Video Transcript
Good morning, everybody.
Welcome to our webinar.
It is 8:00 o'clock, so I'm going to welcome you all here.
My name is Leanne Godfrey and I'm here with Tara Ackley today.
One of our nurse care managers and I really thank you for being here.
I know that there are many competing things in your world these days, so thank you for making this a priority.
It's such an important topic for our seniors.
It's an important topic for their health for them.
Really, there is kind of a life and death kind of conversation today, so thank you for making this part of your morning.
Again, welcome, my name is Leanne Godfrey.
I am the owner of Aaron Health management.
We have actually been around for eight years officially as a professional nursing corporation this year actually last month and I've been in nursing for 30 years this year, so I don't know how the math worked on that.
But that's what it says when I do.
All the calculations it says 30.
Years, and I've really enjoyed the last pretty much almost 10 years in care management and before that was involved in acute care nursing and oncology and managed care, et cetera.
So, it's all brought me to this point here, and I'm really, really happy and proud that we have such a wonderful.
Team of nurses.
Over here we do offer care management.
Ours is sort of a nursing team approach where we have a group of nurses but also an LCSW that we access for appropriate cases where that sort of psychosocial can be very advantageous.
So, I'm going to introduce you to Tara here and maybe Terry you can give everybody a little view of who you are and what you brought, what brought you to care management?
Thank you hi everybody, so glad to know that you're here joining us on this webinar.
Yeah, my name is Tara Ackley and I am an LVN licensed vocational nurse and I've also worked as a respiratory therapist.
Way back in the day I came into care management.
Kind of through the back door.
Quite frankly I started out as a respiratory therapist.
Worked in an acute care setting.
Trauma center environment.
Moved out of the hospital into the skilled nursing environment and that was my launch into senior care.
I have worked in senior care since then so I think.
If you know Leanne's giving numbers.
It means I've.
I have been in senior care for 20 years.
Honestly in different roles, but I have started in care management.
Later in life, after I discovered what it was, I didn't even know it existed for many years. Uhm, so in 2016 I graduated from the nursing program at Stanbridge in Irvine and I immediately went into care management, because I knew that's what I wanted to do. So, I've been doing care management since then, but that was as a licensed nurse.
But I actually.
Was doing care management in the home care industry for many years, even prior to going to nursing?
In school.
And I absolutely love it.
I love seniors.
I appreciate what it takes to stay.
In the journey of aging.
It is not an easy road to tackle and I just love being able to support seniors in their journey and the families that are also supporting them as well.
Thank you, Tara.
Well, I think both of us have learned a lot and our other team members have learned a lot about managing medications for clients over the past many years.
So that's why we thought it was a great topic to bring to everybody.
We made this present.
About three weeks ago, we were mainly fiduciaries, but we thought we would sort of focus again and round back again and maybe invite some other people and homecare.
's especially for today's presentation.
So again, thank you for being here in terms of just the nuts and bolts of what we're talking about here today.
If you are a fiduciary, I.
Don't think we have many today.
But if you are, you will get a CE credit for today and you'll get that certificate emailed to you within the next few business days. All of you are on.
Cute we do have the Q&A box available to you, so feel free to use that type in your questions.
We'll go over them at the end.
We did send out the PowerPoint last evening around dinner time, so please if you don't have that in your computer, check your spam.
If it's not in your inbox, check out your spam just in case.
This will be recorded. It is being recorded. It's going to be available on our website as soon as we do a little bit of editing for the beginning part of this, we'll put it up there, so feel free to go to ourownhealthmanagement.com.
We also have some other videos.
Their medical we've got one on working with the care manager.
We've got one on financials so.
Feel free to go there and peruse, but what we do have there and just as a little side note, most of the references today are from the National Institutes of Health, National Institutes of Health, the World Health organizations.
Publications JAMA as well as the CDC.
So, just in case you want to sort of circle back with any of those agencies regarding what I'm.
Talking about here today.
That's where I got most of my info.
So why is this such an important topic?
Well, there's many reasons why we're going to cover this today, and I know all of you.
I think here that I see are in senior care.
There's a reason why you're really focused on them.
Same people we.
Are, but we're going to in terms of an outline, I'm just going to go quickly through what we're going to talk about this morning.
We're going to review.
Why is it such an important topic for our senior population?
We're going to talk about potential areas of risk for medication management.
We're going to focus on polypharmacy as well as what's called pyms or potentially inappropriate medications, and we're going to discuss specifically the beers criteria.
Yeah, we're going to talk about appropriate prescribing.
Sorry, I'm behind myself here.
We're going to talk about why sometimes we do some tests.
We do some follow up tests as to the levels of medications, et cetera.
Why is that so important?
We're also going to talk about age-related changes and medication use.
And then we're going to leave with some best practice.
And certainly, if you have some best practices that you've come across in your time working with seniors, please feel free to maybe put those in the chat box and let us know what you've learned along the way.
That would be very helpful to everybody that's on call with us today.
Focusing on the elderly.
Gosh, we really have a unique population here.
We love our seniors for many, many reasons, but they're also a great risk related to the medications that they use.
They have a great risk in terms of just the natural physiological changes that happen with aging, and that happens for our brains.
It happens, obviously.
For our bodies, but there's a lot of challenges in that area itself.
Just the aging process.
We also know that our folks.
A lot of chronic diseases, sometimes they have multiple chronic diseases all occurring at one time.
Those conditions that the Parkinson's disease on top of maybe, uh, OCD on top of dementia.
There's just such a layering of illnesses, and then we have the acute illnesses that come up.
So, we get someone who gets pneumonia.
On top of all their chronic conditions.
And we also know that they are a very unique population just because they have so many medications that they're taking.
And we're not just talking about prescription meds, we're talking about the over the counter's we're talking about. Herbal kinds of remedies that supplement those kinds of things as well. So, when we talk about medications today, we're not just talking about prescription.
So just kind of think of that in the back of.
Mind and also impacting our seniors are financial concerns.
Some of the insurance coverage can be problematic.
For our people.
Sometimes they have a lack of availability of support.
Do they have family members who can help them specifically with this really important area of medication management?
Do they have a?
Friend that can come over many of our seniors have nobody.
They're living alone and they have no one to help.
Paid caregivers, we absolutely know and I know that we have many home care companies here today and those caregivers are not able to dispense.
They're not able to administer.
They can only provide those reminders, and Tara spent a lot of time working with caregivers in this arena, so you know, it's a real challenge in many areas.
