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 Constructive Approaches to Common Problems in Skilled Nursing Facilities

Chronic Conditions In Nursing Homes Get Another Look

 


The “same old” approach to persistent disease conditions in long term care isn’t good enough any more, experts say.
The patient population in this setting is different than it was 10 or 20 years ago, and so is how such conditions are addressed. Developments and promising trends in treatments, medications, and diagnostics are designed to improve outcomes and increase efficiency.
Expect to see more such innovations, as accountable care and penalties for rehospitalizations and the occurrence of “never events” become the norm and facilities wrestle with cost, coverage, and reimbursement cuts.
At the same time, long term care has entered a new age of technology, clinical discovery, and personalized care that will have a growing impact on care and outcomes.

The New Model

What kinds of innovations are happening in long term care? “There definitely is an increasing recognition of the need to develop better systems of care,” says Jason Karlawish, MD, professor
of medicine and medical ethics, University of Pennsylvania.
 
William Day, DPh, FASCP, president and chief executive officer, Pharmaceutical Consulting Services of America, New Orleans, adds, “As we move to practicing more person-centered care, we increasingly are approaching care from a global perspective. We’re seeing an emphasis on systems that involve all appropriate team members—with the patient at the center—and set goals accordingly.”
 
Since the average long term care resident has multiple chronic conditions, it isn’t surprising that he or she also is taking several medications—an average of eight or more. But there currently is a focus on making medications just part of treatment, not the central or main component. Many of the recent innovations have to do with early diagnosis and prevention, Karlawish notes.
 
“There will be more vigorous debates in the coming years about whether drugs are cost-effective.” He says, “Professionally, I’m glad that we are having these debates. I think we will look increasingly at patient-reported outcomes; that is, if people taking medications actually do better.”

Diabetes: Slipping Away From Sliding Scale

Formerly the standard of care, prolonged use of sliding scale insulin (SSI) therapy generally is now not recommended in long term care facilities, and practitioners increasingly are moving patients from SSI to basal bolus insulin therapy.
 
According to the AMDA—Dedicated to Long Term Care Medicine—“Clinical Practice Guideline on Managing Diabetes in the Long Term Care Setting,” widespread use of SSI results in greater patient morbidity and increased nursing time because patients’ blood glucose levels must be monitored more frequently, and more insulin injections must be given. Additionaly, the patient’s activities and quality of life may be compromised.
 
John Morley, MB, BCh, Dammert professor of gerontology and director of the division of geriatric medicine, St. Louis University, says, “Sliding-scale insulin generally isn’t good for various reasons. You’re really giving someone insulin after the fact.” Hypoglycemia actually occurs more often with SSI therapy than it does using a basal-bolus regimen, he says.
 
Reducing waste and unnecessary costs is one driver behind a move away from SSI in long term care. “Many providers now recognize that there is significant waste in the way the insulin vial is “sized.” On average, a facility wastes about 40 percent of the insulin it purchases in vials,” says Fred Wendt, RPh, a long term care pharmacist.
 
He explains, “A vial contains 1,000 units, so if you multiply the average 20-unit dose by 28 days [the time period in which an open vial of insulin must be used], you have only 560 units administered. The rest is waste.
 
“That’s about a $52 expense per vial, and that’s unconscionable.” This is propelling facilities to look at insulin pens more, says Wendt, because they have 300 units in them. For patients receiving average or less doses of insulin, these can be more cost effective. “The savings are enough to overcome the extra cost associated with needles for the pens,” he says.
 
Dennis Stone, MD, CMD, MBA, a chief medical officer in Louisville, Ky., and former president of AMDA, agrees that waste is a big concern. “There is a clear issue with waste, and that is one reason we moved to the pen,” he says. “We expect to save tens of thousands of dollars or more.”
 
However, cost isn’t the only issue driving the move to the pen. “It is a wonderful tool for the discharged patient going home,” says Wendt. With an emphasis on effective care transitions and ensuring that patients are not readmitted to the hospital after discharge due to avoidable problems, this is a plus for both patients and providers.
 
“We see it all the time—we try to educate patients on insulin administration, and they have difficulty with it. Because the pen is easier to use, it is a confidence builder, especially with geriatric patients who are being discharged home,” Wendt says.
 
