The document discusses a grand rounds presentation on age-friendly care for older adults with shingles. It provides background information on shingles and its presentation in older adults. A case study is presented of a 69-year-old woman with shingles. For her care, the document emphasizes assessing and addressing the 4Ms framework - what matters to the patient, medications, mentation, and mobility. The recommendations for the patient focus on starting antiviral treatment, managing pain, and following up to monitor for complications while supporting what matters to her, optimizing medications, and maintaining function and cognition.
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GR AFHS Shingles 4.22.21-ho version wo CH.pptx
1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
Joshua
Murdock
PharmD
Sarah Ball, FNP
Educator
Dr. Eric
Marshall
Topic: Age-Friendly Health Systems:
Shingles/Herpes Zoster in the Older Adult
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Aimee Kleppin,
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Educator
2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Providing Age-Friendly Care
The goal is for all care with older adults to be Age-Friendly care, which:
• Follows an essential set of evidence-based practices;
• Causes no harm; and
• Aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each
case scenario. The 4Ms include:
• What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
• Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation,
and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the
older adult, Mobility, or Mentation
• Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
• Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that
older adults move safely in order to maintain function and do What Matters
4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Learning Objectives
At the end of this session, providers will be able to:
• Describe the presentation of shingles/herpes zoster in an older adult
• Identify the interrelationship of the 4Ms in the context of an acute or chronic condition, such as
shingles/herpes zoster
• Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Shingles/Herpes Zoster in an Older Adult
(S) Situation: Eileen is a 69 year old female presenting with a 2 day history of itching and burning on the left side of
her chest and a rash that appeared in the last 24 hours. She reports that prior to this sensation, she had tingling
sensations to the same area and felt she might have slept wrong. She applied over-the-counter hydrocortisone
cream 1% but did not see any improvement to the rash.
She reports more stress at home than usual since her daughter and grandchildren moved back in with her and has
been feeling tired at times.
(B) Background: PMH: Hypertension, hyperlipidemia, GERD
PSH: Hysterectomy
Medications: Omeprazole 20 mg PO daily 30 minutes before breakfast, lisinopril 20 mg PO daily, atorvastatin 20 mg
PO daily at bedtime
6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Shingles/Herpes Zoster in an Older Adult (Cont.)
(A) Assessment: VS: BP 122/68 mmHg, HR 64/min, RR 18/min, Temp 98.2F, SpO2 98% on room air
Mentation: PHQ 2 = 0 (negative); Mini-Cog = 5 (negative)
Mobility: Walks into clinic wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a
chair, walking 10 feet, turning around, walking back, and sitting back in chair.
General: Appears well-nourished and in no apparent distress
Skin: Vesicular, erythematous rash along the left side of the chest in a dermatomal distribution without
crossing midline. Mild tenderness to palpation.
Eyes: Extraocular movements intact; pupils equal and reactive to light, sclera clear; normal exam
Respiratory: Resonant and clear bilateral all lobes. No wheezing, rhonchi, or crackles.
Cardiac: Regular rate and rhythm, S1, S2, no S3, S4, murmurs
Neuro: Cranial nerves II-XII intact
(R) Recommendation: Let’s discuss…
7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Recommendations: Shingles/Herpes Zoster in Older Adults
• Treatment includes antiviral drugs such as Valacyclovir, Famciclovir, Acyclovir, and analgesics which
should be started within 24-48 hours of onset
Note: For those with decreased renal function, reduce dose of antiviral drugs
• Pain medication may include acetaminophen and topical lotions such as calamine lotion
• If pain more severe, will need follow up with primary care provider for ongoing pain management
• Need close follow up for re-check to see if complications from herpes zoster have occurred, monitor
pain, monitor for post-herpetic neuralgia
8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Information about Herpes Zoster
• Herpes Zoster develops typically when Varicella Zoster Virus (VZV) is reactivated
• When VZV is reactivated it migrates to adjacent dermatomes causing a rash that begins as maculopapular
lesions that turn into vesicles and then scab in about 10 days, lasting up to 1 month
• Older adults are more susceptible because suppression of the immune system occurs with aging
• 3 phases of herpes zoster: (1) acute pain phase; (2) subacute pain phase (any pain occurring 30-90 days
after rash healing); and (3) post-herpetic neuralgia phase (pain for more than 90 days after onset of the rash)
• URGENT: Herpes Zoster Ophthalmicus is caused by virus reactivation in the ophthalmic division of the
trigeminal nerve. If lesions on the tip of the nose, Hutchinson’s sign are present consider ocular involvement.