So, as we age, all of us, we're going to be coping with a lot of those.
Multiple chronic conditions.
Whether that's cerebral vascular disease, whether that's depression, diabetes.
Lung issues, cognitive challenges, neuromuscular challenges, degenerative diseases we're all going to maybe be presented with those kinds of things as we age, so that is a huge issue for this population and a study presented through the National Institutes of Health concluded that prescription medication use has.
Increased dramatically among older adults, and they conclude that those on multiple meds have worse health status compared with those on fewer medications.
I think we all know that, but it's also backed up by many.
Studies they have also the NIH labeled the elderly as a as a vulnerable population related to medication use.
So, in that identification we really know and we know as practitioners, we have to provide oversight and support for medication management.
It is just too important to let it just slide.
Merck manual many of you have heard of before.
It's the world bestselling medical textbook that's been around for a long, long time, has stated that drugs are the most common medical intervention that we have, and I don't think any of us would probably argue with that.
Statement they're used to manage the chronic.
They're used to those conditions that we have over a long period of time, but how often do we ask?
How often does the practitioner or the prescriber ask?
Does this person still need to be on this?
Medication, is it time to discontinue?
Is it time to decrease?
Is it time to wean?
Is there something else that maybe we could be trying for this condition?
So, we also have the medications that are used for the short-term use for the infection that happens for the pain related to an acute injury.
Constipation, right?
So, we have these acute medications that are layered on top.
Do we know if that new medication is OK to use with all the other ones who's asking those questions?
I don't think who's checking.
I don't think we can, just.
Assume that the.
The prescriber knows all the meds that that person is on.
That's a common problem we see with our care management clients.
Is nobody knowing what somebody else has prescribed.
And that is hugely problematic, obviously.
And another thing I think when we talk about the elderly is and maybe for ourselves too, that when we go to the doctor, we kind of expect that we're going to go home with something.
And traditionally, physicians feel like they have to do something many times that something is an order.
It's another prescription that's been sent over to the pharmacy.
So, I don't mean to make this all doom and gloom.
We know that there's many, many benefits to medications they can save lives.
They can prevent an event from happening.
How many times do we see someone who's on an anticoagulant related to a history of strokes?
You know, we know that we.
Can prevent problems from happening.
We know that we can minimize side effects and problematic symptoms by the use of medications, but we do know that those medications always come with side effects always every single medication we take, whether that's over the counter, whether that's prescription or one of those supplements, every single one of those has side effects and.
What we know now through these studies is that these side effects are more likely to be severe in the elderly for many of the reasons we're discussing here today.
So as a result of these side effects and what we're going to talk a lot about is adverse drug reactions and those kind of side effects and adverse drug reactions can lead to more doctor's appointments, they lead to more emergency room visits, hospitalizations, and we know where that goes from there many times they're discharged to a skilled nursing.
And you know, we go from that point on, right?
So, this group, this age group, the elderly is definitely more at risk when it comes to the undesirable effects of medications and there is less room for error when we talk about how medications affect their senior population.
So, safety is one of the other reasons why we're so concerned about this topic for our senior population.
The NIH also reports that nearly half of older adults take five or more medications and as many as one in five of those medications is potentially inappropriate.
And we, I think as a group can probably say that five would be a miracle for us to bring someone on our service that only has five meds is very rare, and I'm sure for your folks as well, we're dealing with people who take usually many, many more medications every day than five.
Older adults that are prescribed more medications are more likely to be hospitalized for an adverse drug reaction.
You're going to hear me say adverse drug reaction a lot today because it is a really important element.
With this population and just so we have a bit of a definition here, an adverse drug reaction or what's called an ADR is a response to a drug that is unintended.
And harmful, so let's talk about the rashes that we get.
Maybe it's nerve damage.
Maybe it is kidney damage and in a worst-case scenario, maybe that adverse drug reaction is anaphylaxis.
So very, very threatening to the well-being of our client.
Another thing under safety is drug to drug interactions.
So, drug to drug interactions is a really interesting field and we could talk about that for days probably.
But just as an example, a drug can really duplicate the reaction of the original drug.
It can, they can oppose one another.
They can have opposite reactions.
And having multiple medications can change how the body reacts to each and every one of those medications.
Also, on top of that, just the drug-to-drug interactions.
We also have food; drug interactions and you've heard of these before as well.
So, food affects how medications act in the body, and I think really the most common one we come across because.
We do have a lot.
Of people that are on anticoagulants we see Coumadin.
And vitamin K, right?
So, we know that they have opposite reactions, so we're trying to make sure that the blood is not coagulating and causing the person to maybe have stroke symptoms.
But at the same time, they're eating all these wonderful leafy vegetables that we always tell them to eat.
And it's they oppose each other.
So, the drug isn't working the way that we need it to work, or we want it to work.
Another example is statins that are used to manage cholesterol and grapefruit. Those two things together grapefruit you'll see pop up.
A lot, right?
We see that on the labels a lot, but that really affects how the liver processor metabolizes drugs and our body.
So, another one you see is dairy and antibiotics.
So, when we have those two things together, the calcium and the dairy really affect how the antibiotics are.
Function in the body and make the antibiotic less effective.
So again, it's not just drug to drug, it's drug to food, alcohol and acetaminophen.
That's a biggie, too, right?
As we know, those two do not go together well because of the negative impact on them.
Liver for both of those.
Drug to disease.
Oh, here's another one for you, for your, for your consideration here today.
So, drug disease interactions.
How does a drug impact a disease process?
So, I have high blood pressure.
If I take a nasal decongest.
I have a bit of a cold, some stuffiness I don't want to have that stuffiness, so that results in the narrowing of those little vessels up here and throughout my body.
Well, I've got hypertension and I'm taking this medication that's constricting my blood vessels, so that drug is having a negative impact.
On my disease process, my high blood pressure.
So, there's lots to think about.
Another thing to think about too is quality of life and how the client feels day-to-day.
We know a lot of our clients just feel crummy.
A lot of the time part of it is disease.
Part of it is aging but also part of it is all the medications that they have on board and the side effects that are going on at that same.
Time, how they function, their level of independence there.
Ability to take.
Take care of themselves.
All of those things are impacted by all these medications.
But the good news is that while they have the highest prevalence of adverse drug reactions and drug to drug interactions, those kinds of things.
Many of these events are avoidable, so we have to consider this from a prevention point of view, and I think care management is very.