Since the pens allow for more accurate dosing, they can contribute to better outcomes.
 
“Hypoglycemia certainly is a concern with diabetes patients,” Wendt says. While this condition usually is mild and can be treated quickly, it can lead to confusion or dizziness that can result in a fall. At its most severe, hypoglycemia can lead to seizures or coma. It can be fatal. Better control means fewer instances of hypoglycemia and its consequences, Wendt says.
 
Morley says that there are situations in which SSI is acceptable. However, Stone notes, “Except in the brittle diabetic and rare other instances, long term use of SSI is just not ‘good medicine.’ It’s not fair to the patient and takes time away from nursing that could be used to address other care needs.”
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Reassessing Tight Control

Another issue gaining attention in long term care is when tight control is appropriate. Morley stresses that tight control of diabetes in elderly patients may not always be an appropriate or realistic goal. In general, in fact, a hemoglobin A1C level between 7 and 8.5 is considered acceptable for most patients, including the elderly, says Morley; and not every patient necessarily should be held to the ideal goal of 7.
 
As Stone says, “If I have a younger patient with a 20- to 30-year prognosis, he or she deserves tight control. But if I have an 85-year-old with multiple comorbidities, tight control may not be an appropriate or necessary goal. It really depends on the prognosis.” However, Stone says, “Elevated blood sugar does long-term damage to virtually every organ system in the body. The more patients learn about this, the more the ones with a good prognosis want to keep tighter control.”
 
This move away from tight diabetes control in all cases is a big change, but it fits in with the philosophy of person-centered care. “You have to talk to patients about reasonable control, diet, lifestyle, and risks. If looser control doesn’t put them at great risk of hypoglycemia or other problems and he or she wishes to have a piece of cake, the patient’s wishes should be respected. At the same time, those who have had diabetes for years and are used to tight control should be allowed to continue this if they wish to do so,” says Day.
 
Wendt agrees that individualized treatment—as part of person-centered care—is key to successful diabetes management. “While a Hemaglobin A1C of 7 is a good standard, a patient might not feel good at this level; so you have to do what is best for him or her,” he says. “Astute clinicians won’t just look at the A1C. They’ll consider the results of eye, foot, and skin exams. If you have a patient with an A1C of 8 who looks good, feels good, and is in generally good condition, why would you foist therapies on them that they don’t want or need?”
 
Setting flexible goals also can help with patient compliance, says Wendt. “If you tell a patient with an A1C of 10 that they have to get it to 7 and he or she works really hard and only gets it to 9, that patient is more likely to give up. But if we say, ‘Great—you’re at 9, let’s try for 8,’ this lets the patient celebrate a small victory and is more likely to provide the incentive to keep trying,” he says.
 
While older patients with diabetes with better controlled blood sugar are less likely to experience complications such as vision loss, heart attacks, strokes, or kidney failure, a new study seems to support the trend toward looser control.
 
Researchers determined that older patients with the lowest blood sugar levels have a slightly higher chance of dying than those whose control is in the normal A1C level of 7-8, according to a 2001 study reported in Diabetes Care. 
 
While they couldn’t determine whether increased risk of death was related to low blood sugar, the treatments or medications used to control the patient’s diabetes, or other factors, the authors say the data do suggest that aggressive control or treatment isn’t necessarily the appropriate goal for elder patients.
 

A Personal Choice

Jonathan Marquess, PharmD, CDE, president of the Institute for Wellness and Education in Woodstock, Ga., says, “For people with diabetes, it is all about individualize, individualize, individualize.” He adds, “The goal is to get diabetes in control and not have huge swings up or down.
 
We’re trying to get medications to patients that work more like their bodies’ own insulins and don’t just correct blood sugars reactively. Increasingly, this is a team activity that involves physicians, family members, and patients proactively. They share a common aim of helping the patient feel better and have a better quality of life.”
 
Diabetes care also is at the center of recent efforts to improve care transitions. As Marquess says, “There is a greater understanding that patients who come to the nursing home from the hospital on sliding scale need attention. I have more medical directors consulting with me and saying, ‘We’re getting a patient from the hospital on SSI. We will keep him on that for a week, and then we want you to reevaluate.’”
 