This is an ocular emergency and requires immediate referral to ophthalmology
• URGENT: Patient whose herpes zoster has disseminated can have potentially life-threatening complications
such as encephalitis. Any accompanying neurological symptoms should prompt an immediate referral to
neurology.
9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Back to the case…
Summary: ASSESS and ACT ON the 4Ms as a set
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
• Understand what the patient’s health goals are for the management of an acute condition while managing their chronic medical
conditions; Treat patient with goal to allow her to be able to do what matters to her; Treat pain; Follow up with primary care provider and
educate regarding potential for post-herpetic neuralgia
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters
• Treat shingles per guidelines; Address pain management; Educate patient about possible post-herpetic neuralgia and need for follow up;
assess for any drug interactions or effects
Mentation: Focus on dementia and depression and delirium
• Assess mentation to ensure patient able to manage responsibilities associated with treatment plan; Educate patient to promote cognitive
stimulation (e.g. puzzles, games, reading newspaper); Educate that post-herpetic neuralgia can potentially lead to depression, anxiety,
and/or decrease in quality of life
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Formulate daily mobility plan to maintain optimal ambulation and independence and prevent deconditioning (e.g. walking around home 3
times a day); Educate that post-herpetic neuralgia can interfere with basic and essential functions thus potentially impairing functional
ability and lead to inactivity
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider; include need for follow up regarding
treatment of condition, management of pain, assess for change in mentation
– Don’t forget to scan into the EHR whenever individualized.
10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Interprofessional Team Discussion…
11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Acknowledgements
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare
Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health
Association of the United States (CHA).
MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A.
Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
References
The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially
Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767. Available online at
https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria/CL001
Beuscher, L. (2017, January 1). Managing herpes zoster in older adults: Prescribing Consdierations. The Nurse Practitioner. Retrieved August 18, 2019, from
http://journals.lww.com/tnpj/Pages/ArticleViewer.aspx?year=2017&issue=06000&article=00006&type=Fulltext
Cohen, K. R., Salbu, R. L., Frank, J., & Israel, I. (2013, April). Presentation and management of herpes zoster (shingles) in the geriatric population. Retrieved August 18, 2019,
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684190/
Herpes Zoster Infection Treatment Approach. (2019). Retrieved August 18, 2019, from https://online.epocrates.com/diseases/23/Herpes-zoster-infection
JIbrahimi, O. A., Sakamoto, G. K., & Lee, J. J. (2010, October 01). Acute Onset Vesicular Rash - American Academy of Family ... Retrieved August 18, 2019, from
https://www.aafp.org/afp/2010/1001/p815.pdf
Janniger, C. K. (2019) Herpes Zoster (D. M. Elston, Ed.). Retrieved from https://emedicine.medscape.com/article/1132465-overview
John AR, Canaday DH. Herpes Zoster in the Older Adult. Infect Dis Clin North Am. 2017;31(4):811–826. doi:10.1016/j.idc.2017.07.016
Johnson, R. W., Alvarez-Pasquin, M., Bijl, M., Franco, E., Gaillat, J., Clara, J. G., . . . Weinke, T. (2015, July). Herpes zoster epidemiology, management, and disease and
economic burden in Europe: A multidisciplinary perspective. Retrieved August 18, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591524/
Shingrix Prescribing Information, Indications and Usage. (2019, Oct). Retrieved February 29, 2020, from
https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF
U.S. committee recommends GSK shingles vaccine over Merck rival. (2017, October 25). Retrieved August 19, 2019, from https://www.reuters.com/article/us-gsk-shingles-
idUSKBN1CU2EE
13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Thank You
Hinweis der Redaktion
Today’s topic is: Shingles/Herpes Zoster in the Older Adult
The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older.
