Journal of the American Medical Directors Association

Hypertension: Is It Overtreated in the Elderly?

John E. Morley — 2010-03-01

“A man is as old as his arteries.”Thomas Sydenham17th century physician The reason to have experts in geriatrics and certified medical directors is, in part, because we understand that an 80-year-old frail nursing home resident often does not need the same aggressive medication as a young person. Polypharmacy is a geriatric syndrome where decreasing rather than increasing medications is likely to improve outcomes. Decreased physiological reserve in older persons makes them particularly at danger of developing side effects to drugs. Frail older persons are particularly vulnerable to the side effects of overtreatment of hypertension.

The Anorexia of Aging: Is It a Geriatric Syndrome?

Francesco Landi, Alessandro Laviano, Alfonso J. Cruz-Jentoft — 2010-01-18

Recognizing that anorexia of aging is a frequent problem found after a comprehensive assessment of frail older subjects, this issue of the Journal of the American Medical Directors Association includes a report from Di Francesco and colleagues who have documented how different compositions of macronutrients affect satiety and hunger signals as well as subjective sensations after meals in healthy elderly subjects. They demonstrated that relatively large amounts of fat increase the satiety signal from Glucagon-Like Peptide 1 (GLP-1) and lower the acylated to desacylated ratio of ghrelin, consequently, decreasing hunger. This condition may lead to a reduction in calorie intake and unintended weight loss. This study, in conjunction with others, contributes significantly to our pool of knowledge about anorexia of aging, an area that remains substantially poorly studied. Nonetheless, a number of issues related to definition of secondary anorexia and possible interventions for elderly subjects with anorexia need to be addressed.

A Call to Action

Paul R. Katz — 2010-03-01

Dr Levenson's 5-article treatise on improving and reforming health care is a call to action for all health care professionals committed to nursing home (NH) practice. Dr Levenson has laid bare many of our current administrative, regulatory, and clinical practices and processes, calling for approaches that are truly evidence based and person centered. Dr Levenson admonishes us to eschew fragmentated care and to reward those holistic approaches that are evidenced by “flexibility, comprehensiveness, and sensitivity.”p600 In addition, we are encouraged to critically evaluate extant quality metrics upon which we are currently judged. Overemphasizing outcomes at the expense of processes of care may not be the optimum approach to improving quality of care.

Risk of Venous Thromboembolism in Long-Term Care Residents: What Do We Know Now?

Barbara J. Messinger-Rapport — 2010-03-01

The article by Barbara Zarowitz and colleagues on the risk of venous thromboembolism (VTE) in long-term care (LTC) is a brave attempt to stratify thrombotic risk in LTC. Their systematic review of more than 8 years of data identified a total of 1165 publications relating to VTE and immobility. Rating these publications according to accepted quality criteria resulted in selection of 4 articles relating to thrombotic risk, and 1 article (1 of these 4, actually) relating to immobility. Eight mobility-related statements and 30 VTE risk statements were derived from these articles. The authors' final recommendations (reached by modified Delphi method of analysis of the mobility and VTE risk statements) include baseline thrombotic risk screening on admission; prophylaxis for up to 35 days if high risk; then consideration of prophylaxis indefinitely if the risks and mobility are not sufficiently improved. Recommendations for VTE prophylaxis is not within the scope of the article. However, the vast majority of controlled trials in the past 5 to 10 years has focused on low molecular weight heparins (LMWH) or factor Xa inhibitors. The recommendations of the American College of Chest Physicians (ACCP) guidelines for high-risk patients includes an LMWH or factor Xa inhibitor as either a first or second choice for anticoagulant thromboprophylaxis. ACCP recommends against sole use of aspirin or mechanical methods of thromboprophylaxis in general.

The Basis for Improving and Reforming Long-Term Care. Part 4: Identifying Meaningful Improvement Approaches (Segment 2)

Steven A. Levenson — 2010-03-01

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to “fix” the problem have overshadowed efforts to correctly define the problems and identify their diverse causes.This fourth and final article in the series (divided between last month's issue and this one) recommends strategies to make sense of improvement and reform efforts. This month's concluding segment covers additional proposed approaches. Despite the challenges of the current environment, all of the proposed strategies could potentially be applied with little or no delay.Despite having brought vast increases in knowledge, the research effort may be losing its traction as a formidable force for meaningful change. It is necessary to rethink the questions being asked and the scope of answers being sought. A shift to overcoming implementation challenges is needed.In addition, it is essential to address issues of jurisdiction (the apparent “ownership” of assessment and decision making over patient problems or body parts) and reductionism (the excessive management of these issues and problems without proper context) that result in fragmented and problematic care. Issues of knowledge and skill also need to be addressed, with greater emphasis on key generic and technical competencies of staff and practitioners, in addition to factual knowledge.There is a need to rethink the approach to measuring performance and trying to improve quality of care and services. There are significant limits to trying to use quality measures to improve outcomes and performance. Ultimately, vast improvement is needed in applying care principles and practices, independent of regulatory sources. Reimbursement needs to be revamped so that it helps promote care that is consistent with human biology and other key concepts.Finally, improving long-term care will require a coordinated societal effort. All social institutions and health care settings need to address their own shortcomings and contribute constructively in order to improve and reform nursing homes and health care generally. It is not helpful to scapegoat nursing homes for what are far more universal problems of care, practice, and performance.

Managing Diabetes in Long-Term Care Facilities: Benefits of Switching From Human Insulin to Insulin Analogs

Naushira Pandya, Esther Nathanson — 2010-01-18

The unique requirements of residents with diabetes in long-term care (LTC) facilities necessitate a protocol-driven, individualized approach to care. Established treatment guidelines for the management of diabetes are written with the general population in mind and, although the principles remain the same in LTC patients, clinical priorities and strategies may need to be modified, and glycemic goals should be balanced against quality of life. This article identifies and explores the institutional, staff, patient and medication-related factors that contribute to the complexity of delivering optimal diabetes care in the LTC setting, and focuses on how insulin analogs, and the pens used for their delivery, can simplify and improve care delivery while, in many cases, reducing institutional costs.

Efficacy and Costs of Nutritional Rehabilitation in Muscle-Wasted Patients With Chronic Obstructive Pulmonary Disease in a Community-Based Setting: A Prespecified Subgroup Analysis of the INTERCOM Trial

2010-02-08

Rationale: Limited data are available on effectiveness and costs of nutritional rehabilitation for patients with COPD in community care.Methods: In a 2-year RCT, 199 COPD patients (FEV1%pred. 60% [SD 16%]) and impaired exercise capacity were randomized to the interdisciplinary community-based COPD management program (INTERCOM) or usual care (UC). A prescheduled subgroup analysis was performed on 39 of 199 patients who were muscle wasted and received UC or nutritional therapy in combination with exercise training. Body composition, muscle strength, and exercise capacity were assessed at baseline and 4, 12, and 24 months.Results: Between group differences after 4 months in favor of the intervention group: fat free mass index (FFMI 0.9 kg/m2 [SE = 0.2, P < .001]), body mass index (BMI 1.0 kg/m2 [SE = 0.4, P = .009]), maximum inspiratory mouth pressure (Pimax 1.4 kPa [SE = 0.5, P = .011]), quadriceps average power (QAP 13.1 Watt [SE=5.8, P = .036]), 6-minute walking distance (6MWD 27 m, [SE = 11.5, P = .028]), cycle endurance time (CET 525 seconds [SE=195, P = .013]), and peak exercise capacity (Wmax 12 Watt [SE = 5, P = .036]). Between group difference over 24 months in favor of the intervention group: Pimax 1.7 kPa (SE = 0.53, P = .004), QAP 19 Watt (SE = 6, P = .005), 6MWD 57 (SE = 19, P = .006), and CET 485 seconds (SE = 159, P = .006). After 4 months total costs were Euro 1501 higher in the intervention group than in the UC group (P < .05), but not significantly different after 24 months. Hospital admission costs were significantly lower in the intervention group –€ 4724 (95% CI –7704, –1734).Conclusion: This study in muscle-wasted COPD patients with moderate airflow obstruction shows a prolonged positive response to nutritional support integrated in a community-based rehabilitation program. Clinical trial.gov: NCT00840892.