Prevention oriented, we want to have a forethought right about what's happening here before it becomes a problem.
But certainly, if something is already happening, there's already some something going on change wise.
Do it under medication.
We know that prompt intervention is really, really important.
Having a discussion with this.
With the prescriber to say this symptom, this sign started just after he started that medication three days ago.
Could those things be related?
So, get on very quickly, because we know all these medications are impacting that person.
Quality of life.
Agreed, like only and.
If I could just add to that safety.
Yes, sure.
Doctor Umme kind of seems to me in the time I've been working with families, clients and caregivers who are helping the families come they kind of tend to minimize the potential of the damage that could happen by.
Being on a certain medication and not really understanding which we wouldn't expect people.
I mean, I think honestly, if you're not a nurse or in a medical background training, you're not thinking this way.
That, oh, this medication.
It could interact with something else we're doing with food or another medication, but you know.
It'll be fine and ultimately really it is the risk of the senior themselves who is going to suffer.
And that is a long-time suffering.
I mean it'll.
It has a kidney damage issue.
It could be a.
Heart issue, it could be a liver issue and those are, you know you can't go back and fix the kidney after you've created some damage of exposure to what it has had to process and it couldn't process it anymore.
Now it cannot process for the rest of its life.
So, it's really.
I mean, I just want to emphasize the safety factor around these medications and the more the medications being prescribed, the higher the risks are.
And that's what everyone we want to make sure we're trying to educate people on the importance of closely monitoring what is happening with these medications.
Side effects are showing up.
Look for those things early on and report it as soon as possible so that it can start to be looked at more closely before it's too late.
Right, yeah, very good point.
Thank you, Tara.
Some other potential areas of risk for medication mismanagement.
We know we've already mentioned the fact that our elderly clients often have multiple conditions going on and they have a lot of comorbidities, and they're receiving a lot of medications for that.
But the other thing to consider is that they have multiple providers that are.
Prescribing for them, right?
There were many people.
There's a primary care physician there's.
All the bevy of them.
Specialists who are prescribing we now have psychologists prescribing we have nurse practitioners.
All these people are prescribing so that is another potential area that we run into problems.
We know that many times people have different pharmacies going on, and one of the things we're going to emphasize is that the person, whenever possible, there are sometimes that you can't get away from it.
You need a specialty pharmacy, but for the most part using just one pharmacy because we find when we first get on cases, sometimes there's meds spread out.
So, I think the word is getting around though I see a change.
Over the last few years families have been getting smarter about that and restricting the number of pharmacies to hopefully just one.
We also have potential areas of risk in terms of mismanagement by friends and family.
Many of them have opinions about what meds are good and which ones are not and what dad should be on and what dad shouldn't be on.
So that's another area of risk.
The client themselves may have very strong feelings about what they're willing to take.
But they want what they won't take, what their friends said to them about something.
How willing are they to follow a regime?
And it may not be a cognitive thing that they're saying I don't want to.
Do this, but.
Memory lapses or the inability to open their own?
You know dexterity.
Of getting into some.
Those Med bottles can be challenging for our seniors, so it really is important and we're going to really emphasize today that if there's any way to have a central point person that can coordinate these medications that can communicate with the prescribers and provide that oversight.
Another person, I'm sorry.
Another person, but that same person that they can advocate at appointments doctor's appointments.
And provide accurate information.
I've underlined accurately there because we've been in appointments where the doctor will say, you know how's it going?
Give any you know concerns about the medications or how's the timing of your meds is and they'll say oh great doctor.
No problem.
I'm so happy but we know that that's not the case.
And so, providing.
Accurate information.
If we can't go to an appointment many times, we will send information to the doctor's appointment ahead of time or we will prepare the client.
If they're competent to have that conversation about, you know what I'm finding that the regime is just too complicated for me, or there's too many times a day and I'm missing doses, so we try and prepare clients.
That way as well.
Polypharmacy is one of the main areas we get into a really high risk for medication mismanagement.
It is a huge problem.
We see it and we've already mentioned it in terms of having at least five medications per day being on the low side.
But with polypharmacy there's a couple of different definitions that I pulled out because.
I'm going to back up a second here.
There are so many different definitions of the term polypharmacy.
And what number of meds constitute polypharmacy?
So, I focused on two different sources of definition here.
They're very similar, but there's a couple of different points that are different, so I focused on the World Health Organization definition and it is that polypharmacy is often defined as routine use.
Of five or more medication.
This includes over-the-counter prescription and our traditional and complementary medicines, and those go back to the herbal and the supplements that I mentioned earlier.
The other that I chose in terms of a definition comes from the pharmacist, which is a clinically focused publication that those pharmacists surprisingly use in that definition, is that although there is no concrete definition of the term, polypharmacy has come to mean the use of.
Several, usually five or more medications on a daily basis.
And check this line out with the possibility that these may not all be clinically necessary, so that's why I put a couple of different definitions from credible sources there.
I think that's a really important point.
Do we need to be on all of these many medications?
Let's take a closer look.
Polypharmacy is also known as a major risk factor for mortality death.
US morbidity the existence of conditions, so it's certainly a really important topic so.
A really good best practice is to say that at every doctor's appointment, not just the primary care, but every single doctor's appointment, because, again, not all the prescribers know what anybody else is prescribed recently.
So, all meds should be reviewed at every single patient's visit.
I can't tell you how many times I've gone to.
A specialist and they have.
Totally the wrong list totally and they've had it for a long time. They last updated it maybe 2 1/2 years ago. Well, the person has been seen multiple times.
So that's a really important part there.
Polypharmacy can also result in non-adherence, so if there's all these medications going on for our seniors it may be too overwhelming so non adherence is definitely an issue for this population, particularly if they have cognitive impairment as such.
Now the other thing about non adherence not just following what.
The orders are.
Is that it increases the risk of drug duplication and I'll give you an example of this.
So, the doctor, you know the doctor is seen and the doctor says, you know, Gee, you know you've taken your meds.
Oh yes, doctor.
Just as ordered, yeah?
Just as you want me to.
But they see that there is some edema going on around the ankles. Well, you're taking the meds as I prescribed, so I guess we need to increase your dose of the lasik's so up it goes when really that client has not been taking the medication as ordered. So that's a real risk, right? That polypharmacy?
The other thing about polypharmacy, it's obviously leading to maybe some.
Drug to drug too.