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include:
What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation
Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
At the end of this session, providers will be able to:
Describe the presentation of shingles/herpes zoster in an older adult
Identify the interrelationship of the 4Ms in the context of an acute or chronic condition, such as shingles/herpes zoster
Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
S: Situation: Eileen is a 69 year old female who comes to the clinic reporting a 2 day history of itching and burning on her chest and a rash that appeared in the last 24 hours. She reports that prior to this sensation, she had tingling sensations to that area and thought she had slept wrong. She reports more stress at home than usual since her daughter and grandchildren moved back in, and has been feeling tired at times. She tried putting some over the counter hydrocortisone 1% but did not see any improvement to the rash.
B: Background: PMH: Hypertension, hyperlipidemia, GERD
PSH: Hysterectomy
Medications: Omeprazole 20 mg PO daily 30 minutes before breakfast, lisinopril 20 mg PO daily, atorvastatin 20 mg PO daily at bedtime
A: Assessment: VS: BP 122/68 mmHg, HR 64/min, RR 18/min, Temp 98.2F, SpO2 98% on room air
Mentation: PHQ 2 = 0; Mini-Cog = 5
Mobility: Walks into clinic wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair.
General: Appears well-nourished and in no apparent distress
Skin: Vesicular, erythematous rash along the left side of the chest in a dermatomal distribution without crossing midline. Mild tenderness to palpation.
Eyes: Extraocular movements intact; pupils equal and reactive to light, sclera clear; normal exam
Respiratory: Resonant and clear bilateral all lobes. No wheezing, rhonchi, or crackles.
Cardiac: Regular rate and rhythm, S1, S2, no S3, S4, murmurs
Neuro: Cranial nerves II-XII intact
R: Recommendation: Let’s discuss…
Treatment includes antiviral drugs such as Valacyclovir, Famciclovir, Acyclovir and analgesics which should be started within 24-48 hours of onset. Note: For those with decreased renal function, reduce dose of antiviral drugs
Pain medication may include acetaminophen and topical lotions such as calamine lotion. Though all non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in older adults, may be considered if patient takes on full stomach with glass of water and patient is not at risk for of GI bleed and peptic ulcer disease.
If pain becomes more severe, will need follow up with primary care provider for ongoing pain management.
Need close follow up for re-check to see if complications from herpes zoster have occurred, monitor pain, monitor for post-herpetic neuralgia.
Herpes Zoster develops typically when Varicella Zoster Virus (VZV) is reactivated. Primary VZV occurs in children as “chicken pox” After VZV infection resolves, immunity develops and latent virus persists in the dorsal root ganglia. When Herpes Zoster virus is reactivated it migrates to adjacent dermatomes, causing a rash that begins as maculopapular lesions that then turns into vesicles and then scabs in about 10 days, lasting even one month. VZV reactivation is more common in women than men. Older adults are more susceptible because suppression of the immune system with aging. The three phases of herpes zoster include acute pain phase, subacute pain phase (any pain occurring 30-90 days after rash healing), and post-herpetic neuralgia phase (pain for more than 90 days after onset of the rash). Restricted activities of daily living, severity of acute pain, severity of rash, older age, and immune-compromised status of the patient increase risk of developing post-herpetic neuralgia. Some older adults may present with just pain along a dermatome and little or no rash.
Red Flag: Herpes Zoster Ophthalmicus is caused by virus reactivation in the ophthalmic division of the trigeminal nerve. If lesions on the tip of the nose, Hutchinson’s sign are present consider ocular involvement. This is an ocular emergency and requires immediate referral to ophthalmology. A patient whose herpes zoster has disseminated can have potentially life threatening complications such as encephalitis. Any accompanying neurological symptoms should prompt an immediate referral to neurology.
Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set.
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
Understand what the patient’s health goals are for the management of an acute condition while managing their chronic medical conditions; Treat patient with goal to allow her to be able to do what matters to her; Treat pain; Follow up with primary care provider and educate regarding potential for post-herpetic neuralgia
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters
Treat shingles per guidelines; Address pain management; Educate patient about possible post-herpetic neuralgia and need for follow up; assess for any drug interactions or effects
Adjust dosage and frequency of medication to be Age-Friendly. Older adults are more likely to experience adverse events associated with medication use. Valacyclovir and Famciclovir are better absorbed then oral acyclovir thus higher antiviral activity. Consider kidney function when prescribing medications given antivirals are excreted by the kidneys. Always important to evaluate for any clinically meaningful drug interactions.