The Quantity of Meal Fat Influences the Profile of Postprandial Hormones as Well as Hunger Sensation in Healthy Elderly People

2010-01-18

Background: In healthy elderly people, reduced appetite and the consequent decrease in food intake has been defined as the “anorexia of aging”; this condition may lead to malnutrition. The aim of this study was to investigate how different compositions of macronutrients affect satiety and hunger signals as well as subjective sensations after meals in healthy elderly subjects.Methods: Experimental controlled study. Ambulatory healthy community-dwelling subjects evaluation in a single center on 12 elderly subjects, (75.2±2 years old) and 12 younger controls (28.2±2 years old). Using a visual analogical scale, hunger was evaluated under fasting conditions and at 30-minute intervals for up to 4 hours after two 800-kcal meals, where 20% and 40% of the calories were derived from fat. Serum samples were collected at –30, 60, 120, and 240 minutes to determine the concentrations of GLP-1, acylated and desacylated ghrelin, triglycerides, glucose, and insulin.Results: Serum concentrations of GLP-1 were higher after the 40% fat meal than after the 20% fat meal (P < .01) in the elderly but not in the younger subjects. Acylated to desacylated ratio was lower after the 40% fat meal (P < .05) in the elderly. Only in the older group were triglycerides higher (P < .05), whereas hunger was significantly lower (P < .05) after the 40% fat meal.Conclusion: In healthy elderly people relatively large amounts of fat increase the satiety signal from GLP-1 and lower the acylated to desacylated ratio of ghrelin, consequently decreasing hunger. This condition may lead to a reduction in calorie intake.

Cognitive Bias and Planning Error: Nullification of Evidence-Based Medicine in the Nursing Home

Richard W. Miles — 2010-03-01

Background: Medical error is common, and has a large impact on our national healthcare budget. The elderly and chronically ill are among the largest consumers of the Medicare budget fueling interest in avoiding unnecessary hospitalizations among nursing home residents. In addition to preventive measures involving care coordination and better implementation of advanced directives, this article argues that many nursing home residents have a greatly inflated risk of hospitalization and would benefit from more intensive medical management.Methods: Reflective practice is used to analyze why nullification error (inappropriately omitting evidence-based treatments) regularly occurred among nursing home residents over an 8-year period. The study frames the root causes of clinical inertia and nullification error using terms from cognitive psychology and contemporary philosophy.Results: Unrecognized biases and cognitive pitfalls are the basis for why competent physicians reject evidence-based medicine (EBM) in the nursing home. Six common recurring nullification errors are discussed with the proposed root causes. A glossary of unfamiliar terms is included.Conclusions: The uncertainty over the appropriateness of EBM for the nursing home patient has led to a widespread bias toward undertreatment that has reached alarming proportions. It is true that most elderly patients do not wish to extend their life expectancy, but most do wish to avoid medical complications and unnecessary hospitalizations. Rejecting treatments that extend life expectancy often results in rejection of the very treatments that would improve the probability of achieving their wish to retain fair health. Practitioners do not reject meaningful treatments because of lack of knowledge or lack of concern. They do so because of an incomplete education regarding the biases and cognitive pitfalls that are encountered when planning care for the elderly.

Health Care Providers' Opinions on Communication Between Nursing Homes and Emergency Departments

Suzanne M. Gillespie, Lauren J. Gleason, Jurgis Karuza, Manish N. Shah — 2010-01-18

Objectives: To characterize the beliefs and opinions of nursing home (NH) and emergency medicine providers about communication between NH and emergency departments (ED) during transitions of care of NH residents.Design: A cross-sectional study using a mailed and Internet survey.Participants and Setting: Physicians, nurse practitioners, physicians assistants, and nurses who practice in ED settings and NH settings, affiliated with hospitals of an academic medical center in Rochester, New York.Measurements: Opinions on communication; beliefs about frequency of information transmission; opinions on how often verbal communication should occur.Results: A total of 155 nurses and medical providers participated in the survey for a response rate of 32.2% (155/481). Of the survey participants, 63.0% and 56.8% had been more than 5 years in their position and facility, respectively. Most respondents felt that important information was lost during patient transfers between NH and ED settings. Providers from ED and NH settings had different opinions on the likelihood that key information would be readily identifiable at patient transfer and that care would include requested tests and follow-up. Providers from both sites of care supported verbal communication at their position when NH residents are transferred to the other setting.Conclusion: Nurses and medical providers from both emergency and NH settings agree that transitional communication is poor between NHs and EDs and support a role for verbal communication during the ED transitions of care of NH residents.

Thrombotic Risk and Immobility in Residents of Long-Term Care Facilities

2010-02-08

Background: Hospitalized patients and residents of long-term care (LTC) facilities account for about 60% of all cases of venous thromboembolism (VTE), as incidence is correlated with increasing age, immobility, and underlying medical conditions. The primary aim of the study was to develop an evidence-based VTE risk stratification tool and definition of immobility for residents in LTC facilities.Methods: Using the Delphi process, a panel of vascular thrombotic and geriatric experts reviewed and ranked statements of VTE risk and immobility derived from randomized controlled trials, meta-analyses, cohort trials, case-control trials, and case series to arrive at consensus for the importance of each statement. Rating was conducted before and during an on-site meeting following discussion. Statements rated high and very high were used to develop a VTE risk stratification and immobility tool.Results: A total of 1165 publications related to VTE risk were identified from which 137 (12%) pertained to subjects with a median age of 60 years or older; 42 (31%) met study criteria. Eight (29.6%) of 79 publications pertaining to immobility met study criteria. There were 4 studies related to VTE risk and 1 to immobility that were rated as high quality. VTE risk factors were age older than 60 years, active cancer, acute infectious disease, catheter in a central vein, chronic obstructive pulmonary disease, dehydration, history of VTE, having a first-degree relative with VTE, heart failure, hypercoagulable state, immobility, inflammatory bowel disease, obesity, rheumatoid arthritis and treatment with erythroid stimulating agents to a hemoglobin value greater than 12 g/dL, aromatase inhibitor, hormone replacement therapy, megestrol acetate, or selective estrogen receptor modulators. Immobility was defined as the presence of at least 1 of the following: being bedridden or bedridden except for bathroom privileges, unable to walk at least 10 feet, recent reduction in ability to walk at least 10 feet for at least 72 hours, and having a lower limb cast.Conclusions: A risk stratification tool for VTE and immobility was developed to assist clinicians in caring for residents of LTC facilities. A prospective trial is needed to validate the tool.

Additional Research on the Cost of Caring for Obese Nursing Home Residents is Critical to Maintaining Adequate Resources in the Long-Term Care Industry

2010-03-01

To the Editor: A startling trend in the US population threatens the quality of care available in the long-term care setting. The proportion of nursing home residents who are obese (body mass index > 30) is increasing and now represents approximately 25% of the US nursing home population. Obese residents require specialized bariatric equipment and supplies, which are costly and unavailable in many facilities, and extensive personal care assistance to perform activities of daily living. These equipment and staffing needs present significant challenges for nursing homes now and in the future as the US population ages. This problem is exacerbated in an economic context because, unlike costs, daily reimbursement rates do not vary systematically with size of the resident.

