Richard G. Stefanacci

Understanding Clinical Dehydration and Its Treatment

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patients history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

Improving dementia care: The role of screening and detection of cognitive impairment

The value of screening for cognitive impairment, including dementia and Alzheimers disease, has been debated for decades. Recent research on causes of and treatments for cognitive impairment has converged to challenge previous thinking about screening for cognitive impairment. Consequently, changes have occurred in health care policies and priorities, including the establishment of the annual wellness visit, which requires detection of any cognitive impairment for Medicare enrollees. In response to these changes, the Alzheimers Foundation of America and the Alzheimers Drug Discovery Foundation convened a workgroup to review evidence for screening implementation and to evaluate the implications of routine dementia detection for health care redesign. The primary domains reviewed were consideration of the benefits, harms, and impact of cognitive screening on health care quality. In conference, the workgroup developed 10 recommendations for realizing the national policy goals of early detection as the first step in improving clinical care and ensuring proactive, patient‐centered management of dementia.

Antipsychotic Drug Use Since the FDA Black Box Warning: Survey of Nursing Home Policies

OBJECTIVES To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA. DESIGN/SETTING/PARTICIPANTS A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications. MEASUREMENTS/RESULTS The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions. CONCLUSION Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.

Assisted living facilities: optimizing outcomes.

Seeing that the United States has nearly 36,400 assisted living facilities (ALFs) serving more than 900,000 residents, the American Geriatrics Society (AGS) recognizes that ALFs have become a critical component of long-term care (LTC). ALFs were established in response to consumer demand for an environment that was an alternative to home for older adults, particularly those with medical complexity or functional or cognitive decline, to live and age with grace and dignity. The challenge facing ALFs and the staff who provide their care is how to balance the goals of independence and maintaining a home-like environment in this medically, cognitively, and functionally diverse aging population. The ALFs need to recognize and address when the medical, functional, and safety needs of older people have outstripped their facilities’ capacity to provide safe; therefore quality care is the key. The tremendous variability that states have in definitions of level of care, philosophy regarding care, and licensing standards further complicated this challenge. However, it is clear that ALFs cater to a vulnerable and medically, functionally, and cognitively impaired population. A national study found that more than half of ALF residents were aged 85 and older, 25% had moderate or severe cognitive impairment, 33% experienced urinary incontinence, 51% received assistance with bathing, and 77% received assistance with medications. Of the residents who currently live in ALFs, 81% need help with one or more activities of daily living (ADLs) and 93% need help with instrumental activities of daily living (IADLs). The emphasis in caring for these residents is on maintaining independence and quality of life. There are a number of difficulties in developing standardized approaches to care provided for those living in ALFs. State and local governments regulate these facilities, and these regulations vary from state to state. Nevertheless, although this may account for some of the difficulties in developing standardized approaches in ALFs, there are sometimes conflicting views of the very definition and purpose of the ALF. The differing views of the ALF mission include the idea of the ALF as a facility that provides a distinct level of care versus a living site that provides a wide variety of supportive services to the senior. There is concern that ALFs will lose their role as a ‘‘home’’ if they are subjected to greater degrees of bureaucratic scrutiny with any further attempts to rigidly define and regulate these facilities and their market-driven need in the United States. The intent of this discussion is to balance the need for continued access to these facilities with the need to ensure high quality of care provided in them. This is accomplished by defining those aspects of care that are crucial to effective care of those living in ALFs.

Overcoming obstacles to repurposing for neurodegenerative disease.

Repurposing Food and Drug Administration (FDA)‐approved drugs for a new indication may offer an accelerated pathway for new treatments to patients but is also fraught with significant commercial, regulatory, and reimbursement challenges. The Alzheimers Drug Discovery Foundation (ADDF) and the Michael J. Fox Foundation for Parkinsons Research (MJFF) convened an advisory panel in October 2013 to understand stakeholder perspectives related to repurposing FDA‐approved drugs for neurodegenerative diseases. Here, we present opportunities on how philanthropy, industry, and government can begin to address these challenges, promote policy changes, and develop targeted funding strategies to accelerate the potential of FDA‐approved repurposed drugs.

Prevalence and Description of Palliative Care in US Nursing Homes A Descriptive Study

Objective: To describe rates and policies in U.S. Nursing Homes (NH) related to palliative care, comfort care, and hospice care based on a nationwide survey of directors of nursing. Measurements: A national survey was distributed online and was completed by 316 directors of nursing of NHs (11% response rate). The directors of nursing were asked about availability and policies in their facilities. Specifically, questions were related to policies, referral patterns, discussion about such care, and types of medical conditions qualifying for such services. Results: Hospice is significantly more available than palliative or comfort care programs; also, for-profit facilities, compared to non-profits, are significantly more likely to have palliative care programs and medical directors for palliative care. Social workers and nurses were most likely to suggest palliative type programs. Only 42% of facilities with palliative program provide consultation by a palliative certified physician. Residents with non-healing pressure ulcers, frequent hospitalizations, or severe/uncontrolled pain or non-pain symptoms were less likely to be referred. Conclusions: There is limited availability of palliative type programs in NH facilities and underutilization in those NH with programs.