Food interactions, drug to disease interactions, adverse effects and also higher health care costs.
So, we have someone that is taking all these meds.
There are adverse drug reactions they're ending up in the ER.
They end up being hospitalized for a period of time.
They deconditioned while they're inpatient, and then they're off to the skilled nursing for rehab, etc.
No one wants to be in that situation.
We want to keep our seniors home and happy and safe at home, and certainly.
Falls is in the mix here with all of these medications being prescribed.
I'd absolutely that is a huge issue and we know that we see that every.
Single day so our health care system is really great at starting medications, but not so great at reducing them.
Not so great at stopping them.
What I have started to see is that pharmacies and physicians are now supposedly taking a closer look.
At stopping medications, so I guess that you know that's a good thing.
We're trying to.
DD Prescribe is the term that's going around D prescriptions so.
Let's see one quote I saw here, and I think we've all heard this as well.
Sometimes taking too many medications becomes an illness in and of itself, and it leads to so many problems for us, especially for our elderly clients.
So, we want to move away from that if we can.
Clinicians may not always at may not always ask.
Clients may not always share about all the over the counter and herbal and supplements that they're taking.
We have a client who takes Chinese medicine and she has a nice little discussion with her very traditional.
Very mainstream physician nephrologist every time they meet up together.
She's not going to stop those meds, but she at least tells him that she's taking them.
He may not like it, but at least she's alerting him, right?
Most of our clients we don't see that from.
They don't tend to talk about it.
Greater number of meds.
This could lead to a decrease in the status of our client in terms of physical, cognitive and functional abilities.
And this is very cool when I put this presentation together, I came across this term prescribing cascades.
But polypharmacy increases the possibility of prescribing cascades and I'm going to tell you about prescribing cascades in just a moment here.
But before I do one other slide just to highlight a couple of things here, any new signs or symptoms that your client has?
Should be considered to be drug related until proven otherwise, particularly if they've recently started something or something been increased in dosage or frequency.
Something like that really looks into that.
Sometimes we think, oh, you know they've got a decline going on.
Or maybe it's a UTI or something like that.
That's certainly something to consider.
But also considered the fact that it could be a drug related reaction.
So again, the adverse drug reactions I told you I was going to go over this a couple of times because it's so important.
It's a response that is undesired and unintended, so the confusion the dry mouth, the upset stomach, the drowsiness, the kidney damage that we see, diarrhea that could lead to dehydration, and skin breakdown.
All those kinds of things can be adverse.
Drug reactions of a medication.
No, Leanne had client just recently that I set up medications.
Yes, yeah.
Or and she's on Parkinson's medications and a bunch of other things as well.
And her neurologist had just recently prescribed Flexeril for as a muscle relaxant, and two days after starting that medication she started having visual changes in her vision.
And when I arrived, they hadn't called me and let me know, but uhm, I was so happy to know that they reported it immediately to the physician.
They didn't just kind of work around it, but they really reported it.
And of course, she had to stop it immediately.
And you know, we're not really sure if that was a drug interaction with something she's already on, which was highly likely, or if it was just a reaction to the medication on her own.
But man, can you imagine she was seeing Halos around people?
Faces, I mean that's very disturbing and it was constant.
It wasn't just coming and going, it was a constant visual effect that it was remarkably like.
Wow, but that was just an example of.
That's pretty obvious actually, but that's good.
It's it really does happen.
It can't happen.
And that's a really profound one.
That's a good example of that.
And sometimes they aren't so profound, right?
So, if someone develops diarrhea, well, maybe it's just something I'm eating, et cetera.
Maybe it's not a big deal.
We don't necessarily think that it might be a drug related reaction, but for us for our clients who are elderly, having diarrhea for several days can be really, really problematic for them, yeah?
So, thank you for sharing that, Tara.
The National Institute of Health again says that drug induced adverse reactions are one of the main avoidable causes of hospitalization in older adults.
So that's a really important statement.
Drug induced adverse reactions are one of the main avoidable causes.
We don't want our seniors to be ending.
Up in the hospital.
There was a pub Med analysis published a meta-analysis back in 2018, and it looked at the prevalence of death among patients due to adverse drug reactions that eventually led to hospitalization and.
Yes, and they broke it down by age and of course due to our polypharmacy with our seniors.
The prevalence of death was much higher in the senior population.
And the top causes of.
Death related to adverse drug reactions were intracranial hemorrhage.
You know strokes renal failure that kidney failure.
That Tara was talking about, and also gastrointestinal bleeding.
Related to that is that 60% of all fatal drug reactions in this population were related to, and you'll recognize these ones. Coumadin got side anticoagulant, aspirin again another one that works to prevent the clotting of blood.
In a certain type of blood pressure medication called an ACE inhibitor, you may recognize licina prill or captopril that sort of category of blood pressure medications.
And cardiac medication. Digoxin, which is an older medication. But still, you see it and it helps with people's problems particularly with atrial FIB and also heart failure.
Those categories or specific meds accounted for 60% of all fatal drug reactions in this population. Do you see those medications?
On the list of your clients.
Absolutely we see them daily with us with our clients.
So, it is very, very important to know about these medications and the possibilities of adverse drug reactions.
All right, I think Terra two you have a reaction with one of your clients and his Coumadin while he was in a skilled nursing facility.
Yes, yeah you know this gentleman boy.
I feel so sad.
He's still a client.
I mean he.
Stays he has survived some, a lot of things.
But while he was in the skilled nursing facility for rehab, he was on.
He has multiple issues, health issues.
He has rheumatoid arthritis, congestive heart failure, a fungal infection in his blood in his body that they were treating him for.
The fungal infection had been.
Put it at a lower level.
It wasn't like a raging infection.
He had already been on the antibiotics through Ivy in the hospital, but when he got to the facility, they had stopped the antifungals he was on Coumadin for his CHF and at some point, the fungal infections kind of showed up.
Again, so the infectious disease doctor prescribed some more antifungal.
But the cardiologist wasn't aware of it.
So, for the Coumadin, they have to check the therapeutic range and the INR's. And just too.
Make sure of that.
The clotting condition is in the right zone.
Apparently without anybody realizing it and they were checking eye on ours.
But the antifungal medications had an adverse reaction, it changed the way Coumadin worked.
And his INR's. His clothing factor went sky high like dangerously out of range and they missed it for a few days. And this is in a skilled.
Facility where there.
Are results were showing up every all the time in front of, you know a nurse or a doctor.
