May 2021
Time's Running Out! Register TODAY for PMDA Second Annual Spring Symposium on May 15 from 7 a.m. – 1 p.m.

Join PMDA Saturday morning, May 15 from 7 a.m. – 1 p.m. for a half-day of virtual education designed to be topical and timely and to provide you with 4.0 management hours towards certification as a Certified Medical Director in post-acute and long-term care medicine and 4.0 AMA PRA Category 1 Credits™.
The half-day program will feature four sessions:
Racism in Long-Term Care: A Panel Discussion - PMDA Education Committee Co-chair Danelle Snyderman, MD, CMD and panelists Schyuler Barbour-Johnson, MSN, CRNP, ANP-CN, Denine Crittendon, MPH, Ph.D.(c), Dillard Elmore, DO, MBA, CMD, and Christopher Hwang MD will use case-based discussion and the Ubuntu photo project on microaggression to deepen our awareness and understanding of racism in LTC. 
FDA’s EUAs and Other Related Authorities – Jennifer Ross, JD, Senior Regulatory Counsel for the Federal Drug Administration will provide an overview of the FDA’s emergency use authorities and how “EUA” has become a household word during the COVID-19 pandemic.
The Future of Long-Term Care – Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, the commonwealth’s leading advocacy organization representing Pennsylvania’s most vulnerable residents living in more than 400 member facilities across the state, will explore what nursing homes and long-term care facilities will look like post-COVID-19 and how they will operate.

Advocacy in LTC: COVID-19 and Beyond – PMDA Past President Daniel Haimowitz, MD, FACP, CMD and Pennsylvania State Representative Wendi Thomas will describe opportunities for advocacy, including developing relationships with elected representatives, writing opinion pieces, and interacting with the media. Their program will provide information about various national initiatives and identify useful resources for your advocacy toolbox.

The cost is $50 for PMDA members and $65 for non-members. For more information and to register for the meeting, please visit:

This activity has been pre-approved by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) for a total of four management hours toward certification as a Certified Medical Director (CMD) in post-acute and long-term care medicine. The CMD program is administered by the ABPLM. Each physician should claim only those hours of credit actually spent on the activity. 
ACCME Accreditation Statement Jointly Provided (PAMED and a single educational partner)
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Pennsylvania Medical Society and PMDA. The Pennsylvania Medical Society is accredited by the ACCME to provide continuing medical education for physicians.
AMA Designation Statement
The Pennsylvania Medical Society designates this live virtual activity for a maximum of 4.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Are These Medications Making My Patient More Confused?
Sean Heffelfinger, MD, CMD

I was fortunate to be able to attend my first AMDA Annual Conference this year. I’m sure it would have been undoubtedly more fun in person. One of my goals while listening to the lectures that I registered for was to figure out my topic for the monthly PMDA Newsletter. During the lecture on how psychiatric conditions can mimic dementia, the speakers talked about how the accumulation of anticholinergic drugs in one’s lifetime can increase the likelihood of getting dementia or just being more confused than one probably should be.

I have had two elderly patients in the last year (coincidentally they are sisters) who have come to my office after experiencing hallucinations and periods of confusion. It actually bothered the families more than the patients. When I looked at each medication list, I realized that they had been taking medications like oxybutynin, hyoscyamine, methocarbamol and tramadol for years. I am sure many of you can relate to the difficulty I had trying to explain to the patients and their families how these beloved medications were contributing to the confusion and really needed to be discontinued. 

We all recognize that drugs with anticholinergic activity are associated with such adverse effects as delirium, dizziness and falls as well as cognitive decline and loss of independence. These drugs affect the brain by blocking the neurotransmitter acetylcholine. Older people are more susceptible to these adverse effects because of age-related changes. These changes include an increase in blood-brain barrier permeability, a decrease in cholinergic neurons and receptors in the brain and a reduction in hepatic and renal clearance of drugs. It is felt that patients with Alzheimer dementia may be even more susceptible to the effects of these drugs due to the already marked reduction in the functioning of their central cholinergic pathways.

A recent study lead by Shelley Gray at the University of Washington tracked over 3500 geriatric patients and their medication usage. It concluded that those study participants that took an anticholinergic drug for the equivalent of three years or more had a 54% higher risk of developing dementia than those who took the same drug for three months or less. That should make our patients think twice about taking Benadryl to help them sleep!

There are two popular scales that practitioners can use to calculate the burden of these medications – the Anticholinergic Cognitive Burden (ACB) Scale and the Anticholinergic Risk Scale (ARS). Each scale gives certain anticholinergic drugs a score from 1 to 3, with a score of 3 carrying the highest risk. These scales do deviate somewhat in that they include a different number of drugs and score some drugs differently. What is important to realize is that drugs that may not have much of an anticholinergic effect by themselves (digoxin, furosemide, warfarin, metoprolol, nifedipine) can have dramatic cumulative effects if used in the same patient.