Nursing Home Procedures on Transitions of Care

OBJECTIVE To identify nursing home standards through a nationwide survey of directors of nursing regarding transitions of care for residents transferred from acute care hospitals to skilled nursing facilities (SNFs). METHODS A national survey was distributed online and was completed by 241 directors of nursing of SNFs. The directors of nursing were asked about communication methods, transfer of records, and staff involvement with admissions from acute care hospitals. RESULTS The results of the survey demonstrated widespread use of an admission coordinator in the nursing home to direct admissions to the facility. Admission nurses consistently had the most responsibility for ascertaining the correct medication regimen on admission to the facility. Although there was a variation in types of records received from the hospitals, more than 80% received medication administration record or discharge/transfer sheet within 1hour of a patients arrival. CONCLUSION The results of this survey demonstrate that although direct verbal communication is not the norm, communication via paper documentation of transfer information is highly common. There was a statistically significantly increased likelihood of the SNF receiving the discharge/transfer sheet and the last medication list when it was directly affiliated with the transferring hospital. These affiliations would increase as a result of proposed payment changes that would bundle Medicare Part A acute hospital payments with the SNF payment.

Discontinuation of unnecessary medications in older adults.

OBJECTIVE Identifying and managing the use of medications that may be discontinued is a daunting task for the health care team, especially for the consultant pharmacist. This article discusses a framework to evaluate the risks and benefits of medications. A case-based approach will be employed to demonstrate the application of evidence-based medicine and the challenges that pharmacists face in attempting to discontinue medications in older adults. DATA SOURCES Medline and Micromedex were used as resources for primary literature as well as drug information. STUDY SELECTION Studies were identified based on their relevance to the case to demonstrate the importance of applying emerging literature and evidence-based medicine. DATA EXTRACTION Guidelines on managing osteoporosis as well as diabetes in older adults were used for this case. DATA SYNTHESIS A structured framework was applied to demonstrate considerations when tackling challenging medication regimens. CONCLUSION Patient-centered, individualized medication regimens need to be developed and updated based on the needs of the patient as well as the wishes of the family and caregivers. This is a dynamic process that benefits from the consultant pharmacist, who understands the complexity of the medications and is essential to addressing the use of unnecessary medications.

First Steps in Improving Physical Activity in Assisted Living

A major difference between assisted living (AL) and nursing homes (NH) should be that whereas NHs provide care for residents ALs focus on facilitating and teaching their residents to provide for themselves. ALs as their name implies should be places that assist rather than encourage dependency on caregivers where the core philosophy is promoting autonomy. This continues to be the case although a growing number of residents are frail and have multiple chronic conditions. An area where assisting older adults to be more independent is clear is the area of physical activity (PA). Dr Barbara Resnick and her team in their article in this issue of the Journal of the American Medical Directors Association, ‘‘Perceptions and Performance of Function and Physical Activity in AL Communities’’ not only highlight the levels of inactivity in ALs but some possible opportunities for improvement. Their conclusion that older adults in assisted living are less physically active than those living in the community, although probably not a revelation to many assisted living providers, the extent of this inactivity and the effect may be. These findings and discussion of their conclusions should lead to improvements in PA for AL residents resulting in achieving the AL objective of assisting living for older adults.

Nursing Home Policies on Items Brought in From the Outside for Facility Residents

OBJECTIVE To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes, alcoholic beverages, and over-the-counter medications. METHODS A national survey was distributed online and was completed by 299 directors of nursing of skilled nursing facilities. The directors of nursing were asked about policies regarding whether family and friends of residents are permitted to bring in items such as food, cigarettes, alcohol, and over-the-counter medications. Specifically, questions were related to monitoring, staff involvement, safety precautions, and policy implementation. RESULTS The results of the survey demonstrated a consistent policy practiced among facilities. Items commonly restricted for all residents included over-the-counter medications, alcohol, and cigarettes. On the other hand, food was significantly less likely to be restricted. CONCLUSION Despite overall strict policies regarding the monitoring of access to over-the-counter medications, alcohol, and cigarettes by nursing home residents, ingestion of outside food remains fairly unrestricted. This is especially concerning given the growing number of residents with end-stage congestive heart failure, diabetes, dysphagia, or food allergies where access to outside food could result in an adverse event. Perhaps, facilities need to identify at-risk residents and better communicate to residents and their families regarding dietary restrictions on outside food.