Chart Review at the Department of Elder Affairs in Central Florida of Disease Prevalence Among Recipients of Elderly Services

Mitchell A. Kutner, Morris Kutner — 2010-03-01

To the Editor: The Department of Elder Affairs is responsible for administering human service programs for the elderly population in an effort to try to help them keep their self-sufficiency and self-determination in all possible ways. These services include case management, home-delivered meals, adult day care, caregiver support and training, medical equipment and supplies, respite care, assisted living, and many others. It is estimated that more than 20% of the US population is now 60 years of age and older. As baby boomers continue to age, this percentage is expected to rise. Some individuals suffer from chronic conditions that began long before they reach age 60, whereas others may be able to live their entire lives without needing long-term medical or social services. However, some chronic conditions can put great strain on the ability to provide these services. For example, it is estimated that more than 5 million people in the United States are affected by Alzheimer's disease, and by 2050 this figure may rise to between 11 and 16 million. Knowledge of disease prevalence and commonality among recipients of services by the Department of Elder Affairs may help in developing models for better distribution and allocations of these services and creating budgets.

Long Term Care Medicine 2010 Poster Abstracts

2010-03-01

AMDA Disclaimer Statement

2010-03-01

A Survey of ED Staff about Challenges and Recommendations for Emergency Department Care of Extended Care Facility Patients

2010-03-01

Introduction/Objective: Extended care facility (ECF) patients who transfer to emergency departments can pose problems when complicated health problems require extra resources, without easy resolution. Higher numbers of older patients are projected to use emergency departments, so health researchers recommend that health care professionals prepare for an increasing aging population who may present with multiple special needs. Our aim was to solicit views and opinions of emergency department personnel about key issues related to emergency care of ECF residents and to identify top problems to explore possible solutions and plan for the future.

After Hours Communications between Providers and Long Term Care Staff in a Community Based Setting

2010-03-01

Introduction/Objective: The purpose of this study was to characterize after hours telephone communications with health care providers in community-based nursing homes (NH's), including skilled nursing facilities (SNF's) as well as assisted living facilities (AL's) in metropolitan San Antonio.

An Action-Based Approach to Improving Pain Management in Long Term Care

Sharon Kaasalainen, Sharon Kaasalainen — 2010-03-01

Introduction/Objective: Pain management for older adults in long-term care (LTC) has been recognized as a national and international problem. Untreated pain can lead to depression, loneliness, impaired mobility, sleep disturbances, and decreased quality of life. The purpose of this study was to develop an interdisciplinary approach to improve pain management in long-term care (LTC) in light of the barriers and facilitators that exist within the current system.

An Important Requisite for Personalized Health Services from the U-care Project for the Aged: A Questionnaire Survey

2010-03-01

Introduction/Objective: With the growth of the aging population, providing care services for this segment of the population has become popular. The U-care project is an innovative model of care services for the aged in the Chang Gung Health and Culture Village, in coordination with the Chang Gung Memorial Hospital, the Chang Gung University, and the Ministry of Economic Affairs of ROC, Taiwan. Through the use of information technology, the U-care project aims to build a healthy, dignified, and happy environment for the aged as well as to slow the aging process and decrease illness, thus improving their quality of life.

Analysis of Unscheduled Transfers to the Emergency Department from all Nursing Homes in the Fraser Health Region in 2007 and 2008

Michael McBryde, Michael J. McBryde — 2010-03-01

Introduction/Objective: Fraser Health serves a population of 2.6 million with 8,000 nursing home residents. The study presents detailed information on unscheduled transfers from nursing homes to the local hospital emergency departments and ascertains opportunities to decrease the number of transfers. It will form the basis for ideal target rate for transfers and be a performance indicator for facilities.

Application of Long Term Care Principles in Acute Care: Restraint Reduction and Provider Attitudes toward Restraints and Education

Barbara Hoffmann, Barbara L. Hoffmann — 2010-03-01

Introduction/Objective: The use of restraints in long term care was reduced extensively over the last two decades. The process has been evolving to restraint free environments for residents and to the use of alternatives in long term care. Restraints are still used frequently and readily in the acute care setting. Few studies exist about the attitudes of providers toward the use of restraints. Most of the literature about attitudes exists in the nursing realm despite the fact that orders from physicians are required by law for use of the devices or chemicals. There are many references in the literature to legal disputes but few qualitative studies concerning education of providers. The lack of literature suggests that there is a need for provision of education to providers about this important subject for frail and elderly patients. There is even less literature focusing on restraint reduction and attitudes of care providers in the acute care setting.

Are they Stubborn or are they Sick?

Shinya Ishii, Shinya Ishii, Joel Streim, Debra Saliba — 2010-03-01

Introduction/Objective: Nursing home medical directors and primary care providers are often called about residents exhibiting rejection of care behaviors. Rejection of care behaviors are among the most difficult and labor-intensive behavioral problems observed in nursing homes (NHs). Such behaviors can strain caregiver and NH resident interaction and frustrate caregivers, leading to reduced interactions, withdrawal from the resident or ongoing confrontation. This strained relationship also frustrates residents and families. We aimed to identify potentially mutable resident-level factors associated with rejection of care.

Are You Ready for Pain Management Under F-Tag 309?

Frank Breve, Frank Breve, Dean Gianarkis — 2010-03-01

Introduction/Objective: Published research estimates that 45%-83% of nursing home residents experience pain. However, data suggests that clinicians tend to underestimate pain and often fail to recognize it in some individuals. This may be problematic for some nursing homes because of recently released pain management guidance that provides direction for surveyors known as F-Tag 309. This research was conducted to assess readiness for F-Tag 309 using a survey administered to nursing personnel. This survey was also designed to evaluate current practices related to the key components of pain management.

Can You Hear Me Now? Found: 2 ‘Lost’ Hearing Aids in Otic Canal of Elderly Woman with Mild Dementia

Benito San Gil, Benito San Gil, Sandra Bellantonio — 2010-03-01

Introduction/Objective: Innovation renders hearing aids inconspicuous so they are able to fit small auricular spaces, and have better cosmetic appeal. Long-term care providers strive to augment and correct sensory deficits. Apart from enhancing quality of life, intact hearing helps mitigate risk of delirium and depression. Hearing aids – unlike eyeglasses, are designed to be camouflaged by adaptation to skin color and miniaturization. When fractured, hearing aid parts may get concealed in constricted spaces like the ear canal. Furthermore, earwax can cover and cement broken parts, with potential for complications like otitis or perforation.

Clinical Guidelines for Selection of Support Surface for Pressure Ulcer Prevention and Treatment

Kim House, Kim W. House, Sahebi Saiyed — 2010-03-01

Introduction/Objective: Tissue load management is essential in preventing and treating pressure ulcers. While repositioning every two hours is the main stay of relieving pressure, different support surfaces (mattress, beds, and overlays) are also used to redistribute body weight over a wider area and help relieve/reduce pressure. There are few accessible materials available to help choose the proper support surface. The goal of this quality improvement project was to develop an algorithm for clinical decision making for support surface selection based on a description of characteristics, costs, and patient-related risk factors, and to perform a pilot project in a single VA nursing home (community living center) to assess the degree to which surfaces being used agreed with the algorithm recommendation.

Clinician Heal Thyself: Survival Skills for Self-Preservation among Long Term Care Professionals

Patricia Bach, Patricia L. Bach, Daniel A. Bluestein, William G. Boger — 2010-03-01

Introduction/Objective: Contemporary medical practice presents increasing challenges to fundamental provider well-being, often experienced on both personal and professional levels. Failure to institute self-care measures often exacts a significant and sometimes life-threatening toll, suggesting a loss of "balance" which impacts overall quality of life. Thus, an increasing task demand for LTC providers is the development of creative skills and strategies to ensure ongoing job satisfaction, work empowerment, and resiliency, conceptualized as "survival skills for self-preservation."