Uhm, so unfortunately after they caught that situation.
He had to be on bed rest.
For up to.
Three weeks, no movement, no getting out of bed because he was at such a high risk of bleeding internally, or if he fell and injured himself.
It could be deadly so that it affected him in a significant way.
He didn't want to stay in bed for three weeks.
He was already trying to.
Feel better and he just.
Lost a lot of ground that he had made in his recovery, fortunately again.
And nothing after that.
After that happened, he did survive and things came into the range that they should be and got.
To carry on.
So, he's home now, thankfully with some support and still continuing to recover.
But that was a very, very significant situation going on, even in a community environment facility.
Where there's medical staff actually overlooking things.
Right?
Right, right, that's very scary.
He's a lucky man in a lot of ways.
Even though I did spend all that time in bed at least.
He survived that.
Yeah, thank you Tara.
So bottom line for this I'm going to go onto our prescribing cascades.
My very favorite concept these days is that the elderly as we know they're more susceptible to them.
Side effects and.
Adverse drug reactions.
So that can lead to prescribing cash.
Fades and prescribing cascades are much more than a pretty picture with flowers.
It's actually it's when it develops a prescribing cascade develops when an adverse drug event is misinterpreted as a new medical condition and subsequently additional drug therapy.
Is prescribed to treat this new medical condition that may are not really may or may not really exist.
So, let's give an example of that.
So, let's say you have a client who develops a cough after starting a certain blood pressure medication, and this goes back to the same medication that I talked about accounting for so many deaths, right?
This ACE inhibitor, this captopril licina prill bends out benazepril that.
Category it's notorious for having a side effect is.
To you know.
To decrease blood pressure, people who have hype.
Attention, but these ACE inhibitors can lead to an increase in a substance called Brady Kainin and Brady Kainin.
The body results in it irritates the Airways and it triggers inflammation in the Airways, which leads to coughing.
So, if you.
Have someone like simple life center prill.
Many times, they'll complain about a.
Cough so.
Uh, to the unsuspecting prescriber, they get a.
Call the nurse.
Says so and so called in and said that I have a really bad cough.
Can't get sleep at night, can't get any rest.
Oh, OK, well let's prescribe some Musa necks with codeine and that leads to lethargy, at least to maybe some confusion.
Of this client, decreased alertness in this class.
And now, gosh, you know all those kinds of things.
Maybe, maybe there's something else going on with this cough.
You know, now they're being a little bit harder to awaken.
Maybe they're not being oxygenated properly.
I'm thinking maybe that's pneumonia of some sort, so let's get an antibiotic going.
Antibiotics lead to diarrhea.
Diarrhea leads to dehydration and delirium.
And all of a sudden, we hit the ER because he's not doing well.
So that's an example of a prescribing cascade.
When really what happened was it was an adverse drug reaction to this ACE inhibitor category that they were taking.
They started to manage that blood pressure, so if you were to pick that apart and look in the in the background of all of that could it?
Could we have identified new medication lead to?
A new status of change in condition and we use that term a lot, right?
All of us are changing conditions.
What's that from?
Well, they just started that new medication for blood pressure 2 days ago.
I wonder, you know, I wonder, let's look that up and see.
So, another example might be another one, cardiac medication again and.
Load of pain.
Is another medication that.
Lowers blood pressure.
And it blocks calcium from entering cells.
From the heart.
Uhm, it can also lead to edema.
OK, so that's one of the side effects.
So again, unknowing prescriber that this person had just started on unload oppin I guess we.
Need to have.
A diuretic, because they're getting somebody.
Comma, so the result of that may be that we have someone who's on a diuretic that doesn't need to be on a diuretic.
It's really the side effect that swelling in the ankles etc. in the periphery was a result of starting that medication so.
Examples of this prescribing cascade.
This is a really important element for the seniors, especially that we care for so we can identify these cascades.
We can hopefully identify inappropriate pharmacy.
We can prevent these kinds of things right if we just focus.
On this and we asked ask question.
So, prescribers and us we should be asking ourselves is our client reporting a sign a symptom that could represent an adverse drug reaction?
Is there a new drug that's been prescribed recently?
Could it be related to?
That you know.
It's an interesting thing.
I find it very interesting, so moving on to pyms or potentially inappropriate medications, and these are defined as medications that.
Should be avoided.
Uhm, due to their risk, their risk outweighs the benefit and prescribers are always making this balance right.
The risk is it worth the risk for the benefit that.
That client is going to get.
If so, well, maybe we'll give that a try, but pinsum medications that should be avoided due to their risk outweighs the benefit.
And maybe there are equally or more effective but lower risk alternatives available.
And always we have to, uh, weigh the risk versus benefit.
What's the risk of having an adverse drug reaction?
What's the benefit?
Does a drug really address the sign or symptom of concern?
Does it relieve the pain?
Does it cure the infection?
Does it manage the shortness of breath or decrease the blood pressure?
So, this is in terms of NIH, etc. When I did the research again, PIMs are considered one of the most commonly encountered medication related problems amongst the elderly population that we serve.
Fortunately, we have something called the Beers list, and it's not what you think.
If you haven't heard of this before, it's not the list that you're hoping for, but it's actually an example of clinical guidelines that can support appropriate prescribing, so physicians should be having a beer every day as they look to prescribe medications.
Or their patients?
And I've put here the link where you can find an example of the beer list and this was developed many years ago.
The most current is a 2019 beer list. If you're interested in taking a look at that, but it's been around for many years.
And it's really a list of potentially inappropriate medications for older persons, and it was actually created by Doctor Beers and a panel of American experts.
And it was originally put together in 1991 and it provides guidance for prescribers regarding meds.
That should be.
Avoided in most older patients and in certain situations, so it's really the most widely cited criteria that's used to assess inappropriate drug prescribing.
And just really quickly, we're not going to spend much time.
On this, but they have 5.
Categories and here they are here.
Just to sort of think about.
And put it in the back of your mind.
Here, it really outlines potentially inappropriate medications and older adults, potentially inappropriate meds to avoid in older adults with certain conditions.
Maybe dementia, maybe liver failure.
You know those kinds of conditions, medications to be used with considerable caution in older adults' medication combinations.
That may lead to harmful interactions.
How helpful is that?
After our recent conversation, write in a list of medications that should be avoided or dosed differently with those who have poor renal or kidney function.