Mentation: Focus on dementia and depression and delirium
Assess mentation to ensure patient able to manage responsibilities associated with treatment plan; Educate patient to promote cognitive stimulation (e.g. puzzles, games, reading newspaper); Educate that post-herpetic neuralgia can potentially lead to depression, anxiety, and/or decrease in quality of life
Mobility: Maintain mobility and function and prevent/treat complications of immobility
Formulate daily mobility plan to maintain optimal ambulation and independence and prevent deconditioning (e.g. walking around home 3 times a day); Educate that post-herpetic neuralgia can interfere with basic and essential functions thus potentially impairing functional ability and lead to inactivity
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider; include need for follow up regarding treatment of condition, management of pain, assess for change in mentation
Team discussion: NP, pharmacist, physician, other
Ask contributing pharmacist for input
Pharmacist input
Antiviral therapy for acute herpes zoster 48 is indicated in patients fulfilling any of these criteria (1) age greater than 50 years (2) with moderate to severe rash or pain (3) those with non-truncal involvement and (4) immunocompromised patients.40 Antivirals initiated within 72 hours of rash onset decrease the duration of viral shedding, new lesion formation, and the severity and duration of acute pain. Experts recommend initiating antiviral therapy more than 72 hours after rash onset if there is evidence of new lesion formation, or when there are motor, neurological or ocular complications.6, 40 Hospitalization for closer monitoring and treatment with intravenous acyclovir should be considered in (1) allogenic stem cell transplant recipients; especially those within the first 4 months of transplant, (2) hematopoietic stem cell transplant recipients with moderate-severe graft-versus-host-disease, (3) transplant recipients on aggressive anti-rejection therapy (4), any individual with suspected visceral dissemination (encephalitis/ pneumonitis)and (5) individuals with herpes zoster ophthalmicus or varicella zoster retinitis.13, 40, 4
Ask contributing physician for input
The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767. Available online at https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria/CL001
Beuscher, L. (2017, January 1). Managing herpes zoster in older adults: Prescribing Consdierations. The Nurse Practitioner. Retrieved August 18, 2019, from http://journals.lww.com/tnpj/Pages/ArticleViewer.aspx?year=2017&issue=06000&article=00006&type=Fulltext
Cohen, K. R., Salbu, R. L., Frank, J., & Israel, I. (2013, April). Presentation and management of herpes zoster (shingles) in the geriatric population. Retrieved August 18, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684190/
Herpes Zoster Infection Treatment Approach. (2019). Retrieved August 18, 2019, from https://online.epocrates.com/diseases/23/Herpes-zoster-infection
JIbrahimi, O. A., Sakamoto, G. K., & Lee, J. J. (2010, October 01). Acute Onset Vesicular Rash - American Academy of Family ... Retrieved August 18, 2019, from https://www.aafp.org/afp/2010/1001/p815.pdf
Janniger, C. K. (2019) Herpes Zoster (D. M. Elston, Ed.). Retrieved from https://emedicine.medscape.com/article/1132465-overview
John AR, Canaday DH. Herpes Zoster in the Older Adult. Infect Dis Clin North Am. 2017;31(4):811–826. doi:10.1016/j.idc.2017.07.016
Johnson, R. W., Alvarez-Pasquin, M., Bijl, M., Franco, E., Gaillat, J., Clara, J. G., . . . Weinke, T. (2015, July). Herpes zoster epidemiology, management, and disease and economic burden in Europe: A multidisciplinary perspective. Retrieved August 18, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591524/
Shingrix Prescribing Information, Indications and Usage. (2019, Oct). Retrieved February 29, 2020, from https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF
U.S. committee recommends GSK shingles vaccine over Merck rival. (2017, October 25). Retrieved August 19, 2019, from https://www.reuters.com/article/us-gsk-shingles-idUSKBN1CU2EE