CMD + CGP + RN = Collaboration for Education and Policy as Resolution A06 in Practical Application for Enhancement of Compliance with F309 and F501

2010-03-01

Introduction/Objective: The objective is description of a medical director's experience with informal interdisciplinary interaction for institutionalization of American Medical Directors Association's (AMDA's) Resolution A06 and Pain Management Clinical Practice Guideline for potential enhancement of compliance with F309 (pain) and F501 in a nursing home with non-academic staff.

Complications of Megestrol acetate in a Nursing Home Resident

Niranjan Thothala, Niranjan Thothala, Shikta Gupta — 2010-03-01

Introduction/Objective: Weight loss in Nursing Home (NH) residents is often multifactorial. Management usually involves evaluation and interventions by multiple health professionals. However the morbidity, mortality and the regulations associated with weight loss often push clinicians to consider the option of drug therapy. We report a case of Megestrol acetate (MA) use in a NH resident associated with potentially life threatening complications.

Complying with Regulatory Requirements for Medical Directors in the Nutrition Care of Nursing Home Residents

Linda Handy, Linda Handy — 2010-03-01

Introduction/Objective: How fictional characters (Medical Director and Interdisciplinary Team) in 3 Nursing Homes determine survey compliance and quality improvement systems, and subsequent consequences. This is based upon a training manual for practical application of regulatory requirements: Surveyor MO for Nutritional Status (Regulation F 325), 2009.

Demographics and Acute Medical Needs of Assisted Living Facility Residents

2010-03-01

Introduction/Objective: Background. Increasing numbers of older adults live in assisted living residences (ALRs). Primary care medical practices focusing on the care of older adults who dwell in ALR are developing to meet these patient's special needs. To our knowledge, the types of patients in an ALR medical practice and the use of acute medical care by ALR dwellers have not been previously characterized. Objectives: To characterize the patients participating in an ALR primary care program and their use of acute medical care services.

Depression in Elderly Nursing Home Residents Taking Antiepileptic Medications

2010-03-01

Introduction/Objective: We are currently evaluating elderly nursing home residents who are on antiepileptic drug (AED) therapy and assessing for a number of problems including depression. This abstract gives an updated report on depression as recorded by the Geriatric Depression Scale (GDS-5) and Depression Rating Scale (DRS).

Disease Specific Health Risk Assessments: Steps for Improving Diabetic Patient Care in the Nursing Home Setting

Angela DeRosa, Angela DeRosa — 2010-03-01

Introduction/Objective: Providing LTC provider's education about the American Diabetic Association practice guidelines and alerting providers of patients who would benefit from guidelines has been shown to only minimally improve adherence to clinical standards of care in the nursing home setting. This study was designed to test the theory that in order to improve compliance with diabetic practice guidelines in LTC, providers must be: 1) Educated on the diabetic guidelines; and 2) Given specific recommendations on guideline practice outages for their specific patients utilizing a comprehensive diabetic health risk assessment tool.

DVT Prophylaxis on Transfer from Hospital to Nursing Home

Jignesh Patel, Jignesh Patel, John Voytas — 2010-03-01

Introduction/Objective: Current ACCP guideline suggests a grade (1A) recommendation for high risk medically ill patients, but its use in clinical practice is unknown. Several studies show a large gap between ideal and real-world practice, despite the theoretical possibility that physician awareness might increase use of VTE prophylaxis.

Economic Evaluation of a Handheld Charge Capture Application for Long Term Care Providers

Steven Handler, Steven M. Handler, David A. Nace — 2010-03-01

Introduction/Objective: Previous research has shown that a point-of-care handheld charge capture program can improve coding accuracy and satisfaction for long-term care providers. The objective of this quality improvement project was to determine the impact of a point-of-care handheld charge capture program on the number of charges submitted, payments received, charge lag, and return on investment in a group of long-term care providers.

Effect of an Interdisciplinary Team Approach to Psychotropic Drug Reduction and Elimination on Quality Measures and other Clinical Outcomes in Skilled Nursing Facilities (SNFs): The Medication Evaluation Trial (MET trial)

Mark Coggins, Mark Coggins, Mary P. Evans, Camille Bruce — 2010-03-01

Introduction/Objective: To evaluate the feasibility and efficacy of incorporating a consultant pharmacist (CP) into an IDT approach to psychotropic medication reduction and comprehensive care planning for SNF residents receiving psychotropic medications, exhibiting disruptive behaviors, or identified as 'at risk' for undesirable clinical outcomes. All residents of a 150 bed SNF in Hendersonville, NC, receiving psychotropic drugs or identified by facility staff as having or exhibiting weight loss, psychotropic drug use, disruptive behaviors, pressure ulcers, or falls between January 1 and June 30, 2009 had their medical records and care plans reviewed by facility staff in an IDT meeting comprised of a CP, nurse, social worker, dietician, therapy staff and activity staff. The team met twice a week and reviewed each individual resident's chart every four weeks. Recommendations were communicated to the attending physician and primarily consisted of pain management, depression treatment, therapy referrals, individualized activities, gradual dose reduction of psychotropic drugs, and nutrition interventions. Outcomes of interest: rates of psychotropic drug use and other quality measures, as well as fall related and psychiatric discharges to hospital.

Elderly Orthopedic Patients Transferred to an Intermediate Care Facility in Singapore - A One Year Review

David H. Yong, David H. Yong, Ivan Ngeo — 2010-03-01

Introduction/Objective: The department of geriatric medicine of an acute hospital has been providing regular orthogeriatric services for care of elderly patients with falls and fractures. One of the interventions includes a transfer of selected cases to a new community based step-down ward for optimization of geriatric problems. This 10 bed ward is staffed by senior community family physicians with special training and interest in eldercare and a multidisciplinary team of gerontology-trained nurses and allied health workers. This is a preliminary audit of the outcomes of this ward.

End of Life Care in the Nursing Home Setting

Petra Flock, Petra Flock, Jill M. Terrien — 2010-03-01

Introduction/Objective: For this study a cross-sectional mailed survey to explore next of kin's perspectives on end-of-life care in the nursing home setting was developed. It tested the feasibility of the method in terms of recruitment and response rate, and pilot tested the survey instrument. Decedents who received Hospice services in addition to traditional nursing home care were compared to those who received traditional care alone.

Epilepsia Partialis Continua not Amenable to Medical Therapy

Kofi Quist, Kofi K. Quist, Wanda Horn — 2010-03-01

Introduction/Objective: Epilepsia partialis continua is a type of focal motor epilepsy characterized by persistent clonic movements of a muscle group with repetition at fairly regular intervals every few seconds, continuing for hours, days, weeks, or months without generalization.

Estimating Total Acetaminophen Burden in LTC Residents with Diabetes

Dean Gianarkis, Dean Gianarkis, Robert Fusco — 2010-03-01

Introduction/Objective: In June of 2009 the FDA held an advisory committee meeting to address problems associated with acetaminophen (APAP) toxicity. Several options have been proposed to mitigate these problems. The objective of this research was to determine total APAP dose burden from stand-alone orders and combination analgesics in residents with diabetes.

Evaluating the Impact of Health Care Providers' Knowledge, Attitudes, and Behavior on MOLST Implementation in Long Term Care Facilities

2010-03-01

Introduction/Objective: In 2006, the New York Department of Health approved the MOLST form, as an actionable medical order to transition patients through all health care settings statewide. We evaluated the impact of health care providers on MOLST implementation in long term care facilities.

Health Care Employees' Knowledge and Awareness of Pressure Ulcers in Hospitals and Long-Term Care Facilities

2010-03-01

Introduction/Objective: Using the Centers for Medicare and Medicaid Services pressure ulcers guidelines (CMS, 2008), we designed a study to examine attitudes and knowledge of pressure ulcers among health care personnel in hospitals and long-term care facilities.