So, in addition to these criteria, decisions about medications should consider a variety of other factors, including stopping medications when they're no longer beneficial.
Well, who knew we don't do a good job of that right? We don't circle back when someone's been on something a.
Long time, well that's yes.
You know what Leanne is in?
In addition to that I was thinking just right now while you were starting our session today about the influence of family members or friends or opinions.
And this is a good example.
This is a good list to reference that because.
I just saw a client yesterday who one of her friends told her that calcium was really good for her and she should take more calcium and well, she's on a medication already that has calcium effect on it and then she's had a history of kidney stones.
So actually, she should not be taking too much calcium.
She could generate her own kidney stone again without really.
I've seen it and she's taking the advice from someone else who has good intentions, but without knowing the medical history of each individual like, uh, what's their kidney function, what's their history and stuff?
These things you really could be doing people more harm, so even with good intentions of giving ideas and opinions about something.
We have to always make sure the doctor and the pharmacists are involved before anything is added to.
What people are already on prescribed, wise or over the counter.
Right, and that's where the over counter over the counter is so concerning, because perhaps that client could go out the next day and pick up some calcium, add that into her daily regime, and then she's got a problem.
So, you're absolutely right, and the doctor would not necessarily know that.
Right?
So, it's a good example.
This is just a little sample.
From the beers criteria and this just highlights a couple of drugs here.
It's a little hard to see, but on the left-hand side, the disease or syndrome is dementia or cognitive impairment.
The drugs that they're talking about, anti-cholinergic benzodiazepine's, right? The Ativan's of the world. Those kinds of medications and they're saying with this population to avoid because of adverse CNS on central nervous system effects.
Anticholinergics, like atropine like Benadryl, right diphenhydramine is when we hear a lot, don't give seniors Benadryl.
We hear that right?
We think of it as such, as just a generic kind of medication, but having some very serious implications for our elderly.
It impacts their cognitive status.
It makes them drowsy, etc.
More risk for falls, that kind of thing.
The other one here that they have under kidney slash urinary tract.
It can have some really detrimental effects on the kidney, cause that's where it's metabolized and normally.
Uhm, you know we have good blood flow to kidneys.
If we have a functioning kidney, but something like a non-steroidal anti-inflammatory the ibuprofen.
Advil's of the world. They can really shut down blood flow to that area, so again it's those over. The counter is quite often right that we really have to.
Focusing on as well.
Yeah, I would add to that as well.
Again, just recently a client who had these kidney stones in the in the past.
When she came.
Home from that visit with the ER.
They prescribed her 600.
Milligrams of ibuprofen for pain.
And she still had the bottle and she wasn't currently using it, but she was holding on to the bottle in case she had pain because it said.
It's for pain and I was sitting with her and I said, well, this was a very specific use for a specific time and that time has passed and the use is done and we need to not hold on to 600 milligram tablets one.
Tablet 600 milligrams
Yeah, something.
And you could just see how easily she just thought.
Well, I take N since I take the ibuprofen anyway, what's the difference?
She just doesn't.
They don't understand and they don't know and that's the.
Risk that it's the ignorance about these things.
That and it's not because they're ignorant people, it's just where many people do not have a deep understanding of the causes of something looking so simply every day.
And it isn't every day when.
You get into your late years of life.
Right very true very true.
All right, just a quick word.
We want our medications to be within a therapeutic range to have the best impact on whatever they're treating, so we do know that there's therapeutic drug monitoring.
And Tara had mentioned before about following the PT INR for antique wagon.
Since that's always a really important one, but.
We want to maintain a steady concentration of medications.
That's why when someone says, you know, take your antibiotic really strictly every six, every eight, whatever it's prescribed as be really careful with that.
Always follow that we want the drugs to be in a therapeutic range as much as possible, so.
You might see some testing going on with your client, and if you're not, maybe.
It's a little head up.
Time, but they should be monitoring things like the anti-seizure medications, drawing blood once every while to check the levels.
Make sure they're not too high, not too low.
If too low.
We had actually had a client who was too low.
He did have a seizure and he had been tested, but for whatever reason, right?
Who knows what changed within his system.
All of a sudden that dropped, he had been on it for years, decades.
But he did have a seizure and they drew the blood and sure enough he was too low on his.
Phenobarbital anticoagulants as that error referenced coumadin's. They're constantly being monitored to make sure that the blood isn't too thin.
It's still able.
To clot within that therapeutic range, the doctor has defined cardiac meds.
Digoxin is another one that they'll monitor.
It has a very.
A narrow therapeutic index for digoxin.
It doesn't take much to make it too high and toxic or too low to not have any impact, right?
So those are the kinds of medications we want to keep an eye on, so again, someone to follow that for that client can be helpful.
I would not just say that, oh.
The doctor will remind us right it.
Doesn't always happen.
We see it.
Age related changes in medication use.
We know that most of the pre marketing and testing that's done on these medications, usually those approvals are done through testing that's done on younger and healthier individuals, not necessarily the elderly population, unfortunately.
So, there's lots of things that happen with how the body reacts to medications.
We have a farm.
Oh, not that we're going to make pharmacists out of all of us here today, but pharmacodynamics.
What is the effect of medication on our body?
And even more important for us today is pharmacokinetics.
What does the body do to the drug?
And this includes things that you've heard about through probably many other different avenues, but the absorption of a drug.
How is it absorbed into the body?
How is it distributed throughout the body?
How is it metabolized?
Usually by the liver of the kidneys?
And how is it excreted from the body?
That's pharmacokinetics.
And of course, when we age those elements, those four elements there of pharmacokinetics are all impacted by the aging process.
We don't necessarily having have a great functioning liver by the time we get into our 70s, eighties, 90s, right?
Same with our kidneys.
Our metabolism changes over time.
We tend to retain more medications, especially when they're fat loving.
Believe it or not, you actually.
Gain fat as you age.
Who knew?
But some of our medications are fat loving so they stick around in that fat and they don't leave as they would if we were in our spell 20s back in the day, right?
So, drugs can become toxic more easily in the elderly population.
For all of these reasons.
And in excreting drugs, you know if they're being sucked into fat, they're not being excrete.
We did.
If the kidneys aren't functioning well again, it's not being excreted as building up, and we're not testing most of the medications.
We take right?
But we know that they're building up.
Are they becoming a toxic level of this medication, right?
That's all a possibility with these meds and with our aging bodies some other risks we have with ours.
Aging population, especially vision and hearing, you know, are they hearing things correctly?