What are some things you can do to lessen your patient’s anticholinergic burden? Try to make your patients realize that they probably aren’t getting much benefit from their bladder antispasmodics. Those skeletal muscle relaxants such as cyclobenzaprine or methocarbamol may only be making them sedated and not relieving their discomfort. Sertraline or citalopram are safer alternatives to prescribe than TCAs or even paroxetine. Ondansetron has lesser anticholinergic effects than the older antiemetics such as promethazine. Cetirizine and fexofenadine have no anticholinergic properties at all. Loratadine has some anticholinergic activity but not as much as the first-generation antihistamines. Clozapine, olanzapine and quetiapine are among the antipsychotics with the most anticholinergic properties. Aripiprazole, risperidone and haloperidol score with the least anticholinergic properties.

We need to be vigilant for what adverse effects might be resulting from the medications we prescribe to our vulnerable patients. Evaluation of anticholinergic burden, which can be facilitated by use of one of the two burden scales referenced earlier, should be considered an essential strategy for optimizing polypharmacy and caring for our elderly patients.

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
Upcoming Events

Don’t Forget to Join President Brian Kimmel and the American Society of Consultant Pharmacists Pennsylvania Chapter on May 13

The American Society of Consultant Pharmacists Pennsylvania Chapter (PA ASCP) and PMDA will host a joint virtual education session about overactive bladder management in long-term care on Thursday, May 13, from 7 – 8 p.m. The session will feature Richard Stefanacci, DO, and includes a product theater about Gemtesa (Vibegron)®. PMDA President Brian Kimmel, DO, CMD and PA ASCP President Emily Kryger, PharmD, BCGP, FASCP will open the program with introductions and announcements. RSVP to: 866-700-9296 and follow the link below to join the meeting. 

Zoom Meeting ID: 956 8856 7662   
Zoom Meeting Password: 352585 
Dial in Number: +1 929 205 6099
PMDA's Job Bank

Current Postings

BC/BE Geriatrician
Part-Time | Penn Medicine, Lancaster General Health

BC/BE Geriatrician
Full-Time | Penn Medicine, Lancaster General Health
The PMDA Trainee Education Fund supports PMDA’s efforts to educate, recognize and inspire post-acute and long-term care clinicians in training in the benefits and rewards of a career in the PALTC continuum. Your contribution will allow us to continue to offer complimentary registration to the Annual Symposium for fellows, residents and students and support PMDA’s contribution to AMDA’s Futures Program. Help us invest in the future of practice in PALTC medicine.
PMDA's Winter Webinar Now Available
The PMDA Winter 2021 Webinar is now available for purchase! A recording of the webinar can be purchased using the form linked below.
Each recording is $15 plus 6% sales tax. You will need access to to receive the recordings.
Did you know the post-acute and long-term care setting has one of the highest polypharmacy rates, which increases the risk for adverse events and drug interactions? Join AMDA’s new initiative, called Drive to Deprescribe – Optimizing Medication Use in PALTC.
Who should participate?
Prescribers, pharmacists, DONs, CNOs, CMOs, and CEOs in the long-term care setting.

Date: Thursday, May 20
Time: 4:30 PM – 5:15 PM ET
Conference Recordings Now Available!

If you didn’t attend AMDA’s Virtual Annual Conference in March, you can now purchase the recordings. By purchasing the recordings package, you can still attend the conference on your schedule and earn over 90 hours of CME credit, CMD credit, and ABIM MOC points. Recorded sessions include video of the sessions delivered during the conference, including slides, audio, and presenters and the ability to download session handouts. 
Society Announces 2021-22 Officers and Board Members

The Society has elected its 2021-2022 Board of Directors.
Karl Steinberg, MD, HMDC, CMD (Oceanside, CA)
Suzanne M. Gillespie, MD, RD, CMD (Fairport, NY)
Milta Little, DO, CMD (Hillsborough, NC) - Newly Elected
Swati Gaur, MD, MBA, CMD (Gainesville, GA) – Newly Elected
David A. Nace, MD MPH, CMD (Wexford, PA)
Rajeev Kumar, MD, FACP, CMD (La Grange, IL)
Wayne Saltsman, MD, PhD, CMD (Burlington, MA)
Leslie Eber, MD, CMD (Englewood, CO)
Vicki Walker, MD, CMD (Vermillion, SD)
Diane Sanders-Cepeda, DO, CMD (Cooper City, FL) – Newly Elected
Sabine Maria von Preyss-Friedman, MD, FACP, CMD (Seattle, WA)
Sing T. Palat, MD, CMD (Golden, CO)
Barbara Resnick, PhD, CRNP (Baltimore, MD) 
AMDA On-The-Go
Podcast Series
AMDA membership is not required to access AMDA’s COVID-19 Vaccination Toolkit, however you will need to create an account (which is free) if you don’t already have one.