How did this Happen? Root Cause Analysis of a Thirty-five Pound Weight Gain in a Skilled Nursing Facility

2010-03-01

Introduction/Objective: Congestive heart failure (CHF) is a common syndrome among skilled nursing facilities (SNF) patients. Exacerbations of CHF leading to hospital admissions are common. We use the case of a 35 pound weight gain in a SNF patient with CHF to illustrate risk factors for CHF exacerbations despite the presence of skilled nursing. The goal of this poster is to highlight the need for standardized care of SNF patients with heart failure such as the DEFEAT protocol.

Identifying Patterns of Re-Hospitalization from Skilled Rehabilitation Units

Nancy Istenes, Nancy Istenes, Teresa Albanese, Deepa Patadia, Sara Snyder — 2010-03-01

Introduction/Objective: Re-hospitalization within 30 days of discharge to skilled rehabilitation facilities is common and occurs in over 20% of cases per CMS. These re-admissions increase cost, prevent functional recovery and are becoming performance indicators. Preventing re-hospitalization is challenging due to the many potential contributing factors that are not well identified. Objective: To conduct a preliminary review of re-hospitalization within 30 days of discharge to one of 3 skilled geriatric rehabilitation units (GRUs) and identify correlates that could be targeted to reduce re-admissions.

Improving Care in Nursing Homes in Singapore - Role of the Physician

David H. Yong, David H. Yong — 2010-03-01

Introduction/Objective: Nursing homes (NH) face many challenges. The frail elderly residents may have potentially treatable conditions like recent decline, medication side-effects, pain, and mood disorders besides acute illness episodes. There is increased expectation from healthcare funders and the public for higher standards of care and more efficient use of resources. Acute hospitals want them to take more complex and sicker patients. Doctors generally are not keen to do NH visits. Those who do provide medical services come from various backgrounds and practices. For several reasons including lack of time and know-how they often focus on acute care. NHs may not be prepared to deal with many of these issues including palliative care for end stage conditions. The author, a community aged care physician with interest in intermediate and long term care has adopted an approach to maximize physician time in NH visits in three nursing homes over the past five years. This paper describes the approach used and its outcomes over the years.

Improving End-of-Life (EOL) Care in California Nursing Homes through Education: The End-of-Life Nursing Education Consortium (ELNEC) Geriatric Program

Kathe Kelly, Kathe Kelly, Mary Ersek, Rose Virani, Pam Malloy, Betty Ferrell — 2010-03-01

Introduction/Objective: Nursing's mandate is to provide compassionate care and dignity to persons at the EOL. Approximately, 25% of US deaths occur in nursing homes and the proportion increases with age of residents. The ELNEC Project is a partnership of the City of Hope and the American Association Colleges of Nursing (AACN). ELNEC's Geriatric train-the-trainer program is a synthesis of knowledge in EOL care and teaching methodology to develop expertise and skills for nurses responsible for care of older adults in nursing homes, skilled nursing facilities, hospices, home care, assisted living, etc., as well as in staff education programs. In 2003, Robert Wood Johnson Foundation funded a report, Means to a Better End, grading states on their ability to provide end-of-life care. Most states’ grades indicated a need for improvement including California which rated a “C.” From 2007 through 2009 four ELNEC Geriatric courses supported by grants from the California HealthCare Foundation and the Archstone Foundation have been offered to California nurses and nursing home staff. The purpose of this presentation is to describe the curriculum, implementation, survey results pre and post course and examples of ELNEC trainers’ work following ELNEC Geriatric training.

Indications and Contraindications for Anti-Thrombotic Therapy to Prevent Venous Thromboembolism (VTE): Observations in Long-Term Care Facilities (LTCF) based on Clinical Practice Guidelines (CPG)

2010-03-01

Introduction/Objective: Recent guidelines recommend antithrombotic prophylaxis for VTE based on risk assessment, in absence of contraindications. Practices in the long term care setting are unclear. This report summarizes current practices addressing VTE in 17 LTCFs after phase 1 of a 3-phase educational project aimed to improve practice patterns consistent with CPGs.

Initial Diagnosis and Treatment Patterns in Parkinson's Disease

Marcy Tarrants, Maureen Lage, Marcy Tarrants, Jane Castelli-Haley — 2010-03-01

Introduction/Objective: To our knowledge, nationwide patterns of initial Parkinson's Disease (PD) treatments were last described from 1999-2001 claims data and this analysis serves to update the current literature. This study evaluates the diagnosis and treatment patterns in the US of newly identified PD patients by describing the timing and type of initial treatments.

Insulin Sliding Scare, Does it Exist in the Nursing Home

Junaed Haq, Junaed U. Haq — 2010-03-01

Introduction/Objective: The insulin sliding scale is a very frequently used method to help control blood sugar levels in patients in nursing home settings. Many of the patients on sliding scale may not have blood sugars that are well controlled, and physicians many times may be unaware of the lack of glycemic control as coverage will be as per sliding scale. We wanted to look and see how many patients on sliding scales had adverse events defined as blood sugars less than 60 or greater than 400. Secondly we wanted to see how often nursing intervention in terms of orange juice or glucagon was required for sliding scale patients. Finally we wanted to see how often physicians make adjustments to the sliding scale based on adverse events.

Integrated Medical Model Project Plan at Rowan Community

Justin Moore, Justin Moore, Kristina Stange, Susan Hanson, Cari Levy — 2010-03-01

Introduction/Objective: Culture Change has had a major positive impact on the social environment in long-term care (LTC) facilities providing residents with more control of their lives and increasing quality of life and independence. However, despite the great strides in expanding the social environment of LTC residents, many medical models have lagged behind in terms of an “integrated medical care” focus that would support and enhance resident control of their own health care decisions. In response to this need, the Integrated Medical Model was developed with the following principles:

Key Quality Indicator Reports That Tell a Story

Verna Sellers, Kimberly Woodley, Verna Sellers — 2010-03-01

Introduction/Objective: PACE (Program for the All-inclusive Care of the Elderly) programs have a wide variety of audiences with whom to share data. Medical Directors and Team members need to know if processes to keep participants safe are functioning. Physicians and Medical Directors are interested in Participant outcomes. Administrators want to assure that resources are being allocated as needed. Participants, Family Members, and Community Advocates who serve on advisory boards need an easily understandable report that communicates the quality of services. Regulators want to assure that processes are meeting requirements. To meet the variety of expectations it is necessary to develop a Key Quality Indicator Report that tells that story.

Lack of Knowledge of Skilled Nursing (SNF) Care by Internal Medicine Residents

Michelle Eslami, Michelle Eslami, Katherine Ward, Jodi Friedman — 2010-03-01

Introduction/Objective: Background: More than 25% of older adults require SNF care after acute hospitalization but it is unclear whether Internal Medicine residents have sufficient knowledge about the type of care that can be provided at this site. We assessed knowledge about SNFs among Internal Medicine trainees prior to a mandatory SNF rotation during their first year and either 2nd or 3rd year of training.

Life Extending Preferences Despite a Perceived Terminal State In An Older Mexican American Population

2010-03-01

Introduction/Objective: Care preferences at the end of life continues to receive substantial attention. Less understood are end of life attitudes of specific Hispanic subgroups. The purpose of our study was to examine the relationship between sociodemographic factors on personal attitudes towards life extending treatments during a hypothetical terminal state among community dwelling older Mexican Americans.

Long Term Care Facility Residents with Peripheral and Intestinal Inflammation are Sicker and More Frail

2010-03-01

Introduction/Objective: Aging, on a balance of inflammation, can have chronic, low, systemic inflammation, “inflamm-aging.” Although the increase of inflammatory markers is lower than levels in acute infections, there is an increased mortality. Peripheral inflammation can be a major driving force for frailty. We hypothesize that residents with multiple sites of inflammation (intestinal and peripheral) have worse outcomes and more frailty. In this study, we analyzed LTCF residents to determine if those with peripheral inflammation (defined pressure ulcers) also had intestinal inflammation (defined as elevated levels of quantitative fecal lactoferrin, qLF). We further examined to see if residents with multiple sites of inflammation would be sicker (defined as more hospitalization or emergency department (ED) transfer) or more frail (defined as weight loss) as compared to those without.