Are they understanding from the doctor what's going on?
Are they able to look at the pill bottle to be able to understand what that says?
Are they able to get that darn pill bottle open?
What does that look like for them?
Cognitive dysfunction.
Short term memory we all this is one of the biggest areas I think of risk for people that we see is the short-term memory.
The confusion, especially when they're living by themselves.
Did I take that medication already today?
I don't know.
I'll take another one just in case, or I think I did.
I'll just take it tomorrow, that'll be OK.
We know this happens every single day.
And also, that noncompliance.
We kind of refer to that a little bit ago, but some of our clients, for many different reasons.
Maybe it's just too darn complicated.
A regime for us.
Client, maybe there's just going.
There's too much, it's too overwhelming for them to be.
Able to figure.
This is out.
There may be cost issues.
There may be depression.
There may be fear.
There may be hopelessness.
All of these things contribute to whether someone takes their medications appropriately.
And, you know, Leanne, one of the things that's important to do with a client or a, uh, a patient, that's
Talking about not taking something that has been prescribed is educating them, helping them understand.
OK, if you don't want to take that medication anymore, I totally support you with what you think you want to do, but let's make sure we understand what the consequences could be should you not take it anymore and help them remember why the doctor put.
Them on that medication to be.
Begin with and seek out.
Maybe sometimes if they want to stop something.
There is a tapering off you don't just stop taking a medication.
A lot of these medications have been built up at a certain blood level and now safely to come off.
You've got to bring the blood levels slowly back down.
You just don't Willy Nilly stop something and start.
Something so.
Helping people educate, you know, understand better about why helping them understand if they're going to stop, why and what to anticipate and make sure they understand that they are clear on why they think they don't want it.
Anymore, that's a very good point.
Right?
Very good point.
All right, some best practice here.
Uhm, as we sort of get close to 9:00 o'clock.
This always goes so much faster than I.
I've left you with your hand out there on some other client centered issues, costly.
I feel good I don't need anything too complicated.
Why bother those kinds of?
Things so some best practices here.
One of the most important things that we do for our clients, I feel, is to reconcile medications, confirm every single Med with every single provider.
And this doesn't mean just going back to the prescriber.
It means letting all the prescribers know.
So, what is currently on that Med list?
And this can be time consuming, but you need to have a clean Med list.
You need to have an accurate Med list, otherwise it's kind of pointless to keep on setting meds that aren't correct, so we see this too where there's a medalist in the home 99.
.99% of the time. Yes, Tara it is not correct.
Yeah, yeah.
I don't know that I've ever.
We had a client.
Seen a, correct?
One ever?
Yeah, we had.
So, it's just.
We had a client that had prescription bottles from Walgreens in the home but that didn't match the medication list that they had handwritten and there were different prescribers involved and it was a mess and she wasn't even on a lot.
It was just nobody.
Was really actually looking at it.
And making sense of what?
Is what and what is to be filled and what is to be taken?
And all of that?
And it still took us even multiple attempts to get the doctors to respond to what our questions were and we made it very clear we were asking in order to help the patient get what the prescribers wanted her to have.
But it took a lot of effort to get that completed, but it's.
It happens a lot that what's in the home with what's being filled at the pharmacy and what prescribers have actually ordered are not.
The same, and we've been in appointments too, where the doctor says you're still taking this.
Oh yeah, you still take a medal.
Yeah, and then you'll get the office report afterwards and they'll say reconciled medications well.
To me, that's not reconciliation.
So, review, remember, we talked about this review, the list of all meds at each appointment.
Gather all the medications.
Over the counter, remove anything that's expired you have in your packet there that the take back day is April the 30th, so make sure that you're you know helping clients to clean out stuff that's expired.
Lord knows we have many bags of medications for some.
Clients agree to a centralized location to store all medications.
When we first get into homes, many times meds are spread throughout the home link taking medication to other habits.
So, when you sit down to have your morning coffee, this is what you're going to do, and especially for people who have difficulty remembering those kinds of things.
Manage the inventory.
We don't want to miss doses we don't want to miss doses because it wasn't picked up at the pharmacy or it needs a refill.
And now boy that was two days ago that it needed to be refilled, we better call the doctor.
So being on top of that managing that inventory.
The end we have a client right now that has multiple conditions.
Parkinson's is her major disease that she's managing 13 medications every single day.
She has to take a total of 13 medications or vitamins every day and at specific.
Multiple, isn't it multiple times?
Times every day it has to be.
Structured so that the best outcomes are achieved through the type of medication she's taking based on what time of day she takes them and in relation to a first dose and a second dose and a third dose and a fourth dose.
Anyway, UM, she had been managing her medications, but uhm, with the psychosis that was developing with her Parkinson's her, her husband, began taking over the medications, but he's older, elderly as well and really kind of got a little foggy on the medications.
So even in his charge of being responsible, he was missing doses he wasn't to staying on top of those refills, and he didn't have an accuracy.
Complete comprehensive medication list and when she would go to the emergency.
Room, they didn't know what she was really on.
By the time she got there and looked at her last time, she was in the hospital.
So, one of the key things we asked them to do and did for them was create a real clear medication list.
And again, this client does, unfortunately.
Visit the ER pretty regularly.
But the husband walked in with the medication list and the nurse in the ER.
He told me he says I have to give.
You credit me because you made me look really good.
I had a.
Medication list to hand over.
So that list is very, very important.
It helps keep everybody on track.
Absolutely, it's a critical piece of communication for sure other best practices we talked about using one pharmacy so they can sort of track and be alerted when things go sideways, or if there's something prescribed that shouldn't be given with them.
Others engage the pharmacist, you know, develop that relationship.
Initially when a new medication is ordered and then as needed, right?
If something seems to be going off the rails a little bit, watch for side effects, particularly when starting a new medication so a tracking log can be helpful to sort of track what those what the side effects are.
Is it that you're noticing when did it started, you know, is it getting better or is it getting worse?
That's really helpful.
Subjective information for the prescription.
Never and make a list of questions for the doctor for the pharmacist and that can be helpful as well.
We know going to appointments can stress out some people, so making sure that they have something written can be helpful.
Keep the process as simple as possible, especially for the elderly client.
You know the number of times per day.
How many meds?
Is there any way to simplify?
Can we make something a patch versus an oral medication so that it's less likely to be?
We missed using those dispensing units, the sort of the Med minders can be helpful.