He adds, “I’m changing many of these patients to basal insulin and having success with that.”
While the approach to diabetes treatment has evolved, new developments may lead to additional changes in the future. For example, an experimental drug designed to improve levels of “good” cholesterol improved blood sugar control in diabetic patients on statins, in one new study by the American Heart Association. While the medication was not as effective in managing diabetes as drugs commonly used to treat that condition, it did reduce the adverse impact on blood sugar commonly seen with statin use.
 

Infection Control Takes Center Stage

There are many developments that could positively impact how infections are prevented and managed in long term care and other settings. Among them is Food and Drug Administration (FDA) clearance for the first test for Staphylococcus aureus (S. aureus) infections that can diagnose and distinguish methicillin-resistant infections (MRSA) from methicillin-susceptible (MSSA) ones.
 
The KeyPath MRSA/MSSA Blood Culture Test can determine whether bacteria growing in a person’s positive blood culture sample are MRSA or MSSA in approximately five hours from the time bacterial growth is seen in the sample. The test doesn’t require any special instruments—beyond blood culture equipment—to get results, so it practically can be performed in any laboratory. Ideally, this test will enable practitioners to diagnose these conditions quicker and promptly implement precautionary measures to prevent spreads or outbreaks.
 

Other Conditions Have New Remedies

Elsewhere, FDA recently approved Dificid (fidaxomicin) tablets for treating Clostridium difficile-associated diarrhea (CDAD). Two trials involving a total 564 patients with CDAD compared Dificid with the antibiotic vancomycin. The clinical response was similar between the two groups in both studies. However, more patients treated with fidaxomicin were still symptom-free after three weeks than those in the vancomycin group.
 
To maintain the new drug’s effectiveness and avoid development of a drug-resistant bacteria, fidaxomicin should be used only to treat infections caused by or strongly suspected to be linked to C. difficile, according to FDA. The drug’s most common side effects are nausea, vomiting, headache, abdominal pain, and diarrhea.
 
In another drug-related development, an old osteoporosis drug may be effective in killing influenza viruses, including the H5N1 bird flu virus, according to Reuters Health Information. Pamidronate boosts a class of human immune cells and causes them to attack flu virus-infected host cells.
 
Antiviral drugs target flu viruses, which can be problematic as viruses often mutate and become resistant. However, this isn’t a concern with pamidronate because it targets cells and not the viruses.
To date the drug has been tested for this purpose only with mice specially bred with human immune systems. It is too early to tell the potential use of pamidronate in humans, no less older adults. However, if it is proven to produce positive outcomes in human subjects, the drug could be particularly useful in a pandemic when typical flu medications are in short supply.
 
Indeed, preparing for pandemics and vaccine shortages have been focuses for researchers in recent years. In another study, by A. Pollack, reported in the New York Times, scientists have developed a flu vaccine made by a new, faster method to make flu vaccines.
 
The new process involves growing influenza virus in animal cell cultures, rather than in chicken eggs. This could prevent problems such as the 2009 swine flu pandemic, during which large quantities of vaccines weren’t available until after the height of the flu season. The new vaccine could become available in the United States within a few years. 
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Positive News For Infection Control

Standard precautions haven’t changed much over the years. However, a new precautionary measure could have a positive impact on reducing infections.
 
According to a recent study, antimicrobial copper surfaces in intensive care unit rooms reduced the risk of hospital-related infections. In the Department of Defense-funded study, sites replaced frequently touched areas, including bed rails, over-bed tray tables, nurse call buttons, and poles, with antimicrobial copper. One site experienced a 97 percent reduction in surface pathogens in rooms that replaced existing surfaces with copper.
 
If further studies produce similar results, this could have tremendous repercussions in nursing facilities, where the spread of infections is a constant concern and traditional precautionary measures aren’t always enough.  Of course, facilities will have to weigh the cost of installing copper surfaces with the potential benefits.
 
Another recent study could lead to an additional change in precautionary measures. Researchers in Rhode Island studied 7,700 adult patients in a hospital setting and found that using antiseptic-laced washcloths lowered the risk for MRSA and vancomycin-resistant Enterococcus better than traditional soap and water.  