Reducing Hospital Re-Admission through Disease Management, Outcomes Measurement and Performance Improvement

2010-03-01

Introduction/Objective: To demonstrate the outcomes achieved through disease management, standardized nursing processes, outcomes measurement, and staff performance improvement applied to 3,000 residents in 10 skilled nursing facilities

Mealtime Culture Change: Steps to Success

Suzanne Cryst, Suzanne C. Cryst — 2010-03-01

Introduction/Objective: To outline the steps in developing a plan to incorporate culture change into mealtime. Design/Methodology: Documentation of actual steps to use to evaluate, create a plan and redesign a food service department and delivery system in a long term care setting.

Minimal Trauma Fractures in Long Term Care, A Case and Review of the Literature

Adline Ghazi, Adline Ghazi, Erin Hommel, Heidi White — 2010-03-01

Introduction/Objective: Minimal trauma or "spontaneous" fractures occur in a small at risk population in the nursing home. They create significant morbidity, mortality as well as medical-legal issues. We present a case that illustrates this problem with a review of the available literature.

Muscle Weakness: An Unusual Cause

Roya Rouhani, Roya Rouhani, Paul Takahashi — 2010-03-01

Introduction/Objective: This is a case presentation of a patient who presented with progressive muscle weakness. Differential diagnosis will be discussed. Design/Methodology: This is a 59 year old male with a history of Hepatitis C who presented with progressive weakness. He had been in a nursing home for short term rehabilitation after an ankle fracture following a fall. After three weeks of short term rehabilitation he was felt to have progressed sufficiently for transfer to an assisted living facility. There he was noted to develop progressive functional decline over one week, to the point that he was unable to walk, unable to transfer independently, had almost unintelligible speech, and experienced dysphagia. He also had difficulty lifting objects with his hands and holding up his head for prolonged periods of time. Weakness worsened over the course of a day. He had experienced three years of progressive neuropathy involving both hands and lower extremities secondary to Hepatitis C. He had been experiencing increasing frequency of falls over the past year that were attributed to the neuropathy.

Oral Care in the Atlanta VA CLC

Nokuthula Msimanga, Nokuthula N. Msimanga, Kim House, Monika Mohiuddin — 2010-03-01

Introduction/Objective: Studies have shown that poor oral hygiene and periodontal disease increases a patient's morbidity and mortality through increased risk of infection as well as poor oral intake. However, what is less characterized is the prevalence of poor oral care in long term facilities and barriers to this care. For patients living in long term care, possible risk factors include medical problems, polypharmacy, functional dependence, oral care hygiene assistance, and poor use of dental care. Federal regulations require that nurses complete an oral health assessment on all patients admitted to a skilled nursing facility. The Minimum Data Set 2.0 includes an oral health component that must be completed within 14 days of admission to a skilled nursing facility. The objective of this quality care improvement project is to evaluate the state of oral care in the Atlanta VA CLC. RESEARCH QUESTIONS:

Pain Control Among Patients Admitted to Nursing Home. How are we Doing?

Katherine Adams, Katherine Adams, John Voytas, Shirley Evoe, Kim Lewis-Henley — 2010-03-01

Introduction/Objective: Pain control among patients in sub acute rehabilitation units has important clinical and regulatory implications. The initial pain assessment score is a part of MDS-The Minimum Data Sets. The objectives of study were: 1- To assess initial pain score based on a standardized Pain Assessment Form with scores 1-10, with a score above 5 indicating severe pain; 2- To compare initial pain score among patients admitted with diagnoses grouped into three categories: medical, surgical and trauma; and 3- Is the pain control improving over time?

Perceptions of the Nurse Practitioner Role around Pain Management in Long Term Care

2010-03-01

Introduction/Objective: Considering the high rates of pain in long-term care (LTC) settings, research is needed to explore innovations in health services delivery, including the emerging nurse practitioner (NP) role. The purpose of this study was to explore the perceptions of LTC health care providers and administrators around the NP role in pain management with an emphasis on elucidating barriers and facilitators to optimizing the use of NPs in LTC around pain management.

Prevalence and Recognition of Chronic Kidney Disease (CKD) in Long Term Care (LTC) Residents in Hawaii

R. Bailey, J. Higa, G. Reardon, R. Bailey — 2010-03-01

Introduction/Objective: To estimate the prevalence of CKD in Hawaii's LTC population based on laboratory data and the degree to which a corresponding diagnosis of CKD is identified in the resident's chart.

Prevalence of Nursing Home Orders for Antipsychotic Medications without Indications or Diagnoses Entered By Prescribing Physician in the Nursing Medical Record: A Generalizable Quality Improvement Project

2010-03-01

Introduction/Objective: Antipsychotic drug prescription in most long term care (LTC) facilities is prevalent and common. However, specific indications for antipsychotic medications (APM) is oftentimes lacking when the APM order is written. The purpose of the study is to examine the prevalence of APM orders without documentation of specific target indication or diagnosis in the LTC medical record/chart.

Prevalence of Painful Neuropathy and Use of Analgesic Medications in Residents with Diabetes

Dean Gianarkis, Dean Gianarkis, Robert Fusco — 2010-03-01

Introduction/Objective: Diabetic peripheral neuropathy (DPN) is one of the most common long-term complications of diabetes. The primary objective of this research was to determine the prevalence of painful DPN (pDPN). The secondary objective was to evaluate medications used to treat other related comorbidities.

Prevention of Venous Thrombo-Embolism in Long Term Care: Multi-Center Project to Study Practice Patterns and Implement Clinical Practice Guidelines

2010-03-01

Introduction/Objective: Introduction: Implementation of preventive measures for Venous Thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) are variably adopted in long-term care facilities (LTCF). Recent guidelines recommend that prophylactic measures be based on VTE risk assessment, individualized to patient status. In the LTC setting, patients have differing co-morbidity, life-expectancy and quality of life issues (from other environments) warranting an approach by providers that considers comorbidity, patient/caregiver wishes and advance directives. This report summarizes current practices to prevent VTE in 17 LTCF after phase 1 of a 3-phase educational project aimed at improving practice patterns consistent with CPGs.

Proton Pump Inhibitors and Clostridium Difficile Infection in Long Term Care Facility Residents

2010-03-01

Introduction/Objective: Clostridium difficile (C diff) is a spore forming bacillus causing illness ranging from diarrhea to death. Risk factors associated with C diff infection include antibiotic usage, advanced age, percutaneous endoscopic gastrostomy, increased number of comorbidities and hospitalization. It is more commonly seen in patients residing in long term care facilities (LTCF). Up to 20% of LTCF residents may be asymptomatic carriers of C diff, likely related to two emerging factors: the evolution of increasingly virulent and resistant strains and the increased use of gastric acid suppression medications, particularly proton pump inhibitors (PPIs). Current data indicates the adjusted rate ratio of acquired C diff infection with concurrent PPI use is at 2.9. We attempted to corroborate these findings at our institution.

Psychotropic Medication Reduction through Innovative Activity Programming

Dan Osterweil, Dan Osterweil, Smadar D. Gal, Limor Ness, Kelly A. Hickey — 2010-03-01

Introduction/Objective: Introduction: In August of 2008, a 72 bed nursing home in Los Angeles, California instituted an enhanced recreational activities program that aimed to increase participation among the facility's residents regardless of their care and cognitive levels. This was accomplished through a variety of programs designed to stimulate the resident's senses, promote well-being and inspire creativity. Objective: The objective of this exploratory study is to determine whether SNF residents undergoing psychotropic therapy who regularly participated in a high quality recreational program experienced a reduction of psychotropic medication use.