Use a delivery system.
We've had some really excellent luck with things like pillpack or the CVS delivery system, or Aetna has a delivery system, so we've had some very good luck with those, so consider that.
Set aside meds for emergencies.
If insurance will allow you to have a few extra days in case there is an emergency of some sort.
This requires it to be updated right when those new meds come on or Med changes happen, but we have to think about the emergency and maybe someone like this lady you're talking about Terra with the Parkinson's.
If she's without her Parkinson's meds, that's a pretty significant event.
So, think ahead and engage a nurse care manager and doesn't have to be us.
It would be nice to be us, but does not to be asked to reconcile and to coordinate those medications as well as communicate with the prescriber, the pharmacy, the family, the client.
That's a really.
Good way to go.
All right, a couple of other things, and I know we're at 9:00 o'clock here and I'm going to zoom through this a little bit fast here, we are big fans over here of reconciliation.
So, it is the process of comparing their medication orders to all the medications that they've been taking, and that's a definition from NIH.
And if it's done to avoid medication errors, it's avoided too.
It's done too.
Avoid omissions of meds not being taken correctly, duplicating medications, dosing errors, all those kinds of.
Things prescribers, as we said a million times today prescribers of providers who are prescribing don't always know what other prescribers have ordered and it also provides a really nice baseline.
It's like a clean slate so you come in.
You reconcile, you've got a clean, accurate slate to start from again.
It doesn't make any sense.
Just go set meds day after week, week after week, month after month.
When they're not correct and we see people doing that all the time, get it right.
Reconcile right off the top.
In terms of this.
Looking this crazy looking chart here it's a little hard to see, so I apologize, but this is an actual list from a client we had.
This is only one page for three people.
She was on a ton of medications and this was quite the project for our team.
In the first column you've got medications, second column over dosages.
The next column is based on what the patient had written down.
The next column is the facilities list.
You can see they're not quite the same.
At all.
And then the next 12345 columns are all the prescribers, all the doctors who were involved and we checked what they had ordered and prescribed for that client. Nothing lined up and we had three pages of this mess.
This is a little bit clearer to see here.
You got the medication albuterol breathing treatment right.
The dosage there the patient the client resident in this case because she was at a facility didn't have that on her radar at all.
The facility did, and so we went to the pulmonologist to say, hey, do you still want her to be on this?
Is this dose correct?
If it is, we want you to initial that it's correct.
By the way, I'm sorry.
Ah, I'm sorry that's the one I wanted.
You see that's so close up.
This was what we ended up with at.
The end of the day.
They left hand side medication.
The dosage, the prescribing physician and the date that we confirmed with the provider with the prescriber that that was an accurate order.
The beauty of this list.
Going back to this one, here is that every provider could see what the other providers the prescribers had ordered.
This is an example of what came back from a doctor's office when they saw that list.
They said discontinue this discontinue that they had three discontinues.
Bravo at the bottom.
Bravo at the bottom.
We also had a good one and #4 checked the blood sugars.
Daily fasting and keep a log and that log would go to the appointment.
Ian #5, by the way, since we've interacted with your office, she's due for her Prolia injection.
And then at the bottom, yay.
Thank you for taking the time.
To get that right.
When you have preordered pill packs, again, we've had very sorry almost really good luck with most of the ordering systems we had.
This was from a local provider who made bubble packing mistakes all over the map, so we ended up not using him anymore, but don't assume just because.
Something is bubble packed that it's correct.
Take a look, go through it.
Another one here.
When you're transitioning from regular Med setup to like an on an ongoing delivery system, there's a time period where meds are not going to overlap properly.
It's not a clean transition, this is just an example of some of the pills that the new system sent along to supplement.
So, it gets confusing.
So, you have to pay attention to it.
All those kinds of things.
And last but not least, here folks.
I'm sorry we've gone over a little bit here, but non pharmacological interventions for our clients.
Not everything has to be a medication, right?
We know there's so many other things on the right-hand side or the knowledge areas that care managers dabble into, and certainly our view as care managers is holistic.
So, are there?
Other things that we can do modify for that client, whether that's lifestyle modifications, a change in diet, if someone got anxiety, can we maybe not rely totally on benzodiazepines to manage that?
Is there something else we can do?
What do they do with their free time?
Can we get a psychologist?
Do some cognitive behavioral therapy with our client.
What does that look like for them versus going and taking another medication?
Let's talk about education of caregivers, of training of caregivers.
How can they engage that client every single day?
How can we manage?
Maybe some meditation instead of more blood pressure medications?
So, meds aren't always the answer.
They are an answer.
But they're not always the only answer or the correct one all the time.
Uhm, so uhm, I think I've got some other resources to review medications there for you here in Orange County.
Of course, we have the HAPS program at UCI.
Awesome program for your geriatric clients.
They cover that person head to toe with lots of evaluations and a wonderful report and meeting at the end.
Teamwork, we are all here to act in the best interest of our client.
I hope that after today you're really, really even more than ever believe that Med management is one of those areas that we have to be involved with for the best interest of our client, it is imperative.
We want them to have improved health, cognition, function independence, all of that, and we can do that partly through managing medications correctly, but it needs constant oversight.
The other thing too is managing your risk.
You know we know that medications can result in a negative outcome for our client, and that is not something we want from them.
And also, for.
Our organizations so and even as a care management company, we have to be extremely careful and we have to manage that risk to the best of our ability.
All right, that was a speedy end here.
Are there any questions, see?
Q&A The Q and.
The box is empty, folks.
No questions at all.
We must have answered everything just so fully Terra.
I'm going to give it a second here while I.
Bring up the last slide.
No, let's see no questions.
I know you're out there I.
Can see you, OK?
Well, you've got our information here in terms of contact information for Tara and myself.
Please feel free to reach out.
We're always available to chat if you have any questions about a client in any round.
It doesn't do medication management, but if we can be a resource to you, we are more than happy to do it.
So, thank you for being here today for a really, really important topic.
I hope it's been time well spent with you.
If you want to send either one of us some feedback about the presentation here today, feel free to do that again.
If you're a fiduciary, you'll receive your CE certificate in the next. I would say 5 business days.
At the very latest, but other than that, thank you again all for being here and to make this a priority, because it's certainly a priority for your clients' well-being.
OK, one last look.
Amazing OK all right everybody be careful, be safe.
Thank you again for being here.
We look forward to seeing you.
Thank you, have a great day everyone.