Unraveling The Parkinson’s Mystery


While there have been no recent innovations in Parkinson’s disease (PD), several studies have delved into PD’s causes and how to keep patients with the illness safer and more comfortable. For example, one recent study showed a connection between the use of two pesticides (rotenone and paraqual) and PD, as reported in Environ Health Perspective.
 
According to the study results, people who used either pesticide developed PD about 2.5 times more often than those who didn’t use the chemicals. Still another new study reported in Health Day suggested that methamphetamine abuse increases the risk for PD by up to 76 percent.
 
Another recent study reported in Health Day has suggested a change that needs to be made to better protect PD patients. According to the results, antipsychotic drugs are still being prescribed for many PD patients, despite a six-year-old warning that the drugs can worsen symptoms. In fact, between 2002 and 2008, the rate of antipsychotic prescriptions for PD remained consistent in spite of the warning issues in 2005.
 
While there was a shift toward better-tolerated antipsychotics, researchers stress that these medications aren’t necessarily safer or more effective.
 
“We still need to learn more about the origins of PD. Until we have more insights on this, treatment isn’t likely to change much. In the meantime, we are focusing on keeping patients with the disease as safe and comfortable as possible,” says Day. Another focus is identifying patients who are experiencing drug-related Parkinsonism from antipsychotics and other medications, he says.
 
With antipsychotic use receiving growing national attention, this will be an area of focus for facilities and prescribers alike—for PD patients and others taking these drugs. Karlawish says,
“We need to use antipsychotics carefully. We also need to develop and implement better ways to treat these problems. We are seeing greater attention to implementing systems to monitor medication usage and scrutinize med records.” Increasingly, prescribers will need documentation to support the use of various medications, and payers will be scrutinizing records for cost inefficiencies and medications deemed unnecessary, observers say. 

Pressure Ulcers: Ways To Promote Healing

Preventing and treating pressure ulcers is always a top priority in long term care facilities, and some new research and developments may make this easier. For example, European researchers have determined that negative-pressure wound therapy may not promote healing in chronic persistent and complex wounds any better than conventional wound care.
 
Negative-pressure wound therapy, which involves covering the wound with an airtight film and placing an electric pump over the wound to drain exudates, can be costly and time-consuming. So with the current emphasis on cost cutting, it is important to understand what treatments are most cost effective.
 
At the same time, researchers at Loyola University Health System have determined that it might be possible to promote wound healing by suppressing neutrophils and natural killer T (NKT) cells.
While these cells kill bacteria and other germs that can cause wound infections, they also can be harmful—producing enzymes that digest surrounding tissue, cause scar tissue to develop, and hinder healing.
 
Scientists from the United States, Israel, and Japan have developed an inexpensive nanometer-sized drug that can treat foot ulcers and other chronic wounds. Several growth factor proteins have been shown to speed wound healing, but purifying these proteins is expensive, and they don’t last long on the injured site.
 
Now, scientists have used genetic engineering to produce a “robotic” growth factor protein. Because these respond to temperature, dozens of these proteins can fold together into a nanoparticle more than 200 times smaller than a human hair. This simplifies protein purification, making it inexpensive to produce and enabling the protein to remain at the wound site longer.
 
In general, wound care really hasn’t changed much in many years, says Carolyn Brown, BS, Med, LTC-RN, a clinical consultant for Advanced Tissue, a Medicare Part B billing service company located in Little Rock, Ark.
 
“As far as treatments go, we are seeing more and more collagen products.” These provide a moist wound-healing environment with the benefits of collagen. However, Brown suggests that facilities focus more on “good basic skin care.”
 
“Good incontinence care, good nutrition, and other basics of skin care continue to be the key to pressure ulcer prevention. I’ve seen people taken care of at home by family members, and their skin is healthy—despite the fact that they’re 95 and homebound. The difference is care,” she says.
 
“We’re focusing on disease states that put people at high risk for skin breakdown and making sure that—whenever possible—patients aren’t on drugs that can affect their nutritional status,” says Day. “We are stressing prevention and ways to protect skin and prevent breakdown in the first place.”
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Alzheimer’s Work

Not surprisingly, the diagnosis and treatment of Alzheimer’s disease (AD) and dementia continue to evolve. As Karlawish says, “The field of Alzheimer’s increasingly is recognizing and understanding the biology of the disease with the practical goal of diagnosing the disease at the earliest onset or even before significant symptoms present, and then use these same insights to target interventions and treatments.”
 
