.
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For each minute a stroke goes untreated and blood flow to
the brain continues to be blocked, a person loses about 1.9
million neurons. This could mean that a person’s speech,
movement, memory, and so much more can be affected.
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Stroke is an emergency and getting help and treatment is
extremely important. Learn how to quickly identify stroke by
using the FAST test.
Recognizing Stroke. National Stroke Association Website http://www.stroke.org/understand-stroke/recognizing-stroke. Accessed on May 27, 2016.
Act F.A.S.T.
Recognizing Stroke. National Stroke Association Website http://www.stroke.org/understand-stroke/recognizing-stroke. Accessed on May 27, 2016.
Symptoms are Sudden
Recognizing Stroke. National Stroke Association Website http://www.stroke.org/understand-stroke/recognizing-stroke. Accessed on May 27, 2016.
Drug abuse
Physical Signs
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Cold, sweaty palms; shaking hands.
Red, watery eyes; pupils larger or smaller than usual
Unusual smells on breath, body or clothes.
Extreme hyperactivity; excessive talkativeness.
Slowed or staggering walk; poor physical coordination.
Needle marks on lower arm, leg or bottom of feet.
Nausea, vomiting or excessive sweating.
Tremors or shakes of hands, feet or head.
Irregular heartbeat.
Runny nose; hacking cough
Puffy face, blushing, or paleness
Frequent rubbing of the nose
Frequent twisting of the jaw, back and forth
Signs and Symptoms of Substance Abuse. Phoenix House Website http://www.phoenixhouse.org/prevention/signs-and-symptoms-of-substance-abuse/. Accessed on May 27, 2016.
Behavioral signs
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Change in overall attitude/personality with no other identifiable cause.
Chronic dishonesty.
Sudden oversensitivity, temper tantrums, or resentful behavior.
Difficulty in paying attention; forgetfulness.
Paranoia
Silliness or giddiness.
Moodiness, irritability, or nervousness.
Excessive need for privacy; unreachable.
Secretive or suspicious behavior.
Car accidents.
Change in personal grooming habits.
Possession of a false ID card
Missing prescription pills
Complaints of a sore jaw (from teeth grinding during an ecstasy high)
Signs and Symptoms of Substance Abuse. Phoenix House Website http://www.phoenixhouse.org/prevention/signs-and-symptoms-of-substance-abuse/. Accessed on May 27, 2016.
Drug specific signs
Marijuana
Glassy, red eyes; loud talking and inappropriate laughter followed by sleepiness; a sweet burnt
scent; loss of interest, motivation; weight gain or loss.
Alcohol
Clumsiness; difficulty walking; slurred speech; sleepiness; poor judgment; dilated pupils.
Cocaine, Crack, Meth, and Other Stimulants
Hyperactivity; euphoria; irritability; anxiety; excessive talking followed by depression or excessive
sleeping at odd times; go long periods of time without eating or sleeping; dilated pupils; weight loss;
dry mouth and nose.
Heroin
Needle marks; sleeping at unusual times; sweating; vomiting; coughing and sniffling; twitching; loss
of appetite; contracted pupils; no response of pupils to light.
Signs and Symptoms of Substance Abuse. Phoenix House Website http://www.phoenixhouse.org/prevention/signs-and-symptoms-of-substance-abuse/. Accessed on May 27, 2016.
Drug specific signs
Depressants (including barbiturates and tranquilizers)
Seems drunk as if from alcohol but without the associated odor of alcohol; difficulty concentrating;
clumsiness; poor judgment; slurred speech; sleepiness; and contracted pupils.
Inhalants (Glues, aerosols, and vapors)
Watery eyes; impaired vision, memory and thought; secretions from the nose or rashes around the
nose and mouth; headaches and nausea; appearance of intoxication; drowsiness; poor muscle
control; anxiety; irritability
Hallucinogens
Dilated pupils; bizarre and irrational behavior including paranoia, aggression, hallucinations; mood
swings; detachment from people; absorption with self or other objects, slurred speech; confusion.
Signs and Symptoms of Substance Abuse. Phoenix House Website http://www.phoenixhouse.org/prevention/signs-and-symptoms-of-substance-abuse/. Accessed on May 27, 2016.
Johnathan Hamrick, PharmD
Mercer University College of Pharmacy
3001 Mercer University Drive, Duvall 165
Atlanta, GA 30341
(678) 547-6245
[email protected]
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