Quality Improvement Issues: Weight Loss

Erin Cooper, Erin L. Cooper, Brenda Keller — 2010-03-01

Introduction/Objective: Unintentional weight loss in the nursing home is an important clinical problem that warrants early identification and intervention. The accurate identification of residents with true weight loss is imperative so that efforts and resources may be focused on those who need them the most. In our facility, we undertook a quality improvement project with the goals of improved accuracy of weight collection and documentation, reliable identification of residents with true weight loss, improved accuracy and documentation of meal and supplement intake, and to increase caloric intake from meals and snacks, rather than from liquid nutritional supplements.

Quality Improvement Project: Vitamin D Supplementation in the Nursing Home Residents

Mamata Yanamadala, Mamata Yanamadala, Gwendolen Buhr — 2010-03-01

Introduction/Objective: Elderly nursing home residents are at high risk for falls, which can lead to fractures. Several randomized controlled trials showed that vitamin D supplementation reduces falls in nursing home residents. For instance, one meta-analysis of vitamin D supplementation in elderly nursing home residents found a 22% fall reduction; a second meta-analysis found that 700-800IU vitamin D is needed for fracture reduction. In our nursing home, review of medication administration records of all patients (101) revealed that 27 (26.7%) patients received no vitamin D supplementation, 39 (31.3%) received inadequate vitamin D (<800IU per day), and the remaining 35 (42%) received adequate dosage (800IU a day). These data revealed a need for intervention.

Recognizing the Impact of Obstructive Sleep Apnea Syndrome and Treatment on Activities of Daily Living in Nursing Home Residents

Pauline Daley, Pauline M. Daley, Kalim Ahmed — 2010-03-01

Introduction/Objective: Impairment in the activities of daily living (ADL) decreases quality of life, and has direct implications for long term care needs. The association between sleep disordered breathing (SDB) and functional impairment is well recognized, however studies are sparse on whether treatment of elderly patients with SDB improves ADL. Obstructive Sleep Apnea (OSA) syndrome is a treatable cause of disordered breathing in which the upper airway closes repeatedly during sleep (1). We present a case study of an elderly patient with OSA syndrome, and severe functional impairment who improved with treatment.

Reducing Hospital Admissions of Nursing Home Residents

J.K. Brubaker, J.K. Brubaker — 2010-03-01

Introduction/Objective: Recently there has been a lot of interest at CMS regarding the re-admission rate of Medicare hospitalized patients to the community and nursing homes within one year. The Masonic Village at Elizabethtown, Pennsylvania has been successful in effectively reducing the number of patient admissions to our local hospitals each year since 2005. Due to our success in reducing hospital admissions yearly, we examined those multiple factors that contributed to our success.

Reduction of Antipsychotic Medication Use in a Nursing Facility: Thinking Outside of the Black Box

Dale Hursh, Dale K. Hursh, Ethel Caldwell, Charles R. Maines — 2010-03-01

Introduction/Objective: Antipsychotic medications used for treatment of dementia-associated behaviors pose increased risk of stroke and death and also carry black box warnings. In addition, research suggests this type of drug therapy has limited effectiveness and adverse effects outweigh the benefits. Despite this evidence, antipsychotics are frequently used in demented elderly nursing home residents for management of behavioral problems. Through its quality improvement (QI) process, our 103-bed nursing facility identified higher prevalence of antipsychotic use compared to state and national averages. We organized an interdisciplinary team to achieve the goal of promoting the highest quality of resident life with minimal use of antipsychotic medications.

Reduction of Physical Restraint use is Possible in Your Nursing Home - A Success Story

Liliana Oakes, Kunle Adedeji, Liliana Oakes — 2010-03-01

Introduction/Objective: This study was conducted to document the successful implementation of a restraint free policy. Physical restraint use was decreased from four times state and national averages, 17.5%, to 4.5% and has been consistently maintained for over one year. Prevalence of fall also decreased from 11.5% to 6.1% over the same period. We describe the change process and the experiences of staff, residents and family before, during and after the implementation of the program.

Reduction of Unnecessary Treatment of Our New Employees who have a Positive Two-step PPD

J.K. Brubaker, J.K. Brubaker — 2010-03-01

Introduction/Objective: Recently the Masonic Village's occupational medicine department instituted the use of the QuantiFERON blood test to screen all positive PPDs of recently employed staff. Our goal was to determine how many of our positive PPDs of newly employed staff has a positive QuantiFERON blood test.

Safe Transition of Ventilator Dependent/Tracheostomy Patients from Skilled Nursing Facility to Home

Israel Coutin, Israel Coutin, Ginny Wilde, Kamal Kejriwal — 2010-03-01

Introduction/Objective: There is a continued increase in our elderly population both in terms of size and lifespan. The number of patients that are choosing ventilator assistance for chronic respiratory failure is rising and their stay on a machine is longer in duration. For those patients who are unweanable, there are options available for discharge other than institutionalization. Many patients would prefer to be cared for at home due to emotional, financial or logistical reasons. The benefits for patients living in their own home with a chronic ventilator includes better quality of life, less exposure to infection and decreased cost to insurance and patient/family. The Extended Care Department of a regional medical center was able to successfully transition patients home from 3 different SNFs in the past 5 years with either chronic ventilator dependence or tracheostomy. The goal of this project was to develop a process that would enable ventilator dependent patients a safe, organized and well managed transition from SNF to home.

Safety of Diclofenac Sodium 1% Gel for Knee Osteoarthritis in Patients Aged ≥65 Years with Comorbidities

2010-03-01

Introduction/Objective: Current osteoarthritis (OA) guidelines recommend topical nonsteroidal anti-inflammatory drugs (NSAIDs) for relief of OA pain ahead of oral NSAIDs on the basis of efficacy and safety. (Osteoarthritis: the care and management of osteoarthritis in adults, 2008) Topical NSAIDs may mitigate the risk of adverse events (AEs) by minimizing systemic NSAID exposure.

Screening for Post Traumatic Stress Disorder in Somali Elders through Physician Home Visits

Sowmya Kurtakoti, Sowmya S. Kurtakoti, Lawrence J. Kerzner — 2010-03-01

Introduction/Objective: Post Traumatic Stress Disorder (PTSD) is common among Somali Refugee population. About 50% of Somali elders come to US alone. The high Prevalence of PTSD among elderly immigrant groups contribute to their burden of disease and affects their quality of life. Objective: To screen for PTSD among Elderly Somali population using PC-PTSD tool and determine its contributing factors.

Successful Implementation of an Interdisciplinary Team Approach to Reduce Psychoactive Medications in a Community Based Nursing Home: Tackling F-Tag 329

2010-03-01

Introduction/Objective: Age-related physiologic changes, along with inappropriate medication use, can lead to significant adverse consequences. One of the medication classes with the greatest potential for adverse events in elder nursing home residents are the psychotropics, anxiolytics and sedative/hypnotics. F-Tag 329 mandates that “each resident's medication regimen must be free from unnecessary drugs.” This F-tag prohibits excessive doses, excessive duration, and inadequate monitoring practices. AMDA's policy states that only an interdisciplinary team can make facility level decisions to reduce inappropriate medication use, such as psychoactive medications. The purpose of this study was to evaluate the effectiveness of an interdisciplinary team approach to address F-Tag 329.

The Effect of Medicare Part D on Parkinson's Disease Patients

2010-03-01

Introduction/Objective: The Medicare Modernization Act offers prescription drug coverage through Medicare Part D (MPD). The standard benefit includes a gap in coverage, commonly known as the doughnut hole (DH). Additional information on the impact of the MPD program and the DH on prescription drug utilization and behavior is needed to inform policy. This study evaluates the impact of the MPD DH on Parkinson's Disease (PD) patients medication usage and drug costs.