An expanding focus on diagnostics, says Karlawish, has led to a “relaxation of interest on developments of symptomatic treatment. This is a change from 10 to 15 years ago when the focus was on medications.” In long term care, decisions about medications often involve how long to continue treatment.
 
As Karlawish says, “If patients are on medications designed to slow the disease’s progress, we need to decide if they should stay on these as Alzheimer’s advances.”
 
Clearly, AD is a common diagnosis in long term care. However, according to one study, the diagnosis of AD may not always be accurate. Researchers found that only about one-half of over 200 subjects diagnosed with AD were determined on autopsy to have brain conditions associated with the disease. Instead, they had other brain abnormalities, including generalized brain atrophy, according to a study reported in HealthWorks Collective.
 
While the authors admitted that larger studies are necessary to confirm their findings, this could lead to new ways to diagnose the disease and to ensure that patients aren’t being treated inappropriately or unnecessarily. 

Isolating Risk Factors

Other recent studies have suggested factors that determine one’s risk for AD. For example, a Swedish study published in Neurology has determined that extra weight during middle age (defined as having a body mass index of 25 to 30) could lead to a greater dementia risk in later life.
 
Another, conducted in Germany and involving 3,200 German seniors age 75 years or older, indicated that elderly adults whose alcohol intake is approximately two drinks daily have a significantly lower risk of developing AD and dementia than nondrinkers. In fact, they estimated that the risk for dementia is 30 percent lower and the risk for AD reduced by 40 percent.
 
Another study also has suggested a link between lifestyle and AD. University of Alabama researchers determined that an epigenetic eating regimen—a diet that includes soybeans, cauliflower, broccoli, cabbage, green tea, fava beans, kale, and grapes—may suppress gene aberrations that ultimately can cause diseases such as AD.
 
Confirming that AD may run in families, a recent study also published in Neurology indicated that a person’s risk for developing AD is higher if one’s mother—rather than one’s father—had the disorder.  

New Treatment Options

Other recent studies may help lead to identifying—and treating—AD earlier than ever before. One study indicated that the liver, as opposed to the brain, actually may be the source of the amyloid that leads to brain plaques associated with AD. If confirmed, these data could change how clinicians approach diagnosis and treatment.
 
Elsewhere, scientists have taken a potential step forward in AD treatment by discovering how to turn human embryonic stem cells and a type of human skin cell into the kind of brain cells lost to AD, reported in Stem Cells 2011. The new study suggested that perhaps scientists someday may be able to produce a supply of these cells in a laboratory setting and test different drugs on them to see which ones keep the cells alive. This, in turn, could aid in the development of drugs to combat AD.
Looking further into the future, this technology eventually might be used to transplant healthy cells back into AD patients’ brains to treat the disease.
 
Of course, drugs are still a part of AD treatment; and Karlawish notes that there are several drugs in later phases of clinical trials that “we will hear results of in the next 24 months. All have a common approach—addressing the accumulation of amyloid plaque in the brain.” He says, “We’ll know when the results come out if this approach is successful.”  

Geriatric Research Lags

While much has changed regarding how common conditions are treated in long term care, one thing hasn’t changed. Clinical trials still fail to involve older patients to any significant degree. One in five studies still excludes many patients simply because of their age; about half of the remaining trials employed criteria that were likely to eliminate older adults from involvement. This is according to a study analyzing over 100 studies published in The Journal of the American Medical Association, The New England Journal of Medicine, Lancet, Circulation, The British Medical Journal, and others, according to a report in the New York Times. While the average age of participants in the trials included in the study was 61, many excluded nursing facility residents and patients with physical disabilities or existing medical conditions.
 
“We just don’t have the data on how medications affect geriatrics as much as we should. We are still dealing with trial and error,” says Day. “We really need more studies specific to this population.”
Considering that the geriatric population is growing exponentially, says Day, this is a key issue that calls for national attention.
 
He says, “More and better studies addressing this population are likely to influence how we manage conditions such as PD, AD, pressure ulcers, and others in the years to come.”
 
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.
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