The Nursing Home Visit: An Exercise in Time Management

Dan Osterweil, Dan Osterweil, Kelly A. Hickey, Barbara Hulz — 2010-03-01

Introduction/Objective: This exploratory study is to identify the components of a clinicians visit in the nursing home, to evaluate the time required to complete each task and identify opportunities to improve the efficiency of the work process.

The Prevalence of Anemia and Anemia Treatment in Residents of Long Term Care Facilities (LTCF) in Colorado

2010-03-01

Introduction/Objective: To evaluate the prevalence of anemia and anemia treatment in anemic LTCF residents. Design/Methodology: Data were derived from the AnalytiCare(SM) long term care database containing laboratory results, Minimum Data Set (MDS) reports, and pharmacy fills for residents of 27 LTCFs in Colorado. Study timeframe was 1/1/2007-9/15/2008. Residents were included based on: residence in LTCF >90 days, an index hemoglobin (Hb) and serum creatinine values ±90 days of the earliest MDS. Residents were excluded if they had cancer, chemotherapy, end-stage renal disease, dialysis, <6 month life-expectancy or hospice care. Anemia was defined using World Health Organization threshold values of <12 g/dL Hb for females and <13 g/dL for males. Anemia treatments were defined as prescription iron, folic acid, vitamin B12, or an erythropoiesis-stimulating agent (epoetin alfa or darbepoetin alfa) ≤30 days before or ≤90 days after the index Hb value.

The Role of Cognitive Impairment in the Use of the Diskus Inhaler

Meenakshi Patel, Malcolm Fraser, Meenakshi Patel — 2010-03-01

Introduction/Objective: Background and Purpose: Drugs delivered by Metered-Dose Inhalers (MDIs) and various types of Dry Powder Inhalers (DPIs) are a mainstay in the treatment of chronic lung disease. However, previous studies suggest cognitive impairment hinders proper use of inhalers, thereby compromising their potential benefit for people with Alzheimer's disease and related dementias. Since chronic lung disease is a common co-morbidity in people with dementia, predicting success of inhaler use based on cognitive function should be an important part of clinical decision making in the treatment of chronic lung disease. The purpose of this study is to determine the relationship between the score on the Mini-Mental Sate Exam (MMSE) and the ability to successfully complete the steps required for the proper use of a multi-unit dose DPI (DiskusTM).

The Safety Walker Program: Reducing Immobility Complications in Hospitalized Elderly

2010-03-01

Introduction/Objective: A recent study by Korbstein et al. showed the devastating functional impact of prolonged bed rest on healthy older adults as evidenced by substantial loss of lower extremity strength, power, and aerobic capacity. Significant losses in performance measures in frail, hospitalized long term care (LTC) residents can be anticipated with possibly more severe and prolonged consequences. The time commitment to regularly walk these patients often overwhelms nursing and physical therapy staff. This 6-month pilot Safety Walker Program was designed to train non-licensed staff to provide extra ambulation time to hospitalized elderly to help prevent the well known complications of immobility, including falls, pressure ulcers, delirium and functional decline.

Transfers of Nursing Home (NH) residents to an Emergency Department (ED) in Singapore- A Four Year Audit

David H. Yong, David H. Yong, Lina Ma — 2010-03-01

Introduction/Objective: Introduction: Residents in NH develop acute problems and are sent to EDs of acute hospitals. These transfers are clinical indicators for Singapore NH. This particular NH is studying the problem with a view to working with the local acute hospital to reduce future transfers. Aim: To describe the characteristics and outcomes of transfers of residents from a NH to the ED of a hospital.

Transitions of Frail Seniors across the Spectrum of Healthcare

Kamal Kejriwal, Kamal Kejriwal, B.Coutin Israel, Ginny Wilde — 2010-03-01

Introduction/Objective: It has been suggested that 2 major cost containment strategies were implemented at a time in which an increase of transfers from the hospital to the NH occurred, including DRG prospective payment system & increased managed care reductions in hospital LOS. One consequence of this strategy was the birth of transitional care, sometimes defined as a "set of actions designed to ensure the coordination and continuity of health care as patients transfer between locations or different levels of care or within the same location".(Coleman et al. J Am Geriatric Soc 2003). Problems inherent in this model arise secondary to poor, or no communication, and fragmentation, leading to known increases in rehospitalization, morbidity, and mortality. Additionally, poor or inappropriate transitions lead to increased skilled & overall utilization & poor functional outcomes.

Tuberculosis Skin Testing: Knowledge and Barriers of Healthcare Practitioners

2010-03-01

Introduction/Objective: Long term care residential facilities house older adults at increased risk of infection by Mycobacterium tuberculosis (TB); in addition, direct care providers are often born in countries with endemic TB. Thus, the Centers for Disease Control and Prevention (CDC, 2005) deem residents and employees in long-term care to be at high risk of TB infection. Routine tuberculosis screening, through PPD (purified protein derivative) testing, identifies individuals who may have latent TB or TB disease. Whereas most illness screening protocols use venipunctures, tuberculosis protocol relies on skin testing. Thus, we studied physicians' knowledge and practice patterns of PPD tests.

Unintentional Weight Loss in Long Term Care Residents with Alzheimer's Disease and Weight Response with the Use of Docosahexaenoic Acid (DHA)/Eicosapentaenoic Acid (EPA) and Bioflavinoids: A Case Series

Mario Cornacchione, Mario Cornacchione — 2010-03-01

Introduction/Objective: Cachexia/dehydration may be the immediate cause of death in the end stage of dementia in as many as 35% of nursing home residents. Cachexia is associated with suppressed appetite, food intake and body weight while proinflammatory cytokines are increased. Proinflammatory cytokines directly result in feeding suppression and lower intake of nutrients and cachexia is nearly always accompanied by anorexia. IL-1 beta and tumor necrosis factor alpha (TNFa) act on the glucose-sensitive neurons in the satiety and hunger sites in the hypothalamus. An association between high levels of circulating TNFa and unexplained weight loss in AD has been shown. Serum TNFa has been shown to be lower in mild-moderate Alzheimer's disease (AD) compared to severe AD.12 The levels of TNFa, IL-1beta, IL 6, and IL10 were elevated in the serum of patients with dementia. A minority of studies have shown no significant differences between AD subjects and controls in the mean serum levels of TNFa and other cytokines. Brain synthesis of cytokines has been shown in peripheral models of cancer, peripheral inflammation, and during peripheral cytokine administration and strikingly increased CSF levels of TNFa have been demonstrated in AD.

Visual Stimulation: An Approach to Weight Loss in Long Term Care

Rachel Shipley, Rachel A. Shipley, Namita Ahuja, Subashan Perera — 2010-03-01

Introduction/Objective: Excessive weight loss in long term care is common and is frequently targeted as a quality measure. It has been demonstrated previously that food consumption in patients with advanced Alzheimer's disease can be increased through use of brightly colored dinnerware to overcome diminished sensitivity to visual contrast. Our pilot program seeks to generalize the findings to all patients in long term care including those without dementia.

Vitamin D Deficiency in a Subacute Care Setting

Michael Felver, Michael E. Felver — 2010-03-01

Introduction/Objective: Vitamin D deficiency has been identified in the long-term care population but little is known about the risk of this deficiency in patients admitted to subacute care following hospitalization. This is a preliminary study to estimate the frequency and risk of vitamin D deficiency in this population.

Why Aren't Physicians Prescribing Vitamin D for Nursing Home Residents?

2010-03-01

Introduction/Objective: In the past decade, there has been growing scientific evidence of the clinical impact of vitamin D supplementation on a multiplicity of chronic medical conditions affecting the elderly, as well as reduction of institutionalization rates. Yet, underutilization of vitamin D has been demonstrated in nursing home and rehabilitation facilities. We sought to study the reasons for physicians' vitamin D prescribing patterns in long-term care settings.

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